Half a century ago, after the Supreme Court ruled abortion a constitutional right, Choices became the first clinic to open in Memphis, Tennessee. It has performed abortions in the state capital ever since. Now that the justices have overturned Roe v Wade it will stop doing so. Tennessee is one of 13 states with a trigger law that clicks into effect with Roe’s demise. Instead Choices will refer women to the new clinic it is opening this summer in the neighbouring state of Illinois, where abortion will remain legal.
The Memphis clinic will not close, however. In recent years, as Roe’s end has looked increasingly likely, the clinic has expanded its services. It now offers transgender health-care (providing cross-sex hormones), hiv testing and birth control. In 2020 it opened a birthing centre, thus becoming the first non-profit clinic in America to accommodate both abortions and births.
Jennifer Pepper, the clinic’s chief executive, says she hopes it will provide a model for other independent abortion clinics in a post-Roe America. Planned Parenthood, the biggest provider of abortions in America, has long offered other health-care services, but most independent—that is, not affiliated with Planned Parenthood—clinics, which carry out nearly 60% of abortions in America, tend to focus on abortions (though some provide contraceptives).
That has been a strength and a weakness. It has helped clinics become powerful champions of abortion rights. Dobbs v Jackson Women’s Health Organisation, the case that Supreme Court used to overturn Roe, concerned a battle between Mississippi and its last abortion clinic. The clinic fought highly publicised attempts to close it and end abortion in the state. The previous two abortion cases considered by the Supreme Court were won by clinics.
But focusing on abortion has left clinics vulnerable. Many, including some in states that are friendly to abortion rights, have closed. The Abortion Care Network, which represents independent clinics, says that in 2012 America had 510 of them. In 2021 there were 358. Since 2016, it says, 113 independent clinics have closed. Of these, 18 were in California, six in New York and several in other states broadly supportive of abortion rights, including New Jersey, Massachusetts and Pennsylvania.
Robust or Roe-bust?
The biggest pressure clinics face, regardless of location, is financial. In America’s profit-driven health-care market, abortion provision is an anomaly. Though most clinics operate for profits, getting paid is a struggle. Most patients are poor. Federal Medicaid funds cannot be used to pay for abortions except in rare cases. Even in states that use their own Medicaid funds for abortions, reimbursements tend to be low and slow to arrive. Not all progressive states provide Medicaid coverage for abortions. Clinics have had to keep their prices low even as costs have risen. In conservative states pernickety regulations designed to close clinics have had exactly that effect.
More positive changes, however, have also made the abortion-clinic business more challenging. America’s abortion rate has dropped dramatically, to around half what it was in the 1980s, though it has ticked up a bit in recent years. Some abortion providers say that since 2010 the improved contraceptive coverage provided by the Affordable Care Act (“Obamacare”) has contributed to sharply dropping demand.
Another development, the full effects of which are yet to be seen, is the increasing use of abortion medication. During the pandemic, the Food and Drug Administration dropped a requirement that women collect the first of two drugs used from a health-care provider in person. Women can now be prescribed the pills via telemedicine consultation and receive them in the post. Several telemedicine startups run by doctors and nurses, but not affiliated to clinics, now offer abortion medication at a lower price than clinics do.
One such startup, Abortion on Demand, is so concerned about the effect abortion medication could have on clinics that it gives 60% of its profits to the Abortion Care Network. “We didn’t want to start a business that jeopardises brick-and-mortar clinics, says Leah Coplon, director of clinical operations. A nurse, she previously worked at an independent abortion clinic in Maine, where abortions have been covered by Medicaid since 2019. It was in a stronger financial position than many, she says, and yet it sometimes struggled with costs other health-care providers do not have to consider, like security. There were protests at the clinic every day that abortions were performed, she says.
Ms Coplon says that, however prevalent the use of abortion medication becomes, some women will always need to use clinics. Post-Roe, she reckons, women in states in which abortion is illegal may prefer to travel for surgical abortions so they don’t risk requiring medical attention that could get them or a doctor into trouble. Abortion medication is extremely safe, but bleeding can continue for several days. And some women, she says, “just want to walk into an abortion clinic and walk out again knowing they are not pregnant”.
In theory, the end of Roe should mean that a surge in women heading to states where abortion remains legal should channel funding to America’s remaining clinics. But funding will remain a problem. Many patients travelling across state lines will lack Medicaid or insurance coverage. And costs are likely to rise if more women need abortions later in pregnancy, as seems likely. Currently, only independent clinics provide abortions after 26 weeks.
Some other costs, too, are likely to go up. Amy Hagstrom Miller, the founder and chief executive of Whole Women’s Health, which runs clinics in Indiana, Maryland, Minnesota, Texas and Virginia, says anti-abortion activists will now hone in on states where abortion remains legal. This is likely to push up security costs. It could also make it harder to recruit and retain staff. Clinics are bracing themselves for the next phase of America’s long abortion war. ■