REPRODUCTIVE HEALTH DIGEST (6/9/23)

Legal Changes at the State Level: 

  • Brief Overview

    • Oklahoma: This week, the Oklahoma Supreme Court struck down two near-total abortion bans as unconstitutional, ruling that pregnant people have a constitutional “right to terminate a pregnancy to preserve [their] life.” Although this is a positive development, Oklahoma still bans abortion under its pre-Roe 1910 ban.

    • South Carolina: On May 25, Governor McMaster signed a 6-week abortion ban into law. The law was immediately challenged in state court, and a South Carolina judge halted the implementation of the law, pending litigation. South Carolina’s Supreme Court has now agreed to directly hear the case, bypassing the lower courts and likely expediting a ruling. 

    • Ohio: In Ohio, the state Supreme Court ruled that a ballot initiative aimed at enshrining reproductive rights into the state’s constitution does not need to be split into two separate issues. This means that Ohio Physicians for Reproductive Rights and Ohioans for Reproductive Freedom may continue to gather the signatures needed to get the initiative on the November ballot. A contrary ruling would have forced proponents of the ballot measure to collect twice as many signatures. In anticipation of this ballot initiative, Ohio Republicans have set an August special election to decide whether to raise the threshold needed to pass a constitutional amendment from a simple majority to 60%. 

    • Wisconsin: Wisconsin Republicans have introduced a package of bills that seek to clarify exceptions to the state’s abortion ban. Democratic governor Tony Evers has stated that he would veto the bills, as he supports restoring abortion rights in Wisconsin to what they were before the Dobbs decision. 

    • Tennessee: Tennessee’s amended abortion law has been signed into law.

    • Texas: Texas is advancing HB17, a bill that allows for the removal of district attorneys who refuse to prosecute certain classifications of cases, including those involving abortion. This move comes after several Texas DAs stated that they would not pursue abortion-related charges in their counties. 

    • Alliance for Hippocratic Medicine v. FDA: In the last edition of this newsletter, we reported on oral arguments in the case challenging the FDA’s approval of mifepristone. At this time, we are still awaiting the Fifth Circuit’s ruling following arguments. In anticipation of that ruling, states like Maryland have begun to stockpile mifepristone. 

Deeper Legal Analysis 

  • Oklahoma:

    • This week, the Oklahoma Supreme Court struck down two of the state’s abortion bans, ruling that they are unconstitutional. Both laws, one total ban, and one 6-week ban, were enforced through private civil lawsuits, similar to the Texas ‘bounty hunter’ provisions of SB8.  The justices found that the vaguely defined “medical emergency” exception was insufficient to protect a person’s constitutional right to terminate a pregnancy to save their life. Abortion remains banned in Oklahoma as a result of the still-standing 1910 ban. The 1910 ban makes it unlawful to perform an abortion at any point in the pregnancy, unless it is “necessary to preserve [the person’s] life, and it imposes a threat of prison time for violations. 

    • Earlier this year, the Oklahoma Supreme Court struck down a similar law, which made it unlawful to perform an abortion “except to save the life of a pregnant woman in a medical emergency,” taking issue with the strict interpretation of “medical emergency.” Since the overturning of Roe, Oklahoma has somewhat notoriously had a multitude of intersecting and conflicting abortion bans on the books, creating chaos and uncertainty about how to apply exceptions and definitions. Although this latest decision is only an incremental win, it may provide some clarity and security to physicians by ensuring that they are able to intervene to save the life of their patient without first waiting for the pregnant person to become sicker.

  • Ohio:

    • For the past several months in Ohio, abortion advocates have been working to collect signatures for a ballot initiative that, if successful, would enshrine abortion protections into the state constitution. Opponents of this effort attempted to disrupt the process by arguing that the ballot issue should be split into two separate issues: one for abortion, and one for all other reproductive healthcare. This would have required proponents of the ballot issue to effectively start over and collect twice as many signatures. However, on June 1, the state Supreme Court sided with the Ohio Ballot Board over anti-choice groups, finding that the initiative is properly one issue. This frees Ohio Physicians for Reproductive Rights and Ohioans for Reproductive Freedom to continue gathering signatures in support of placing abortion on the November ballot. 

    • If abortion does make it onto the November ballot, Ohio Republicans have passed a proposal that could make it substantially harder for the initiative to ultimately succeed. Lawmakers have set an August special election to decide whether to raise the threshold needed to pass a constitutional amendment from a simple majority to 60%, a move that is, to quote Ohio Secretary of State Frank LaRose, “100% about keeping” abortion out of the Ohio constitution. The nonpartisan coalition ‘One Person One Vote’ has filed a lawsuit challenging the August special election. The group points to the fact that mere months ago, the Ohio General Assembly revised state law to only permit elections in November, March or May. At that time, Secretary LaRose stated that August special elections have low turnout and are bad for taxpayers and voters. Ohio’s attempt to reverse course on that decision in order to thwart an abortion measure is undemocratic and elevates the political platforms of legislators over the voting power of Ohioans. 

    • Unfortunately, Ohio is not the only state attempting to circumvent the democratic process in order to stymie reproductive rights. Missouri’s attorney general continues to delay the finalization of a ballot initiative similarly seeking to enshrine abortion protections into the state constitution. AG Ashcroft is currently refusing to approve the cost estimate for the amendment.

  • Wisconsin:

    • In an attempt to further legitimize Wisconsin’s abortion ban, republicans have introduced a package of bills that seek to clarify exceptions to the ban. The first measure would clarify that certain medical procedures do not qualify as abortion, including inducing early labor, performing cesarean sections, and removal of molar or ectopic pregnancies. Another bill would allow parents to claim a tax exemption for unborn children (a fetal personhood law). The third bill would require Wisconsin’s Department of Health Services to provide a grant to Choose Life Wisconsin, Inc., in order to fund “pregnancy resource centers.” The final bill pertains to the provision of state funds to organizations that facilitate adoption. Proponents of the slate of bills have stated that they believe that they “offer an important clarification and reinforce the sanctity of life.” However, Democratic governor Tony Evers has said that he would veto the bills, as he supports restoring abortion rights in Wisconsin to what they were before Roe fell. Like the rest of the country, a majority of Wisconsinites support reproductive rights; accordingly, abortion advocates are skeptical of legislative attempts to lend credibility to the state’s currently enforced ban. A challenge to that ban is headed to the state Supreme Court which, with the election of Janet Protasiewicz earlier this year, will have a 4-3 liberal majority in August.

  • Texas:

    • In Texas, lawmakers are advancing HB17, a bill that allows for the removal of DAs who refuse to prosecute certain classifications of cases. Although the bill does not specifically call out abortion, the move comes in response to several Texas DAs stating that they would not pursue cases involving abortion-related charges. This bill, if successful, would interfere with prosecutors’ ability to use their professional judgment to determine whether and how to pursue cases. The legislature does not have the authority to impeach an elected prosecutor; however, they can be removed for official misconduct. Accordingly, in order to effectuate this bill, lawmakers would alter the definition of “official misconduct” to include categorically refusing to prosecute specific criminal offenses. A petition for removal could be filed by anyone who has resided in the county for at least six months, permitting private citizens to bring claims of misconduct against elected DAs.

What else is happening in access? 

  • Illinois is aiming to protect the data of individuals traveling to the state to receive abortion care from out-of-state investigations. 

  • The Missouri attorney general has asked the police to enforce the state’s ban on gender affirming care, despite the law being a civil ban, not within the jurisdiction of law enforcement. 

  • Missouri has launched a new program that allows residents to request free emergency contraceptives. 

  • Plan-b vending machines continue to make their way to college campuses across the country, thanks in large part to the advocacy work done by the American Society for Emergency Contraception (ASEC). 

  • Texas has now  become the latest state to ban trans healthcare for minors. 

  • In a surprising turn of events, a federal judge in Florida has issued an injunction halting the enforcement of the state’s ban on gender affirming care. In some particularly striking language, Judge Robert Hinkle stated that “[a]ny proponent of the challenged statute and rules should put up or shut up: do you acknowledge that there are individuals with actual gender identities opposite their natal sex, or do you not? Dog whistles ought not be tolerated.”

Issue of the Week: Trans Health and Abortion 

Every June, people all over the country and all over the world celebrate Pride month. Pride, which originated as a single day, now serves as a month-long opportunity to commemorate the 1969 Stonewall uprising in New York, an event that galvanized the fight for gay and trans rights, remember and honor those lost to hate crimes and discrimination, and celebrate queer joy and the contributions of LGBTQ+ individuals  to our communities. This year, Pride takes on particular significance, as the trans community has faced relentless legislative attacks from the right. In the first half of 2023 alone, nearly 500 anti-trans bills were introduced in state legislatures, including bills discriminating against trans athletes, limiting funding for gender affirming care, restricting the use of pronouns, censoring reading materials that include discussion of sexual orientation or feature gender diverse characters, and dictating which bathroom individuals are permitted to use. Additionally, and perhaps most alarming, 18 states now ban or attempt to ban medically necessary gender affirming care–a stunning intrusion into individual bodily autonomy rights. The fight for trans rights and the fight for reproductive freedom are critically intertwined, but all too often, calls for reproductive rights fall short of acknowledging this intersectionality. This Pride month, let us be reminded that if we are to succeed, it is urgent that advocates stand united. 

As reported on in our last edition of this digest, Nebraska recently enacted LB 574, a bill limiting abortion to 12 weeks. However, LB 574 did not start as an abortion bill. It started as a gender affirming care ban, and after republicans failed to pass other abortion restrictions, they tacked the 12-week law onto the bill at the last second and squeezed it through the legislature. It is no accident that conservative lawmakers thought (correctly) that they were politically safe in combining these two issue areas into one discriminatory law. Restrictions on trans health and restrictions on reproductive freedom are rooted in the same effort to control people’s bodies and impose patriarchal, heteronormative and white supremacist norms onto those bodies. Both movements elevate subjective “morality” over the objectivity of medicine, and they do so to the detriment of already marginalized communities. 

The trans community has always faced substantial discrimination in health care systems. And the Supreme Court’s decision in Dobbs added new and heightened barriers to obtaining care. Not only does Dobbs restrict the ability of trans people to access reproductive health care, but it places all other privacy rights in jeopardy–a fact that conservative legislators have seized upon in this legislative session. You need look no further than Justice Thomas’s suggestion in Dobbs that the judiciary revisit key precedent protecting LGBTQIA+ rights  to understand how truly interconnected these issues are. Nebraska’s new law is just further proof of this relation.  Although voices of color and the trans community are at the forefront of the fight for bodily autonomy, those voices are so often minimized or erased entirely from the popular narrative surrounding reproductive freedom. If the opposition is united in their playbook against bodily autonomy, we must be even more aligned in our fight to protect it. 

Every person has an equal interest in being able to make private medical decisions in consultation with their doctor and their loved ones. When we look the other way as laws are passed that restrict the ability of a community of people to do so, we not only fail to protect one another from harm, but we allow dangerous precedent to grow and take root–precedent that ultimately impacts the rights of all people. ​​So, this Pride month, please take some time to speak out in defense of the right of all people to be safe and secure in their bodies, elevate historically silenced voices, and empower yourself with a greater understanding of why intersectionality is absolutely crucial to protecting bodily autonomy. 

REPRODUCTIVE HEALTH DIGEST (5/26/23)

Developments in Abortion, Autonomy, and Access: 

Rapid legal developments in abortion, autonomy and access to health care continue to change the landscape of the law on a weekly basis. As many states near the end of their legislative sessions and the dust settles, we will have a clearer picture of where access remains, where it has been eliminated entirely, and where it is limited or in the line of fire. Please read on for more detailed information about the legal changes that have taken place in the past 2 weeks.


Legal Changes at the State Level: 

  • Brief Overview

    • Nebraska: Nebraska passed LB 574, narrowing the window for abortion from 20 weeks to 12 weeks, with exceptions for rape, incest, or to save the life of the pregnant person. 


    • South Carolina: South Carolina lawmakers continued to work into legislative overtime this week, and on Tuesday May 23, the state passed the proposed 6-week abortion ban. Governor McMaster signed the bill into law on Thursday, May 25, and it was immediately challenged in state court. On Friday May 26, a South Carolina judge temporarily blocked the law while the court evaluates its constitutionality. 

    • Montana: Montana Governor Gianforte signed a host of restrictive abortion bills, most notably a ban on dilation and evacuation (D&E) procedures after 15 weeks. This 15 week ban was immediately blocked by a temporary restraining order issued by a Montana district judge. 

    • North Carolina: North Carolina’s legislature passed SB20, a 12-week abortion ban, over Governor Roy Cooper’s veto.

    • Alliance for Hippocratic Medicine v. FDA (mifepristone case): Last Wednesday, federal judges at the Fifth Circuit Court of Appeals heard oral arguments in the case that will determine whether mifepristone remains available for medication abortion. 


    • The Federal Government found that hospitals in Kansas and Missouri violated federal law (the Emergency Medical Treatment and Labor Act, or ‘EMTALA”) for failing to provide an abortion to a woman in a medical emergency, reinvigorating conversations about the federal government’s obligation to protect the rights of pregnant people from state encroachment. Secretary of Health and Human Services Xavier Becerra has sent a letter to all hospitals that participate in medicare, reminding them that their obligations under federal law supersede state abortion bans. The Propublica report linked above is a striking example of how entire hospital systems can fail patients in dire need of care, highlighting how these patients’ stories are not individual one-off cases, but rather the inevitable result of poorly drawn laws.


Deeper Legal Analysis 

  • Nebraska: 

    • Nebraska has passed LB 574, its 12-week abortion ban, narrowing the window down from the previous 20 weeks. This new ban includes exceptions for rape, incest or to save the life of the pregnant person.  Notably, this latest restriction was added as an amendment to Nebraska’s ban on gender affirming care for individuals under the age of 19. Nebraska’s passed LB 574 by one vote, against the backdrop of protestors chanting “one more vote to save our lives.” Trans health and reproductive rights are at the heart of the fight for bodily autonomy, and they have both been subjected to unrelenting attack during this legislative session. The packaging of these two issues into one bill signals a need for advocates to act in unity in opposing restrictions of this kind. Restrictive abortion bans and bans on gender affirming healthcare seek to achieve the same overarching goal: political control over individual bodies and medical decisions. It is no coincidence that this control is exercised in a way that elevates “traditional” ideas about heteronormativity and reproduction. For more on how these two issue areas are related, I highly recommend this opinion piece from the Guardian.


  • South Carolina:

    • The South Carolina legislature continued to work into legislative overtime this week, and on Tuesday May 23, lawmakers passed the proposed 6-week abortion ban, which restricts abortion after fetal cardiac activity is detectable. The bill will became operative upon signing by the Governor on Thursday, May 25, . The bill contains narrow exceptions for rape or incest until 12 weeks gestational age as well as for cases of fatal fetal anomaly and risk to the life of the pregnant person. The rape or incest exception only applies if the crime is reported to law enforcement within 24 hours of the abortion procedure, and the physician is required to inform the patient that they will report it to the sheriff. As we have previously discussed,  requirements that victims of assault report the crime to law enforcement create substantial barriers to care, particularly for those individuals whose perpetrators are family members, friends or intimate partners. This new was immediately challenged by South Carolina advocates, on the grounds that it violates South Carolinians constitutional right to privacy. On Friday May 26, less than 24 hours after being signed by the Governor, a South Carolina judge temporarily blocked the law pending the court’s evaluation of its constitutionality. Earlier this year, a very similar 6-week ban was found to be unconstitutional and permanently blocked by the state’s Supreme Court on those same grounds. 

    • The “sister senators,” who successfully blocked previous attempts to ban or restrict abortion in South Carolina,  attempted to do the same with this bill, but were unfortunately unable to overcome the vote. The 5 female senators span the political spectrum, but are united in their view that this law is bad for pregnant people in South carolina. 6-week bans function as near-total bans. They restrict abortion at a point in pregnancy before most people are able to know they are pregnant–let alone make a decision and schedule, pay for, and receive care. With North Carolina restricting access to 12 weeks, and Florida standing poised to implement its 6-week ban, South Carolina’s passage of this bill is devastating for abortion access in the South. 

  • Montana:

    • Montana governor Gianforte signed a host of restrictive abortion bills, most notably a ban on dilation and evaluation (D&E) procedures after 15 weeks. This 15 week ban was immediately blocked by a temporary restraining order issued by a Montana district judge. Among the other bills signed were two restrictions on medicaid coverage for abortion and stricter regulations for clinics providing abortion services. This suite of newly passed laws comes shortly after the Montana Supreme Court upheld the ability of certain nurses to perform abortions, and in the opinion, reaffirmed that abortion is a medical decision that falls under the purview of Montana’s constitutional right to privacy. 

  • North Carolina:  

    • North Carolina has passed SB20, a 12-week abortion ban, over Governor Roy Cooper’s veto. The bill is set to take effect on July 01, 2023 and contains exceptions up to 20-weeks for victims of sexual assault, and up to 24 weeks for diagnosed life-limiting fetal anomalies. North Carolina previously permitted abortion until 20 weeks gestation. In addition to narrowing the window during which abortion is available, this bill contains a whole host of provisions that unnecessarily restrict and regulate access to care, including a requirement that medication abortion only be administered after an in-person physician visit verifying that the fetal gestational age is less than 70 days (10 weeks), and 3 required in person visits. Please read on for more detail about this new law, in this week’s ‘issue of the week.’ 

    • Despite a years-long record of supporting abortion rights, including discussing her own medically necessary abortion, state representative Tricia Cotham recently flipped parties and handed republicans the one vote that they needed to override the Governor’s veto and pass SB20 into law. 

  • Alliance for Hippocratic Medicine v. FDA:

    • Last Wednesday, in New Orleans, the Fifth Circuit Court of Appeals heard oral arguments in Alliance for Hippocratic Medicine v. FDA, the mifepristone case that will determine whether the FDA’s approval of the drug for medication abortions remains intact. The uniformly conservative panel, made up of two Trump appointees and a George. W. Bush appointee disproportionately hammered FDA and intervenor Danco counsel with questions from the very first moments of the argument. 

    • Throughout the two-hour arguments, much of the discussion centered on whether the Plaintiffs had suffered any injury as a result of FDA’s approval of mifepristone. Individualized injury is a constitutional prerequisite to bringing a lawsuit. The panel appeared sympathetic to the Plaintiffs’ claim that they will be imminently harmed by being forced to participate in surgical abortions after a failed medication abortion, despite no evidence supporting that claim. Plaintiffs, and the Fifth Circuit panel, relied in part upon flawed studies that purport to demonstrate that mifepristone is far more dangerous than it actually is. The panel seemed skeptical of Defendants’ argument that conscience objections, which permit doctors to decline to provide treatment that violates their conscience, protect the doctors from any risk of harm (they do). 

    • With respect to the long term availability of the drug, the panel did appear less sympathetic to the Plaintiffs’ argument that their failure to challenge the 2000 approval of mifepristone within the 6-year statute of limitations should be excused. Generally speaking, failure to file a lawsuit within the statute of limitations is fatal to the claim, and the Plaintiffs have presented no meaningful reason to deviate from this norm.  A finding that that claim is time-barred would restrict Plaintiffs to their challenge to their challenge to the 2016 relaxation of the terms of use, leaving the 2000 underlying approval intact. Regardless of the Fifth Circuit’s ruling, which could take weeks or months to come down, this case is all but certain to end up in front of the Supreme Court once again, despite the Court’s proclamations last year that it was returning the question of abortion to the states.

What else is happening in access? 

  • Viability: Please read this excellent write up from the American College of Obstetricians and Gynecologists (ACOG) on the complexities of ‘viability’ and why it is inappropriate for legislators to interfere in that complex and medical determination. 

  • Florida: Florida governor (and presidential hopeful) Ron DeSantis signed a host of anti-trans and anti-LGBTQ+ bills; although these do not specifically impact abortion, the opposition uses the same playbook against all rights to bodily autonomy. 

  • A recent report from the Center for Reproductive Rights (CRR), Physicians for Human Rights (PHR), and Oklahoma Call for Reproductive Justice,  highlights the troubling lack of information, guidance or consensus on abortion protocols in Oklahoma hospitals, leading to worsened care for patients. 

  • Mifepristone: Individuals who have taken mifepristone for a medication abortion tell their real experiences with the medication, and their reasons for taking the drug–ranging from miscarriage management to elective abortion to alleviation of gender dysphoria. 

  • In Iowa, the Supreme Court is set to end its term soon; however, the Court still has not ruled on the State’s request to lift an injunction that is currently blocking Iowa’s 6-week abortion ban from going into effect. Failure to do so in this term will mean that the issue is not closed at least until the next term."

  • A recent survey shows that restrictive abortion laws are likely to drive away new doctors, increasing strain on the medical system in those states. 

  • This Reuters article provides an overview of changes in abortion law in 2023, both restrictive and protective.

Issue of the Week: North Carolina’s Abortion Ban

Last week, North Carolina joined South Carolina and Nebraska in passing abortion restrictions at the tail end of their legislative sessions, when the state passed  a 12-week abortion restriction over Governor Roy Cooper’s veto. Although supporters of the new law touted it as a compromise between the left and the right leaning factions of the state, a detailed look at the bill contradicts that, and it is worth discussing why. To borrow Governor Cooper’s words, it is in reality “a compromise between the right wing and the radical right wing.” In order to better understand the true impact of any new legislation, it is important to take some time to look beyond the bill’s headline, at the text  of the law itself. 

North Carolina’s new laws regulates surgical abortion at 12 weeks and medication abortion at 70 days (10 weeks) gestational age. The full text of the bill spans approximately 45 pages of amendments and new language and contains numerous medically unnecessary or misleading provisions. First, the bill requires a patient seeking a surgical abortion within the first trimester to have an in-person visit with their doctor at least 72 hours prior to performance of the procedure–the longest waiting period in the country. Previously, patients could start the 72-hour clock with a phone call to their physician; however, the new law removes that option and implements an in-person only requirement. Waiting periods like this serve no medical purpose, but they do create significant barriers to care. Pregnant people seeking an abortion, particularly those who have to travel long distances to obtain care, now must take multiple days off work, arrange childcare for multiple doctor’s appointments, cover the costs of travel, and if they are not in a situation to safely disclose their decision–find a way to conceal their absence. This 72-hour waiting period is particularly problematic when considered against the backdrop of North Carolina’s geography–the state is surrounded by restrictive southern states, meaning that many pregnant people are forced to travel from their home state to North Carolina for access. And, for patients who elect to have a medication abortion, the doctor performing the procedure is required to schedule a follow up visit within 7-14 days and “make all reasonable efforts to ensure that the woman returns” for the scheduled visit. This means that the law requires a third in-person visit to the prescribing physician, rather than permitting the pregnant person to seek medical care in the rare circumstance that they encounter complications, or to follow-up with their local physician or emergency room. 

Like all abortion bans, SB20 purports to contain certain exceptions. But again, a closer look is warranted. The law permits abortions in cases of rape or incest until the twentieth week of pregnancy, and in cases of “life-limiting” fetal anomalies until twenty-four weeks gestational age. The law also includes a provision permitting abortions in cases of medical emergency. It imposes penalties including loss of professional licensure, civil lawsuits and potential criminal prosecution on physicians who are found in violation of the law. This means that doctors and hospitals are necessarily forced into risk-averse positions, to the detriment of patient care. This patient harm has been documented time and time again since the overturning of Roe.  Turning to North Carolina’s exception for medical emergencies, the language is drawn in highly subjective and non-medical terms. Specifically, the law defines a medical emergency as a condition which, “in reasonable medical judgment, so complicates the medical condition of the pregnant woman as to necessitate the immediate abortion of her pregnancy to avert her death or for which a delay will create series risk of substantial and irreversible physical impairment of a major bodily function.” Functionally, this requires a patient to become “sick enough” before a doctor can feel secure in their decision to provide care–even if they know that the patient’s health is in inevitable jeopardy. Additionally, the exception expressly excludes “any psychological or emotional conditions” from its definition of medical emergency. This means that a patient who presents with immediate suicidality in the face of an unwanted pregnancy cannot invoke an exception for medical emergency. With respect to exceptions for life-limiting fetal anomalies, North Carolina requires “the diagnosis … of a physical or genetic condition that (i) is defined as a life-limiting disorder by current medical evidence and (ii) is uniformly diagnosable.” Its that second provision that is troubling, because even where a doctor’s training and judgment indicates the overwhelmingly likely outcome, it can still be difficult for doctors to be absolutely certain that a particular condition or set of conditions is “uniformly” fatal. This opens the physician up to the risk of another person questioning their professional judgment, with dire consequences attached. In short, these exceptions are inartfully drawn, making it difficult for both patients and providers to utilize them effectively. 

This is certainly not a comprehensive overview of everything contained within North Carolina’s new law, but SB20 does provide an informative case study on how seemingly facially moderate abortion restrictions may operate to severely restrict access. We encourage interested readers to look into the details of these laws and consider their practical implications. 

REPRODUCTIVE HEALTH DIGEST (5/12/23)

Developments in Abortion, Autonomy, and Access: 

Rapid legal developments in abortion, autonomy, and access to health care continue to change the landscape of the law on a weekly basis. As many states near the end of their legislative sessions and the dust settles, we will have a clearer picture of where access remains, where it has been eliminated entirely, and where it is limited or in the line of fire. These past two weeks have brought a slew of legislative changes or attempted changes, and the lawsuit challenging nationwide access to mifepristone continues before the Fifth Circuit Court of Appeals. Please read on for a summary of key developments:

Legal Changes at the State Level: 

  • Brief Overview

    • Idaho: Idaho’s “abortion trafficking” bill is officially operative law.

    • Nebraska: Nebraska continues to attempt to pass more restrictive abortion laws, rushing to pass a 12-week ban mere weeks after a 6-week ban failed.

    • South Carolina: South Carolina once again rushed to advance a 6-week abortion ban prior to the close of the state legislative session on May 11, after several failed attempts at passing restrictive legislation. Their legislative session will reconvene for overtime.

    • North Carolina: North Carolina’s legislature is advancing its attempt to pass SB20, a 12-week abortion ban. Although the governor has vowed to veto the law, republicans hold a veto-proof majority.

    • Tennessee: Tennessee’s amended abortion law has been signed into law.

    • Louisiana: Louisiana has rejected legislation that would have added exceptions for victims of rape or incest, despite testimony from rape victims in favor of the legislation.

    • Vermont, Minnesota, Oregon, and Washington have all passed or are working to pass protective legislation for abortion rights, gender-affirming care, or both.

Deeper Legal Analysis 

  • Idaho:

    • Idaho’s “abortion trafficking” bill, passed in April and discussed in the last digest, went into effect last Friday, making it criminal “trafficking” to assist a minor in obtaining an out-of-state abortion without their parent’s consent. This is the first law of its kind, but it is unlikely to be the last, and it exemplifies the role that the right to interstate travel will play in a post-Roe world.  Although Idaho’s is the only law to use trafficking language thus far, other states are similarly attempting to extend their influence beyond their own state borders, an effort that pro-choice states have met with attempts to pass shield laws that protect providers and patients from out-of-state investigations. As U.C. Davis legal historian Mary Ziegler put it “if red states pass laws saying, ‘We can go after people for X, Y and Z,’ and blue states say “you can’t,’ we’re in uncharted territory. These interjurisdictional conflicts will be something to watch in the coming months and years.

    • If you are curious about how the effects of restrictions like these play out, take a few moments to listen to two women describe their inability to access necessary medical care after being diagnosed with life-threatening conditions during their pregnancies. Even in states, like Florida, where the existing abortion bans carve out exceptions for lethal fetal anomalies and to save the life of the mother, physicians are forced to grapple with legal uncertainty in their provision of care. 

  • Nebraska:

    • Nebraska continues its attempts to further restrict abortion access, as a new legislative effort that would restrict abortion to the first 12 weeks of pregnancy was introduced late Monday. This latest attempt comes less than two weeks after a 6-week abortion ban failed to overcome a filibuster by a single vote. Advocates hoped that after the 6-week ban failed to pass into law, the question of abortion access in Nebraska would be settled for this legislative session; however, that may not be the case. The latest anti-abortion attempt has been added as an amendment to a bill calling for a ban on gender-affirming care for youth in the state. The newly proposed law includes exceptions for rape, incest, or medical emergencies.

  • South Carolina:

    • In South Carolina, legislators once again rushedto advance a 6-week abortion ban prior to the close of the state legislative session on May 11; however, their Governor has signaled his intent to call legislators back for an overtime session. This move comes about a week after another attempt to pass a near total ban failed, thanks in large part to the filibuster efforts of the so-called “sister senators,” a group of 5 female legislators made up of 3 republicans, a Democrat, and an independent.  That failed bill would have banned abortion at conception, with only narrow exceptions for rape or incest in the first trimester, fatal fetal anomalies that were confirmed by two physicians, and abortions necessary to preserve the pregnant person’s life or health. One of the “sister senators,” Republican Penry Gustafson stated that she participated in the filibuster despite her “pro-life” beliefs, because the proposed bills left “no room for empathy, reality or graciousness.” A previous, but very similar, 6-week ban was ruled unconstitutional by the state Supreme Court earlier this year on privacy grounds. 

  • North Carolina:

    • North Carolina continues to make progress in attempting to pass SB20, a 12-week abortion ban. Governor Roy Cooper has vowed to veto the law; however, North Carolina Republicans currently hold a veto-proof majority. North Carolina needs only one Republican lawmaker to flip their vote in order to block the bill from passing into law, and advocates hope to use the coming days to persuade legislators to do so. North Carolina currently permits abortion until 20 weeks gestational age, and has become a bastion of access in the South, where many neighboring states have passed highly restrictive laws and bans. Abortion in North Carolina has increased more than any other state since the fall of Roe, reflecting the many patients who have flocked to the state to receive care; the passage of this bill would devastate that access point. 

  • Tennessee:

    • Tennessee’s law, as discussed in the last edition of this digest, has now been signed into law by the governor. The new law replaces the prior affirmative defense language with exception language, a move that facially loosens the abortion ban without functionally increasing access to care.

  • Alliance for Hippocratic Medicine v. FDA: 

    • In our last digest, we discussed the federal challenge to the FDA’s approval of mifepristone, one of two medication abortion drugs. At this time, briefing has been submitted to the Fifth Circuit Court of Appeals by both parties, and oral arguments are set for May 17. The Fifth Circuit will determine whether Judge Matthew Kascmaryk erred in ordering a stay of the FDA’s 2000 approval of the drug for medication abortions.

      • Additionally, in a bid to preserve access to the abortion pill, another lawsuit has been filed by abortion providers in Kansas, Virginia, and Montana, seeking to preserve the status quo of mifepristone availability. This new lawsuit seeks similar relief to that ordered in the Washington state decision.

  • Vermont, Minnesota, Oregon, and Washington pass protective legislation:

    • Blue states continue to try and pass protective legislation aimed at safeguarding out-of-state patients and their providers from the reach of states that restrict access.

    • Washington has adopted the “My Health, My Data Act”, a  “first of its kind” data privacy law that safeguards consumer health data and location data held by sources like telehealth platforms and period-tracking apps.

    • Minnesota Governor Tim Walz signed three bills into law last Thursday. Together, these bills aim to protect abortion access, ban conversion therapy and preserve access to gender-affirming care for transgender youth. These laws go into effect immediately.

    • Vermont, a strong support state for reproductive and LGBTQ+ rights, signed new “shield laws” protecting Vermont doctors from out-of-state investigations and professional discipline for providing reproductive and gender-affirming care. H.89 shields doctors in cases where an out-of-state investigator seeks to prosecute a patient who received care in Vermont. The Senate’s companion bill, S.37 protects medical licenses for Vermont doctors and guards against medical malpractice insurance rate hikes for providers. Unfortunately, Vermont “can only shield doctors and patients so long as they remain in state lines.”

    • Oregon lawmakers continue to advance measures aimed at protecting providers and patients giving or receiving reproductive or gender-affirming health care.

What else is happening in access? 

  • First, a new poll reaffirms that an easy majority of Americans support the right to abortion, including in states where their own legislatures attempt to ban it.

  • In Michigan, SB 147 has passed both chambers of the legislature; this bill would ban employment discrimination on the basis of having had an abortion, a relatively novel strategy to protect abortion rights.

  • A panel of FDA advisers has recommended approving an over-the-counter birth control, which would increase ease of access to contraceptive care.

  • Pro-choice Floridians are mobilizing to get a measure that would protect abortion on the 2024 Florida ballot; the groups aim to protect abortion until the point of viability.

  • Two hospitals, one in Kansas and one in Missouri, are under federal investigation for failing to provide emergency life-saving care to a pregnant woman who required an abortion. This comes as a strong reminder that, regardless of state law,  providers are obligated under the Emergency Medical Treatment and Labor Act (EMTALA) to provide care to any patient in an emergency situation.

  • A recent Texas case illustrates how restrictive abortion laws exacerbate harms to victims of domestic violence and coercive abuse.

Issue of the Week: Abortion Exceptions and Why They Don’t Work 

It is an obvious proposition that parents possess certain rights, responsibilities, and obligations with respect to the care of their children. However, in the context of reproductive rights and gender-affirming care (among other issues), parental rights are all too often used as a sword rather than a shield. 

The majority of states require at least some level of parental notification or consent prior to a minor obtaining an abortion, with some states requiring the involvement or consent of both parents. Although most minors do consult with their parents about an unintended pregnancy, notification and consent laws that mandate parental involvement remove decision-making power from the hands of the most impacted party: the pregnant person. These laws force pregnant minors who cannot safely obtain consent to face what can be a terrifying situation alone and to overcome unnecessary barriers to safe medical care. Although judicial bypass procedures, procedures by which the minor can petition the court for the right to have an abortion, exist for circumstances where a minor cannot notify their parents safely or obtain consent, these processes can be difficult to navigate and are subject to the whims of the courts. For example, one Florida judge denied a pregnant minor an abortion based on her grade point average. And regardless, judicial bypass procedures still involve an external person in the private and medical decision about whether to carry a pregnancy to term, diminishing the minor’s agency over their own life-altering choices. Certainly, the ideal circumstance is one in which a minor experiencing an unintended pregnancy is able to obtain information and support from a compassionate parent or guardian, but this is not the reality for many households. Our laws need to engage with this reality. Although parents have responsibilities over their children, minors have rights over their own bodies. Indeed, this value is emphatically enshrined in norms of international law. 

Parental rights are also asserted by Republican lawmakers in other legislative contexts, including those implicating lbgtq+ rights. For example, in what has come to be known as a “don’t say gay” bill, Florida attempts to restrict conversations about gender identity or sexual orientation in the classroom. Advocates for the bill say it is about parental rights over their child’s education, but detractors argue that it is about discrimination and state-sponsored censorship targeting particular groups of people. Other states attempt to pass “forced outing” bills in the name of parental rights, requiring parental notification if a child expresses doubt about their sexual or gender identity. Of course, these arguments about parental rights conveniently disregard a parent’s right to support their child’s gender identity and altogether ignore governmental efforts to penalize parents who do so. Again, in an ideal scenario, all children would be able to safely discuss their experiences with their identity and orientation with a supportive guardian, but we know that this is not reality. A political agenda that pushes an inaccurate narrative of “parental rights” over the reality of the safety and well-being of children is something worth guarding against.

REPRODUCTIVE HEALTH DIGEST (4/27/23)

Developments in Abortion, Autonomy, and Access: 

The past several weeks have brought an onslaught of rapid changes to abortion and bodily autonomy law at the state and, with the addition of the federal case challenging medication abortion, federal levels. Anti-choice legislators have been aggressively proposing, enacting and amending abortion restrictions, while other states attempt to mitigate this harm and carve out protections for providers and patients. Meanwhile, the future of access to medication abortion is uncertain, as parties litigate the FDA's approval of mifepristone before the Fifth Circuit Court of Appeals. Although not an exhaustive overview, read on for a summary of some of the actions to watch: 

Legal Changes at the State Level: 

  • Brief Overview

    • On April 13, Florida passed a 6 week abortion ban, which will take effect once the state Supreme Court rules on the currently challenged (but operative) 15 week ban. 

    • On April 25, North Dakota’s governor signed into law a ban on abortion throughout the entire pregnancy, with very limited exceptions for the life or health of the mother and for cases of rape, incest or medical emergency up until 6 weeks gestational age, reasserting its determination to be a staunchly anti-abortion state. 

    • On April 4, Idaho’s governor signed into law a statute that amends the language of its abortion ban, creating exceptions for rape or incest and life of the pregnant person, but restricting its rape or incest exception to first trimester procedures. 

    • Throughout March and April, Colorado and New Mexico have passed protective legislation aimed at shielding providers and patients from out-of-state prosecution and investigation. 

    • On April 18, HB0883 was transmitted to the governor’s desk. Tennessee’s new law that would amend its abortion ban to include exceptions (rather than affirmative defenses) for the life of the pregnant person has made its way to the governor’s desk. 

    • At the federal level, The Supreme Court ruled last week in Alliance for Hippocratic Medicine v. FDA that mifepristone will remain available pending resolution of the appeal at the Fifth Circuit Court of Appeals and a subsequent petition to the Supreme Court, if one is sought. Mifepristone is one of two drugs used in a standard medication abortion regime; the plaintiffs in this case seek to reverse the FDA’s 2000 approval of the drug. 

Deeper Legal Analysis 

  • Florida

    • On April 13, 2023, Florida Governor Ron DeSantis signed SB 300; this law further restricts abortion access in Florida from 15 weeks to 6 weeks, a restriction that the majority of Floridians do not support. 6-week bans prohibit abortion at a gestational point before most people know they are pregnant, and as we have seen play out in other states like Texas, they functionally operate as complete bans. Because of an ongoing legal challenge to the state’s operative 15-week ban, the new 6-week restriction will go into effect 30 afters after the Florida Supreme Court rules on that challenge. 

  • If you are curious about how the effects of restrictions like these play out, take a few moments to listen to two women describe their inability to access necessary medical care after being diagnosed with life-threatening conditions during their pregnancies. Even in states, like Florida, where the existing abortion bans carve out exceptions for lethal fetal anomalies and to save the life of the mother, physicians are forced to grapple with legal uncertainty in their provision of care. 

  • North Dakota: 

    • In North Dakota, lawmakers have passed another total abortion ban, which would criminalize abortions with limited exceptions for the life or health of the pregnant person and for cases of rape or incest, if the abortion occurs within the first 6 weeks of pregnancy. The bill passed the state house and senate with veto-proof majorities and was signed into law by the governor on April 25. This new legislation comes a month after North Dakota’s Supreme Court declared the state’s trigger ban unconstitutional; the North Dakota House Majority Leader explained that they passed this new to “send another message to the North Dakota Supreme Court,” that “[t]his is what the Legislature wants[;] we want pro-life in North Dakota.”

  • Idaho:

    • As you may recall, Idaho’s Supreme Court determined in January that the state constitution did not include a right to abortion. Since then, the Idaho Legislature has been aggressive in its anti-abortion agenda. In early April, Idaho became the first state to enact a law targeting interstate travel to access abortion care. HB 242 criminalizes so-called “abortion trafficking”, which the statute defines as recruiting, harboring or transporting a pregnant minor within Idaho without parental consent; the pregnant person’s consent to the travel and procedure is not a defense to the law. 

    • Also in April, Idaho passed HB 374, which amended the language of its criminal abortion statute; this amendment will take effect on July 1, 2023. It replaces the current affirmative defense language for circumstances of rape or incest, or where the pregnant person’s life is at risk with exception language. The bill also amended the rape or incest exception to clarify that it only applies to procedures performed during the first trimester. 

    • Idaho has recently had to contend with its physicians leaving the state, or considering leaving the state. And one hospital closed the doors to its obstetrics ward, citing in part the fact that the “the Idaho Legislature continues to introduce and pass bills that criminalize physicians for medical care nationally recognized as the standard of care.” 

  • Colorado & New Mexico:

    • Colorado and New Mexico both recently passed protective legislation, aimed at shielding providers and patients from anti-abortion attacks from both in and out of state. 

      • On April 5, 2023, New Mexico passed SB13, the Reproductive and Gender-Affirming Health Care Protection Act, which prohibits state entities from cooperating with out-of-state criminal and civil investigations of patients and providers. Last month, New Mexico passed HB 7, the Gender-Affirming Health Care Freedom Act, which prohibits any public body from imposing laws, ordinances, policies or regulations that prevent patients from receiving reproductive or gender-affirming care. 

        • This legislation comes at a time when certain New Mexico cities are attempting to pass and defend local abortion bans, arguing that the mailing of materials used for abortion is in violation of federal law. 

      • Colorado passed similar protective legislation in Mid-April. Abortion providers in Colorado are now partially protected by both executive order and by statute. In 2022, Colorado’s governor signed an Executive Order aimed at protecting providers engaged in lawful acts under CO state law from facing liability or disciplinary action connected to out-of-state investigations. This past week, the governor passed additional protective laws. Mostly notably, SB 23-188, which lays out non-interference mandates for government officials. Under this law, Colorado won't comply with wiretapping and extradition requests from other states related to abortion or gender affirming care; the state will not issue subpoenas, summons or search warrants related to the same; and, state courts won't consider civil actions brought by individuals.

  • Tennessee: 

    • We have heard a lot about Tennessee in the past few months, as their abortion ban is arguably the most extreme in the nation. Earlier this week, a bill made it to the governor’s desk which would allow narrow exceptions to the state’s abortion ban by replacing the currently existing affirmative defenses with exception language.  The governor can sign the bill, veto it, or let it sit for 10 days without action, at which point it will become law. 

  • Alliance for Hippocratic Medicine v. FDA 

    • Alliance for Hippocratic Medicine v. FDA is the case everyone has been watching and talking about, as it threatens to restrict access to the medication abortion drug mifepristone nationwide. This case was initiated by a group of anti-abortion physicians and physician groups who sued the FDA, arguing that its 2000 approval of mifepristone, one of two drugs used in a standard medication abortion regimen, was improper. The case also challenges the easing of certain restrictions on the administration of mifepristone that took effect in 2016 and 2021, including lifting the requirement of an in-person visit during the Covid-19 pandemic, and increasing the window of use from 49 days gestational age to 70 days. Kaiser Family Foundation created an excellent explainer on the initial case, available here: https://www.kff.org/womens-health-policy/issue-brief/legal-challenges-to-the-fda-approval-of-medication-abortion-pills/

    • Procedural Recap: 

      • On April 7, conservative Judge Matthew Kascmaryk  granted the Plaintiffs’ motion for preliminary injunction and ordered the FDA to halt its approval of mifepristone as well as its subsequent easing of restrictions, including the lifting of the in-person requirement for administration of the drug In his order, he granted the government 7 days to appeal that decision to the Fifth Circuit. 

        • Shortly after Judge Kascmaryk issued his ruling, a federal court out of Washington state issued a conflicting ruling, ordering the FDA to maintain the status quo of mifepristone in the 17 states and District of Columbia involved in that case. 

      • On April 13, The Fifth circuit reversed course on the 2000 preliminary injunction, finding that the plaintiffs’ challenge was past the statute of limitations, but it upheld the district court’s findings as to the 2016 and 2021 revisions to the drug’s regulations, and it approved and adopted some of the most troubling aspects of Judge Kascmaryk’s legal reasoning. 

      • Following the Fifth Circuit’s ruling, the government sought an emergency stay from the Supreme Court–meaning that they are asking SCOTUS to rule that mifepristone must continue to be available while the parties litigate the merits of the case. After initially granting a temporary stay, the Supreme Court ruled on April 21 that the lower courts’ ruling is stayed “pending the disposition of the appeal in the United States Court of Appeals for the Fifth Circuit and disposition of a writ of certiorari” to the Supreme Court, if one is sought. 

  • The Current Takeaway: at this moment, the FDA’s approval of mifepristone stands and the legality of distributing the drug will remain in place while the parties litigate before the lower courts. At this time, the Fifth Circuit Court of Appeals is set to receive briefing and hear oral arguments in May; depending on how that court rules, the case could end up back in front of the Supreme Court or it could go back down to the District Court for full litigation. 

What else is happening in access? 

  • The Texas House has advanced HB9000, a law that restricts access to books in schools. During debate on Wednesday, State Rep Ron Reynolds, explained that book bans have a long history of being applied in a discriminatory manner, with targeted titles centering on LBGTQ issues, protagonists of color and teen pregnancy.  

  • Iowa’s republican Attorney General suspended coverage of emergency contraception for rape victims. 

  • The abortion clinic in West Virginia that was challenging the state’s abortion ban has voluntarily dropped its suit, citing its inability to continue providing abortion care in the state at this time. 

  • Missouri has passed a gender affirming care ban that affects adults as well as minors, making it the most extreme in the nation. 

    • As we all know, the fight for bodily autonomy in gender affirming care and the fight for abortion rights are inextricably intertwined. Both of these movements center the right to make healthcare decisions in consultation with your doctor and family, without the state inviting itself into the room.  For a detailed look at these laws, see Lawyers for Good Government’s Trans Health Report.

  • The ongoing threat to Mifepristone could “spur increased activism and lobbying from organizations opposed to other drugs or medical treatments, such as COVID-19 vaccines, contraceptives, hormones for artificial reproductive technology or gender affirming procedures, and HIV prevention drugs.

Issue of the Week: Abortion Exceptions and Why They Don’t Work 

This week’s newsletter contains a few legal hits relating to states like Tennessee seemingly loosening their abortion bans by adding in or amending exceptions. While this may look like progress, it is worth taking a moment to discuss why these exceptions may be politically expedient for legislators who hope to appear more moderate, but are ultimately unworkable. At the outset, these exceptions largely use vague non-medical language, like “life or health of the mother.” This language is open to interpretation and reasonable medical minds can differ. Where there is ambiguous language combined with severe criminal and civil penalties for violations of the law, physicians are forced to take risk averse positions rather than provide medically standard care. States that require the pregnant person’s life or health to be in imminent danger before action can be taken have created a framework where, by the letter of the law, the doctors must wait until the pregnant person is sick enough to require emergency care before they can feel safe intervening–even if they are medically certain that the pregnancy is no longer viable. For example, in Texas 5 women are suing the state for circumstances just like that. One of those women, Amanda Zurawski, was diagnosed with a condition that guaranteed that she would lose her very wanted pregnancy. However, because the fetus still had a heartbeat, and she was not yet in life-threatening danger, she was denied care until she developed sepsis and nearly lost her life. The bottom line is this: life and health exceptions inappropriately insert the state’s judgment into medical decisionmaking and both providers and patients are forced to bear the consequences. 

With respect to exceptions for rape or incest, the few ban states that have these exceptions often require the victim to report the violation to law enforcement in order for the exception to apply. However, we know from decades of data that the majority of victims will not or cannot report the assault. This is especially true when we consider minors who are victimized by members of their own family or family friends; they are forced into an untenable and potentially unsafe situation in order to access abortion. 

Finally, it is worth considering how conversations focusing on exceptions shift the conversation away from the very real harms that abortion bans cause for individuals who do not fit within any exception but still require and deserve safe healthcare. Certainly, stories of pregnant people in emergency circumstances or those who have faced assault highlight the cruelty of these laws. However, all abortion is a deeply personal choice, and it is crucial that our advocacy views all reproductive care as equally valid and worthy, regardless of the circumstances that necessitate it.