Fewer states allow abortions, yet American women are having more

On a commercial stretch of Queens, New York, across from a hair-braiding salon and next to a McDonald’s, two security guards mark the entrance to the Jamaica Sexual Health Clinic. For decades this has been the neighbourhood’s go-to place for STI testing and HIV treatment. Joaquin Aracena, from the Bureau of Public Health Clinics, proudly shows its newest addition: the reproductive-health wing. With freshly painted white walls and pastel-green doors, it is distinctly less institutional-looking than the rest of the clinic.

“Once they did [away with] Roe v Wade I was able to get this space,” he says. The clinic now offers walk-in medication abortions free to all. Word is clearly spreading; last year it provided just over 700 abortions, in January it was 100 and this morning the two nurse practitioners have already sent four women home with a non-transparent bag containing the pills they need to terminate their pregnancies (as well as a care package containing heating pads, pain medication and an information leaflet). Although the clinic has received visitors from other states, the majority of patients are locals.

This abortion service is one of the more unexpected results of the Supreme Court’s decision in 2022 to overturn Roe, a ruling that returned the issue of abortion to states and triggered a number of bans. It gave the city’s government new energy to take a much more active role in co-ordinating access to the procedure, remembers the city’s health commissioner, Ashwin Vasan. “Our number-one goal was to ensure that we expanded access to abortion care in New York City and redoubled our efforts to make New York City the safe haven it’s always been,” he adds. This meant putting up billboards in Arizona and Texas, starting a central abortion-referral hotline and opening new clinics in previously underserved pockets of the city. Less than nine months after Dobbs v Jackson, the ruling that overturned Roe, the Jamaica clinic’s abortion service was up and running.

While much of America’s political conversation has been about whether and until what stage abortion should be legal, legality alone is not enough for it to be available. Many hurdles—practical, financial, social—can stand in a woman’s way, even in a state that is on paper abortion-friendly. One of the most positive things to come out of Dobbs may well turn out to be improved access in states with a supportive approach to abortion.

image: The Economist

New data by the Guttmacher Institute, a pro-abortion-rights research group, estimates that over a million abortions were performed in America in 2023—a rise of 10% compared with 2020 and the highest number in over a decade. This is astonishing given that the procedure is now banned in 14 states and has become restricted in several more. The number of abortions has risen in almost every state without a ban. States bordering those that prohibit terminations had the steepest rises: in Illinois abortions were up by 72% since 2020; in Virginia by 76%; and in New Mexico by a whopping 257%. But even states surrounded by ones that allow abortions all notched up increases (see map).

Last year more than 160,000 women—over 400 a day—crossed state borders to terminate pregnancies, versus 67,000 in 2020 (albeit a covid year). With nearly a third of women now living in states that ban abortion either outright or after six weeks, such a surge in travel was expected. More surprising is that a significant part of America’s total growth in abortions is the result of increases among residents of abortion-supporting states. In California, locals had an estimated 21,470 more abortions in 2023 compared with 2020 (accounting for 88% of the state’s increase), in Illinois they had 12,350 more (32% of the increase) and in New York 20,460 (97%). Overall, in states without bans, over half of the rise was down to locals having more abortions.

This growth is likely to be, at least to some extent, the result of efforts to improve access in such states. Some of this work predates the Dobbs decision, but it accelerated as abortion politics heated up. In early 2023, 20 Democratic governors started the Reproductive Freedom Alliance, pledging to “work together to strengthen abortion firewalls across America” and proclaiming: “This fight isn’t over.”

What have they done?

Because costs can be a big barrier, several states have reduced out-of-pocket spending for patients. Illinois, New Mexico and New York have increased their Medicaid reimbursement rates for first- and second-trimester abortion procedures by more than 200%, according to forthcoming analysis by KFF, a health-research organisation. This means more clinics may now be willing to accept lower-income patients. In ten states health insurers are now required to cover abortion, up from six before Dobbs. California is one of a handful of states that has gone further still. It now requires health insurers to eliminate all out-of-pocket costs.

image: The Economist

Nothing has helped expand access as much as abortion pills, which now account for 63% of abortions in America, up from 45% in 2019 (see chart). Medication abortions are cheaper than procedural ones, and easier for clinics to provide and (often) for patients to receive, especially in rural areas. They are effective in the first trimester, when 93% of abortions happen. Their expansion can largely be credited to a successful tele-health experiment during the pandemic and, crucially, by the Food and Drug Administration (FDA) loosening  rules around their distribution in January 2023. Next week, the Supreme Court will consider whether the rules for one of these drugs, mifepristone, should be tightened again.

Whereas in 2020 only 7% of providers offered abortions via tele-medicine, by 2022 that had increased to 31%. In October last year New York City’s public-health system became the first to also offer virtual abortions. Commercial providers are cagey about sharing pricing information, but Sylvia Ghazarian from WRRAP, an abortion fund, says she has been able to agree on a bundle deal with providers whereby a patient gets an all-in virtual abortion for $150 (including two consultations, medication and postage). Mai Fleming from Hey Jane, one of several virtual-only abortion providers, says she can offer medication abortions at “a fraction” of the cost of bricks-and-mortar clinics. She has seen particularly large increases in customers ordering pills from states that border restrictive states, such as Colorado, Illinois and New Mexico.

Caitlin Myers, from Middlebury College, estimates that, net, the country is down about 49 physical facilities since Dobbs. Although some clinics are clearly struggling with the extra influx, the estimated share with a waiting time beyond two weeks—almost one in five—is largely unchanged.

Abortion havens have also solidified legal protections, both for patients (eg, data privacy) and providers (eg, malpractice insurance). Some have amended state constitutions to include a right to abortion—several more are expected to include this question on the ballot in November’s general election. Six states now have tele-medicine shield laws that explicitly protect licensed practitioners from prosecution if they prescribe and send abortion pills to patients in states that ban abortion.

Alternative explanations for the nationwide rise in abortions, beyond these efforts to lower barriers, do not seem to hold water. The increase does not, for example, appear to be the result of a spike in unplanned pregnancies, the rate of which—a short bump during the covid-19 pandemic excepted—appears not to have changed much since Dobbs. New York City’s health commissioner, Mr Vasan, certainly sees no reason to believe this is happening on his patch: “There’s nothing to suggest that anything has changed in terms of the volume of unplanned pregnancies,” he says, which leads him to believe the rise is probably the result of greater access, even if it can’t be stated definitively yet.

It would, however, be wrong to conclude that all is fine in post-Roe America. While abortion pills may be a godsend for early unplanned pregnancies, for women in states with bans who need an abortion later—often due to fetal abnormalities that can only be detected at the 20-week scan—getting an abortion in America is harder than it has been for decades. For such women, the fight goes on.