Angel Kai’s* heart sank when she found out she was pregnant again. The 20-year-old had delivered her second child only three months prior. She was on unpaid maternity leave from her job in Amarillo, TX, and she’d just received a $130 electricity bill in the mail that she didn’t know if she’d be able to pay. “Everything that was happening financially was just bad,” she remembers. “I couldn’t have another kid. I knew getting an abortion would be the best thing, because I couldn’t walk up the street to get a soda if I wanted one at the time. We were that tight on money.”
It turned out, though, that Angel couldn’t even afford the abortion she knew she wanted. Her health plan was offered under state-funded Medicaid, which, in Texas, only covers abortion in cases of life endangerment, rape, and incest. So, Angel Googled “abortion financial help.” She came across a few different nonprofits called abortion funds, which provide financial assistance to people who can’t afford to go through the process themselves. One, Fund Texas Choice, said they would help Angel. They ended up footing the bill for the gas it would take to drive to the clinic, an overnight hotel stay, and her food for the trip. They also connected her with another fund that helped pay for the pill she was prescribed.
The morning of her abortion, Angel dropped her baby off with a relative at 6 a.m. Then she put in a shift at the lawn company where she worked, her first since going on maternity leave. After clocking out, she started the four-and-a-half-hour drive to Albuquerque, NM. (The closest in-state clinic to her was in Dallas, an additional hour away.) Her then-partner was supposed to join her, but they got in a fight on the way, and she had to turn around and drop him off. She barely made it to the clinic on time, but she got there. And it changed her life for the better, she says.
Before finding Fund Texas Choice, Angel had tried to get an ultrasound at a “crisis pregnancy center,” which is actually a coded name for an anti-abortion clinic. “They told me abortion is murder, and that I would go to hell if I had one,” Angel remembers now, a year later. “But I knew the abortion was the best thing for me to do.”
Angel’s story could have looked very different. If she hadn’t learned about the fund, she may have not been able to get the abortion pill. Alternatively, if she lived in a different state, she may have been able to use her health insurance to pay for the abortion, at a clinic much closer to her house.
In reality, the state of abortion access in America is woefully unequal. And soon, considering the tenuous status of Roe v. Wade, abortions may become even less attainable.
If Abortion Is Legal, Why Is It So Hard To Access?
In September 2020, Supreme Court Justice Ruth Bader Ginsburg died at age 87. This opened up a spot on the Supreme Court, and President Donald Trump quickly nominated conservative judge Amy Coney Barrett to fill Ginsberg’s seat. Many fear that Barrett’s appointment could lead to Roe v. Wade, the landmark 1973 Supreme Court decision that legalized abortion in the U.S., being overturned.
While this possibility has led some to envision a future reminiscent of an episode of The Handmaid’s Tale, the reality is that some people who already find it easy to get an abortion — those with wealth, power, and connections — may not notice such a big change in a post-Roe world. The ones who will be hit the hardest are those who already struggle to get abortion care. Namely, low-income people in states with already-restrictive abortion legislation.
“Over the last few decades, Roe has been an unfulfilled promise for many,” says Jessica Arons, senior advocacy and policy counsel for reproductive freedom at the American Civil Liberties Union. States in the South and the Midwest tend to have the most restrictions around reproductive rights. The Bible Belt is known for legislation that typically makes abortions more expensive and time-consuming, and therefore less accessible.
For instance, 34 states and Washington, D.C. only provide healthcare funding for abortions in the most extreme circumstances, such as rape or life endangerment. This is in accordance with the Hyde Amendment, which was passed just three years after Roe v. Wade legalized abortion. This is, in part, why Angel couldn’t use her Medicaid insurance to pay for her abortion.
Nearly half of abortion recipients live below the federal poverty line, according to the Guttmacher Institute's 2014 Abortion Patient Survey, so the Hyde Amendment is particularly damaging. Those who are denied abortions are more likely to experience years-long economic hardship, according to a 2017 analysis from The American Journal of Public Health. The 16 states that let Medicaid be used for most “medically necessary” abortions, (a broad definition that includes physical, emotional, familial, and psychological factors) are largely liberal states.
Another way state governments restrict access is through overly punitive regulations that are often called TRAP laws, short for Targeted Regulation of Abortion Providers. They're medically unnecessary, and make it harder and sometimes impossible for clinicians to offer abortion care, according to The Planned Parenthood Action Fund. That can limit the number of clinics in some areas. Five states have only one remaining abortion clinic: North Dakota, South Dakota, Missouri, Mississippi, and West Virginia. People living in these states might have to travel up to 200 miles to reach a clinic, and could have to wait a few weeks for an available appointment.
In 2019, the average woman of childbearing age lived 25 miles away from the nearest abortion clinic, according to data from the journal Contraception. But that number doesn't tell the whole story. Large cities with clinics have high populations concentrated in one area. Although the mean travel distance for a person in New York was five miles, it was 136 for a woman in South Dakota.
What's more, some states have mandatory 24-hour waiting periods or require counseling before going through the process. That means patients may have to make two individual trips to the clinic, or get a hotel and stay overnight. The trips, plus the cost of the medical regimen or procedure — which can be $1,000 or more — can be untenable without financial aid.
“Across the country, we’ve already seen a systematic chipping away at the right to access abortion, even without overturning Roe,” explains Rachel Sussman, The Planned Parenthood Action Fund’s vice president of state policy and advocacy. “Since the 2010 elections, we’ve seen 480 state-level abortion restrictions passed.”
The legislation disproportionately affects Black women and people of color, says Marcela Howell, president and CEO of In Our Own Voice, the National Black Women’s Reproductive Justice Agenda. Some of the states with the most restrictions have higher POC populations. In Mississippi, for instance, which upholds the Hyde Amendment and requires patients to undergo counseling before having an abortion, 38% of the population is Black, according to the U.S. Census Bureau. “Roe is the floor, not the ceiling,” Howell says. “What we’re concerned about is: How do we grant access to that right for everyone?”
And the future of abortion rights is looking bleaker and bleaker by the year, many abortion rights advocates say. In 2019, 58 new restrictions were enacted, including 25 abortion bans in 12 states, according to the Guttmacher Institute. They seek to place limitations on how, when, or why an abortion is performed. Some of the bans offer “exceptions” for pregnancies that occur due to rape or incest, but only if the patient has filed an official police report. Alabama has proposed a ban that would prohibit all abortions — period.
All this is to say, access to abortion is already compromised, and that’s with the Roe v. Wade decision intact. “Yes, we all have a constitutional right to abortion, but the access has never been equally shared,” Howell says. “Women who are poor, those who have the kind of jobs that don’t have flexible hours to go to a clinic in states where they need to wait 24 to 48 hours between the initial appointment and procedure — they don’t have access.”
What Will Happen If Roe v. Wade Is Overturned?
At the first presidential debate in September Trump said, “there is nothing happening” with Roe v. Wade, and that he didn’t “know [Barrett’s] view on” the landmark ruling. But, during her confirmation hearings last week, Barrett noted “Roe is not a super-precedent because calls for its overruling have never ceased.” The prevailing belief is that the ruling is in grave danger of being overturned, Arons says.
Perhaps unsurprisingly, at least some anti-abortion advocates are happy with Barrett's appointment. “Americans United for Life was the first pro-life group to urge the president to select Judge Barrett,” Catherine Glenn Foster, president & CEO of the anti-abortion organization, told Refinery29 in a statement. She noted it’s likely the Supreme Court will have the opportunity to rule on questions of abortion rights. “We are confident that if confirmed to the Supreme Court, Judge Barrett would prove herself a trusted caretaker of the constitutional protections extended to every human person in America,” Glenn Foster said.
The Supreme Court may get its chance to reconsider Roe v. Wade within the next year, according to multiple experts Refinery29 spoke to. “Right now, there are 17 abortion-related cases that are one step away from the Supreme Court,” Sussman says. “There are several cases that could give the court the opportunity to completely gut Roe or perhaps overturn it.” That’s more likely to happen if Barrett is confirmed.
Barrett has not returned a message Refinery29 left with the United States Court of Appeals for the Seventh Circuit requesting comment.
If Roe v. Wade was overturned, abortion wouldn’t become illegal across the nation overnight. However, “trigger laws” that are on the books now would go into effect and ban the procedure almost immediately. And, more broadly, access would be even more dependent on state legislation than it is now, says Noel León, interim director of state abortion access at the National Women’s Law Center. Some states may pass bills or change their constitutions to protect access. Others, such as New York (where abortion was legal even before Roe was decided), have already passed laws to protect access in the event the landmark case is overturned. Meanwhile, other states could further curtail access or ban abortions completely. Without Roe, abortion would likely become illegal in 22 states, according to a recent analysis from Middlebury College. In that case, for 41% of women of childbearing age, the nearest abortion clinic would close. They'd then have to travel and average distance of 280 miles to the nearest one — compared to 36 miles, the current average for counties where a Roe reversal is likely to occur, explains Caitlin Knowles Myers, a professor of economics at Middlebury College.
And even if Roe is not overturned in one fell swoop, states could continue passing legislation that chips away at access bit by bit, and the Supreme Court could uphold those state laws, explains Laurence H. Tribe, university professor of constitutional law emeritus at Harvard. If Roe is dismantled, Sussman says that 25 million women of reproductive age live in a state where abortion would be banned.
This is perhaps the most likely scenario: That a more conservative Supreme Court will first “hollow out” Roe until there’s almost nothing left. That could look like banning common procedures for abortion, such as Dilation and Evacuation, or even forbidding abortions after brain waves are detected, Tribe says.
Right now, with the 17 abortion-related cases held up in federal appeals courts, the Supreme Court has what Tribe describes as a “menu” of cases, and they’ll get to pick and choose which to take.
“They’re going to be looking for cases that will give them the maximum opportunity to do the most damage to Roe v. Wade,” Tribe says. “You've heard of death by a thousand cuts? That’s what may happen to Roe, after about a dozen decisions over the next three to four years.”
If that occurs, or in the case of overturning Roe entirely, Congress could try to enact a national law protecting the right to abortion. “But the Supreme Court with three Trump-appointed Justices, plus Justices [Samuel] Alito and [Clarence] Thomas might hold that it’s beyond Congress’s power under the interstate commerce clause to pass such a law,” Tribe adds. Then, determining access would be in the hands of the states.
But it won't necessarily stay with them. If Roe is eventually overturned, a more liberal state, say California, could write in their constitution that it’s still legal to have an abortion in the first two trimesters. But eventually, anti-abortion advocates could take a case to the Supreme Court saying that’s depriving the fetus of its “right to life.” “That kind of argument, which would have gone nowhere five or 10 years ago, might well have five justices behind it if Barrett is confirmed,” Tribe says. Congress could also pass a federal abortion ban that the president signs. The worst possible outcome is a sweeping constitutional amendment banning abortion federally, according to Talcott Camp, the chief legal and strategy officer at the National Abortion Federation — though she doesn’t see it happening in the near future. However, it's been part of the Republican platform for years. “We are confronting a world in which women can be controlled by people in power,” Tribe says.
But no matter which scenario actually becomes reality, abortion access will continue to affect people unequally. “You’ve got to hold two things at once,” Camp says. “It would be a terrible, tragic loss if Roe was overturned, and that would have a huge impact on low-income, Black, brown, and rural women. But it is also true that those folks are already suffering from lack of abortion access today. And that they would suffer disproportionately were the courts to hollow out Roe so much that states could effectively ban abortion.”
Organizations that help fund abortions, like the one Angel used, are already struggling to meet the needs of their communities. “Here’s the reality a lot of people aren’t talking about,” says Laurie Bertram Roberts, executive director of both the Mississippi Freedom Fund and the Yellowhammer Fund in Alabama. Roberts, who uses she/her and they/them pronouns, has been helping low income folks pay for abortions in the South since 2013. “People are saying, ‘Well, we’ll just get money together and drive all these people to states where abortion is legal like we did before Roe,'" Roberts says. "As I always say when something is ridiculous, 'That’s cute.’ Capacity-wise, clinics could not afford to take all of those patients. Even if we all had private jets to fly people out of state, it still would not solve the problem.”
As Roberts says, “You’re gonna see folks who, with Roe, could swing it not be able to swing it any more.” The same person who could drive from Texas to New Mexico for an abortion may not be able to make it all the way to Chicago. And definitely not to Europe.
This may prompt more women to try terminating their pregnancies at home, says Jen Villavicencio, MD, MPP, a physician providing abortions in Michigan and a fellow of the American College of Obstetricians and Gynecologists.
“There’s evidence to suggest that self-managed abortion — whether done with guidance from others, or done by a woman herself — can be done safely,” Dr. Villavicencio says. “I worry about the stigma associated with this… We’re in a scary place where people will potentially not be willing to seek care if they have one of the few rare complications because they’re afraid of the consequences. There are laws that exist right now that criminalize this, and people have been put in jail for it, taken away from their families.”
Even though abortion is legal, there have been numerous attempts to charge and convict women for self-inducing abortion. Arons says that Black and brown women are at heightened risk for being targeted by overzealous prosecutors misusing statutes to criminalize behavior during pregnancy. States with abortion bans held up in courts right now, such as Alabama, claim they’d only prosecute doctors, not pregnant people seeking abortions. “But how would you enforce that?” asks Mary Ziegler, a law professor at Florida State University and author of Abortion and the Law in America: A Legal History of the Abortion Debate. “People are going to fly out of state or order abortion pills online. If you’re Alabama, you’re faced with this choice: Do you not enforce your law, or do you punish your patients? That’s going to be a zero-sum decision.”
All this may seem dismal, but not all is lost, advocates say. “There are certainly states looking to protect abortion rights right now,” says Elizabeth Nash, the interim associate director of states issues at The Guttmacher Institute. “Virginia just rolled back restrictions such as counseling and waiting period requirements this year, and expanded access to abortion. In that state, 10 years ago you wouldn’t have thought that was possible, but it shows that progress can be made.”
But those advancements won’t happen if people don't make their voices heard and vote, says Rachel Fey, the senior director of public policy at Power to Decide. She urges people to learn where their national and local candidates stand on the right to choose before casting a ballot. She notes that folks can call their Congresspeople to voice support for bills that aim to protect reproductive rights. Two are currently in the House of Representatives: the Women’s Health Protection Act, which would stop restrictions that block access to abortion care; and The EACH Woman Act, which would eliminate restrictions on abortion coverage in public and private insurance plans.
Tribe adds that it’s not too late to continue to push your senators to hold off on the confirmation of Barrett before the vote on Oct. 22. “If there was a massive uprising and people realized what was at stake for them, and marched on Washington on reproductive rights, who knows?” Tribe says. “She will likely be confirmed very narrowly, and, at this point, only political pressure will matter. There’s no procedure or silver bullet available to stop this nomination. Rising up is the only way.”
What To Do If You Need An Abortion (Or Know Someone Who Does)
These days, most people who need an abortion start in the same place as Angel: Google. But it can be hard to decipher your state’s laws, and sometimes doing so takes time that you may not have. Luckily, there are organizations that make it easier.
To find the abortion clinic nearest to you, visit the National Abortion Federation’s website or call them at 1-877-257-0012, Roberts suggests. They have a list of certified clinics on their website, which demonstrate that they comply with NAF's high standards for safety and patient-centered care. Additionally, the nonprofit Power To Decide launched a digital abortion finder tool just last month that can help you safely find a verified physician or nurse practitioner in your area. This can be accessed at abortionfinder.org.
If you know you won’t be able to pay for your abortion, NAF has a confidential hotline you can call to request help with funding: 1-800-772-9100. If they can’t cover you, try the National Network of Abortion Funds website, which lists organizations that help folks pay for their abortions, broken down by state. If your state doesn’t have a fund, call the one in the neighboring state, and they’ll likely know what to do. “If someone goes through the trouble to find us, we’ll rarely turn them away," Roberts adds. Besides money for abortions, these funds may offer assistance with travel, hotels, and emotional support, too.
Worth noting: Many abortion funds need financial support. If you’re able, consider donating to a fund using the resources above. "Any way people want to give money or resources, we'll make it happen and find a way to take the donation, just reach out," Roberts says. "Even if that means giving us a gift card you got for your birthday that you know you won't use, everything helps."
Angel, now 21, is pregnant again — and this time, she’s thrilled. Her abortion allowed her to get back on her feet financially, and she says she has no regrets. She’ll forever be grateful for the emotional and physical support that Fund Texas Choice gave her as she traveled across state lines to take the abortion pill at five weeks. She remembers sipping a Sprite on her long drive home — a soda the fund’s program coordinator had bought her — knowing she’d made the right decision. And she feels even more confident in her choice today.
“I’m much happier now,” she says. “Right now, if I wanted to have an abortion, I could actually afford to make that choice. My abortion helped open up doors to get me where I’m at now. It was something that needed to happen.”
*Angel’s name has been changed to protect her identity.