REPRODUCTIVE HEALTH DIGEST (1/19/24)

Developments in Abortion, Autonomy, and Access: 

Welcome back and Happy New Year! We thank you for your patience while we were closed over the holidays. The break gave us all at L4GG a much-needed chance to rest and restore before hitting the ground running in 2024. As you know all too well if you read this newsletter, 2023 was a critical and devastating year for bodily autonomy. As this new year begins, we are keeping a close eye on bills coming out of state legislative sessions, ballot initiatives that will go before voters this year, ongoing litigation, and–of course–the reproductive rights politics surrounding the 2024 presidential election. We are starting this year ready and energized to fight back against anti-choice attacks and misinformation and to support the right for everyone to be safe and free in their body. 


To stay up to date on reproductive health policy during this crucial year, please consider registering for our Policy Resource Hub for Reproductive Health, available at L4GG.org/Repro. The Hub contains our state abortion law research database, which is updated daily and explains the state of abortion law in every single U.S. state and territory. The Hub also includes our constantly growing media bank of thousands of searchable reproductive health-related articles, and the archive of every issue of the Repro Health Digest. We look forward to seeing you there!

Legal Changes at the State Level: 

  • Brief Overview: 

    • EMTALA in Idaho and Texas:  Federal courts out of Idaho and Texas have come to differing conclusions about whether the Emergency Medical Treatment and Labor Act’s stabilizing care requirement preempts state abortion bans. The U.S. Supreme Court will consider the Idaho-based challenge in April. 

    • Kentucky: In our last digest, we reported on a lawsuit brought directly by a Kentucky woman challenging the State’s abortion ban. However, in late December, lawyers for the plaintiff voluntarily dropped the lawsuit after the fetus lost cardiac activity. Lawyers for the ACLU and Planned Parenthood are now seeking other potential plaintiffs to challenge the State’s ban. Historically, cases challenging abortion restrictions were brought by providers and clinics rather than the patients themselves; however, post-Dobbs, state courts, and anti-abortion activists have argued that these parties do not have standing to challenge the laws. Cases brought directly by pregnant people avoid this potential roadblock. 

    • Ohio Update:  As we have reported on extensively in this Digest, last year Ohio passed Issue 1, enshrining “pre-viability” abortion rights into the State’s Constitution. Although Issue 1 officially took effect on December 7th of last year, contradictory laws remain on the books, including the state’s fetal heartbeat ban. However, late last year, the State’s Supreme Court dismissed the State’s attempt to enforce the near-total ban, citing a change in the law. The case now goes back down to a lower court for further litigation. 

    • North Carolina: In North Carolina, advocates presented arguments challenging the state’s restrictions on the use and distribution of mifepristone, which exceed the FDA’s more permissive regulations of the drug. 

    • Alliance for Hippocratic Medicine v. FDA Update: Judge Matthew Kascmaryk has granted Kansas, Idaho, and Missouri’s motions to intervene in the case challenging the FDA’s approval of mifepristone. Their inclusion threatens to complicate the argument that the current plaintiffs lack standing. 

    • Idaho: The injunction blocking enforcement of Idaho’s abortion trafficking law has been upheld for the time being. In an earlier decision enjoining the law, Judge Debora K. Grasham articulated that “abortion trafficking is not a thing,” because the procedure remains legal in other states. She further explained that while Idaho is free to criminalize abortion and human trafficking, it cannot “craft a statute muzzling the speech and expressive activities of a particular viewpoint with which the state disagrees under the guise of parental rights.” Arguments surrounding interstate travel for abortion are a unique feature of the post-Dobbs legal landscape, and we will be closely tracking their development as they wind their way through the courts this year.

    • Ohio and Brittany Watts: Ohio woman Brittany Watts will not be indicted on charges related to her miscarriage. Although this is the obvious correct outcome of her case, the fact that the case was brought at all sounds alarm bells about increased surveillance and the criminalization of pregnancy outcomes. 

  • Legal Analysis: 

  • Idaho, Texas, and EMTALA: 

    • Litigation about states’ obligations to provide stabilizing abortions when necessary under the federal Emergency Medical Treatment and Labor Act (EMTALA) will reach the U.S. Supreme Court

    • After the 2022 Dobbs decision overturned Roe v. Wade, states including Texas and Idaho swiftly enacted total or near-total abortion bans, with extremely narrow exceptions to save the life or health of the pregnant person. In response, the Biden Administration issued guidance explaining that EMTALA’s requirement that hospitals receiving medicare funds provide stabilizing care to any emergency patient preempts state abortion bans. In other words, if the treating providers determine that an abortion is what is needed to stabilize a patient, EMTALA requires them to provide that care even in ban states. Both Idaho and Texas challenged this guidance. 

    • In Idaho, a lower court issued an injunction against the state’s abortion ban, insulating emergency room providers from legal risk in cases where they perform an abortion to save a patient’s life. However, in early January, the Supreme Court issued a ruling rolling back that injunction and allowing the law to take full effect while litigation plays out. The Justices indicated that they will hear oral arguments on the matter in April of this year. 

    • In a nearly identical case out of Texas, the Fifth Circuit Court of Appeals sided with the State, finding that EMTALA cannot be enforced over state abortion bans, even in emergency cases. Rabia Muqaddam, an attorney with the Center for Reproductive Rights, explained that the Fifth Circuit’s interpretation was a “radical narrowing” of the law and essentially means that everyone in an emergency room is entitled to stabilizing care “unless they happen to be a pregnant person who needs an emergency abortion to be stabilized.” Under norms of statutory construction, a federal statute almost always takes precedence over a conflicting state statute; however, the courts appear willing to turn established precedent on its head if it means removing protections for pregnant people. Although the Fifth Circuit’s ruling largely narrows EMTALA’s scope, it seems to expand the law in one striking way–the Court’s Opinion takes the position that EMTALA’s requirements apply with equal strength to both the pregnant person and the fetus, stating that “EMTALA imposes obligations on physicians with respect to both the pregnant woman and her unborn child . . . [t]his is a dual requirement.” This suggested expansion of EMTALA obligations jeopardizes emergency medical care for pregnant people and places providers in an even more untenable position. 

    • It is important to note that, for now, EMTALA protections remain in place in all other states, as the courts’ rulings are currently limited to Idaho and Texas. However, with the Supreme Court set to consider Idaho’s appeal in April, that could change before the year is up.

  • North Carolina:

    • Advocates in North Carolina presented arguments this week in a lawsuit challenging the State’s restrictions on medication abortion. These restrictions exceed the FDA’s own regulations on the drug and have drawn criticism for going beyond what is medically necessary to ensure safety. ​​FDA regulations currently allow mifepristone to be prescribed up to 70 days (10 weeks) of pregnancy, and permit it to be distributed via telehealth without a mandatory waiting period. In contrast, North Carolina requires patients to first have a consultation and then wait 72 hours prior to having the drug administered in person in specified facilities. In some cases, the State also mandates an ultrasound prior to prescribing the medication. 

    • The plaintiffs in the case argue that these requirements create medically unnecessary burdens to care and conflict with clear FDA guidance, which specifically considered and rejected the idea that mifepristone must be distributed in person. The Defendants argued in response that the FDA’s regulations are a ‘floor’ and that states are free to build off on them with their own additional restrictions. This North Carolina case occurs against the backdrop of a looming Supreme Court determination about the propriety of the FDA’s approval of mifepristone, as well as ongoing arguments about how to reconcile state and federal law with respect to abortion. Depending on how the Supreme Court rules in these cases, we could see a significant shift in the legal landscape surrounding the regulation of medicine.

  • Alliance for Hippocratic Medicine v. FDA: 

    • Judge Matthew Kascmaryk, the Trump-appointed Texas judge who drew criticism for his anti-abortion rulings in Alliance for Hippocratic Medicine v. FDA has granted 3 states’ motions to intervene in the lawsuit. Republican-led Idaho, Missouri, and Kansas successfully argued that they are appropriate parties to the case because their states’ interests are purportedly affected by the FDA’s approval of mifepristone. Their addition complicates a key argument in the ongoing litigation: that the provider and provider groups who brought the lawsuit do not have standing to challenge the FDA’s regulations. With the intervention of these states, even if the Supreme Court agrees that the original plaintiffs lack standing, the states could attempt to keep the case alive based on their own independent allegations. 

    • Medication abortion accounts for more than half of all abortions in the U.S., and with many states severely limiting or outright banning abortion, telemedicine has become increasingly critical post-Dobbs. Clinics, advocates, and individuals are all bracing for a Supreme Court ruling limiting access to medication abortion, and exploring options for how to mitigate the harm that will inevitably follow. Providers are preparing to switch to a misoprostol-only regimen, in lieu of the current two-medication process. And advance orders of mifepristone are likely to surge in the coming months, as they have previously when access in a particular state or region has been imminently threatened.

  • Ohio and Brittany Watts:

    • Although we typically use this section of the Digest to analyze changes to state law, Brittany Watts’ story deserves to be told, and its implications for reproductive justice and pregnancy criminalization are critical to discuss and understand. Brittany Watts is a 34-year-old Ohio woman who faced felony criminal charges for her handling of a miscarriage that occurred in the bathroom of her own home. Last week, a grand jury declined to indict Ms. Watts, and while that is absolutely the correct result, the reality is that this should have never happened in the first place. 

    • Last September, Ms. Watts, who was nearly 22 weeks pregnant at the time, was admitted to the hospital for vaginal bleeding. Her doctors determined that her water had broken prematurely and that her pregnancy was unfortunately no longer viable. Ultimately, Ms. Watts miscarried at home in her bathroom. She then went to the hospital where she had a D&C procedure to remove the remaining placental tissue. During this hospital visit, a nurse called the local police department. 

    • Police responding to that call went to Ms. Watts’ home and retrieved the fetal remains from the toilet. An autopsy confirmed what Ms. Watts and her doctors already knew: that the fetus had died in utero following a premature rupture of the membranes. Regardless, in October, Ms. Watts was charged with the felony of “abuse of a corpse.” In supporting the charges, prosecutors argued that the issue wasn’t “how the child died, when the child died” but “the fact that the baby was put into a toilet, was large enough to clog up the toilet, left in the toilet, and she went on [with] her day.” This argument demonstrates a stunning lack of understanding and empathy about the heartbreakingly common experience of miscarriage. And the charge itself raises important legal questions about fetal personhood. Generally, common law does not consider a fetus a human being for purposes of abuse of a corpse until after birth. Expanding the scope of that law to circumstances of miscarriage would create a near-limitless increase in the potential for the criminalization of pregnancy outcomes.

    • The grand jury’s determination that Ms. Watts should not be indicted is the obvious and just conclusion. But, the fact that these charges were brought at all is chilling. Pregnant people miscarry alone in their homes every day. They should not have to fear that their miscarriage might lead to accusations of criminal conduct or that a visit to their doctor for post-miscarriage care could lead to a call to law enforcement. The criminalization of pregnancy outcomes is very real and all too common. As Ms. Watts’ home state amends its constitution to protect access to abortion, stories like hers are a reminder that the fight for reproductive justice affects all aspects of reproductive care and equity–and that it is far from over.

More News in Access: 

  • As we consider how to vote in 2024, please take a moment to read this piece from Rolling Stone about the official Republican plan to restrict access to abortion, and contraception and to increase surveillance of pregnant people and pregnancy outcomes.

  • A Virginia legislator has introduced a bill that, if passed, would ban abortion entirely with a narrow exception to save the life of the pregnant person. Thanks to last year’s elections, democrats control both houses of the state legislature, so the bill is unlikely to pass into law. 

  • A coalition of Missouri abortion rights groups has finalized language for a proposed ballot measure to protect reproductive rights in the state. The measure would protect the right to abortion up until “fetal viability,” with exceptions for the life or health of the pregnant person throughout pregnancy. 

  • Amarillo may be the next Texas city to ban so-called “abortion trafficking,” following the lead of several other cities and localities. This tactic of restricting travel is one of the latest anti-choice strategies aimed at stopping pregnant people from traveling out of ban states to access care. 

  • In Indiana, a new report shows that only 17 pregnant people have been able to obtain an abortion in the state since its total abortion ban went into effect last August. This number clearly demonstrates a fact that we talk about a great deal in this newsletter: abortion exceptions do not actually increase access to care. 

  • The 11th Circuit Court of Appeals allowed Alabama’s ban on gender-affirming care to take effect during the pendency of litigation. 

  • A Seattle lawsuit alleges that the Texas Attorney General requested medical records for minors from Texas who received gender-affirming care. 

  • In the first post-Dobbs presidential election year, how reproductive rights affect voters' choices in the ballot box is top of mind, and research shows that many Republicans support access to abortion even while they support anti-choice candidates.  

  • The U.S. Supreme Court has declined to hear a case about whether a school district can force trans students to use the restroom that corresponds with their sex assigned at birth. 

  • Arizona abortion advocates are facing pushback on their proposed ballot initiative from a campaign called “It Goes Too Far.”  

  • Ohio Governor Mike DeWine vetoed the state legislature’s passage of a gender-affirming care ban for minors. However, shortly after the veto, he signed an Executive Order heavily restricting access to certain types of gender-affirming care. And, the Ohio House has now voted to override the Governor’s veto altogether. At this time, advocates are calling for the state legislature to uphold the veto. 

  • In Kentucky, a bill has been proposed that would allow pregnant people to collect child support during pregnancy. Although at first glance this may seem like a move to support parents, laws that define a fetus as having the same rights as a born child are a dangerous tactic employed by anti-choice activists wishing to slowly change the legal landscape. We will be watching for these kinds of bills as states return to their legislative sessions this year. 

  • Florida advocates have officially collected enough signatures for their ballot initiative to go before voters. 

  • The Iowa Board of Medicine is considering changes to proposed rules about how to implement the state’s abortion restrictions. We previously reported on how the original draft of the proposed rules would undermine the practice of medicine and the doctor-patient relationship. 

  • This piece from the New Yorker takes a look at how one young woman may have lost her life as a result of Texas’s restrictive abortion laws and the chilling effect that they have on healthcare providers. We must remember her story as we continue the fight for everyone’s right to autonomy over their own body. 

REPRODUCTIVE HEALTH DIGEST (12/15/2023)

Developments in Abortion, Autonomy, and Access: 

A great deal has happened in reproductive health law in the past two weeks. Several state supreme courts heard abortion-related oral arguments, the Texas Supreme Court overturned a lower court's ruling that permitted a pregnant woman facing a lethal fetal diagnosis and severe complications to obtain an abortion, and new abortion rights lawsuits have been filed. At the federal level, the U.S. Supreme Court has agreed to hear the case brought by the Alliance for Hippocratic Medicine challenging regulations on mifepristone for medication abortion. Please read on for more details.

Legal Changes at the State Level: 

  • Brief Overview: 

  • Texas: Just days after the Texas Supreme Court heard oral arguments about the scope of the state’s abortion ban, a Dallas woman brought a lawsuit requesting an emergency order allowing her to obtain an abortion in light of a grave fetal diagnosis and increased risk to her own health and future fertility. Although her request was briefly granted, the State appealed, and the Texas Supreme Court ultimately denied her request.

  • Ohio: Issue 1 went into effect on December 7th, adding constitutional protections for pre-viability abortion in the state. However, other contradictory laws have not been repealed, and at this time providers have indicated that they will continue to operate under the pre-Issue 1 law until those laws are removed from the books or a court issues an order finding them unconstitutional.

  • Kentucky: Planned Parenthood and the ACLU filed a new lawsuit on behalf of a pregnant Kentucky woman seeking an abortion. The lawsuit directly challenges the State’s abortion ban. After filing the lawsuit, the original plaintiff learned that her embryo no longer had detectable cardiac activity; however, the lawsuit will continue, and the attorneys are asking other potential plaintiffs to come forward and join the challenge.

  • Developments in Ongoing Litigation: A number of important abortion-related arguments have been heard in state courts across the country in the past two weeks, including in New Mexico, Wyoming, Arizona, and Indiana.

    • New Mexico: On Wednesday, December 12th, the New Mexico Supreme Court heard oral arguments about whether cities and counties can pass local abortion bans, despite abortion being legal in the State. Proponents of the local abortion bans rely on the Comstock Act, a long-dormant 1873 law that bans the mailing of materials used for abortions. During the arguments, the Justices did not indicate which way they will rule, but they did at times appear extremely skeptical of the argument that cities can limit abortion in direct defiance of established state law.

    • Wyoming: The Wyoming Supreme Court is weighing whether pro-life activists and lawmakers can join the ongoing lawsuit about whether abortion is protected health care under the State’s Constitution. 

    • Arizona: In Arizona, the State Supreme Court heard oral arguments on Tuesday about whether an 1864 total abortion ban can be enforced post-Dobbs. Currently, abortion is legal until 15 weeks in the state. The panel of judges appeared mixed; however, several of the judges seemed persuaded by the argument that the current legislature never intended to ban abortion outright in the state.

    • Indiana: An Indiana Court of Appeals heard oral arguments about whether the State’s total abortion ban violates the Indiana Religious Freedom Restoration Act (RFRA). The suit was brought on behalf of Indiana Jews for Choice and other individuals whose belief systems permit abortion outside of what state law allows. Using religious freedom to fight for abortion rights is a unique strategy that we saw employed shortly after Dobbs. Although the pro-life movement often falsely claims religion as its own, the reality is that many religions have diverse and permissive views about abortion and the spiritual conceptualization of when life begins. 

  • Mifepristone Update: The U.S. Supreme Court has agreed to hear the case challenging regulations on the abortion drug mifepristone. Access to the drug remains unchanged for the time being. 

Legal Analysis: 

  • Texas: 

    • Texas has been front and center in abortion news in the past few weeks, as the State argues over how to properly interpret exceptions to its total abortion ban. Mere days after the Texas Supreme Court heard oral arguments about the scope of the State’s ban in Zurawski v. Texas, 31-year-old Dallas woman Kate Cox brought a separate lawsuit requesting an emergency order allowing her to obtain an abortion. Ms. Cox petitioned for relief after learning that her fetus had Trisomy 18 and was unlikely to survive the pregnancy or live longer than a few moments outside of the womb. The complication with her pregnancy also significantly increased the risk to Ms. Cox’s own health and fertility, as alleged in the Complaint. Texas’s total abortion ban does not include an exception for cases of fatal fetal anomalies; instead, it only permits abortion to save the pregnant person’s life or prevent substantial impairment of a major bodily function. 

    • Initially, Ms. Cox’s request was granted by district court judge Maya Guerra Gamble, who issued a temporary restraining order protecting Ms. Cox, her husband, and her provider. However, Texas Attorney General Ken Paxton filed a Petition to stay the order. AG Paxton also sent a letter to several Texas Hospitals threatening prosecution for assisting in providing the procedure, despite the lower court order allowing it. The State Supreme Court granted Paxton’s request for a stay and ultimately denied Ms. Cox’s request for an order permitting an abortion. In its unanimous Order, the Court found that a “good faith belief” by Mrs. Cox’s doctor that the procedure was medically necessary was insufficient to invoke the exception to the State’s ban. The Court offered little guidance on when the exception would apply, but did state that “[s]ome difficulties in pregnancy…even serious ones, do not pose the heightened risks to the mother the exception encompasses.” The Court came to this conclusion despite Ms. Cox’s physician’s determination that her patient’s life, health and future fertility were all placed in jeopardy by continuing the pregnancy. While awaiting the ruling from the State Supreme Court, Ms. Cox was forced to leave the state to obtain the care she needed without further delay. 

    • As noted above, Ms. Cox’s legal battle unfolded within weeks of the State’s arguments in Zurawski v. Texas, the case challenging the scope of the State’s exception to its abortion ban. During the Zurawski hearing, the attorney for the State seemed to argue that in order to have standing to challenge the State’s abortion ban, a pregnant person in the midst of a health crisis could petition the court for emergency relief. That is exactly what Ms. Cox did, and instead of showing that the State’s abortion ban is workable, as Texas has steadfastly insisted, it made apparent that judicial involvement in medical decision-making harms patient care. By placing its own judgment over that of Ms. Cox’s doctor and the families’ own wishes, the State would have Ms. Cox continue to carry a doomed pregnancy and face potentially severe harm to her own health and her ability to have more children in the future. The cruelty cannot be overstated. 

  • Ohio:

    • As we have reported on extensively, Ohioans passed Issue 1 in November, enshrining “pre-viability” abortion rights in the State’s Constitution. Issue 1 officially took effect on December 7th. However, other contradictory laws, including the State’s attempt to ban abortion after detection of a fetal ‘heartbeat’, and the currently enforced 20-week abortion ban, have not been repealed. Although it seems that Ohio Republicans have backed off of some of their initial suggestions on how to block Issue 1’s effectiveness, including stripping the judiciary of jurisdiction to hear cases related to it, the fight is far from over.

    • Democratic leaders have introduced legislation to try and repeal contradictory and access-limiting legislation, including the fetal heartbeat ban. But, with a Republican-controlled legislature, it is more likely that advocates will have to go through the protracted process of having the courts evaluate each of the remaining laws and determine whether they are now void under Issue 1. At this time, despite the passage of Issue 1, providers have indicated that they will continue to operate under pre-Issue 1 law until the legislature repeals existing bans, or a court issues an order finding them unconstitutional. This means that for now access in Ohio remains functionally unchanged.

  • Kentucky: 

    • In Kentucky, Planned Parenthood and the ACLU have filed a new lawsuit on behalf of a pregnant Kentucky woman seeking an abortion. The plaintiff is directly challenging the State’s total abortion ban and fetal heartbeat ban. After filing the lawsuit, the initial plaintiff learned that her embryo no longer had detectable cardiac activity, meaning that the State will likely argue that the case is moot and should be dismissed. However, the ACLU has indicated that they do not plan to drop the suit. Brigitte Amiri, deputy director of the ACLU’s reproductive freedom project highlighted the importance of patient-led lawsuits, and has called on other Kentuckians who need an abortion to come forward and join the suit. 

    • Suits led directly by pregnant people have been a growing trend in the past few months, with notable litigation coming out of Texas. These suits have the advantage of avoiding the standing questions that arise when the provider brings the case, rather than the patient themselves. In fact, Kentucky abortion clinics attempted to sue over the State’s ban last year, but the State Supreme Court ruled that they did not have standing to bring the claim on behalf of their patients. The present lawsuit will avoid that particular challenge. Instead, the initial plaintiff and any others who may join, argue directly that Kentucky’s trigger ban and six-week ban are unconstitutional under the State’s guarantee of liberty, which they persuasively allege encompasses rights to privacy and self-determination. Unlike the suit out of Texas, which brings a limited challenge to clarify the scope of the life and health exception to the State’s abortion ban, the Kentucky suit challenges the abortion bans in their entirety. This will be an important one to watch as litigation over post-Dobbs bans ramp up into the new year. 

  • Mifepristone Update:

    • On Wednesday, December 13, the Supreme Court agreed to hear the case challenging the FDA’s approval of mifepristone for use in medication abortions. Notably, the Court will not take on the question of the FDA’s original 2000 approval of the drug. Instead, it will consider whether the FDA acted improperly when it eased restrictions on the drug’s use, including permitting it to be prescribed via mail. It will also consider questions about whether the plaintiffs, a group of anti-choice providers and provider groups, have standing to bring the challenge when they themselves do not prescribe abortion medication to their patients. The High Court agreed to hear this case a year and a half after it purported to wash its hands of abortion questions and return them to each individual state. 

    • As a quick refresher, the plaintiffs strategically brought this case in the Northern District of Texas, in front of Trump-appointee Judge Matthew Kacsmaryk. Initially, they sought to not only restrict the use of mifepristone, but to have its FDA approval revoked altogether. Although Judge Kacsmaryk initially issued an order in their favor, the Fifth Circuit Court of Appeals later partially reversed that order, finding that the challenge to the 2000 approval was outside of the statute of limitations. While the appeal played out in the lower courts, the Supreme Court issued an Order staying the lower courts’ decisions until it had a chance to weigh in, preserving access to the drug for the time being. 

    • Following briefing and oral arguments, the Court will likely issue a ruling in the case by summer 2024. There is no way to know exactly how the Court will rule, but there is reason to be skeptical that the Court that overturned Roe will issue a favorable ruling. If the Court reinstates old restrictions on mifepristone–specifically, the requirement that it be dispensed in person-it will have devastating effects on the ability of patients in ban states to access care. This Digest will continue to post updates as briefing and oral arguments occur. 

More News in Access: 

  • For information on ways in which anti-choice lawmakers and advocates have moved to restrict access to contraception, please read here

  • A “brain drain” is occurring in conservative states that are waging a ‘culture war’ against free speech, diversity, and the right to healthcare. In increasing numbers, college-educated workers, including educators and physicians, are beginning to set their sights on more progressive states to call home. 

  • Ohio finally removed the spousal exception for charges of rape. Representative Bill Dean was the singular “no” vote on the measure. He later told a reporter from USA Today that “I personally don’t believe that a man, if he’s married and has physical relations with his wife, that can be considered rape.” 

  • Republicans in New Hampshire have proposed a 15-day abortion ban, which would effectively ban abortion from the time of fertilization. Although it is not likely to become law, it is an important reflection of anti-choice intent and the basic lack of understanding about how and when pregnancy detection is possible that undergirds so much anti-choice legislation. 

  • For an update on Florida’s attempt at a ballot initiative, please read here. Although advocates are making significant progress, they face weighty challenges with the extremely conservative state supreme court. 

  • Ohio legislators have passed a ban on gender-affirming care for minors and a sports ban; the bills will now go to the governor for signature or veto. 

  • Business Insider investigated the predatory tactics of one group ‘Let Them Live,’ that purports to offer pregnant people money and support in exchange for agreeing to not have an abortion. However, the group has failed to fulfill its promises on numerous occasions, leaving women without the promised support and past the point in pregnancy where termination is an option. 

  • 23 independent abortion clinics have closed in 2023, on top of the 42 that closed in 2022, leaving many states with no physical facility to obtain the procedure.  

  • Wisconsin Governor Tony Evers voted to veto the State’s proposed ban on gender-affirming health care for minors. 

  • In Montana, advocates have launched an effort to protect abortion rights in the State’s Constitution. 

  • In Missouri, lawmakers have begun pre-filing bills for the next legislative session, including one that would make it more difficult for constitutional amendments to pass in the State. This comes as advocates attempt to get a reproductive rights ballot initiative in front of Missouri voters. 

  • A Wisconsin Judge affirmed her previous determination that an 1849 law criminalizing abortion in the state does not apply to ‘consensual’ abortions and does not impact care in the state. You can find that ruling here

  • Interstate travel for abortion care has doubled since 2020, highlighting the difficulties that pregnant people are facing in accessing care and the continued need for accessible telemedicine.  

  • In South Dakota, indigenous supporters of the rights of transgender and two-spirit people reflect on the significance of a failed anti-trans bill in the state.

REPRODUCTIVE HEALTH DIGEST (12/1/2023)

Developments in Abortion, Autonomy, and Access: 

This week’s Digest discusses ongoing litigation in Texas, Ohio, and Idaho, as well as new legislation out of Michigan. We also take a look at what is going on around the country in both abortion care and other bodily autonomy issues and do a deep dive into medically problematic proposed abortion regulations out of Iowa.

Legal Changes at the State Level: 

  • Brief Overview: 

  • Texas: On Tuesday, November 28, the Texas Supreme Court heard arguments about the scope of the State’s exceptions to its total abortion ban in a case brought by Texas patients who were denied abortions while facing severe pregnancy complications.

  • Ohio: The Ohio Supreme Court has asked the parties to an ongoing lawsuit over the State’s fetal heartbeat ban to weigh in on how the passage of the new Reproductive Freedom Amendment impacts the constitutionality of that ban. This briefing will occur against a backdrop of Republican pushback to the passage of the Amendment and Democrat-led attempts to clear the way for its implementation.

  • Idaho: Idaho has asked the U.S. Supreme Court to step in and allow the state to fully enforce its near-total abortion ban, which allows for the prosecution of medical providers in certain circumstances.

  • Michigan: Michigan Governor Gretchen Whitmer signed a watered-down version of the Reproductive Health Act. The Act repeals outdated and medically unnecessary abortion restrictions in the state, including the requirement for providers to screen pregnant people for signs of being coerced into having an abortion and arbitrary building code requirements for facilities where abortions are performed. Governor Whitmer initially attempted to pass a more comprehensive bill that would have also rescinded a 24-hour waiting period for abortion seekers and allowed state Medicaid funding for abortions; however, Democrat Representative Karen Whitsett refused to vote in favor of those amendments.

Legal Analysis: 

  • Texas: 

    • This past Tuesday, the all-Republican Texas Supreme Court heard arguments about the proper scope of the life and health exceptions to the State’s otherwise total abortion ban. The suit, Zurawski v. Texas, was the first to be brought directly by pregnant people who were denied abortions in emergency situations. Since the suit’s inception, the number of plaintiffs has more than tripled, to twenty women and two doctors. Each of the patient plaintiffs in the case faced severe pregnancy complications, including diagnoses of lethal fetal abnormalities. Some of them had to travel outside of Texas in the midst of a health crisis to receive care,  others were forced to carry and gave birth to babies who survived only briefly outside of the womb, and others faced severely delayed care while their doctors had to wait until they became “sick enough” to invoke the state’s narrow exceptions.

    • At present, Texas is enforcing a total abortion ban, with extremely narrow exceptions to save the life or health of the pregnant person. However, as we have discussed previously in this Digest, the exceptions are drawn in broad non-medical terms that do not provide sufficient clarity to providers who face prosecution and loss of licensure if they are found to be in violation. This lack of clarity has directly harmed each of the plaintiffs in the lawsuit, and undoubtedly countless other Texans. In August, Texas Judge Jessica Mangrum issued a ruling that the state’s ban cannot be enforced in cases of complicated pregnancies, including when the pregnancy poses a serious risk to the pregnant person, exacerbates an existing health condition or where there is a lethal fetal diagnosis. The State immediately appealed that ruling, placing it on hold. 

    • During this week’s hearing in Austin, the State argued that the exception is sufficient as is, and that any harm incurred by the plaintiffs as a result of the law is the fault of overly risk-averse doctors, not the legislation. In other words: sue your doctors, not the State. In response, the Plaintiffs argued that the exception is written in broad unclear terms and that providers have been given no meaningful guidance on how to properly interpret it, forcing them to make decisions under threat of prosecution and loss of career. The State also argued that the Plaintiffs lacked standing, or the right to bring the lawsuit, because they are not currently seeking abortions. The attorney for the State seemed to suggest that in order to have standing to challenge the statute’s exceptions, a person would need to be actively facing a pregnancy complication and bring a challenge to court at that time. The Plaintiffs’ attorney rightfully pointed out the absurdity of requiring pregnant people in the midst of medical complications to obtain a lawyer and seek a judge’s order prior to receiving medical care or having standing to challenge a harmful statute. 

    • Although the Justices peppered both sides with questions throughout the hearing and appeared skeptical of the State’s argument at several points, the Plaintiffs’ case faces an extremely conservative Court. The Justices did not indicate when they will rule, and it will likely be a matter of months before an order is handed down. 

  • Ohio:

    • As we reported in last week’s Digest, Issue 1 has passed in Ohio, constitutionally protecting abortion rights up until the point of “viability.” However, the final votes had hardly been counted before Republican lawmakers began suggesting ways to block the democratically passed Amendment from going into effect, including potentially stripping state judges of jurisdiction to hear cases interpreting the Amendment. It remains to be seen whether Republicans will move forward with these efforts. 

    • Although Issue 1 should automatically go into effect 30 days after its passage on November 7th, its passage did not repeal the 30+ abortion restrictions that remain on the books. These laws include the State’s ban on abortion after detection of fetal cardiac activity, which is currently being challenged in litigation. Last week, the Chief Justice of the State Supreme Court ordered the parties to submit arguments on how they believe the passage of Issue 1 impacts the litigation. Of course, the legally apparent answer is that the Amendment now renders the fetal heartbeat ban unconstitutional. However, it is not clear that Republicans are going to honor that interpretation. Democratic lawmakers are hoping to avoid the need to go to court and fight over the continued constitutionality of each of Ohio’s abortion restrictions. To that end, they have called for or introduced legislation to repeal certain conflicting laws and restrictions, including the heartbeat bill. However, it appears unlikely that the Republican-led legislature will be willing to step aside and clear the way for a smooth implementation of Issue 1. 

    • In case we needed further reminding that the fight for bodily autonomy affects us all, almost immediately after their loss on Issue 1, Ohio Republicans began targeting trans rights. Within two days of the Issue 1 vote, Republicans announced hearings on legislation that would target drag performances, gender-affirming care for minors, and bathroom access. As lawmakers fight to limit bodily autonomy across issue areas, it serves as a clear reminder that the fight to retain control over our bodies cannot end with abortion. 

  • Idaho: 

    • Idaho has asked the U.S. Supreme Court to weigh in on whether the state can fully enforce its near-total abortion ban, which permits prosecution or license revocation of doctors in certain circumstances. At present, Idaho bans abortion at all gestational ages, with narrow exceptions to save the life of the pregnant person or in cases of rape or incest. Last year, the Biden Administration sued Idaho on the theory that its law is in conflict with federal Emergency Medical Treatment and Labor Act (EMTALA) obligations, which require physicians to provide care to anyone who presents with an emergency situation. 

    • In August of 2022, U.S. District Judge B. Lynn Winmill sided with the Biden Administration and enjoined the ban for emergency cases, citing concern that doctors would be put in an impossible position of complying with both a harsh state ban and federal obligations under EMTALA while trying to make quick life or death medical decisions. Although a 3-judge panel out of the Ninth Circuit Court of Appeals initially allowed the state to enforce the ban while the case goes through the litigation process, a full panel of the Circuit Court reversed course, putting Judge Winmill’s order back in place for the time being. The State has now asked SCOTUS to weigh in on whether it can enforce the totality of its ban. 

    • If the High Court agrees to hear the case, it will be the first time since Dobbs that the Justices have substantively considered an abortion-related challenge, and certainly the first time that they have considered a case involving prosecuting providers directly. A ruling from SCOTUS would send a signal to the states about how far they can reasonably take sweeping abortion bans. If the Court declines to hear the case, it may indicate that it is less willing to become involved in disputes over state abortion legislation at this moment. 

    • Since Dobbs, Idaho has become one of the harshest anti-abortion states in the country. In addition to its abortion ban, it has come under scrutiny for the passage of its first-of-its-kind abortion trafficking law, as well as the sweeping scope of its “No Public Funds for Abortion Act,” which has chilled academic speech across the state. The abortion trafficking law is currently enjoined; however, earlier this week, the state Attorney General asked that the law be allowed to take effect during the pendency of the litigation. 

More News in Access: 

  • A North Dakota Judge has declined to block the state’s ban on gender-affirming care for minors.

  • Advocates in Missouri presented arguments on why a religious challenge to the state’s abortion ban should stay alive in the face of the State’s attempt to have the case resolved in its favor. 

  •  In Florida, a ballot initiative to protect abortion rights is underway, but faces obstacles in gaining the support needed to succeed. 

  • A Nevada judge has struck down an initial effort to create a ballot question protecting reproductive rights. He stated in his decision that the proposed initiative was “too broad” because it encompassed all matters relating to pregnancy and therefore violated the single-subject rule. This same argument was raised and failed in Ohio earlier this year.

  • The Supreme Court has declined to intervene and allow Florida to enforce its drag ban while the ban is being litigated, meaning that a lower court order will remain in place, and the law will not be operative for the time being.

  • Two transgender boys have sued the University of Missouri for ceasing the provision of gender-affirming care. 

  • Over 100 Congresspeople have signed on to an amicus brief urging the Supreme Court to restrict access to mifepristone. 

  • A ballot initiative effort in Missouri to add a rape exception to the state’s abortion ban has drawn criticism for its proposed requirement that victims contact a crisis hotline in order to invoke the exception. 

  • As we gear up for 2024, the Biden campaign says that it wants to use a second term to, among other things, finish the job of restoring abortion rights. 

  • Even as abortion continues to be a winning issue, some anti-abortion lawmakers are willing to undermine the democratic process itself to restrict the right to choose. 

  • This week, the dating app Bumble became the lead signee on an amicus brief in the case challenging Texas’ exceptions to its abortion ban. Bumble cited its duty to speak out and provided myriad examples of how abortion bans are bad for business and bad for Texans. 

  • For a look at where ballot initiatives have been proposed thus far (although this list seems to be constantly expanding), read here.

  • In Virginia, Democrats have proposed an abortion rights constitutional amendment, following their legislative win earlier this month.

Issue of the Week: Iowa and the Business of Politicizing Medicine

In Iowa, abortion is currently permitted until the 20th week of pregnancy. However, the State is fighting to enforce a ban on abortion after detection of fetal cardiac activity. That ban, which was signed into law by Governor Kim Reynolds in July, was pushed through in a single day-long special legislative session and came under heavy scrutiny for the rushed and politicized process. Although the so-called heartbeat ban very briefly went into effect after its passage, it is currently blocked by a Polk County District Judge while litigation over the ban's constitutionality plays out. The Judge blocked all of the ban’s substantive provisions, but he did allow the section of the law directing the Iowa Board of Medicine to adopt rules relating to the heartbeat ban to stand. On Friday, November 24th, the Board considered a set of such proposed rules and, although not final, they provide critically valuable insight into what it looks like when non-medical professionals attempt to regulate the practice of medicine against the backdrop of a politically charged legal battle. 

The purported intent of the  proposed rules is to establish “standards of practice for physicians who perform or induce abortions.” However, they diverge from standard medical practice in both substance and language used. For example, with respect to the determination of whether a fetal heartbeat is detectable, they would require the performance of an abdominal ultrasound; however, this is not standard medical practice for abortion cases. One of the legislators supporting the heartbeat ban acknowledged in hearing testimony that using an abdominal ultrasound to determine the presence of cardiac activity can be an imprecise business, with results varying based on a number of factors, including the patient’s weight. With respect to the rape or incest exception to the law, the rules would require the crime to have been reported within 45 days for cases of rape or 140 days for cases of incest. This suggestion ignores all credible data that shows that many survivors of assault do not or cannot come forward to report the crime against them. The rules also suggest requiring doctors to ask their patients questions such as “did the sex act constitute a rape” and who the rape was reported to, or whether the sex act occurred between closely related persons (incest). These questions are wholly medically unnecessary and problematically intrusive–medical providers are not charged with investigating or interpreting potential crimes. One Des Moines OB-GYN expressed that these requirements deviate from standard patient care by requiring a provider to ask questions “unrelated to the patient’s health and potentially asking [the patient] to prove their honesty” and “trying to put the physician in a position of interpreting these complex legal scenarios” which “prevents us from just providing the best care that we can to our patients.” 

The rules fail to provide any meaningful guidance whatsoever about what may constitute a medical emergency such that a health or life of the pregnant person exception may be invoked. We have seen this same lack of clarity play out to disastrous results in other states with similar abortion bans in place. In regards to invoking the lethal fetal abnormality exception, the rules proposed suggestions fail to engage with the complex reality of fetal medicine, which often deals with uncertainty and changing probabilities. For every provider who makes one determination as to lethality, the state could likely find an opposing physician to testify that they would have concluded the opposite. 

In response to the proposed rules, a group of over 100 Iowa physicians signed on to a letter expressing their “grave[]” concerns about aspects of the proposed guidance, including that the patient-physician relationship may be jeopardized by the requirement to “demand[] horrifying details” about a potential assault. The physicians also expressed concern that, although the law subjects physicians to potential discipline, the proposed rules fail to give any details about what that discipline may entail, forcing providers to operate with an ambiguous threat of consequence looming over their practice. A public comment period will be open from December 13 until January 2nd, should interested parties wish to express their views on the propriety of the proposed rules. 

The insertion of politics into medicine is at the heart of the fight for abortion rights, and the proposed guidance out of Iowa is emblematic of this tension.  We have seen legislation pass across the country that is grounded in medical inaccuracies, such as improperly labeling early electrical impulses as a “fetal heartbeat” and the use of political terms like “unborn child” instead of medically accurate ones like “fetus or embryo.” We have seen states like Texas force physicians to practice their craft pursuant to rules and regulations that detract from the standard of care that they were trained to give and are deleterious to the physician-patient relationship. The flow of trust in a healthy physician-patient relationship goes both ways, with the physician trusting the patient to accurately convey their needs and the patient trusting the physician to meet them. Abortion bans and other legislatively-derived restrictions on healthcare stand in the way of this trust and all of our care suffers as a result.

REPRODUCTIVE HEALTH DIGEST (11/10/2023)

Developments in Abortion, Autonomy, and Access: 

In this week’s edition of the digest, we get to celebrate the outcomes of many of the elections that we have been reporting on for months, including those out of Kentucky, Ohio, Virginia, and Pennsylvania. The impact of these wins cannot be understated, but of course, the fight is far from over, and anti-choice actors continue to push to restrict access. Please read on for more information.

Legal Changes at the State Level


Brief Overview:

  • Ohio: On election day, Ohioans successfully voted to enshrine reproductive rights in their state constitution, despite months of relentless opposition and underhanded political maneuvering from anti-choice groups and lawmakers in the state.

  • Virginia: Virginia’s Republican Governor Glenn Youngkin has been vocal about his plans to pass a 15-week abortion ban if Republicans managed to take control of the state senate. In Tuesday’s election, however, Democrats not only retained their majority in the Senate, but flipped the House, securing the relative safety of abortion rights in the state for the immediate future.

  • Kentucky: Kentucky’s gubernatorial race resulted in another huge win for abortion rights, with Democrat Andy Beshear securing reelection after running a heavily abortion-focused campaign.

  • Kansas: A Kansas District Judge issued a ruling halting enforcement of several of the state’s barriers to abortion care, including a 24-hour waiting period and medically unnecessary and misleading mandatory disclosures. 

  • Mifepristone Update: Missouri, Idaho, and Kansas have filed a new Complaint in the Northern District of Texas. The states are asking the court to reinstate 2016 regulations on the distribution of mifepristone, including a requirement for in-person dispensing. Missouri Attorney General Andrew Bailey has requested that the lawsuit be joined with the ongoing Alliance for Hippocratic Medicine v. FDA case.

  • Idaho: Idaho’s abortion trafficking law has been temporarily halted by a federal court. The first-of-its-kind law makes it a crime to assist a minor in obtaining an abortion outside of Idaho without parental consent and has drawn a great deal of criticism for infringing on various fundamental constitutional rights. In her opinion, Magistrate Judge Debora Grasham explained that the case is not about abortion, but about “long-standing and well-recognized fundamental rights of freedom of speech, expression, due process, and parental rights.” She also expressed that Idaho cannot label the targeted activity as trafficking when the abortion obtained in another state would be a completely legal activity. The injunction is only preliminary, and we will continue reporting on this case as it develops.

Legal Analysis: 

  • Ohio: 

    • After months of tireless effort and unrelenting advocacy, Ohioans have officially voted to pass Issue 1, enshrining reproductive rights into their state constitution. The amendment protects contraception, fertility treatments, the choice to continue a pregnancy, miscarriage care, and abortion. With this vote, Ohio becomes the fourth state to explicitly protect reproductive rights in its state constitution, joining the ranks of California, Vermont, and Michigan. The path to the November 7th vote has been fraught with opposition, including an August special election to try and raise the threshold for passing a constitutional amendment from a simple majority to 60%, manipulative ballot summary language intended to mislead voters, and widespread misinformation campaigns about the impact of the amendment. Despite all of this, choice won in Ohio–a state that voted for Donald Trump in both 2016 and 2020.

    • The impact of the passage of Issue 1 cannot be overstated. It is a critical indicator that, despite Republican insistence to the contrary, Americans want to have control over their own bodily autonomy and medical decision-making. And, this race inevitably serves as a test case for advocates working to pass ballot initiatives in other red-leaning states, including Florida

    • For Ohio itself, the passage of Issue 1 should render the state’s so-called heartbeat bill void. The Amendment effectively codifies the Roe standard, prohibiting the government from intruding on reproductive rights pre ‘viability’, or in cases where the provider determines that the pregnant person’s life or health is at risk. Post-‘viability’, the state may prohibit abortion. The amendment defines fetal viability as “the point in a pregnancy when, in the professional judgment of the pregnant patient's treating physician, the fetus has a significant likelihood of survival outside the uterus with reasonable measures. This is determined on a case-by-case basis.” A coalition of Republican lawmakers in Ohio have already said that they plan to do everything within their power to stop Issue 1 from taking effect, including “introducing several bills to address th[e] issue” and possibly stripping the judiciary of jurisdiction over the constitutional amendment. In other words, rather than allowing the will of the people to stand, these elected officials are willing to wield their positions of power to overturn it.

  • Virginia:

    • In another huge win for abortion rights this Tuesday, Virginia Democrats not only retained control of the state Senate, but took control of the House. Prior to this election, the state’s General Assembly was split, with Democrats holding the Senate and Republicans controlling the House. The state’s Republican Governor Glenn Youngkin has been clear about his plans to pass a 15-week abortion ban if Republicans managed to take control of the Senate, giving him the political structure needed to do so. Rather than taking the Senate, however, Republicans lost their majority in the House, meaning that Democrats now hold a majority in both legislative chambers. With the results of this election, abortion rights in Virginia are likely relatively safe for the time being. Virginia is the only southern state without an abortion ban in place and will remain a critical access point for pregnant people in the south.

    • The Virginia election also offers important insight into what kind of messaging around abortion voters respond to. The campaign rhetoric leading up to the election day heavily centered on abortion, with Governor Youngkin testing new messaging strategies, including insisting that the bill that he would pass is not an abortion ban, but a “reasonable 15-week limit.” This shift in language reflected an overall strategy of painting Democrats as extreme on abortion and deflecting from the narrative that Republicans have gone too far on the issue. Had Governor Youngkin’s message succeeded, it would have signaled to other lawmakers that positioning a 15-week ban as a reasonable middle ground is a winning strategy. Instead, Virginia Republicans’ legislative loss delivers a severe blow to that agenda and reinforces the fact that autonomy over reproductive decision-making matters to voters. 

  • Kentucky 

    • The pro-choice wins continued in Kentucky this week, as the historically red state reelected incumbent Democratic Governor Andy Beshear. Like the legislative race in Virginia, abortion was a centerpiece of the Kentucky gubernatorial race. Governor Beshear ran against Republican Attorney General Daniel Cameron. 

    • The pro-choice wins continued in Kentucky this week, as the historically red state reelected incumbent Democratic Governor Andy Beshear. Like the legislative race in Virginia, abortion was a centerpiece of the Kentucky gubernatorial race. Governor Beshear ran against Republican Attorney General Daniel Cameron.

  • Kansas: 

    • In Kansas, District Judge Christopher Jayaram issued a ruling halting the enforcement of several of the state’s barriers to abortion care. His ruling primarily focused on medically unnecessary disclosure requirements and the state’s mandatory 24-hour waiting period. Proponents of these restrictions assert that they are necessary for informed consent and protecting “maternal health and safety and the lives of the unborn.” However, Judge Jayaram disagreed, writing that the “Women’s Right to Know Act” “appears to be a thinly veiled effort to stigmatize the procedure and instill fear in patients who are contemplating an abortion, such that they make an alternative choice, based upon disproven and unsupportable claims.” 

    • Judge Jayaram rejected the arguments that mandatory disclosures about certain “risks” associated with abortion were necessary to protect the pregnant person’s health. He wrote that “the weight of the credible evidence submitted…reveals that the State’s mandated disclosures regarding ‘increased’ risks (whether preterm labor or breast cancer)…are likely inaccurate, misleading, and/or not generally accepted views within the mainstream medical community” set forth to “promote the State’s clear preference in favor of childbirth, rather than abortion.” His opinion also determined that the imposition of a medically unnecessary 24-hour waiting period between receiving disclosures and obtaining the procedure and a 30-minute waiting period on the day of the abortion impose substantial roadblocks to pregnant people accessing their fundamental right to bodily autonomy. The injunction also halts the requirement that providers inform their patients of the possibility of abortion reversal, a scientifically unsupported non-standard practice. The removal of these restrictions will remain in place pending a trial, which is currently set for June 2024. 

  • Mifepristone Update:

    • If you read this newsletter, you know that the abortion drug mifepristone has been under relentless attack this year, despite its exemplary record of safety and efficacy. Most notably, in Alliance for Hippocratic Medicine v. FDA, the plaintiffs brought a challenge to the FDA’s approval of the drug and subsequent changes to its terms of use. That case has wound its way through federal district and circuit courts out of Texas and now sits before the U.S. Supreme Court, who will decide whether to hear the case. 

    • If you read this newsletter, you know that the abortion drug mifepristone has been under relentless attack this year, despite its exemplary record of safety and efficacy. Most notably, in Alliance for Hippocratic Medicine v. FDA, the plaintiffs brought a challenge to the FDA’s approval of the drug and subsequent changes to its terms of use. That case has wound its way through federal district and circuit courts out of Texas and now sits before the U.S. Supreme Court, who will decide whether to hear the case. 

More News in Access: 

  • Pennsylvania has elected Democrat Dan McCaffery to its open state Supreme Court seat, solidifying the liberal majority. Like other state races this election day, McCaffery’s campaign and supporters centered abortion rights as a key issue in the lead up to the vote. 

  • In Michigan, pro-life groups and lawmakers are suing to overturn the constitutional amendment protecting abortion that Michiganders voted to pass last year. The lawsuit attacks the amendment on constitutional grounds, arguing that it creates a “super right” in violation of the First and Fourteenth Amendments to the U.S. Constitution. This will be an important lawsuit to watch. If it is successful, anti-choice groups will undoubtedly use it as a roadmap to attempt to overturn similar ballot measures in other states. 

  • Idaho’s first abortion trafficking arrest has taken place, with Idaho officials arresting a mother and son based on their taking of a teenager to Oregon to obtain an abortion. Although they have not formally been charged with abortion trafficking, the prosecutor’s language mirrors identically the language in the trafficking statute. It also raises important questions about the strength of shield laws in cases where officials are able to use cell phone location technology to circumvent those laws and directly obtain information about whether a person visited an abortion clinic in another state. 

  • In Florida, a lawsuit challenging the state’s restrictions on trans health for minors has received the go-ahead to proceed as a class action, an important development for protecting all trans people in Florida, not just the plaintiffs named in the lawsuit itself. 

  • New data shows that in the year since Roe fell, abortions in the U.S. have not actually dropped nationwide. Instead, the states where people have gone for care have changed, and reliance on telemedicine has drastically increased. 

  • Families out of Tennessee have petitioned the U.S. Supreme Court to hear their challenge to a Sixth Circuit ruling allowing the state’s ban on transgender healthcare to go into effect. Although the necessity of challenging the lower courts’ ruling is manifest, the challengers face a high court hostile to bodily autonomy rights–the same court that overturned Roe nearly a year and a half ago. 

  • In Missouri, advocates are attempting to get abortion on the 2024 ballot. However, the state has repeatedly tried to stymie these efforts. Most recently, a Missouri appeals court ruled against Secretary of State Ashcroft’s suggested ballot language summaries, which contained inflammatory and false descriptions of the ballot measure, including a statement that it would “allow dangerous and unregulated abortions until live birth.”  

  • A satanic temple in Indiana has lost its lawsuit against the state’s abortion restrictions. The temple argued that their beliefs allowed members to obtain abortions, in conflict with the abortion ban. The State’s Attorney General called the lawsuit “ridiculous.” 

  • In Texas, the Biden Administration is arguing in federal court for the right of minors to obtain contraception from federally-funded Title X clinics without parental consent. The Administration faces an uphill battle with an extremely conservative circuit court that has repeatedly ruled against bodily autonomy. 

  • One of the physicians involved in the lawsuit challenging the FDA’s approval of mifepristone has been recruited to an advisory board to assess the potential use of the drug to treat breast cancer. In a statement, he opined that “the concept of leveraging the effect of the abortion pill in life-saving as opposed to a life-taking scenario is extremely exciting,” tipping his hand that the opposition to mifepristone was always about ideology–not medical safety. 

  • In more news out of Texas, the Fifth Circuit Court of Appeals heard oral arguments about whether and to what extent federal EMTALA obligations to treat patients in emergency situations conflict with the state’s extraordinarily narrow exceptions to its abortion ban. A similar argument about EMTALA and abortion is playing out in Idaho. 

REPRODUCTIVE HEALTH DIGEST (10/27/23)

10/27 - Developments in Abortion, Autonomy, and Access: 

In this edition of the digest, we discuss the latest attack on reproductive freedom in Texas and how it relates to broader efforts to restrict travel for abortion, Ohio’s upcoming ballot initiative, and rulings out of Colorado and Georgia.

Legal Changes at the State Level:
 

  • Brief Overview: 

    • Texas: In Texas, anti-abortion groups have sued the city of San Antonio over its Reproductive Justice Fund, asking the court to block the city from allocating any money to funds that help pregnant people pay for travel and lodging for out of state abortions. 

    • Colorado: A federal judge has temporarily blocked enforcement of Colorado’s law barring facilities from providing or advertising provision of “abortion pill reversal” procedures or falsely implying that they provide abortion services if they do not. 

    • Ohio: By the time the next issue of this digest comes out, Ohio’s vote on whether to enshrine abortion rights in the constitution will have occurred–this pivotal moment for the post-Roe abortion rights movement will inform how both sides approach the fight in the coming months and years. 

    • Georgia: Georgia’s Supreme Court has ruled that the state’s 6-week abortion ban is constitutional and can remain in place under state law. The case will now go back to the lower court for further argument. 

Deeper Legal Analysis 

  • Texas:

    • Last month, the city of San Antonio, Texas passed its budget plan and agreed to allocate $500,000 of the $3.7 billion budget for the creation of a reproductive justice fund. The city has not yet determined how it will spend that money; however, hearings on the fund included discussion of sexual education, STI testing, pregnancy testing, resources for contraception and emergency contraception,  and potential funding for travel and lodging for people seeking abortions in states where it remains legal. Anti-abortion groups have filed a lawsuit against the city of San Antonio in an attempt to block the reproductive justice fund. They allege that it would use taxpayer money to fund “criminal organizations that violate the state’s abortion laws,” which prohibit helping someone  “procure” an abortion. Whether the state’s laws can apply to funding for travel to obtain a lawful abortion in another state is an open legal question, and San Antonio emphasizes that the funds will be used in “accordance with all federal and state laws.” After Dobbs, abortion funds in Texas temporarily ceased funding travel out of concern that they could face legal jeopardy; however, they resumed provision of service after a federal judge ruled that Texas likely had no authority to enforce its own abortion ban outside of state boundaries. Despite this prior ruling, the Plaintiffs in the lawsuit seek to stop the critical work done by abortion funds. John Seago, the president of plaintiff Texas Right to Life stated that they intend to take “discovery from every one of these abortion funds to expose their violations of state law and the criminal activities of their members and donors.” Potential discovery of donor, member and patient information related to an abortion fund at a time when Texas is pursuing an aggressively anti-choice agenda is chilling. Disclosure of the private details of who has traveled out of state to obtain an abortion, and who has helped to support that effort would be devastating. This is the latest in a series of brazen attempts by state Republicans to block pregnant people from traveling to receive legal care. We have seen similar efforts unfolding in states like Idaho, where an “abortion trafficking” law was passed, and in cities in Texas that seek to criminalize the use of their roads for abortion-related travel. The right to travel is fundamental, and efforts to restrict it must be pushed back against and rejected as undemocratic and inconsistent with a system of governance that claims liberty among its highest values.

  • Colorado: 

    • In Colorado, a federal judge has temporarily blocked enforcement of Colorado’s abortion pill reversal law, which would bar facilities from providing or advertising provision of “abortion pill reversal” procedures or falsely implying that they provide abortion services.. So-called abortion pill reversal is an experimental treatment that involves taking a dose of the hormone progesterone after taking the first of two medication abortion drugs in an attempt to “reverse” the medication abortion’s effects. However, as we discussed in a previous digest, the first attempt to clinically study the reversal protocol ended when three of its 12 participants had to be hospitalized due to severe bleeding. The procedure is not considered clinically standard care. After passage of the Colorado law restricting the procedure, a Catholic health clinic sued, arguing that the law infringed upon its First Amendment right to free religious exercise because it considers provision of abortion reversal services to be a religious obligation. Judge Daniel Domenico agreed with this argument and wrote in his ruling that the law must satisfy strict scrutiny–meaning that the state must “come forward with a compelling interest of the highest order” in order for the law to survive. Judge Domenico’s determination that the Colorado law infringes on religious freedom is an important development in a decades long debate about how to balance claims of sincerely held religious beliefs against other individual rights, including rights to contraception and abortion. His conclusion that the law targets religious practice and is not neutral and generally applicable is particularly interesting, as abortion opponents come from all different backgrounds–religious and non-religious–and the law applies  equally to any party that seeks to provide abortion reversal procedures, regardless of their affiliation. Judge Domenico’s ruling rests against the backdrop of the abortion rights movement’s ongoing  fight to regulate the conduct of crisis pregnancy centers and deter them from coercive and misleading tactics. You can read more about how CPCs operate here

  • Ohio: 

    • We have discussed the Ohio ballot measure at length in this digest, but it is now only weeks away and it is more important than ever that voters understand what is on the ballot and get out to vote. Republicans have tried relentlessly to stop this ballot measure from making its way to voters, and have consistently spread misinformation about its contents and potential impact. . Issue 1 is backed by Ohioans United for Reproductive Rights and a coalition of providers and reproductive rights groups including Planned Parenthood Advocates of Ohio, the ACLU of Ohio, the Abortion Fund of Ohio, and Pro-Choice Ohio. It is opposed by prominent anti-choice groups, as well as Republican Governor Mike DeWine and other Ohio Republicans. The actual text of the ballot measure is relatively straightforward and largely codifies the Roe standard.  It would guarantee the right of every individual to make reproductive decisions, including abortion, up until the point of viability. It allows the state to prohibit or regulate abortion after viability. However, opponents of the amendment have attempted to create confusion and fear around the amendment in a number of different ways, including manipulating the language that voters will actually see in the ballot box. Most recently, Republicans have tried to reframe the issue as being one of parental rights. In a new campaign ad, Ohio First Lady Fran DeWine claimed that the amendment would “deny parents the right to be involved when their daughter is making the most important decision of her life.” Of course, the amendment does not actually say anything about parental rights, and it certainly does not “deny” parents the right to consult with their child about abortion. Ohio law generally requires parental consent for a minor to obtain an abortion, and Republicans seem to be arguing that the amendment’s language allowing individual decision-making would override this. But, whether the word “individual” will be interpreted to include minors is an open question, and in order to overturn the state’s currently enforced parental consent laws, a party would have to bring a legal challenge, and the state’s conservative Supreme Court is unlikely to strike the consent requirement down. Opponents of Issue 1 have also tried to argue that it could allow for greater access to gender affirming care. This argument is both transphobic and factually false. The amendment makes no mention of gender affirming care, and its supporters have not suggested that it would be applied in such a way; however, even if it were true that it would expand access to trans health care, that is just one more reason to support the amendment. Finally, it is worth reminding readers that, although abortion is currently legal until about 22 weeks in Ohio, the state has passed a 6-week ban that is in active litigation. If Issue 1 fails, the likelihood of that ban passing into effect and access in the state being decimated significantly increases.

  • Georgia: 

    • Relying on Dobbs, Georgia’s Supreme Court has ruled that the state’s 6-week abortion ban is constitutional and can remain in place. The law bans abortion after detection of a fetal ‘heartbeat’ and contains narrow exceptions for the pregnant person’s life, pregnancies that are determined to be “medically futile,” and rape or incest prior to 20 weeks, if the crime is reported to law enforcement. Of course, even where an abortion ban has exceptions, we know that in practice these exceptions serve as political safeguards for anti-abortion legislators and fail to meaningfully increase actual access to care. Georgia’s law was one of many “trigger bans” that became operative after the fall of Roe. Previously, a lower state court ruled that it was unconstitutional because it was passed while Roe was still controlling federal law. However, that ruling was reversed and the law was allowed to take effect during the pendency of the ongoing litigation. This latest ruling from the state’s highest court deals a significant blow to arguments against the ban.. The court did not rule on the plaintiffs' additional arguments that the law violates privacy and equal protection rights under the state constitution, and the case will be handed back down to the lower court for further consideration on those points. . The ruling was praised by anti-abortion groups and conservative state politicians. Advocates for abortion access, including plaintiff SisterSong and the Biden Administration criticized the ruling and lamented the impact that it will have on an already severely limited reproductive healthcare landscape.

What else is happening in access? 

  • In Alliance for Hippocratic Medicine v. FDA, diverse stakeholders have penned amicus briefs urging the Supreme Court to preserve access to mifepristone. Supporting the Biden Administration’s appeal are “reproductive rights organizations, medical and legal experts, patient advocacy groups, 257 members of Congress, 23 states and D.C., over 600 state legislators, state and local governments and officials, and pharmaceutical representatives.” In the coming months, the Court will decide whether it will hear the case and whether to alter the availability of mifepristone.

  • In the wake of sweeping state restrictions on abortion and driven by a deep sense of duty, many abortion providers have made the difficult decision to become traveling providers, oftentimes at great personal cost to the stability of their own lives. Read the account of one such doctor here

  • After being denied a necessary abortion in the face of a devastating fetal diagnosis, Tennessee woman Allie Phillips has decided to take the fight into her own hands and run for a seat in the Tennessee statehouse. After her experience of being turned away for care in her home state, she met with the representative whose seat she is now challenging–during this meeting, he reportedly expressed to her that he had been under the impression that complications only occur during a person’s first pregnancy. 

  • Jeff Landry, a Trump-supported Republican and anti-abortion, anti-lgbtq+ politician, has won Louisiana’s governor’s race. 

  • In Michigan, Democratic state Rep. Karen Whitsett continues to hold-up passage of the Reproductive Health Act, citing concerns about the removal of restrictions like a 24-hour waiting period and the potential for state funding of reproductive services. 

  • The Wisconsin legislature has passed a series of anti-abortion laws and a ban on gender affirming care for minors, all of which Democratic Governor Tony Evers has said he will veto. 

  • The 11th Circuit Court of Appeals has ruled against Florida Governor Ron DeSantis’s anti-drag bill on First Amendment grounds. 

  • With all eyes on state-level elections around the country that are turning on abortion rights, watch out for ways in which Republicans are changing their language and messaging on the subject in order to paint Democrats as extreme. After anti-abortion campaigns failed to receive the support that Republicans expected in 2022, some politicians are trying to flip the script. 

  • The new Speaker of the House Mike Johnson, a Republican from Louisiana, has a long anti-abortion and anti-lgbtq+ history, including previously serving as counsel for the Alliance Defending Freedom, the group behind many state abortion bans and restrictions. 

  • Japan’s Supreme Court ruled unconstitutional a law that required transgender people to undergo mandatory sterilization in order to receive legal gender recognition.

REPRODUCTIVE HEALTH DIGEST (10/13/23)

10/13 - Developments in Abortion, Autonomy, and Access: 

In this week’s digest, we discuss the recent rulings out of Idaho and North Carolina, the Supreme Court’s new term, and the importance of abortion in upcoming state-level elections. Read our issue of the week for a dive into the role and power of abortion storytelling in the reproductive freedom movement.

Legal Changes at the State Level:
 

  • Brief Overview: 

    • Idaho: About two weeks ago, a U.S. Court of Appeals ruled that Idaho’s near total abortion ban does not conflict with obligations to provide emergency care under the Emergency Medical Treatment and Labor Act (EMTALA). This week, the Ninth Circuit has agreed to reconsider that ruling.  

    • North Carolina: A federal judge has blocked 2 portions of North Carolina’s 12-week abortion ban from taking effect during litigation. Judge Catherine Eagles halted enforcement of the requirement that abortions after 12-weeks must take place in a hospital (rather than a clinic or other appropriate setting), and she extended her block on the requirement that providers determine and document the intrauterine location of the pregnancy prior to prescribing medication abortion. 

    • Virginia: As with other state-level elections, abortion has taken center stage in Virginia’s upcoming legislative race. The outcome of the election will determine the political viability of Republican Governor Glenn Youngkin’s proposed 15-week abortion ban. 

    • Mifepristone: The Supreme Court has returned for its new term, and in the coming months it will decide whether or not to hear the case challenging the FDA’s approval of mifepristone. Whether it decides to hear the case or not, the long and short term consequences  for access to the drug will be significant.

Deeper Legal Analysis 

  • Idaho: 

    • On September 29th, the Ninth Circuit Court of Appeals issued a ruling that Idaho’s total abortion ban does not conflict with obligations under the federal Emergency Medical Treatment and Labor Act (EMTALA). On Tuesday, October 10, however, the Court agreed to reconsider that decision.  Previously, the Biden Administration sued the state of Idaho, arguing that its ban, which prohibits abortion at any gestational age unless to save the pregnant person’s life, was so strict as to run afoul of EMTALA’s federal requirements. Under EMTALA, any hospital or medical system that receives medicare funding must provide stabilizing emergency care to patients presenting at the E.R., regardless of their ability to pay. The Biden administration argued that Idaho’s narrow “life” exception put doctors in a position of risking criminal prosecution under Idaho’s state laws or risking the loss of funding under EMTALA. In August, a district court judge sided with the administration and ruled that emergency room doctors could not be subjected to criminal penalties under Idaho’s abortion ban for providing abortions in emergency cases where it is stabilizing care. However, a Ninth Circuit panel reversed that ruling.  Although the Ninth Circuit has a well-earned reputation for being one of the most liberal federal appeals courts, the panel that overturned the district court’s ruling was made up of three  Trump appointees. The panel unanimously found that the state’s law, which requires a physician to refrain from performing an abortion unless they believe it necessary to save the pregnant person from death, was sufficient under federal obligations. However, with Tuesday’s order granting reconsideration, the lower courts’ injunction is back in place, and providers are temporarily protected in cases of emergency. The case will be reconsidered by an “en banc” panel of 10 judges, randomly selected from the Court’s 28 active judges.

  • North Carolina:

    • In North Carolina, a federal judge has issued an order blocking 2 portions of the state’s 12-week abortion ban from taking effect for the time being. Specifically, Judge Catherine Eagles (1) halted enforcement of the requirement that abortions performed after 12 weeks must take place exclusively in hospital settings; and (2) extended the block on the requirement that the location of the pregnancy in the uterus be confirmed prior to prescribing a medication abortion. The order will stay in place until the litigation is resolved. As you may recall, when North Carolina passed its abortion ban over Governor Roy Cooper’s veto, it was the subject of intense scrutiny for its many medically unnecessary requirements, each of which act as additional barriers to care. With respect to the requirement that a provider document the intrauterine location of the pregnancy prior to prescribing a medication abortion, Judge Eagles found that the statute’s language is so vague that providers cannot fairly know what is required of them. She reasoned that, because pregnancy is not detectable by ultrasound until 5-6 weeks, providers may be subjected to punishment for a failure to definitively locate an early pregnancy.  This would then operate as an implicit ban on medication abortion early in pregnancy despite its legality until 12 weeks. With respect to the requirement that abortions after 12 weeks be performed in hospitals, Judge Eagles correctly found that miscarriage care performed after 12 weeks in pregnancy is not required to take place in a hospital, despite it being the exact same procedure as the one used in cases of surgical abortion. Republicans supporting the requirement offered no sound reason why the location requirement should differ between abortion and miscarriage patients. Although this is far from the final word on the details of the state’s abortion ban, it sets an optimistic precedent for the current challenge, and we will continue to update you as the litigation progresses.

  • Mifepristone

    • The Supreme Court has returned for its new term, and in the coming months it will decide whether or not to hear the case challenging the FDA’s approval of mifepristone. As a reminder, the Biden Administration filed a Petition for a Writ of Certiorari with the U.S. Supreme Court in September. A “cert petition” is the process by which a party asks the Supreme Court to review an order of a lower court–typically a federal appeals court. Unlike the federal courts of appeals, where a party has the right to have their appeal heard, the Supreme Court is not obligated to take up a case. In fact, in any given term, it grants cert in under 5% of cases. However, given the extremely public and vitally important nature of this particular case, the likelihood that the Court takes it appears higher than usual. Regardless of what the court decides, it will have massive consequences for access to the drug. If the Justices agree to hear the merits of the case, the Biden Administration faces an extremely conservative court–the very same court that overturned Roe just over a year ago. The Court could (and likely would) rule in ways that severely restrict access to the drug and upend the FDA’s regulatory process. But, if the Court declines to take the case, its stay on the lower courts’ rulings will expire and the Fifth Circuit’s ruling will go into effect, reimposing unnecessary and medically unsupported restrictions on the terms of use for the drug. As uncertainty over the future of mifepristone looms large, a small number of certified pharmacies across the country have begun directly dispensing mifepristone, with CVS and Walgreens indicating that they are also seeking certification to do so. 

  • Virginia

    • Across the country, state level elections are turning on the question of abortion policy, and Virginia’s legislative race is a key one to watch. Currently, Virginia’s Republican Governor Glenn Youngkin has not had the legislative power needed to pass abortion restrictions, making Virginia one of the only southern states where abortion remains relatively accessible. However, if Republicans take control of the state legislature, this will change. Governor Youngkin has consistently expressed his desire to pass a 15-week abortion ban, with narrow exceptions, and the debate over abortion has taken center stage in the runup to the election. Both sides attempt to paint the other as extreme on the issue, and each has invested heavily in political ads and messaging. This week, Governor Youngkin’s PAC spent 1.4 million dollars on an ad focused on abortion, with the sound of a baby cooing and an ultrasound heartbeat in the background throughout. He insists that the proposed 15-week ban is not a ban at all, but a “limit.” How Virginians turn out to vote will serve as a bellwether for other states as they strategize for their own legislative races.  And ahead of next year’s presidential election, Virginia offers a test case for the effectiveness of both pro and anti abortion messaging and tactics. 

What else is happening in access? 

  • Illinois recently had its day in court over a challenge to a 2017 state law requiring providers who do not perform abortions to give referrals to or information about abortion providers to patients who request it. This case is relevant to the simultaneous litigation around Illinois laws regulating crisis pregnancy centers. This article offers a thorough breakdown and contextualization of the ongoing cases. 

  • Massachusetts’ Attorney General has appointed Sapna Khatri as Director of its new Reproductive Justice Unit, the Unit will be dedicated to ensuring that Maryland enacts strong and comprehensive protections for both reproductive healthcare and gender affirming care. 

  • As we mentioned in our last digest, House Republicans attempted to advance a package of appropriations bills that included a provision severely restricting access to medication abortion. Thanks to heavy bipartisan opposition, that bill failed. 

  • Two shotgun rounds were fired into the front entry of a Planned Parenthood in Helena, Montana. No one was injured; however attacks and threats against providers and clinics have increased in recent years. 

  • Advocates in Nebraska have taken a page out of the pro-life playbook and put up billboards and banners pushing back against the state’s restrictive laws. 

  • Another Texas county has passed anti-abortion trafficking laws, meaning that it outlaws the use of its roads to seek an abortion. Anti-choice advocates praised this move specifically because of Cochran County’s location on the New Mexico border, a key state for Texans traveling to  access care. 

  • Russia, although historically fairly liberal on abortion, has passed restrictions on the use of medication abortion, continuing the trend of countries around the world moving backwards on reproductive rights. 

  • As we reported last week, Missouri is engaged in an ongoing fight to enshrine reproductive rights into its constitution. A Republican-led group has now weighed in in favor of easing restrictions in the state’s strict law, calling for broader exceptions. 

  • In Oklahoma, a judge has allowed the state’s ban on gender affirming care to go into effect. 

  • For a solid roundup of ongoing abortion litigation, read here. 

  • A North Carolina family, doctor, and two LGBTQ+ rights groups are suing to block the state’s gender affirming care ban for minors. 

Issue of the Week:Abortion Storytelling

Storytelling is powerful. It is how we share our human experience with others and come to learn about, relate to, and empathize with theirs. In this digest, we talk a lot about policy, legislation and litigation, and while those shape our political and legal landscape, they do not tell the full story. Legal arguments can be abstracted and compartmentalized–we can discuss and debate them intellectually without engaging more deeply with their very real human impact. But that human impact is powerful, and sometimes, the most compelling way to reach others is by simply and authentically telling our own stories. 

Throughout the reproductive justice movement, storytelling has played a huge role in opening up dialogue and breaking down stigma. And in the past several years, abortion storytelling has taken on more and more importance. Each story told allows others to see themselves reflected back and understand the nuance and incredible complexity of each person’s circumstances and decisions. Over the past year, we have seen countless harmful and restrictive laws passed in states across the country, and storytellers give a voice to the impact of those  laws and the necessity of continuing to fight for access. In states where the message from the government is that having or seeking an abortion is a morally reprehensible choice, access to stories of people who have made that choice can be empowering, validating and healing. When discussing the issue with anti-abortion advocates, storytelling can put a face to a policy and act as a tool for facilitating more empathetic and grounded conversations. Storytelling also plays an important role in moving political forces and shaping public opinion on a larger scale. 

You may recall a few years ago in Texas, when a high school valedictorian made headlines and went viral for using her commencement speech to address the passage of SB-8 (the Texas fetal heartbeat bill) and how it would impact the futures of her fellow graduates. While her speech was not an abortion story, it made waves as a reminder that personally speaking out has the power to move the listener. Organizations like We Testify make it their mission to change the narrative by amplifying the voices of abortion storytellers, “particularly those of color, those from rural and conservative communities, those who are queer-identified, those with varying abilities and citizenship statuses, and those who needed support when navigating barriers while accessing abortion care.” Similarly, Abortion Out Loud uses the power of storytelling as a tool for breaking down stigma and advocating for abortion access. In addition to written stories, activists with Abortion Out Loud “lead abortion speakouts, [] public education campaigns, and work with campus and local officials to strengthen young people’s access to abortion services.” Dr. Meera Shah, a family medicine physician and advocate for reproductive health used the power of storytelling, combined with her expert insights as a physician who provides abortions, to write her book “You’re the Only One I’ve Told, the Stories Behind Abortion.” Through the stories told, she was able to  give a platform to the diverse experiences of abortion patients. 

The truth is that everyone knows and loves someone who has had an abortion (whether they know it or not). So, as we continue in the fight for reproductive freedom and policy debates swirl around us, I encourage everyone (regardless of your position) to take a moment to explore these resources, read some of the stories and consider the storytellers behind them.

REPRODUCTIVE HEALTH DIGEST (9/29/23)

9/29 - Developments in Abortion, Autonomy, and Access: 

The legal landscape for abortion and bodily autonomy continues to change rapidly from week to week as litigation unfolds, legislatures debate and advocates organize to push back. Please read on for a discussion of the latest updates:

Legal Changes at the State Level:
 

  • Brief Overview: 

    • Ballot Initiatives Across the States: Advocates in Ohio, Arizona, Nevada and Missouri, among other states, are launching or continuing their bids to get abortion on the ballot in their state, in hopes of enshrining reproductive rights into their state’s constitution. 

    • California: In California, Attorney General Rob Bonta has sued a group of anti-abortion counseling centers and an anti-abortion group, arguing that their claims about medication abortion reversal procedures are misleading and medically unproven. 

    • Ohio: On Wednesday, September 27th, the Ohio Supreme Court heard oral arguments in the ongoing challenge to the state’s 6-week abortion ban. The ban is currently blocked by a lower court ruling, but the state has appealed that preliminary order, arguing that the ban should go into effect while the litigation plays out. 

    • Kentucky: Abortion has taken center stage in Kentucky’s gubernatorial race, highlighting how the role of abortion in state-level elections has drastically changed post-Dobbs.

Deeper Legal Analysis 

  • Ballot Initiatives Across the States: 

    • Advocates in states across the country are mobilizing to get abortion protections before voters in 2023 and 2024. In 2022, states like New York, Vermont, and Michigan voted to amend their constitutions to protect reproductive freedom, and voters in Kansas, Montana, and Kentucky rejected proposed amendments that would have limited abortion rights.  In fact, every single time reproductive rights appeared on the ballot in 2022–they won. Advocates are hoping to build on that momentum and constitutionally protect reproductive health in states across the country. The level of protection in the language of the proposed ballot initiatives varies from state to state, and they are each in different procedural stages; however, their success or failure will serve as a model for other states in the coming months and years. Please note that the states highlighted below are not a  comprehensive list of ongoing ballot initiative efforts. 

      • Ohio: We have reported extensively on developments with the ballot initiative in Ohio, and we are now a matter of weeks away from the vote. As a review, the Ohio reproductive health ballot initiative has faced opposition from anti-choice Republicans at every turn. First, they argued that the proponents of the initiative needed to collect twice as many signatures as is standard. When that effort was unsuccessful, the state held an August special election to try and raise the threshold for passing a constitutional amendment from a simple majority to 60%. Voters themselves shot down that attempt. Advocates were then forced to file another lawsuit after the ballot board returned summary language (the language that voters will actually see in the ballot box) that was materially misleading. Unfortunately, this past week, the Ohio Supreme Court issued a ruling approving the majority of the ballot board’s language. Among other things, this means that the word “fetus” will be changed to “unborn child” in the summary. The Supreme Court did rule that the ballot board must rewrite the summary to change its reference to “citizens of the state” being prohibited from passing laws restricting access, because it is the state government, not the citizens of the state, that will be constrained from doing so. As a reminder, Ohio’s proposed ballot initiative only includes protections until “viability,” with exceptions for the pregnant person’s life or health. Ohioans will vote on the referendum on November 7th. Throughout the long road to this election day, Ohio Republicans have consistently attempted to undermine the ballot initiative, choosing to place their own political agenda over the democratic process. Efforts to subvert direct democracy cannot be allowed to succeed. 

      • Arizona: Arizona for Abortion Access announced that they have begun collecting signatures for a 2024 ballot initiative protecting reproductive health care. The proposed amendment would make abortion a constitutionally protected right, prior to viability. In order to succeed, advocates need to collect almost 400,000 signatures before July 3rd, 2024. As the law currently stands, abortion is legal until 15 weeks in Arizona. 

      • Missouri: In Missouri, advocates are locked in their own battle over the language of an abortion ballot initiative. In a win for reproductive freedom, a Missouri Judge rejected misleading and inflammatory Republican-written summary language that described proposed constitutional amendments as allowing “dangerous and unregulated abortions until live birth.” The same judge also ruled against anti-abortion efforts to argue that the state auditor’s cost estimates were too low, based on their failure to provide any credible evidence to support that argument. Voters will decide the issue in 2024.

      • Nevada: In Nevada, Nevadans for Reproductive Freedom have filed a petition to add pre-viability abortion protections to the state constitution. Nevadans will have to collect just over 100,000 signatures in order to advance the petition. And, it is a long road ahead. If voters approve the ballot initiative in 2024, it would need to appear again on the ballot in 2026 for final approval before passing into law. 

  • California:

    • California Attorney General Rob Bonta is suing anti-abortion organizations over their abortion-pill reversal claims. AG Bonta’s suit argues that these organizations are advertising medically unproven treatment and misleading vulnerable pregnant people, in violation of the state’s False Advertising and Unfair Competition laws. The groups claim that the effects of mifepristone can be blocked by administering a large dose of progesterone; however, the only clinical trial ever held on the practice had to be stopped after 3 of the 12 women experienced severe bleeding. Fights over abortion pill reversal claims are ongoing across the country, with Colorado attempting to ban the practice for a lack of proven safety, and Kansas attempting to pass a law requiring abortion providers to tell their patients that their medication abortion can be reversed.

  • Ohio

    • There is more news out of Ohio this week, as the state’s Supreme Court heard oral arguments on whether to reinstate a ban on abortion after fetal cardiac activity (around 6-weeks). Previously, a lower court judge enjoined enforcement of the ban pending the outcome of the litigation, finding that it was likely unconstitutional. The state’s high court on Wednesday heard oral arguments on 1) whether the state can immediately appeal that judgment in order to have the ban reinstated while litigation plays out; and 2) whether the doctor plaintiffs have standing to bring the claim on behalf of their patients. The Court is currently made up of 4 Republicans and 3 Democrats. Although the court did not clearly indicate which way it would rule, it peppered both sides with questions throughout their arguments, and several of the justices appeared skeptical of the state’s argument that it would be irreparably harmed if the abortion ban was not immediately reinstated. An opinion from the court is likely to come only weeks or days before Ohio voters will determine whether to protect abortion rights in the constitution, as discussed above.

  • Kentucky

    • In Kentucky, abortion has taken center stage in the ongoing gubernatorial race, highlighting how the role that abortion plays in state-level politics has dramatically shifted since Dobbs. Kentucky Attorney General and gubernatorial candidate Daniel Cameron indicated last week that, if elected, he would be willing to sign a bill with exceptions for rape or incest if one crossed his desk–a complete reversal of his prior position stance. Previously, Cameron consistently indicated that he would defend the law as it is currently written, with only a narrow exception for the life of the pregnant person. Cameron’s opponent, Democratic Governor Andy Beshear has been aggressive in pushing back on Cameron’s anti-choice positions. His campaign recently released a political ad featuring a young rape survivor and accurately pointing out that the law that Cameron supports would leave her without options for care. Kentucky democrats rarely focused on abortion as a major campaign issue when Roe was still good law, with candidates instead seeking to take a middle ground and avoid the hot-button issue. However, post-Dobbs, voters have made it clear that reproductive health is a key issue for the electorate, and politicians have responded in kind, staking out their positions. 

What else is happening in access? 

  • In a truly terrifying must-watch story, the Texas attorney behind the state’s 6-week abortion ban has asked Texas abortion funds for information about every abortion that they have “assisted or facilitated in any way” in the last two years, “including details about the abortion provider, the city and state where the abortion patient lived, as well as the identity of every person,” other than the patient or their family, who assisted in the process. 

  • Michigan’s Reproductive Health Act has stalled as a democratic legislator objects to using Medicaid funds for abortion. If passed, the Reproductive Health Act would repeal a host of outdated and medically unnecessary abortion laws in Michigan, such as required waiting periods. It would also ensure that a person’s access to abortion is not dependent on the specifics of their insurance plan. 

  • In a piece of fantastic news, a Montana judge has blocked the state’s ban on gender-affirming care for minors, finding that the ban likely discriminates against minors and intrudes on their constitutionally protected privacy rights. 

  • North Dakota families are challenging the state’s ban on gender-affirming care for minors. 

  • House Republicans have introduced a bill to ban medication abortion nationwide. 

  • Poland has created a laboratory test capable of detecting whether a person has taken abortion pills. The test has purportedly already been used in investigations into pregnancy outcomes. This technology could easily be adopted in other countries, and Americans should be aware of this looming possibility. 

  • We all know how interconnected the fights for abortion rights and gender-affirming care are, but if you need any more evidence–just take a look at how the opposition treats the two issues. For more perspective on the cross-pollination between these movements, take a few moments for this must-read piece from the New York Times.  

  • As we reported in the last digest, Planned Parenthood has resumed providing abortion services in certain Wisconsin clinics for the first time in over a year. Anti-abortion groups are calling on the District Attorneys in those counties to put a stop to it, despite the D.A.'s pledges to not prosecute cases under the 1849 abortion law that the pro-life groups rely on for their argument against access. 

  • On September 21st, the Fourth Circuit Court of Appeals heard oral arguments on the question of whether insurance providers must provide coverage for gender-affirming care. The panel of judges, 8 of whom were appointed by Democrats and 6 by Republicans, did not indicate at oral argument which way they will likely rule.

Issue of the Week: Pregnancy Criminalization

This week’s Issue of the Week is guest-written by Mahathi Vemireddy, the Knighton-Newman Legal Fellow at Pregnancy Justice. Pregnancy Justice is the nation’s leading advocacy organization in the fight against pregnancy criminalization. 

In the United States, pregnant people face a unique set of obstacles: they may experience discrimination in the workplace, difficulty accessing prenatal care, and biased medical systems and providers that contribute to high maternal mortality rates. In recent years, the Supreme Court and several states have gone even further to make pregnancy more precarious for millions of Americans by revoking their fundamental right to make decisions about their pregnancies and their own bodies. While abortion restrictions have been prominently reported, a lesser-known but troubling danger many pregnant people face is the looming threat of pregnancy criminalization. Pregnancy criminalization occurs when a person is charged with alleged crimes arising from their actions or omissions during pregnancy or for their pregnancy outcomes. These types of criminal prosecutions have already occurred in the United States, but the number of cases will likely increase in a post-Dobbs America. 

Pregnancy criminalization first became widespread in the 1980s amid the disastrous and racist  “crack baby epidemic.” This unsupported moral panic armed the anti-abortion proponents with a false narrative that played on racist, sexist, and classist tropes that villainized Black women and poor people. Unfortunately, this rhetoric continues today and has essentially normalized the scheme to criminalize pregnant people despite every leading national health organization condemning the practice. Black women were overwhelmingly the victims of pregnancy criminalization in the first several decades after Roe.

Just this month, Pregnancy Justice released a report documenting cases of pregnancy criminalization from January 2006 until the Dobbs ruling in June 2022. Over this period, we identified 1,396 cases. This represents a startling increase compared to the 2013 Pregnancy Justice study which reported 413 cases between 1973 to 2005. There have been over three times as many cases in half as many years. While cases were tracked in 46 states, the vast majority of cases occurred in just five states: Alabama, South Carolina, Oklahoma, Mississippi, and Tennessee. Moreover, more than 9 in 10 cases involved allegations of the co-occurrence of pregnancy and substance use. 

State actors have increasingly penalized pregnant people through an alarming combination of carceral approaches to substance use and the spread of fetal personhood laws. Fetal personhood is the radical and false belief that an unborn fetus should have equal legal rights and protections to a living person. Moreover, fetal personhood laws are often interpreted to pit the interests and rights of the pregnant person and fetus as staunchly opposed. This leads to depriving pregnant people of their own liberties and autonomy in favor of a fetus. 

Notably, the charges a pregnant person might face range from child neglect to endangerment to manslaughter to homicide. Local prosecutors sometimes use homicide statutes to criminally prosecute pregnant people for experiencing pregnancy loss. Importantly, there is very little a pregnant woman can do, including use illicit substances, to cause a pregnancy loss. Prosecutors may also criminalize pregnant people and parents under child abuse and neglect laws for their actions or omissions during pregnancy. These cases frequently rely on a misconception that in-utero substance exposure to the fetus during pregnancy causes substantial harm to the child post-birth. Our report finds that one in three cases was first instigated by a medical professional, and two in five involved family regulation workers. 

The threat of prosecution and criminalization also prevents pregnant people from actively seeking necessary medical care, including perinatal services and substance use treatment. While all pregnant people are vulnerable to these statutes, low-income women and people of color are particularly harmed, further driving disparities in access to care and treatment. The states’ use of prosecution and punishment does not address the underlying public health needs of pregnant people and people with substance use disorders. To move forward, advocates need to understand how pregnancy criminalization, the war on drugs, and the country’s maternal health crisis are all interconnected public health concerns and require coordinated strategies to address the issues facing each impacted community.

There are many ways to challenge pregnancy criminalization and prevent future cases including: (1) providing zealous legal advocacy for pregnant people and making use of medical experts and scientific evidence in their defense; (2) increasing public understanding of the realities of pregnancy and substance use;  (3) repealing and preventing fetal personhood legislation in your state; (4) organizing to enshrine full legal rights and protections for pregnant people in state and federal law; and (5) dismantling and decoupling the healthcare system from the policing and surveillance of poor communities and communities of color.

Pregnancy Justice works with defense attorneys, medical experts, and advocates to provide free legal assistance for those facing charges stemming from their pregnancy outcome and/or their actions or omissions during their pregnancy. We also engage in policy advocacy, coalition building, public education campaigns, and track and document cases to advocate on behalf of pregnant people and their families. If you need assistance with a case or would like to get involved, please contact us

REPRODUCTIVE HEALTH DIGEST (9/15/2023)

Developments in Abortion, Autonomy, and Access: 

Abortion is set to go before the U.S. Supreme Court yet again, as the case challenging approval of mifepristone by the U.S. Food and Drug Administration (FDA) winds its way to the high court. Florida’s Supreme Court heard oral arguments last week on the constitutionality of the state’s abortion restrictions. Wisconsin Republicans are threatening to unseat a duly elected judge for politically partisan reasons, while Planned Parenthood Wisconsin has announced that it will resume offering abortion services for the first time in over a year. Threats to interstate travel continue, as states seek to extend their abortion bans beyond state borders. And, state-level battles over gender-affirming care for minors continue across the country. Because of the sheer volume of abortion and bodily autonomy news in this week’s digest, we are breaking from our normal format and omitting the “issue of the week.” But stay tuned as we share an extra special edition of that regular feature in the next Digest! Now, let’s dive into the key news from the last two weeks.

Legal Changes at the State Level


Brief Overview:

  • AHM v. FDA (mifepristone): The Biden Administration has officially asked the Supreme Court to review the Fifth Circuit’s ruling limiting the availability and terms of use of mifepristone. Because of the high profile nature of the case and the important and consequential legal issues involved, it is extremely likely that SCOTUS will agree to hear the case. 

  • Wisconsin: 

    • Planned Parenthood in Wisconsin announced on Thursday that it will resume providing abortion services on Monday, September 18 for the first time in over a year. This decision follows a July preliminary ruling from a state judge that an 1849 pre-Roe statute does not prohibit abortion. 

    • Wisconsin Republicans are threatening to remove recently elected Justice Janet Protasiewicz over claims that she should recuse herself from cases involving redistricting. Although this may not sound like a reproductive rights issue at first glance, Justice Protasiewicz’s election has shifted the court to a liberal majority at a time when Wisconsin’s abortion laws face a legal challenge that is likely to end up before the state’s highest court. 

  • Florida:

    • Last week, Florida’s Supreme Court heard oral arguments about whether the state constitution’s privacy clause protects the right to abortion. The court’s decision will determine the constitutionality of the state’s currently operative 15-week abortion ban, as well as the 6-week abortion ban that Governor Ron DeSantis signed into law earlier this year. 

  • Alabama:

    • Alabama’s Attorney General is doubling down on his position that helping a pregnant person obtain an out-of-state abortion is a prosecutable offense.

Legal Analysis: 

  • AHM v. FDA (mifepristone): : 

    • The Biden Administration has filed a Petition asking the Supreme Court to hear a challenge to the Fifth Circuit’s ruling limiting the availability of mifepristone, one of two drugs used in a standard medication abortion regime. The Supreme Court is not obligated to hear cases that come before it from the circuit courts of appeal. Generally speaking,  the Court denies the vast majority of requests for review, opting to not interfere with the lower courts’ judgment. However, the Supreme Court seems positioned to grant review of this case, given its high profile nature, potential consequences for other areas of the law, and several departures from well-accepted rules of law in the lower courts’ decisions. Now that the Biden Administration has filed its Petition, the anti-abortion physician organizations driving the litigation will have an opportunity to file their own brief, opining on whether they think the Supreme Court should review the case. It is likely to be several months before the Supreme Court makes a decision. If the Court agrees to hear the case, the parties will then submit their arguments on the merits. The outcome of this case will be incredibly consequential for both reproductive rights and health law generally, as it seemingly stands as the first time that a court has intervened to override the FDA’s expert judgment about the safety of a particular drug. 

    • As a reminder on where this case stands, the Fifth Circuit issued a decision in late August finding that the FDA’s 2016 relaxation of mifepristone’s use regulations was improper, but allowing the drug to stay on the market because the plaintiffs’ challenge to the FDA’s underlying approval in 2000 was outside of the statute of limitations. At this time, the availability of mifepristone remains unchanged, as a result of a previous Supreme Court order that stayed the effect of any lower court decisions during the pendency of litigation.

  • Wisconsin:

    • In a huge win for abortion access in Wisconsin, Planned Parenthood Wisconsin has announced that it will resume providing abortions on Monday, September 18th. Abortion has been unavailable in Wisconsin since June of last year, with providers fearing prosecution under an 1849 anti-abortion law that came back into play after Roe was overturned. However, in July of this year, state court Judge Diane Schlipper issued a ruling that the 1849 law does not apply to abortion, but instead criminalizes feticide, or the killing of a fetus by assaulting or battering the pregnant person. “There is no such thing as an ‘1849 abortion ban’ in Wisconsin,” she wrote. Armed with this ruling, Planned Parenthood has made the decision to resume operations, providing critical access to healthcare for countless pregnant people in the region. According to Planned Parenthood, Madison’s website, they offer in-clinic abortion until 20-weeks, as well as medication abortion. Although this is incredible news, it is important to note that litigation in this case is ongoing  and there has not yet been a final ruling shielding providers from prosecution or guaranteeing a right to abortion in the state. We will continue to provide updates as the situation unfolds. 

    • Wisconsin Republicans are threatening to try and remove recently elected Justice Janet Protasiewicz, if she declines to recuse herself from redistricting cases before the state’s Supreme Court. They claim that Justice Protasiewicz’s comments on the campaign trail about redistricting and abortion demonstrate that she will not adjudicate fairly. However, as the Associated Press reports, many former state justices have made public statements about issue areas, including gun rights, planned parenthood and lgbtq+ rights. In a state like Wisconsin, where state Supreme Court justices are elected, it is not uncommon for candidates to discuss specific subjects while campaigning. However, Justice Protasiewicz’s election gave the Wisconsin Supreme Court a 4-3 liberal majority for the first time in 15-years. The redistricting cases in question could disrupt Republicans’ stronghold on the state legislature. And, Justice Protasiewicz’s presence on the court drastically increases the likelihood of a favorable ruling on the state’s abortion laws. Generally, this section of the newsletter is dedicated to discussing changes in reproductive health law, and a segment like this would be saved for the section below covering other news in access. However, this developing story is of vital importance. It shows that the opposition is continuing to operate in bad faith, and that, when they lose in a free and fair election, they are willing to resort to other means to undo that loss. Removing a duly elected sitting justice for purely partisan reasons would be a stunning and disturbing disavowal of the democratic process by Wisconsin’s Republican party and it should unsettle onlookers on both sides of the aisle.

  • Florida 

    • Last week, the Florida Supreme Court heard oral arguments about the constitutionality of abortion restrictions in the state. Five of the seven current justices of the court were appointed by conservative anti-abortion Governor Ron DeSantis, and several of them have ties to the anti-abortion movement. The Florida Supreme Court previously ruled that the privacy clause in the state’s constitution extends to the decision to have an abortion. Advocates now argue that the state’s 15-week ban violates this previously recognized constitutional right. However, the state of Florida argues that the privacy clause was never intended to extend to reproductive rights, despite the court having previously found the exact opposite. At stake here is not just the currently operative 15-week ban, but also the 6-week ban that Governor DeSantis signed into law earlier this year. By the 6-week’s ban’s terms, it will go into effect 30 days after the Supreme Court issues a ruling finding that abortion is not constitutionally protected. Although it is likely to be a matter of months before the justices hand down a decision, the current makeup of the court leaves little reason to hope for a positive outcome. A negative ruling would knock out yet another access point in the already extremely restricted south, further limiting and delaying healthcare decisions. Pro-choice Floridians are already preparing for this outcome, in part by planning a campaign to get abortion access on the state’s ballot in 2024. 

  • Alabama: 

    • Alabama’s Attorney General appears to be standing behind his claim that Alabama can prosecute providers who refer pregnant people out of state for abortions. As a reminder, anti-choice advocates insisted when Roe fell that abortion should be handled by each state on its own terms, but in this case (as with other states), it is not enough for Alabama to regulate abortion within its own borders and under its own laws. The Republican AG now wants to penalize providers, and potentially family and friends, who assist Alabamians in accessing healthcare that is completely legal in another state. He appears to be arguing that, although it is legal for a pregnant person to get an abortion in another state, he can use state conspiracy laws to prosecute those who may help that person by providing assistance such as transportation, finances or information. The ACLU has filed a lawsuit challenging Alabama’s position. In it, they argue that Alabama law does not authorize such prosecutions and that it would “a blatant extraterritorial overreach of state power that not only contravenes the Due Process Clause, the First Amendment, and the fundamental constitutional right to travel, but also the most foundational principles of comity upon which our federalist system rests.” Alabama is not alone in its attempt to reach beyond its borders and regulate abortion. As we have reported on in the past, Idaho passed its own “abortion trafficking” law earlier this year. And, in Texas, where the abortion is also banned, some cities and counties have proposed ordinances that would make it illegal to use highways to transport people out of state for abortion. The architects behind this strategy are specifically targeting interstates and areas with access to airports, in an effort to hem in abortion seekers and force them to carry a pregnancy to term. 

More News in Access: 

  • Data from Guttmacher shows how abortion numbers have increased or plummeted at the state-by-state level since Roe was overturned and patients have been forced to travel out of state or carry a pregnancy to term. 

  • In building a post-Roe future, the reproductive rights movement faces important questions about how to frame the right to bodily autonomy. Advocates are grappling with whether to compromise for the sake of political moderation or use this moment as an opportunity to push for better, stronger and more comprehensive protections than were ever available under Roe. 

  • On the 2-year anniversary of Texas’s infamous ‘SB8’ (the 6-week bounty hunter law passed before Dobbs), Ms. Magazine recalls its impact and the women who have suffered  under it. And, the harm is not just limited to the patients themselves; physicians are also suffering under a legal regime that criminalizes the ethical practice of their chosen profession.

  • In a huge win for reproductive health advocates in Mexico, the country’s supreme court has decriminalized abortion, ruling that its continued criminalization constitutes violence and gender discrimination. 

  • Idaho faces an impending maternal health crisis as the state’s draconian abortion laws cause doctors to leave the state and recruitment and retention of new providers to fall. A statement provided by Idaho Republican Representative John Vander Woude sheds light on how well thought out these anti-abortion laws are–he stated “[w]e never looked that close, and what exactly that bill said and how it was written and language that was in it…[w]e did that thinking Roe v. Wade was never going to get overturned.” 

  • Against the wishes of many of his fellow Republican senators, Alabama Senator Tommy Tuberville continues to hold up more than 300 nonpolitical military promotions, in protest of the Pentagon’s policy of allowing time off and reimbursement for service members who need an abortion. 

  • A district court out of Georgia has reversed course on gender affirming care, allowing the state’s ban to resume, after the 11th Circuit Court of Appeals–the federal appeals court over Alabama, Florida and Georgia–issued an adverse ruling in a case challenging Alabama’s ban. 

  • Women in Idaho, Tennessee and Oklahoma have filed suit against their respective state’s abortion bans, recounting the deeply personal stories of how each state’s harsh and poorly written laws have placed their lives in jeopardy during pregnancy and forced their physicians to provide substandard medical care. These new lawsuits follow on the heels of the Texas lawsuit brought by women affected by the state’s total abortion ban.

REPRODUCTIVE HEALTH DIGEST (9/1/2023)

Developments in Abortion, Autonomy, and Access: 

Since L4GG’s last digest, two state supreme courts have ruled against abortion, allowing Indiana’s total abortion ban to go into effect and South Carolina to restrict access to approximately 6-weeks gestational age. A federal court out of West Virginia has dismissed a lawsuit relating to mifepristone, Ohio advocates continue to fight for a reproductive health ballot initiative, and debates about gender-affirming care and abortion continue in courtrooms and statehouses all over the country. Please read on for more detail.  

Legal Changes at the State Level: 

  • Brief Overview: 

  • Indiana: Abortion is now banned in Indiana, following the state Supreme Court’s denial of the ACLU and Planned Parenthood’s request for rehearing. The law contains narrow exceptions for the life or health of the pregnant person, lethal fetal anomalies detected prior to 20-weeks gestation, and circumstances of rape or incest prior to 10-weeks gestation. 

  • South Carolina: On August 23, the South Carolina Supreme Court issued an order upholding the state’s renewed ‘fetal heartbeat’ ban, which restricts abortion to approximately 6-weeks gestational age. This ruling comes just months after the court struck down a nearly identical ban. 

  • West Virginia: A U.S. District Judge out of West Virginia dismissed the majority of a case challenging West Virginia’s ban on mifepristone. The case was brought by GenBioPro Inc., the manufacturer of the generic version of mifepristone. They argue that the ban conflicts with federal regulation of the drug, which approves of its use for medication abortion. 

  • Ohio: The saga over the proposed reproductive health constitutional amendment in Ohio continues this week, as advocates have been forced to file a lawsuit challenging the summary language approved by the ballot board. The phrasing of the summary is important, as this will be the language that voters see in the ballot box when they decide which way to vote. 

Legal Analysis: 

  • Indiana: 

    • Following the Indiana Supreme Court’s denial of the ACLU and Planned Parenthood’s request for rehearing, Indiana’s total abortion ban is now operative.. Although abortion has been functionally unavailable in the state since August 1st, when the law was initially set to go into effect, advocates had hoped that the court would grant their petition and put the ban on hold while further litigation over the ban’s constitutionality played out. Justice Christopher Goff dissented from the opinion, stating his concerns about the contours of the life and health exception and asserting that, “having declared the right of a woman to protect her life, [the] court should not now let that right go unprotected.” His concerns are consistent with the reality of how vaguely written life and health exceptions are playing out across the country. As a reminder, the Indiana ban prohibits abortion at all stages of gestation with narrow exceptions for 1) the health of the pregnant person; 2) lethal fetal anomaly if the gestational age is 20-weeks or less; and 3) rape or incest if the gestational age is 10-weeks or less. In a survey of the 8 major hospital systems in the state about whether they would provide abortions in cases of rape or incest, only 1 affirmed that they would perform the procedure; 3 (religious affiliated hospitals) stated that they would not provide such abortions, 2 did not respond to a request to comment, and 2 declined to comment. Indiana is the 15th state to fully ban abortion, with many others severely limiting access or attempting to ban it altogether. 

  • South Carolina:

    • South Carolina’s Supreme Court issued a ruling upholding the state’s renewed 6-week 'fetal heartbeat’ ban, narrowing abortion access in the state to a gestational age when many people do not yet know that they are pregnant. The order comes mere months after the state supreme court struck down a nearly identical 6-week ban on the grounds that it was unconstitutional. The court reasoned that, although the 2023 law infringes on a pregnant person’s “right of privacy and bodily autonomy,” those interests do not outweigh “the interest of the unborn child to live.” The South Carolina Supreme Court is all-male, after the Republican majority legislature replaced former Justice Kaye Hearn in February. Only Chief Justice Warren Beatty dissented from his colleagues, citing his concern that the way fetal cardiac activity is characterized in the bill is “medically and scientifically inaccurate” and is a “quintessential example of political gaslighting; attempting to manipulate public opinion and control the reproductive health decisions of women by distorting reality.” Despite conflicting arguments by the parties and medical ambiguity, the majority’s opinion failed to define “fetal heartbeat,” instead stating in a footnote of the order that it would leave that question for “another day.” Unfortunately, physicians who face devastating penalties if they are found to be in violation of the law do not have the luxury of operating in uncertainty until “another day” comes. Providers in the state have already reported that the vague law is having a chilling effect on the practice of reproductive health care, and this confusion and ambiguity is exactly what anti-abortion legislators are counting on. 

  • West Virginia: 

    • In West Virginia, a U.S. District Court Judge has dismissed the majority of a case challenging the state’s ban on mifepristone. The plaintiff in the case, GenBioPro Inc., the manufacturer of the generic version of mifepristone, argues that the state’s prohibition conflicts with federal regulation and approval of the drug for use in medication abortions. In his ruling, Judge Chambers stated that SCOTUS “has made it clear that regulating abortion is a matter of health and safety upon which States may appropriately exercise their police power.” Although Judge Chambers dismissed the majority of the suit, he allowed GenBioPro’s challenge to West Virginia’s ban on the use of telemedicine for abortion to survive, finding that it was in conflict with federal law. However, due to the severe restrictions on abortion availability in the state, the benefit of that ruling is limited. Interestingly, although he granted dismissal, Judge Chambers’ opinion is unambiguous in its appraisal of the safety of mifepristone. In his ruling, he states that “Defendants have not disputed the safety of the mifepristone REMS, nor could they,” and explains that, with respect the Fifth Circuit case challenging the FDA’s approval of mifepristone, the court “has reviewed the Fifth Circuit decision and does not find its primary determinations to be persuasive.” 

  • Ohio: 

    • In Ohio, advocates supporting the reproductive health ballot initiative that will be before voters in November have been forced to file another lawsuit, this time challenging the summary language approved by the ballot board. The summary language will be what voters actually read in the ballot box when they decide whether to vote for or against the amendment, so the manipulation of the language is just one more opportunity for anti-abortion Republicans to attempt to deceive and coerce voters. The summary language diverges from the actual proposed amendment in a number of material ways. First, although the amendment would protect a whole spectrum of reproductive decisions including contraception, fertility treatments, miscarriage care, and continuing one’s pregnancy, the approved summary only mentions abortion by name. Further, the clause in the proposed amendment that explains that the state shall not interfere with the right to pre-viability abortion has been changed to read that the “citizens of the state of Ohio” may not interfere with that right. This change in language is blatantly deceptive, as it is the state itself that would be prohibited from passing laws infringing on the rights of pregnant people, not Ohio citizens. The summary additionally changes the phrase “pregnant patient” to “pregnant woman,” and the medical term “fetus” is changed to “unborn child.” None of these changes actually provide clarity about the content of the amendment for the voters who will decide on its passage; instead, they muddy the waters and replace accurate language with politically coercive and misleading phrasing. Although we have said it before, it bears repeating yet again that if Ohio Republicans are so sure that their constituents do not support abortion–why not just let them vote on it in a fair and clear election? 

More News in Access: 

  • Virginia Governor Glenn Youngkin is considering a 15-week abortion ban as the state gets closer to its November legislative election. If Virginia Republicans manage to flip the Senate and hang on to their current majority in the House, the Governor will be emboldened to advance a more conservative agenda. This could be devastating for abortion in the South, where Virginia is one of the only remaining strongholds of access. 

  • In Alliance for Hippocratic Medicine v. FDA, Fifth Circuit Judge Ho has been criticized for arguing that the plaintiffs have standing to challenge the FDA’s approval of mifepristone because, similar to environmentalists who suffer harm from governmental actions that threaten an animal’s habitat, “[u]nborn babies are a source of profound joy for those who view them,” and “[d]octors…experience an aesthetic injury when they are aborted.” 

  • In Texas, a state district court judge granted an injunction pausing the state’s ban on gender-affirming care for minors. The state appealed that ruling, and on Thursday, the Texas Supreme Court lifted the injunction, allowing the ban to go into effect during the pendency of litigation. 

  • New Mexico’s Supreme Court has agreed to hear oral arguments on whether local abortion bans enacted by counties and cities across the state are a violation of state law, which protects the right to abortion. 

  • Kentucky’s gubernatorial race will be a crucial determinant of future abortion access in the state. 

  • In another win for gender-affirming care, a federal judge in Georgia has issued an injunction temporarily halting enforcement of the state’s ban on gender-affirming care for minors. This ruling is already under fire, after the Eleventh Circuit issued an adverse ruling in a federal case relating to Alabama. 

  • In Nebraska, abortion groups have begun a push for a 2024 ballot initiative protecting abortion. 

  • Missouri’s gender-affirming care ban is now in effect, following a judge’s denial of a legal challenge to the law. 

  • Anti-abortion activists, including one who was found to be storing fetal remains in her D.C. home, have been convicted under the Freedom of Access to Clinic Entrances Act for blockading a D.C. abortion clinic for over three hours, disrupting care, and causing harm. They will face sentencing later this year.

Issue of the Week: Healthcare Amendments and Abortion Access

This week’s “Issue of the Week” is a continuation of our series focusing on the different strategies being used to protect reproductive freedom. This week’s installment has been guest written by L4GG intern Veronica Dickstein.

A post-Dobbs world has forced abortion advocates to be creative about the strategies used to combat restrictive abortion bans. While a previous blog post featured religious freedom challenges to abortion bans, this post will focus on state-level healthcare-related constitutional amendments and how they are being used to protect abortion.

After the Affordable Care Act (ACA) was passed by the Obama administration, Wyoming, Ohio, Alabama, Arizona, and Oklahoma all amended their constitutions in an effort to circumvent the ACA’s individual coverage mandate. Generally, these state constitutional amendments assert that citizens of the state have a right to make healthcare decisions for themselves. For example, Ohio’s 2011 Healthcare Care Freedom Amendment states that “no federal, state, or local law or rule shall compel, directly or indirectly, any person, employer, or health care provider to participate in a health care system.” Alabama’s Amendment 864, Article 27, Section 2 of the Arizona Constitution, and Oklahoma’s 2010 Healthcare Freedom Amendment each state exactly the same.

Although the language in these amendments was not intended to protect abortion, their broad character leaves room for pro-choice arguments. Pro-choice advocates in Wyoming and Ohio argue that they protect a citizen’s right to make healthcare decisions without governmental intrusion, including the decision to have an abortion. Conversely, defendants respond that, because these amendments do not completely prevent the government from regulating healthcare, prohibitions and limitations on abortion remain constitutional.

In Johnson v. State of Wyoming, the plaintiffs challenge the state’s total abortion ban under Wyoming’s healthcare amendments and state constitutional guarantees of equality, due process, equal protection, bodily autonomy, and privacy. A related argument was used by Wyoming judge Melissa Owens earlier this summer to at least temporarily block proposed legislation that would ban abortion pills in the state. Similarly, advocates in Preterm-Cleveland v. Yost rely on the Ohio Healthcare Care Freedom Amendment and state constitutional protections for equal protection, individual liberty and privacy to challenge Ohio’s attempted fetal heartbeat ban. In August 2022, Wyoming’s Supreme Court granted a preliminary injunction, temporarily blocking the state’s ban from implementation, and in October 2022, Ohio’s First District Court of Appeals issued a preliminary injunction in Preterm-Cleveland v. Yost. In both of these decisions granting preliminary injunctive relief, the courts expressed concern about the vagueness of the bans, saying it was unclear how health-related exceptions would be applied to medical decision-making – a concern that is echoed for abortion bans across the country. Vague non-medical language harms the provider’s ability to effectively exercise their expert judgment, developed through years of education and training, in determining the appropriate course of treatment. This restricts or delays patient access to high-standard care, harming health outcomes and impeding on the right to make healthcare decisions for oneself in violation of Ohio and Wyoming’s state constitutions. And, the invocation of 14th Amendment-esque protections as a supporting cast in cases that focus on the right to make healthcare decisions demonstrates the inherent interconnection between healthcare and questions of bodily autonomy, privacy, and freedom from governmental intrusion. 

Although the outcomes of these cases are not yet known, the strategy of using healthcare amendments to fight for abortion access is an extremely important one to watch, particularly in states that are traditionally hostile to abortion. These healthcare amendments are a potentially highly effective tool for protecting abortion access. They were originally enacted to promote a conservative agenda by stifling the effectiveness of the ACA, and their use for this purpose is both creative and a little ironic. As the ACA has “indisputably improved [health insurance coverage],” historically, efforts like these amendments to undermine it have not improved equality or medical care in America. Maybe now, through these cases, these amendments can find new life and efficacy in the reproductive rights arena, saving thousands of American lives.

REPRODUCTIVE HEALTH DIGEST (8/18/23)

Developments in Abortion, Autonomy, and Access: 

In the past two weeks, the Fifth Circuit’s ruling in the mifepristone case dropped, Ohio held its vote on Issue 1, and litigation and legislation around the country saw movement in both positive and negative directions. Please read on for more information. 

Legal Changes at the State Level: 

  • Brief Overview: 

  • AHM v. FDA (mifepristone): The Fifth Circuit has ruled in Alliance for Hippocratic Medicine v. FDA, the case challenging the FDA’s 2000 approval of mifepristone for use in medication abortion. The conservative 3-judge panel’s Opinion upheld restrictions on access to the drug, but declined to pull it from the market entirely. Please note: Despite this ruling, there will be no changes to the drug’s availability during the pendency of the litigation, as a result of a previously issued Supreme Court Order. 

  • Ohio: In Ohio, the Issue 1 vote to raise the threshold for a constitutional amendment from a simple majority to 60% has failed. This has huge implications for the proposed constitutional amendment to protect abortion that will appear on the November ballot. 

  • Idaho: Educators in Idaho have filed a lawsuit challenging the state’s “No Public Funds for Abortion Act” as a violation of their First and Fourteenth Amendment rights. 

  • Nebraska: In Nebraska, a judge has ruled in favor of the state’s combined 12-week abortion ban and gender affirming care ban. 

Legal Analysis: 

  • AHM v. FDA (mifepristone): 

    • On Wednesday afternoon, the Fifth Circuit issued its much anticipated Opinion in Alliance for Hippocratic Medicine v. FDA. In the 93 page order, the 3-judge panel ruled to restrict access to the drug, but declined to pull it from the market entirely. As a reminder, this case was brought by anti-abortion physicians and physician groups challenging the FDA’s 2000 approval of mifepristone for use in medication abortions. Relying on scientifically dubious studies, the Plaintiffs argue that mifepristone is not sufficiently safe and that the FDA erred in approving the drug in 2000 and later modifying its regulations for use in ways that increased access. In April, Trump-appointee Judge Matthew Kascmaryk sided with the Plaintiffs and ordered the pill to be removed from the market; however, the Supreme Court issued an order in April blocking Judge Kascmaryk’s ruling from going into effect until the litigation reaches its final conclusion. Wednesday’s Order reverses Judge Kascmaryk’s ruling on the FDA’s 2000 approval of mifepristone, finding that the Plaintiffs are outside of the statute of limitations. But, it maintained restrictions on the drug’s use, including limiting its use to 7 weeks (though it is currently approved through 10-weeks), and requiring it to be prescribed in person, rather than allowing for  telemedicine. The Fifth Circuit’s opinion is out of step with major health organizations worldwide, which approve of the safety of telemedicine for prescribing mifepristone. If the ruling holds, it would devastate clinic capacity and patient access to care, as overwhelmed clinics rely heavily on the availability of telemedicine to serve the surge of patients traveling from ban states to receive care. The Court’s finding that the Plaintiffs have standing to bring their challenge is also a stunning departure from accepted standing jurisprudence and could have precedential consequences in countless other cases. The panel found that the doctor’s have standing to challenge the FDA’s approval of mifepristone, because they may someday have to participate in abortion care if a patient who took mifepristone presents in their E.R. or clinic–despite the fact that federal law protects the doctors’ right to assert conscience objections in circumstances where providing certain care is against their moral beliefs. In his concurring opinion, Judge Ho suggested that, in addition to the injuries asserted, the plaintiff’s also have an “aesthetic injury.” Judge Ho analogized this case to cases involving wildlife preservation and offered the following reasoning: 

"its well established that, if a plaintiff has ‘concrete plans’ to visit an animal's habitat and view that animal, that plaintiff suffers aesthetic injury when an agency has approved a project that threatens the animal ....[u]nborn babies are a source of profound joy for those who view them. Expectant parents eagerly share ultrasound photos with loved ones. Friends and families cheer at the sight of an unborn child. Doctors delight in working with their unborn patients--and experience an aesthetic injury when they are aborted."

The case is all but guaranteed to make its way back up to the Supreme Court, although when the Court would take up the case, and on what question, is uncertain. Crucially, access to mifepristone remains unchanged at this time, as a result of the Supreme Court’s April Order.  

  • Ohio:

    • In other much-anticipated news,  Ohio Issue 1, the special election issue to determine whether to raise the threshold to pass a constitutional amendment from a simple majority to 60% has failed. This has huge potential implications for abortion in the state, as a ballot initiative protecting certain abortions will be directly before voters in November. The success or failure of the Ohio ballot initiative will serve as a model for advocates on both sides of the abortion fight in other states around the country.

If the proposed amendment passes, it would effectively codify the Roe standard in Ohio by providing a fundamental right to abortion pre-viability and allowing the state to enact restrictions post-viability. Although the outcome of the November election is far from a foregone conclusion, reproductive rights have succeeded all six times that they appeared on a state ballot in 2022. 

  • Idaho: 

    • Educators in Idaho have filed a federal lawsuit challenging the state’s “No Public Funds for Abortion Act” (NPFAA) as a violation of their First and Fourteenth Amendment rights. The NPFAA prohibits the use of public funds, including those used to fund Idaho public universities, to “promote” or “counsel in favor” of abortion. In their Complaint, six Idaho professors and two teachers’ unions argue that the law, which does not provide a definition for “promote'' or “counsel in favor of” is unconstitutionally vague and criminalizes academic speech that could be construed as expressing a viewpoint favorable to reproductive rights. The Plaintiffs argue that they are forced to either alter their lesson plans, or risk the state enforcing the NPFAA against them, with prison time up to 14 years as a potential consequence. In the complaint, the plaintiffs describe the chilling effect that the law has already had on free academic discourse. For example, a philosophy professor has stripped a module about human reproduction from the curriculum, because it would typically include materials presenting viewpoints on both sides of the abortion issue and could lead to a classroom discussion about the merits of reproductive freedom. A political science professor ceased giving a lecture about public opinion on abortion across the states for fear that it could run afoul of the law. Another professor scrubbed reference to their research on reproductive freedom from their online profile. The Complaint details several other concrete examples of how the law is impacting academic freedom. The state has issued no guidance or reassurance on how the law would be applied to academics. The NPFAA’s potential application to academic discussion underscores how the fight for bodily autonomy is inextricably linked to the fight for a free and open society. We cannot have one without the other.  

  • Nebraska: 

    • In a Nebraska lawsuit, a judge has ruled in favor of the state’s combined 12-week abortion ban and ban on gender affirming care for minors. As we have previously reported on, after failing to enact other abortion bans, the Nebraska legislature tacked a 12-week abortion ban onto a preexisting bill banning gender affirming care for minors. The combined law was pushed through at the last second in the state’s 2023 legislative session. Planned Parenthood and the ACLU challenged the law, arguing that it violated the state constitutional requirement that bills only contain one subject. The Court sided with the state, finding that the subjects were appropriately contained in one bill, because they both relate to health. Planned Parenthood and the ACLU have indicated their intent to appeal the order; however, for the time being, Nebraska’s law remains effective and abortion is severely limited in the state. 

More News in Access: 

  • A Texas prison guard who experienced a stillbirth after being forced to stay at her post while 7-months pregnant and experiencing labor pains is suing the state of Texas. Texas is fighting the suit, arguing in part that her fetus did not have personhood rights. This is a significant departure from Texas’s decades-long insistence that a fetus should be recognized as a person from the time of fertilization. 

  • Maine recently amended its abortion law to grant providers greater discretion in using their medical judgment to determine when an abortion is necessary. Opponents of this move will not attempt to nullify it via a constitutional referendum

  • Arizona abortion advocates have begun a push for a 2024 ballot initiative that, if successful, would put the question of whether to constitutionally protect abortion directly before voters next year. 

  • An anti-choice student group, Students for Life of America,  continues to challenge mifepristone access under the Clean Water Act, circulating a petition that calls for an assessment of the drug’s impact on the country’s recreational water sources. SFLA President Kristan Hawkins stated the following in support of SFLA’s position: “[t]oday, more than half of all abortions–says the abortion industry–are committed with pills, meaning that all of that tissue and human remains goes into our water supply[;] [s]ome ingredients of the pill in the Chemical Abortion Pill protocol continue to be active after leaving a woman’s body. What is that doing to fish, animals, endangered species, plans and even human beings?” 

  • In Georgia, supportive parents are fighting to block the state’s ban on gender affirming care for minors, arguing that the law is unconstitutional and supersedes their ability to make medical decisions on behalf of their children. 

  • In Idaho, a federal judge has temporarily blocked legislation requiring public school students to use the bathroom that corresponds with the sex they were assigned at birth. 

  • Texas is seeking more than $1.8 billion in reimbursements from Planned Parenthood. The lawsuit moved forward this week with a hearing in front of Judge Matthew Kascmaryk, the judge who ruled against the FDA’s approval of mifepristone earlier this year. 

  • In Montana, the Attorney General made comments during an interview suggesting that Planned Parenthood has covered up instances of human trafficking.

  • North Carolina lawmakers have voted to override Governor Roy Cooper’s veto on the state’s ban on gender affirming care, allowing the ban to pass into law. 

Issue of the Week: State Constitutional Amendments 

This week’s “Issue of the Week” is a continuation of our series focusing on the different strategies being used to protect reproductive freedom. This week’s installment has been guest written by L4GG intern Kieran Malik. 

It has been barely a year since the Supreme Court’s decision in Dobbs, and our country is facing a landscape more hostile to reproductive healthcare than we have seen in decades. This is a time of profound crisis for millions of Americans, but it also offers an opportunity for us to reimagine reproductive rights law and create something far more protective, comprehensive, equitable and lasting than Roe ever was. 

There are a variety of state-level legal strategies being pioneered in defense of reproductive freedom. One of these is the enshrining of  reproductive rights into state constitutions. Below are some examples of how this tactic is being employed by activists across the country and how it can be effective:

  

ERA approach: 

Originally passed by Congress in 1972, the Equal Rights Amendment (“ERA”) was an attempt to establish sex equality under the law in the US Constitution. While opponents of the women’s liberation movement prevented the amendment from being ratified by the states before the deadline, reproductive rights activists are reviving the ERA as a strategy for protecting bodily autonomy at the state-by-state level. State level ERA’s can provide a legal hook for arguments that abortion is constitutionally protected. A lawsuit filed by a reproductive health center in Pennsylvania argues that the state’s failure to provide Medicaid coverage of abortion is a form of sex discrimination that violates the state’s equal rights amendment. If successful, the suit will serve as an example for the defense of bodily autonomy in as many as 24 states with ERAs. This past January, the New York legislature passed an equal rights amendment that will appear on the ballot for ratification in November 2024. The ERA broadly defines sex discrimination as encompassing “sexual orientation, gender identity, gender expression, pregnancy, pregnancy outcomes, and reproductive healthcare and autonomy” – explicitly protecting both reproductive rights and trans rights as an integral part of sexual equality. 

Reproductive Rights Amendments: 

After the devastating decision in Dobbs, many states are going a step further and working to establish constitutional amendments directly and explicitly protecting reproductive rights alone . These protections tend to be more comprehensive than those provided under pre-Dobbs law. For example, in 2022, Vermont and California passed ballot measures protecting abortion without any reference to viability, a limit to reproductive freedom imposed under Roe. As discussed in the last digest, although state legislatures commonly refer to viability and define it as a fixed moment in fetal development, medical professionals assert that fetal viability is a complex concept that cannot be determined by gestational age alone. The American College of Obstetricians and Gynecologists “strongly discourages the use of viability in legislation or regulation.” A state-by-state approach to reproductive freedom legislation provides an avenue to avoid such misuse of medical concepts by politicians at the federal level. 

However, in other states it has proven more difficult to defeat the ideological warping of medicine in the law. Michigan’s 2022 constitutional amendment and Florida’s proposed amendment for 2024 only protect the right to abortion before viability (Florida’s law clarifies that such an amendment would not threaten parental notification). While legislation that makes such concessions can provide much-needed healthcare rights to millions of Americans, they fall short of achieving true reproductive freedom. When dealing with law as powerful and lasting as state constitutional amendments, we must be sure that it provides access to all people who need it, and that it lays a proper foundation for future policies.  

Expanding Access, Not Just Rights: 

Roe may have provided temporary and limited protection from infringement upon one’s bodily autonomy, but it failed to engage with or create the resources necessary to ensure equity in reproductive healthcare access. The Hyde Amendment still prevents Medicaid coverage for abortion in many states, leaving the most disadvantaged Americans without access the full range of their reproductive choices. In the fight for new legal protections, we have the opportunity to not just defend reproductive healthcare access, but to expand it and reimagine what reproductive freedom looks like. For example, in May, Rhode Island passed the Equality in Abortion Coverage Act, which provides abortion coverage under Medicaid and state insurance. It joins 16 states that have rejected the Hyde Amendment in order to provide reproductive healthcare for all their citizens. 

Protect Our Future: 

This June, the Supreme Court ruled in Moore v. Harper that powers granted to the states by the federal government must be exercised in accordance with state supreme court decisions and constitutions. As such, a state-by-state constitutional amendment strategy can be an incredibly powerful defense of reproductive rights. When written comprehensively, these amendments can protect our rights now and provide a powerful defense against any future state-level attacks that may be leveled against them.

As early as November, Americans across the country will have the opportunity to enshrine reproductive rights in their state constitutions. These amendments have the potential to significantly strengthen existing protections, or reverse devastating restrictions on reproductive healthcare. But more than that, they have the power – we have the power – to expand reproductive healthcare access more than ever before, and protect our bodily autonomy for generations to come.

REPRODUCTIVE HEALTH DIGEST (8/4/23)

*Note: An urgent update was also sent on August 7th due to important developments in abortion law that came out of Illinois and Texas. This update is here:

Illinois

  • As we reported in last week’s digest, Illinois recently passed legislation expanding its existing consumer fraud protections to allow civil actions against Crisis Pregnancy Centers (CPCs) that are found to have engaged in deceptive and dishonest business practices. The new law was immediately challenged on First Amendment grounds by anti-choice groups claiming that it discriminates against their pro-life viewpoint. Late on Thursday, August 3rd, a Trump-appointed federal judge issued an oral order granting a preliminary injunction temporarily blocking the new law from taking effect. Illinois Governor JB Pritzker defended the law on Friday, stating “I’m confident this is constitutional. It's legal. Remember what they're doing. They're putting their crisis pregnancy centers next door to abortion rights centers, and they're directing people to go in their front door or telling them things that aren't true, often.” 

Texas

  • A Texas state district judge issued a ruling on Friday, August 4th, temporarily enjoining enforcement of the state’s total abortion ban in cases where physicians used their “good faith judgment” to end a pregnancy because of serious complications or risk to the pregnant person. The case was brought by a group of women who were denied abortions despite serious risks to their health or diagnoses that their pregnancies were no longer viable, and it is believed to be the first case brought directly by patients denied abortion care. The Texas Attorney General’s office immediately filed an appeal against the ruling, blocking it from taking effect. The outcome of this litigation will inform strategies used in other cases that seek to challenge harsh and poorly written abortion bans across the country.


8/4 - Developments in Abortion, Autonomy, and Access: 

The legal landscape for abortion and bodily autonomy continues to change rapidly from week to week as litigation unfolds, legislatures debate and advocates organize to push back. Please read on for a discussion of the latest updates:

Legal Changes at the State Level:
 

  • Brief Overview

    • Indiana: Indiana’s total abortion ban was set to go into effect on Tuesday, August 1st. However, the ACLU filed a petition with the state supreme court late Monday evening, asking the court to keep the ban on hold while it considers challenges to law. Although this move has temporarily delayed implementation of the ban, it seems that all Indiana abortion clinics have ceased offering abortion care in the interim.

    • Maine: Maine passed changes to the state’s abortion law that expand access to care and place greater medical decision making authority in the hands of providers.

    • Alabama: A group of Alabama health care providers have filed suit in federal court in response to Alabama Attorney General Steve Marshall’s threats to prosecute individuals who assist pregnant people over state lines to obtain legal abortions. This lawsuit comes on the heels of a similar interstate travel-based challenge in Idaho, to that state’s “abortion trafficking” law.

    • Ohio: As we have reported on in previous issues of this digest, Ohioans are fighting to get abortion protections on the state’s November ballot. Last week, the Ohio Secretary of State certified that advocates have obtained enough valid signatures for the ballot initiative to move forward, taking them one step closer to a vote. However, Ohio Republicans continue to attempt to block the ballot measure–this time with a new lawsuit challenging its compliance with statutory requirements. 

    • IllinoisIllinois has joined other states in passing legislation aimed at deterring “crisis pregnancy centers” from engaging in deceptive and misleading practices. The Illinois law is being challenged on First Amendment grounds by groups advocating for the value of CPCs. 

Deeper Legal Analysis 

  • Indiana: 

    • Indiana’s total abortion ban was set to go into effect on Tuesday, August 1st. However, late Monday evening, the ACLU filed a petition with the state supreme court, asking it to keep the law on hold while it pursues a narrower preliminary injunction at the trial court level. This move has temporarily delayed implementation of the ban, while the court considers the filing. However, Indiana’s six abortion clinics have all ceased offering abortion services in anticipation of the ban becoming operative,, devastating access for pregnant people in the state. As a reminder, Indiana’s law bans abortion at all stages of pregnancy. It limits where abortions may take place to hospitals and ambulatory surgical centers, despite the demonstrated safety of abortions performed in a clinic setting. It provides only narrow exceptions for instances of rape or incest until 10 weeks in pregnancy and for fatal fetal anomaly until 20 weeks. Although the law was subject to immediate challenge upon passage, the state supreme court ruled that the ban did not violate the Indiana constitution. Advocates now face an uphill battle in renewing their legal opposition to the law.  

  • Maine:

    • In Maine, Democratic Governor Janet Mills has signed a new bill into law that expands access to abortion in the state and defers to the expert judgment of providers. The previous law banned abortions after fetal viability, but it made an exception for circumstances where the patient’s life is in danger. Under the new law, a post-viability abortion is permissible if it is deemed necessary in the professional judgment of the physician. This makes Maine’s new law one of the most expansive in the country, and it does the crucial work of putting expert decision making authority into the hands of the medical professionals rather than legislators. In support of the amended law, Governor Mills cited the case of a Maine woman who was forced to travel to Colorado for an abortion at 32 weeks after discovering that her fetus had a deadly form of skeletal dysplasia. Under Maine’s previous law, she was unable to obtain care in her home state despite the devastating fetal diagnosis. Cases like this highlight the problem with laws that fail to engage with the complex realities of pregnancy and the need for physician’s to be able to exercise their expert judgment in concert with a patient’s wishes. 

  • Ohio:

    • As we have discussed in previous issues of this digest, Ohio is locked in an ongoing battle over whether a constitutional amendment protecting certain abortions will be on the November ballot. Last week, the Ohio Secretary of State certified that advocates have obtained enough valid signatures to satisfy requirements for a ballot initiative, taking them one step closer to a vote. However, Ohio Republicans continue to attempt to block the ballot measure–this time with a new lawsuit challenging its compliance with statutory requirements. As groups on both sides continue to fight over the ballot initiative, it is worth taking a moment to recall all of the steps that Republicans in the state have taken to attempt to stop it from advancing to a direct vote in November. 

    • At the outset, Republicans brought a baseless legal challenge arguing that the ballot initiative should have been split into two separate issues: one for abortion and a second for all other reproductive healthcare. Had this argument succeeded, proponents of the initiative would have been forced to go back to the drawing board and collect twice as many signatures as they had planned for. The state Supreme Court struck down this argument, unanimously finding that the issues were properly contained within one initiative. Republicans then successfully set an August special election to determine whether to raise the threshold for passing any state constitutional amendment from a simple majority to 60%. Ohio Secretary of State Frank LaRose has admitted that this election is entirely about keeping abortion off of the ballot. In addition to the August special election, Ohio Republicans have now filed another lawsuit, primarily arguing that the petition proposal did not satisfy statutory requirements. The Ohio Supreme Court has set a deadline of August 7th to receive documentation from each of the parties. 

      The entire fight over this ballot initiative shines a light on ways in which direct democracy can be subverted by special interests. It also begs the question–if Republicans are so certain that Ohioans don’t support abortion, then why not simply let them vote on it?

  • Alabama: 

    • A group of Alabama health care providers have filed suit in federal court, challenging Attorney General Steve Marshall’s threats to prosecute individuals who help Pregnant Alabamians over state lines to obtain an abortion. The Complaint argues that the Attorney General’s threatened actions are a violation of due process, the First Amendment, and the fundamental right to travel. It also places the challenge in the context of Alabama’s high maternal mortality rate and the reality that women of color are disproportionately impacted by a lack of access to healthcare. This lawsuit comes on the heels of the challenge in Idaho to the state’s “abortion trafficking” law.  In the Idaho case, A federal judge has just issued a temporary injunction blocking Idaho Attorney General Raul Labrador from prosecuting providers for referring patients out of state for abortion care. With the erosion of Roe’s legal reasoning, the landscape of legal arguments for preserving access to abortion is changing. Arguments for access are now turning on concepts like the right to travel, freedom of expression and even religious freedom. Many of these legal theories are as yet untested in an abortion context, and the litigation that unfolds in the coming months and years will inform the strategies used by the next generation of advocates. 

  • Illinois:

    • Illinois has joined the ranks of states passing legislation aimed at deterring “Crisis Pregnancy Centers” from engaging in deceptive and misleading practices in order to achieve their goal of dissuading pregnant people from accessing abortion care. Crisis Pregnancy Centers, commonly referred to as CPCs, are certain facilities that represent themselves as health care clinics in name, appearance and advertising, in order to attract pregnant people and dissuade them from seeking abortion care. As ACOG explains, “[s]taff members at these unregulated and often nonmedical facilities have no legal obligation to provide pregnant people with accurate information and are not subject to HIPAA or required by law to maintain client confidentiality” and many “are affiliated with national organizations that provide funding, support and training to advance a broadscale antiabortion agenda.” CPCs often use deceptive wording on their websites about abortion so that they appear in search results for abortion care. They also spread disinformation about the risks of abortion including advancing an “abortion as trauma” model, making false statements that abortion increases the risk of certain diseases such as breast cancer, and pushing the medically unsubstantiated claim that medication abortion can be reversed. These centers utilize manipulative and coercive tactics to prey on pregnant people who are seeking legitimate information and medical care in order to advance their anti-choice agenda. 

    • In response to the proliferation of CPCs, states like Illinois have passed legislation aimed at deterring the centers from lying to the public. The new Illinois law is an expansion of the state’s existing consumer fraud protections; it subjects these centers to civil liability and penalties if they are found to be in violation of the law. Shortly after the bill was passed, anti-abortion groups challenged it as a violation of their First Amendment Rights, arguing that it penalizes them for their pro-life viewpoint. Illinois Attorney General Kwame Raoul responded by asserting that he is confident that the law will withstand legal challenge, as nothing in the First Amendment permits entities to lie to the public. Late on Thursday, August 3rd, a Trump-appointed federal judge issued an oral order granting a preliminary injunction temporarily blocking the new law from taking effect.

What else is happening in access? 

  • The political fight over medication abortion has now reached the first health-related spending bill to pass through the House this year. Lawmakers are at odds over a proposed rider that would alter the FDA’s current policy of allowing mifepristone, one of two common medication abortion drugs, to be sent via the mail and dispensed at pharmacies. 

  • Iowa has filed an appeal challenging a state district court’s grant of a preliminary injunction blocking implementation of the state’s 6-week ‘fetal heartbeat’ abortion ban. 

  • Arkansas is appealing a federal court’s decision striking down the state’s gender affirming care ban. The appeal was anticipated and the case will now go up to the Eighth Circuit Court of Appeals. 

  • In Florida, advocates are advancing their efforts to get abortion on the 2024 ballot, although they are aware that the state Supreme Court has the power to strike the proposed initiative if they determine that it is not sufficiently clear. Republicans are highly motivated to keep these ballot initiatives away from voters, as every time abortion has been on a state ballot post-Dobbs, it has uniformly won. 

  • Two transgender patients are suing Vanderbilt for sharing their health records with the Tennessee Attorney General, citing the AG’s hostility towards gender affirming care in the state and the state’s harsh gender affirming care ban. 

  • You can read the detailed account of how two teen parents who were unable to obtain an abortion because of Texas’s laws are navigating life as young parents to twins two years after the fact. 

  • A new study sheds light on shifting public opinions about when in pregnancy abortion should be legally permissible, showing a trend towards opposition to any government intervention into medical decision making.

Issue of the Week: The problem with the viability standard 

This week, we are going to take a break from our series on ways that advocates are pushing back against abortion bans to discuss an important and unavoidable subject in the ongoing conversation about abortion policy: the viability standard. 

If  you follow reproductive rights policy at all, there are few phrases that you will hear thrown around with greater frequency than “fetal viability.” In addition to the trimester framework, fetal viability has become an accepted way to frame conversations about appropriate abortion policy. But here's the thing: fetal viability is a medical concept, not a legal, ethical or moral one. Although “viability” as a medical term exists in its own right, fetal viability as a legal standard was created, not by experts in the medical field, but by a Supreme Court clerk at the time of Roe’s consideration. And, in the decades since Roe, the concept of viability as an acceptable legal demarcation has gone relatively unchallenged. Post-Dobbs, many states continue to use it as a guiding standard. For example, the Ohio ballot initiative discussed above would permit lawmakers to restrict abortion after fetal viability, as the proposed initiative defines it. Although mixing ideology with medicine has become standard practice in the politics of abortion, the treatment of viability as a fixed moment in gestation can lead to legislation that is medically inaccurate and out of alignment with the realities of pregnancy. It also fails to account for the many reasons why people may need abortions later in pregnancy. 

Fetal viability is generally defined as the point at which a fetus can sustain survival outside the uterus; this commonly occurs somewhere between 24 and 28 weeks LMP. Although the vast majority of abortions occur during the first trimester (around 93%), and less than 1% occur after 21 weeks gestation, pregnancy is exceedingly complex and abortions later in pregnancy can become necessary for any number of reasons. Legislation that relies on gestational age to define viability and declare when abortion is permissible fails to engage with these complexities. As ACOG explains, “[f]etal viability depends on many complex factors, of which gestational age is only one[,]” and while “gestational age may be helpful in predicting the possible chance that the fetus would survive at time of delivery, many other factors also influence viability, such as sex, genetics, weight, circumstances around delivery, and availability of a neonatal intensivist health care professional.” Even taking all of these factors into consideration, it is still not possible to predict survival with absolute certainty or to predict quality of life if survival is feasible. Fetal viability is not a simple calculation based on gestational age. Although health care providers are able to use a variety of tests and methodologies to assess fetal development, there is not a definitive way to diagnose viability, and making that determination often comes down to clinical judgment and case-specific factors. Clinicians should be able to use their expertise to make those judgments, without the law drawing bright lines that don’t account for a particular patient’s medical circumstances. This kind of harsh line-drawing is especially inappropriate when the law seeks to attach civil, criminal and professional penalties to providers who are found to be in violation. 
Abortion later in pregnancy is heavily politicized, with politicians and anti-abortion groups describing it in terms that simply do not comport with reality (for example, former President Trump’s statements about “ripping babies straight from the mother’s womb”). However, the reality is that abortion later in pregnancy, like all abortion, is a matter of health care. Regardless of any individual’s personal views on the morality of abortion, patients are best served when they are able to make decisions in consultation with a trusted expert provider who knows the facts of their case. Legislation that interferes with that relationship harms that standard of care, erodes provider-patient trust, and inevitably paves the way for worsened health care outcomes.

REPRODUCTIVE HEALTH DIGEST (7/21/23)

Developments in Abortion, Autonomy, and Access: 

In the past two weeks, legal changes to abortion, autonomy and health care access have unfolded at both the state and federal level. These developments include the passage of Iowa’s new 6-week abortion ban, the FDA’s approval of an over the counter birth control pill, and ongoing legal battles over the right to gender-affirming care. This week’s digest also has a great deal to report in its “more news in access” section, as concrete changes to the law slow down with the close of state legislative sessions but litigation and policy efforts continue. With today’s digest, we are also kicking off an “issue of the week” series highlighting strategies that are being used to push back against abortion bans, with our first post being guest-written by L4GG intern Veronica Dickstein.

Please read on for more detail and discussion.

Legal Changes at the State Level:
 

  • Brief Overview

    • Iowa: In a single-day special legislative session called for the “sole purpose” of passing anti-abortion restrictions, Iowa pushed through a renewed 6-week abortion ban. The ban was immediately subject to legal challenge, and although it briefly took effect, a judge issued a temporary injunction halting its enforcement on Monday, July 17.

    • Connecticut: Connecticut Governor Ned Lamont has signed additional protections for reproductive health care into law, protecting both providers and patients.

    • Idaho: Groups have filed a lawsuit challenging Idaho’s abortion trafficking law, arguing that it violates their right to interstate travel, as well as their First Amendment rights to speak and engage in expressive conduct.

    • FDA: On the federal level, the FDA has approved an over-the-counter birth control pill for the first time.

Deeper Legal Analysis 

  • Iowa: 

    • In a single-day special legislative session called for the “sole purpose” of passing anti-abortion restrictions, Iowa pushed through a renewed 6-week abortion ban, despite polling that clearly reflects Iowans’ support for abortion rights.  The ban was immediately subject to legal challenge. Although it briefly took effect, a judge issued a temporary injunction halting its enforcement on Monday July 17, preserving access to abortion until 20 weeks gestational age for the time being. The bill  bans abortions after the sixth week of pregnancy, based on the detection of a “fetal heartbeat.” It is nearly identical to a 2018 law that the state Supreme Court has declined to reinstate, prompting Governor Reynolds' renewed attempt at circumventing that judicial deadlock by enacting this new ban. If this legislative maneuvering sounds familiar, it's because it is. Other states, like South Carolina, have likewise responded to courts’ blocking of abortion bans by simply passing functionally identical new laws. 

    • The latest Iowa ban includes exceptions for vaguely defined “medical emergencies” throughout the pregnancy. It also contains exceptions until 20 weeks for cases involving fetal anomalies that are deemed “incompatible with life,” rape (if reported within 45 days) and incest (if reported within 140 days). As we have discussed many times in this digest, we know that requirements that victims of rape or incest report those crimes are cruel, medically unnecessary, and impose barriers to safely accessing health care. They are also inconsistent with research that shows that many victims are unwilling or unable to safely report the crime. Although we have seen the consequences of bans just like this one in the year since Dobbs, Republicans continue to go to extraordinary lengths to enact them, placing patients, providers and our entire democratic process at risk.

  • Connecticut:

    • Connecticut Governor Lamont signed additional protections for reproductive health care into law. The series of bills were approved by the Connecticut general assembly prior to the end of the legislative session, and, in the Governor’s words, they are enacted to “safeguard the rights of all persons in Connecticut to access an abortion and the contraceptive care they choose.” As other states restrict reproductive rights, laws like Connecticut’s are aimed at preserving them. The new laws create the following protections:

      • Public Act 22-128 protects medical providers from adverse actions taken by another state based on the provision of legal and competent reproductive health care services. The protections are designed to cover provision of care to individuals traveling to Connecticut from other states where abortion is illegal. The law protects providers from suspension, revocation or denial of licensure based on their provision of that care. 

      • Public Act 23-52 allows pharmacists to prescribe birth control without first requiring the patient to have an appointment with their physician. This law is aimed at increasing access to contraception, particularly in rural and remote areas where reproductive health care is limited. 

      • Public Act 23-41 increases access to reproductive care for college students at public institutions by requiring the institutions to develop a plan by January 1, 2024 that addresses student needs for contraception, abortion and gender-affirming care. The goal of this law is to increase access for students who live on campus and rely on their educational institutions for living necessities including food, housing, transportation, and health care needs. 

      • Public Act 23-56 aims to protect the data privacy of patients by establishing restrictions on the collection, sharing and selling of personal health data by business and service providers who use online platforms. Although the law uses broad healthcare language, it also explicitly protects reproductive rights. Protection of patient data is key in safeguarding against investigations into legally provided health care.

  • Idaho 

    • Groups have sued to challenge Idaho’s abortion trafficking law, arguing that it violates their right to interstate travel, as well as their First Amendment rights to free speech and expression. This challenge is a crucial one to watch, as its success or failure will  inform whether other states enact similar “abortion trafficking” legislation. As a reminder, Idaho’s law defines assisting a minor across state lines to receive an abortion without their parent or guardian’s consent as “trafficking.” Any adult who is prosecuted under the law faces the prospect of 2-5 years in prison. The language of the law is broad and ambiguous, and what might constitute a parent’s “consent” is unclear; this lack of clarity is purposeful and will ultimately “deter ever more conduct because people don’t know where the line is.” 

    • The Department of Homeland Security explains that “human trafficking involves the use of force, fraud or coercion to obtain some type of labor or commercial sex act.” The conduct criminalized by Idaho’s law does not come close to resembling any accepted definition of “trafficking.” Under the law’s express terms, if a minor becomes pregnant, determines that they want an abortion and asks a trusted adult for help in safely obtaining that abortion, the adult could find themselves facing a prison sentence of up to 5 years. The minor’s consent to the abortion is not a defense to the law. Because courts are generally more willing to allow restrictions on the rights of minors, Republicans across the country have strategically cloaked restrictive laws in a false narrative about preserving parental rights and protecting children.

  • FDA: 

    • On the federal level, the FDA has approved the first over the counter birth control pill, a move lauded by reproductive rights advocates as concern grows about access to contraception becoming a renewed target of republican attacks. The medication, marketed as Opill, was first approved for prescription usage over 50 years ago, and the FDA has determined that it is both safe and effective in preventing pregnancy. The drug is expected to become available at pharmacies across the country in early 2024, although the cost is not yet known. Additionally, a growing number of states are allowing pharmacists to prescribe birth control, removing the obstacle of requiring the patient to have a physician visit prior to obtaining medication. According to The Guttmacher Institute, 24 states and the District of Columbia currently allow pharmacists to prescribe birth control. Although access to contraception, including birth control pills, is an important part of reproductive freedom, it does not eliminate the need for safe and legal abortion. Not everyone has access to contraception. Not every sexual encounter is consensual. No contraceptive works 100% of the time, even when used correctly. Not all wanted pregnancies are viable. Each of these realities (and countless others) mean that, although the FDA’s approval of this medication for over-the-counter use is certainly progress, it is no substitute for abortion rights.

What else is happening in access? 

  • A single Republican Senator, Tommy Tuberville of Alabama, is blocking approximately 265 military officer nominations, citing his disapproval of the Pentagon’s policy of supporting service members and their families in seeking abortion care. Seven former defense secretaries have criticized this move and expressed concerns that it harms military readiness and national security. Senator Tuberville’s stonewalling of the nominations comes as contentious legislative debates continue over the question of military spending and abortion. 

  • The U.S. Court of Appeals for the Sixth Circuit has reinstated Tennessee’s ban on gender affirming care for minors while the litigation challenging the ban plays out. This was the first time a federal court allowed a gender affirming care ban to take effect, and the Court’s opinion cited Dobbs (the case that overturned Roe) as supporting authority. Any expansion of Dobbs to limit other privacy rights should be a cause for great concern. You can read more about the relationship between the fight for trans rights and the fight for reproductive rights here

  • Approximately a week after the Sixth Circuit’s opinion came out, a federal judge lifted the injunction on Kentucky’s ban on gender affirming care, allowing it to take effect

  • State laws banning gender affirming care for minors are forcing trans youth and their families to uproot their lives and leave their own communities in order to seek gender affirming healthcare in other states. You can read some of their stories here

  • Litigants in Texas are suing for clarification to the state’s total abortion ban; these women went to court this week and provided moving testimony about their experiences trying to access necessary health care under the unclear and medically ambiguous terms of the ban. 

  • A Nebraska judge heard oral arguments this week in the ACLU’s case challenging the state’s combined gender-affirming care and abortion ban. No ruling has been issued at this time. 

  • A relatively small Christian conservative group is making headway in its efforts to promote its agenda at the local level. The group has organized around support for things like limitations on sex education in school, banning books that discuss subjects like abortion or gender identity, and limiting diversity and inclusion efforts. 

  • Abortion advocacy group “Plan C” explains how patients can access abortion pills in every state.

  • Australia is set to ease restrictions on medication abortion, citing the need to improve accessibility for remote and rural communities.

Issue of the Week: Freedom of Religion and Abortion

This week’s “Issue of the Week” kicks off a series focusing on the different strategies being used to protect reproductive freedom; it has been guest written by L4GG intern Veronica Dickstein.

In the wake of recent disheartening SCOTUS decisions and the erosion of reproductive rights in many U.S. states, it can be difficult to  see the positive developments and progress made  that provide hope for the future. Yet, across the country, attorneys and advocates are using creative strategies to protect bodily autonomy in a post-Dobbs legal landscape.

One particularly compelling argument is currently being made in Florida, Kentucky, Missouri, and Indiana. Plaintiffs in each of these states argue that abortion bans restrict their religious freedom and are therefore unconstitutional or in violation of their state’s Religious Freedom Restoration Acts. This strategy is especially interesting, as anti-choice advocates have historically claimed religion as their own and positioned it as diametrically opposed to abortion rights. However, like any aspect of religion, beliefs about abortion are not a monolith–they vary greatly between faith traditions and the views of the individuals who follow them. 

The following cases make this argument in court, arguing that the plaintiffs’ ability to freely exercise their religious beliefs must include access to reproductive freedom:

  • Florida - Generation to Generation v. State of Florida

    • The Plaintiffs in this case are suing the State of Florida, contending that the Reducing Fetal and Infant Mortality Act is unconstitutional.They argue that because Jewish law states that “abortion is required if necessary to protect the health, mental or physical, or well-being of the woman,” and Florida’s law does not allow for abortion in all of these circumstances, the act unconstitutionally violates the plaintiffs’ freedom of religion.

    • This case is ongoing.

  • Kentucky

    • The Plaintiffs in this case filed suit against Kentucky Attorney General Daniel Cameron and Jefferson County Attorney General Thomas Wine.

    • This case draws on Kentucky’s Religious Freedom Restoration Act, which states that “no preference shall ever be given by law to any religious sect, society or denomination; nor to any particular creed, mode of worship or system of ecclesiastical polity.” 

    • Plaintiffs argue that the bill’s declaration that life begins at conception conflicts with commonly held Jewish beliefs, and therefore violates their religious freedom. They also claim that the law’s abortion restrictions give preferential treatment to those with Christian beliefs and are, therefore discriminatory.

    • This case is ongoing

  • Missouri - Rev. Blackmon v. Missouri 

    • Missouri’s abortion ban was described by state legislators in explicitly religious terms. Missouri Representative Adam Schnelting said the following when discussing the ban: “I know of no greater way of affirming the natural rights of man than to declare that they are a gift from our Creator that neither man nor government can abridge.” The Plaintiffs in this case argue  that this faith-based justification for the ban  is a violation of the separation of church and state, something clearly protected in Missouri’s Constitution. Like the Florida and Kentucky plaintiffs, the Missouri Plaintiffs also argue that  this ban forces all Missouri residents to adhere to a definition of life only held by some specific sects of Christianity. The 13 Plaintiffs, all religious clergy members belonging to different Christian sects, Unitarian Universalism, and Judaism, do not share those religious beliefs.

    • This case is ongoing.

  • Indiana - Anonymous Plaintiffs, Hoosier Jews for Choice v. Medical Licensing Board of Indiana

    • As mentioned in L4GG’s 7/07/23 repro digest, this case argues that Indiana’s abortion ban infringes on  the religious freedom of the Jewish, Muslim, and spiritual plaintiffs, in violation of Indiana’s Religious Freedom Restoration Act. The plaintiffs’ respective religions do not ascribe to the belief that life begins at conception or that a fetus is entitled to the same rights as a born child. Like other cases, this one argues that Indiana’s constitutional clause prohibiting the state from giving one religion preferential treatment over another is violated by the state's extreme abortion ban.

    • This case is especially important because the plaintiffs were granted a preliminary injunction by Indiana state trial court in December 2022. The state has appealed this injunction and Americans United along with other organizations filed an amicus brief arguing that the injunction should hold. Although there is no clear outcome for this case at this time it demonstrates that courts even in states hostile towards reproductive rights and bodily autonomy may respond favorably to a religious-freedom-oriented argument. 

    • This case is ongoing.

     

Using religion to combat abortion bans is ingenious, because it is so often weaponized to create and promote them. This irony is compounded in the cases that use their states’ Religious Freedom Restoration Acts, as these same acts are sometimes used to discriminate against LGBTQ+ people, something fighting abortion bans helps combat. Contrary to the recent abortion bans that often, whether explicitly or implicitly, use Christianity as an excuse for restrictive legislation, religion in America is not monolithic. These cases serve as beacons of hope in tough times for reproductive rights in America, using religious diversity as a shield to protect our democracy, rather than a sword to cut it down. 

REPRODUCTIVE HEALTH DIGEST (7/7/23)

Developments in Abortion, Autonomy, and Access: 

Rapid developments in abortion, autonomy, and access to health care continue to shape the legal landscape in the U.S. In the past two weeks, significant changes have occurred. Both North Carolina and Indiana received the green light from their respective supreme courts to further restrict abortion access. Iowa and Ohio are both engaged in efforts to subvert direct democracy. South Carolina heard oral arguments in the case challenging a fetal heartbeat law, and Texas quietly passed new abortion ‘clarifications.’ Additionally, advocates continue to push back against the legality of bans on gender-affirming care for minors, and Republican lawmakers continue their attempts to restrict that care. Please read on for more detail and discussion. 

Legal Changes at the State Level:
 

  • Brief Overview

    • North Carolina: In North Carolina, a twelve-week abortion ban with limited exceptions for rape, fetal anomaly, and life or health of the pregnant person has gone into effect, over legal objection. The text of the ban was subject to several last-minute changes that seemed aimed at eliminating the lawsuit challenging the law. 

    • Indiana: The Indiana Supreme Court has issued a ruling clearing the way for the state’s near-total abortion ban to go into effect. 

    • South Carolina: Last week, the South Carolina Supreme Court heard oral arguments in the case challenging the state’s renewed ban on abortion after fetal cardiac activity is detected (a “6-week ban”). 

    • Iowa: Iowa Governor Kim Reynolds has called for a special legislative session devoted to enacting “pro-life legislation.” This announcement comes after the Iowa Supreme Court issued a split ruling that continued to block Governor Reynolds’ 6-week abortion ban from going into effect. 

    • Ohio: Ohioans have successfully obtained enough signatures to get an amendment that would create constitutional protection for abortion onto the ballot in November.

Deeper Legal Analysis 

  • North Carolina: 

    • North Carolina has implemented a twelve-week abortion ban, with limited exceptions for rape or incest, lethal fetal anomaly and the life or health of the pregnant person. The law, which was passed over Democratic Governor Roy Cooper’s veto, went into effect on July 1st. Planned Parenthood South Atlantic and a physician who performs abortions have brought a lawsuit challenging the law, arguing that it is unworkably vague and contradictory. However, the courts allowed the law to go into effect while that litigation plays out, only temporarily blocking one small provision of the law which required abortion providers to document the “location of the pregnancy” in the body prior to performing the abortion. Notably, just days before the law’s effective date, North Carolina Republicans rolled out new ‘clarifications’ that seemed designed to address several of the specific complaints listed in the lawsuit challenging the ban. The revisions to the law clarify that medication abortion is lawful until 12 weeks of pregnancy, not ten weeks, as the previous text of the law indicated. The new bill also purports to make clear that it is not a violation of the law to help a pregnant person obtain a lawful abortion in another jurisdiction. As we have previously written about in this digest, although proponents of North Carolina’s 12-week ban have touted it as a moderate regulation, it contains many medically unnecessary provisions that restrict access to care, including stringent requirements for in-person visits with the performing physician. Litigation challenging the law will continue, but in the meantime, North Carolina has lost its status as a safe haven for reproductive rights in the South. 

  • Indiana: 

    • In Indiana, the state Supreme Court has issued a ruling clearing the way for the state's near-total abortion ban to go into effect. The Court’s ruling overturned a county judge’s previous determination that the ban likely violated the state constitution’s privacy protections. In their order, the justices found that the legislature has broad discretion to regulate the conditions under which abortion may be performed in the state. 

    • Indiana’s new law is uniquely harsh. It bans abortion entirely, with only narrow exceptions for rape or incest until ten weeks post-fertilization, cases of lethal fetal anomaly, and circumstances where the mother’s life is at risk. It also contains a number of “TRAP” laws, such as requiring abortions to be done only in certain hospitals. It imposes harsh penalties on providers who are found to be in violation of the law, including up to six years in prison. The total ban has not yet gone into effect; however, the Supreme Court’s ruling paves the way for it to become operative law in the coming weeks. Further complicating the matter, an Indiana court in a separate case temporarily halted implementation of the ban in December for patients who say that the abortion ban violates their sincerely held religious beliefs, protected by the state’s religious freedom act. That injunction remains effective, despite the state Supreme Court’s ruling. 

  • South Carolina: 

    • On June 27, 2023, the all-male South Carolina Supreme Court heard oral arguments in the case challenging the state’s fetal heartbeat ban. As reported previously, the law was signed by Governor McMaster on May 25, and within 24 hours, Planned Parenthood filed a request for an injunction and a state court judge granted it, halting implementation of the law during the pendency of the litigation. In addition to challenging the law’s constitutionality, Planned Parenthood’s lawyers argue that the new law is functionally identical to the 6-week ban that the Court struck down as unconstitutional in January of this year. The state’s lawyers argued that the new law is substantively different in ways that cure the Court’s concerns with the previous 6-week ban, while Planned Parenthood maintained that, although some language may have changed, the effect of the law is the very same as before. During arguments, lawyers from both sides faced significant questioning, with a heavy emphasis on exactly how the law is meaningfully different and whether or not a ban on abortion after detection of fetal cardiac activity gives pregnant people enough time to discover the pregnancy and decide whether or not to continue it. The Court has not yet issued its ruling.

  • Ohio: 

    • In Ohio, advocates have successfully obtained enough signatures to get a constitutional amendment protecting abortion in front of voters in November. This success is the latest in a hard-fought battle to get abortion onto the ballot. Previously, Republicans in the state unsuccessfully tried to argue that abortion is separate from other reproductive rights that the ballot measure addresses, and therefore proponents of the ballot measure must collect twice as many signatures as planned. That argument was struck down. Further, the state legislature has successfully called for an August special election to determine whether to raise the threshold needed to pass a constitutional amendment from a simple majority to 60%. This move is a blatant attempt to block the passage of abortion protections, and polling shows that Ohio's support for a constitutional amendment sits at about 59% currently. This kind of political maneuvering disempowers voters and weakens direct democracy, and it cannot go unchallenged. 

What else is happening in access? 

  • The Texas legislature has quietly passed a new bill that creates an affirmative defense to the state’s abortion ban for cases of ectopic pregnancy or preterm premature rupture of membranes (PPROM). This move likely comes in response to public outcry over the many stories coming out of the state detailing ways in which pregnant people’s medical care has suffered under the Texas law. The bill will take effect on September 1. 

  • Republicans are quick to compare their proposed abortion bans to those found in Europe, making the case that the proposals are internationally mainstream; this piece does an excellent job of eviscerating that argument. 

  • As we have reported on previously, Idaho has passed an abortion trafficking law, defining assisting a minor over state lines to obtain an abortion as “trafficking.” Legislation like this not only creates barriers to reproductive care but harms victims of actual human trafficking. 

  • Advocates are beginning to turn the tide in the fight for trans rights, with many favorable rulings coming out of state courts. This is a reminder that this fight is winnable–we just need to fight. 

  • In Kentucky, plaintiffs have dropped their lawsuit challenging the state’s abortion restrictions, based on the court’s requirement of a patient as a plaintiff; however, the plaintiffs indicate that they have not given up the fight.

  • In Georgia, parents of trans youth are fighting back against laws restricting access to gender-affirming care for minors.

Issue of the Week:
Where do Presidential Hopefuls Stand on the Question of a National Abortion Ban

As more and more Republicans officially throw their hat in the 2024 presidential ring, the possibility of a national abortion ban has emerged as a major talking point, with potential nominees eager to distinguish their positions on the issue. The idea of a federal abortion ban flies in the face of the “abortion should be returned to the states” argument that was previously embraced by pro-life advocates and enunciated by the Supreme Court in Dobbs. Of course, we know that the movement to restrict abortion was never actually about federalism, but it is still worth calling out the about-face done by much of the anti-choice movement in just one short year. The possibility of a national abortion ban may seem extreme and unlikely, but so too did the overturning of Roe–until it happened. If a Republican takes office in 2024 and the party establishes a majority in both houses of Congress, a national abortion ban all of a sudden becomes very possible, if not likely. So, let's take a look at where some of the top-polling candidates stand at this time: 

  • Donald Trump: The former President has arguably done more to advance the pro-life movement than any other president. His nomination of three conservative justices to the Supreme Court paved the way for the overturning of Roe v. Wade. And, his many lower court appointments created a climate where anti-choice attacks, like the challenge to the FDA’s approval of mifepristone, can thrive. However, the former President has waffled on whether he would support a national abortion ban if re-elected. In April of this year, he faced backlash from a prominent pro-life group for stating that abortion should be left up to the states. However, he has also stated that he believes that there is a role for both the states and the federal government to play in “protecting unborn life,” seeming to leave the door open to the possibility. Regardless, we can be certain that another Trump presidency would mean 4 more years with an administration hostile to abortion and bodily autonomy rights. 

  • Ron De Santis: Ron De Santis, the current governor of Florida has positioned himself as staunchly anti-abortion, signing into law a 6-week abortion ban in his own state. However, similar to Mr. Trump, he has not definitively taken a position on whether he would support the passage of a national ban, likely because that position is demonstrably unpopular amongst the American people. However, Governor De Santis, if elected, is certain to continue Donald Trump’s work of appointing extremely conservative judges opposed to abortion. 

  • Mike Pence: Former Vice President Mike Pence has consistently reiterated his anti-abortion views. As a presidential candidate, he has stated that both himself and his campaign “stand without apology for the right to life.” He has been critical of President Biden’s pro-choice position and endorsed a 15-week federal ban, encouraging his fellow 2024 candidates to do the same. 

  • Nikki Haley: Former South Carolina Governor Nikki Haley has stated that she would “absolutely” sign a 15-week national abortion ban if elected. The former governor has emphasized what she describes as the need for greater Republican consensus on the issue before a federal ban would be politically viable; however, she is clear on her anti-abortion stance, and if a proposed ban cleared Congress, she would support it. 

  • Tim Scott: South Carolina senator Tim Scott initially waffled on his position on a national abortion ban; however, he has since made it clear that he would be in support of such a measure. In late June, the Republican senator published an opinion piece in the Des Moines Register in which he stated that he is 100% pro-life, would sign the most pro-life legislation that made it to his desk, and that we should start with a 15-week national abortion ban. 

  • Vivek Ramaswamy: Entrepreneur Vivek Ramaswamy has described himself as “unapologetically pro-life.” However, he has declined to support a federal abortion ban, explaining his belief that if abortion is murder and murder laws are handled at the state-level, then abortion should also be a state issue. At the state level, he has signaled his support for 6-week abortion bans. 

  • Chris Christie: Former New Jersey governor has described himself as pro-life; however, he has not come out in favor of a national abortion ban, instead stating that abortion should be decided by the states. It is worth nothing, however, that during Christie’s 2016 run for president, he did announce his support for a 20-week federal abortion ban. Christie has also expressed his view that there is no constitutional right to abortion, signaling that his would be an administration hostile to choice. 

  • Doug Burgum: Doug Burgum’s tenure as Governor of North Dakota has made his stance on abortion unmistakably clear. In his own state, he signed a 6-week abortion ban into law, effectively outlawing the procedure. However, Governor Burgum has stated that he believes that abortion belongs with the states and, if elected, he would not sign a federal abortion ban. 

Although there is still time before the 2024 election race ramps up in earnest, abortion is certain to continue to be a major talking point. A Republican president could signal disaster for reproductive and bodily autonomy rights. It is crucial that we stay informed and that, when the time comes, we get out and vote. Our rights depend on it. 

REPRODUCTIVE HEALTH DIGEST (6/26/23)

Developments in Abortion, Autonomy, and Access: 

Rapid legal developments in abortion, autonomy, and access to health care continue to shape the legal landscape in the U.S.. In the past two weeks, significant changes have occurred. The state Supreme Court in Ohio approved an August special election to raise the votes needed to pass a constitutional amendment in an attempt to hinder abortion rights and direct democracy. In Wyoming, a judge blocked the implementation of a state law banning medication abortion, offering temporary relief in an ongoing battle. Iowa's Supreme Court retained the block on a 6-week abortion ban, ensuring abortion remains legal until 20 weeks in the state. A lawsuit challenging Indiana's abortion ban on religious grounds gained class-action status, with the attorney general appealing the decision. The Planned Parenthood lawsuit against Nebraska's abortion and gender-affirming care ban has been temporarily stayed, allowing the ban to continue. In North Dakota, abortion providers, and clinics continue to challenge the state's restrictive abortion ban. Additionally, there were two significant victories for bodily autonomy in New York as Governor Kathy Hochul signed an order protecting reproductive rights and gender-affirming care in the city. 

Legal Changes at the State Level:
 

  • Brief Overview

    • Ohio:  In Ohio, the state Supreme Court has given the ok to an August special election that will determine whether to raise the votes needed to pass a constitutional amendment from a simple majority to 60%, a dark money-fueled move designed to hinder attempts to enshrine abortion rights into the constitution that also has chilling implications for the future of direct democracy across our nation.

    • Wyoming: A Wyoming judge has blocked the implementation of the first state law that would have specifically banned the use of medication abortion, which was otherwise set to take effect on July 1.

    • Iowa: The Iowa Supreme Court has declined to reinstate a 6-week abortion ban, allowing abortion to remain legal until 20 weeks in the state for the time being. 

    • Indiana: In Indiana, a lawsuit challenging the state’s abortion ban on religious grounds has been issued class-action status. The State’s attorney general is appealing this decision.

    • Nebraska: The Planned Parenthood lawsuit challenging the constitutionality of Nebraska’s abortion and gender-affirming care ban has been stayed for another month, allowing the ban to continue in the meantime. 

    • North Dakota: In North Dakota, an abortion clinic and abortion providers continue to challenge the state’s restrictive abortion ban. 

Deeper Legal Analysis 

  • Ohio: Dark money-funded groups won big last week when the Supreme Court allowed a provision that would increase the burden on ballot amendments. Republicans in support of Issue 1, including Ohio’s elections chief Secretary of State Frank LaRose, have pointed to the abortion proposal as a main reason they’d like to see the voter threshold amendment pass in August, as it would cause significant challenges for the amendment, for which signature gathering has been well under way. In their suit, reproductive rights advocates questioned why the standards would have changed so quickly and so dramatically. They suggested that Republicans in the state Legislature only reversed themselves on the issue because if the threshold measure is passed in August, it could prevent the approval of a proposed amendment in November to enshrine abortion rights in the state constitution. However, in its 4-3 decision, the conservative majority on the state Supreme Court sided with the GOP lawmakers. The court ruled that the August 8 election is entirely legal and constitutional, and legislators had the freedom and leeway to schedule the race.

  • Wyoming: A Wyoming judge issued a temporary block on the country’s first state law specifically banning the use of pills for abortion, the most common method in the country, just over a week before the ban was scheduled to take effect. The group behind the suit also filed a lawsuit against the state's near-total abortion ban, which had previously been temporarily blocked by Wyoming's Ninth District Court Judge Melissa Owens in March. The broader abortion ban would essentially supersede the medications ban by outlawing most abortions regardless of the method used, rendering a prohibition on medication abortion largely symbolic. In Owens’ ruling, she argued that the state failed to show that allowing the law to go into effect before the lawsuit was resolved wouldn't hurt the plaintiffs.

  • Iowa: Iowa’s Supreme Court maintained the state’s block on a 6-week abortion ban, with a deadlocked 3-3 court (as one judge is conflicted out). The court’s ruling stemmed from a 2018 so-called ‘heartbeat bill’  that banned abortions in the state at the sixth week of pregnancy, or when, in some cases, a fetal pulse could first be heard via ultrasound. An Iowa district court swiftly blocked the law from taking effect, ruling that it violated the state Constitution — specifically its due process and equal protection clauses, the same legal arguments that U.S. Supreme Court justices issued in the landmark 1973 Roe ruling that provided federal abortion protections.

  • Indiana: A group of plaintiffs won class action status in a religious objection lawsuit, which was filed by attorneys at ACLU on behalf of 5 anonymous plaintiffs and the organization Jews for Choice. Plaintiffs seek recognition of the right to abortion on the basis of Indiana’s 2015 Religious Freedom Restoration Act, which they argue applies to a broad definition of religion, providing the opening for the creation of a class “whose religious beliefs ‘direct them to obtain abortions in situations’ prohibited by the ban, and ‘who need, or will need, to obtain an abortion and who are not, or will not be, able to obtain an abortion.”

What else is happening in access? 

  • One year post-Dobbs, pregnant patients and providers are both still struggling to stay on top of the constant, kaleidoscopic changes in the law, leading them to seek safety and care outside of their home communities.

  • Several doctors have consistently testified in favor of bans on gender affirming care; you can read about those doctors here. 

  • Massachusetts has taken steps to protect the cell phone data of abortion seekers. 

  • Connecticut has appointed special counsel to manage and advise on the defense of reproductive rights in the state. Also in Connecticut, the Governor has signed legislation that will allow pharmacists to prescribe birth control. 

  • The Guardian has compiled a comprehensive list of the 1,572 politicians who have helped to ban abortion in the year since the Dobbs decision, labeled by state and broken down by party affiliation. 

  • New York Governor Kathy Hochul has signed bills into law protecting both abortion rights and gender affirming care from out of state encroachment. 

  • One year post-Roe, you can read about the state of abortion rights across the country here.

Issue of the Week:
One year since Dobbs, it’s being used to… Circumvent direct democracy?
 

This week is the one-year anniversary of Dobbs, the Supreme Court decision that overturned Roe v. Wade and purportedly returned the issue of abortion to the states. In reality, the decision has created uncertainty across and within these “United” States of America, with nearly half restricting abortion, fourteen banning it entirely, an ever-growing list enshrining abortion rights in their statutory law or state constitution, and several passing “shield laws” aimed at protecting patients traveling for abortion and their medical providers from the reach of out of state investigations. 

Despite the political maelstrom precipitated by Dobbs, support for abortion rights remains consistent, even in conservative states. In fact, a new Gallup poll shows that support for abortion rights has reached an all time high. No wonder anti-choice politicians are now taking the fight to the ballot box, where they seek to circumvent the tools of direct democracy by increasing the stakes to get a measure passed through ballot measures.

For this week’s analysis of the connection between bodily autonomy and democracy, we at L4GG turned to our friend and ally Brendan Fischer, Deputy Executive Director of Documented, a nonprofit organization that tracks how dark money has infiltrated and corrupted the political process. As Brendan reported in this weekend’s Guardian, a Florida-based group mainly funded by one Illinois billionaire is driving attacks on direct democracy in states such as Ohio, Missouri, South Dakota and Arkansas, largely based on his desire to ban abortion. Key takeaways from his analysis include:

  • This group, the Foundation for Government Accountability, is affiliated with the alliance of conservative think tanks called the State Policy Network, which has been central to raise the threshold for passing citizen ballot initiatives from a simple majority to a supermajority, and to make it harder to place measures on the ballot in the first place.

  • In at least four states, FGA and its lobbying arm, the Opportunity Solutions Project, have lobbied or testified in favor of changing ballot initiative rules to enshrine minority rule, financed ballot committees advocating for those changes, and issued reports, legal memos, op-eds and polling that advocate for gutting direct democracy.

  • They led the latest fight in Ohio, where Republican lawmakers last month passed a measure requiring future constitutional amendments to receive at least 60% support from voters – rather than a simple majority – and that would make it harder for proposed amendments to make it onto the ballot. Ohioans will now vote in August on whether to approve the higher thresholds, which are designed to derail an abortion rights initiative expected to be on the ballot in November.

  • When Ohio Republicans first proposed the supermajority requirement last year, a representative of FGA’s lobbying arm was the only person who testified in favor. FGA’s lobbying arm again testified in support of the proposal earlier this year, in hearings before the House and Senate. FGA argued that the proposal was necessary to “make it more difficult for out of state billionaires and dark money groups” to change Ohio law.

  • As the measure moved through Ohio’s Republican-controlled legislature, the Illinois billionaire Dick Uihlein gave $1.1m to the newly created “Save Our Constitution PAC”, which ran ads pressuring state lawmakers to support the measure; Uihlein is expected to contribute more as the August vote approaches.

  • A foundation controlled by Uihlein is also the largest known source of FGA’s funding, giving $17.6m since 2014. Uihlein has also been one of the key funders of election denial. Among other things, Uihlein has poured tens of millions into his “Restoration of America” network that promotes ludicrous election conspiracy theories and which created a controversial database that published voters’ personal information online in the name of uncovering election fraud. In the 2022 cycle, Dick Uihlein and his wife, Liz, were also top donors to election-denying candidates like the Pennsylvania gubernatorial hopeful Doug Mastriano and Nevada secretary of state candidate Jim Marchant. 

  • FGA itself began to focus on “election integrity” in 2021, and boasted that it “achieved more than 70 election integrity policy wins across 19 states” last year.

  • FGA has actually been promoting a supermajority requirement in Ohio and other states since at least 2021. That year, FGA issued a legal memo arguing for the constitutionality of a 60% requirement for enacting ballot initiatives, and a report decrying how voters in red states like Missouri, Oklahoma and Nebraska had approved Medicaid expansion through the ballot initiative process. FGA and its lobbying arm also began testifying in support of state efforts to make it harder to enact ballot measures, and its in-house polling firm released Ohio polling showing voter support for a 60% threshold and for placing other restrictions on the initiative process. FGA’s tactics in Ohio echo those used previously – and unsuccessfully – in Arkansas and South Dakota. 


Brendan’s research reminds us that attacks on abortion and democracy are intimately connected, and we cannot win one fight without the other. It is also a reminder that the opposition will pursue their own moral agenda to the detriment of foundational democratic principles–we cannot allow that to happen. However, support for the right to abortion is at an all-time high, and we can win these fights–we just have to stay in them and remain vigilant against billionaire-backed plans to overrule the clear will of the people.

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.