Amy Hagstrom Miller probably knows US geography better than most.
The founder and chief executive officer of Whole Woman’s Health, an abortion provider with clinics in multiple states, says it’s become a critical part of her work to know the routes of major highways and the best travel patterns for people to get out of states with restrictions to a provider.
After the US Supreme Court decision that removed guaranteed access to abortion in June 2022, disparate state laws have created a fractured abortion landscape in the US – with massive upheaval across the South, in particular.
“I’m staring at this map I have of the United States – it’s on a dry erase board because I’ve had to change things all along – but it looks like what I would describe as a new borderlands,” Hagstrom Miller said. She used to think of Mexico, the Gulf of Mexico and the oceans as the borders. Now, she said, she can trace a finger around the South, “and that’s the border now. All those contiguous states [to the South] have banned abortion.”
Of the 16 states in the South, 10 have banned abortion. Two have restricted it to the first trimester: Georgia with a six-week limit and North Carolina with a 12-week limit. Florida is one of four states in that US Census region – along with Delaware, Maryland and Virginia – where abortion is legal past the first trimester.
And things are far from settled in the region. Major legal and political challenges loom in some states, with impacts that would reverberate through the region – and nationwide.
Abortion is legal up to 15 weeks in Florida, making it one of the least restrictive states in the South. It has become a key access point for people who are no longer able to receive care where they live, in addition to a significant number of its own residents. But an impending ruling from the state Supreme Court could bring a dramatic shift.
Abortion rights advocates have challenged the state’s 15-week ban, citing a decades-old precedent that abortion is protected by the state Constitution under the right to privacy. If the state’s high court rules that it does not protect the right to abortion, a stricter six-week limit would take effect a month later, limiting access to a time before most people even know they’re pregnant.
In the year since the Dobbs decision, abortion providers in Florida reported the third most abortions of any state and the second largest increase, according to a report from #WeCount, a research project led by the Society of Family Planning. There were more than 92,000 abortions in the state, about 20,000 more than the year before.
If Florida’s high court rules to restrict abortion access there, it would affect more than a third of abortions in the South and nearly 1 in 10 nationwide.
“Florida would be extreme,” Hagstrom Miller said. “I just stare at the map and think, ‘OK, if they ban abortion in Florida or they ban abortion in Georgia, where are people going to go?’”
An unbalanced equation
Displaced patients from Florida and those from other states who relied on the clinics there would probably head north for care, experts say, flooding providers that are already stretched thin and straining the limited resources that remain.
“Abortion bans don’t change the need for an abortion,” Hagstrom Miller said.
In fact, average monthly abortions in the US increased in the year after the Dobbs decision, the #WeCount report found – but thousands more patients were served by a significantly smaller number of providers.
Providers in states where abortion remains legal are doing their best to keep up.
“We don’t know what the next step will be, and it certainly causes anxiety,” said Michael Scheinberg, director of operations for the Falls Church Healthcare Center, an abortion clinic in northern Virginia.
It’s hard to say whether the clinic is at full capacity at any time, he says, because there’s ongoing analysis of patient needs and regular adjustments the clinic’s offerings to match. Requests for medication abortion have become more common, for example, but there’s also been an increased need for procedural abortions for people with later gestational age, many of whom have had to travel from other states.
“We kind of tweak things around to make sure that we’re able to see as many patients as we possibly can with the resources that we have available, just hoping that we are able to keep up with the trends,” he said. “In this case, the best way that we can work is to be as positive as we can and try to help as much as we can.”
Whole Woman’s Health has two clinics in Virginia: one in Alexandria and one a bit farther south in Charlottesville. Although it doesn’t always fill all available appointment slots, patient volumes have increased significantly over the past year, Hagstrom Miller said – and the potential impact of a Florida ban is big enough that she’s considering opening another clinic along the North Carolina border, along with expanding gestational limits and increasing capacity in the existing locations.
Even if providers are able to absorb a surge from Florida, individuals seeking abortions need to find the means to travel significant distances for care.
Abortion funds can help fill the financial gap for some, but many of those organizations are stretched thin, as well.
The Tampa Bay Abortion Fund had to close its doors to new clients for a month this fall, said Bree Wallace, its director of case management. And now, for the first time, it’s budgeting how much it’s spending each month.
Donations aren’t as large or as frequent as they were right after the Dobbs decision, Wallace said, despite a growing need.
“We’re spending more, but we’re not recouping,” she said. And supporting out-of-state travel would be raise expenses significantly.
At the midway point for the latest budget cycle, the Tampa Bay Abortion Fund had used about three-quarters of the allotted monthly funds. Only about $1,000 has been spent on practical support such as travel costs, with the remaining $41,000 put toward appointment costs at clinics. But that ratio would flip dramatically with additional restrictions to abortion access in Florida – and the overall need would only grow, Wallace said.
“It’s a lot easier to come up with $350 for appointments versus $350 plus a flight, hotel and all the travel costs for one appointment,” she said. “We’d never leave anyone stranded, so we’re trying to make sure we have money when people might be traveling a lot and it gets more expensive.”
No safe haven
The potential change in Florida isn’t the only looming uncertainty around abortion access in the US.
Virginia is also a crucial access point for people seeking abortion and, like Florida, reported a significant increase in abortions in the year post-Dobbs. Average monthly abortions rose 25%, according to the #WeCount report, a difference of about 550 abortions a month or more than 6,600 additional abortions over the course of a year.
This week, Virginia has its first general election since the Dobbs decision, and shifts in the control of the Legislature could pave the way for new restrictions.
“This election is so critical for Virginians and so many of our neighbors because Virginia is such a key access state,” said Jamie Lockhart, executive director at Planned Parenthood Advocates of Virginia. “Virginia is truly holding the line, and we need to keep it that way.”
Impending change – from a court decision, election results or otherwise – raises anxiety for local providers and compounds broader uncertainty nationwide.
The staff members at A Woman’s Choice, an independent abortion clinic with locations in Florida and North Carolina, know that the Florida Supreme Court decisions are typically released each Thursday at 11 a.m.
“Our frontline staff in the midst of it. They’re in the middle of clinics, consults, making sure patients are educated about their care and making the best decisions for them and their family,” said Amber Gavin, vice president of advocacy and operations for the organization. “But our leadership team, that’s when we’re on the Florida Supreme Court website, checking and refreshing. There’s a lot of anxiety for a few hours.”
The past few Thursdays have brought a “sigh of relief,” she said, but the regular anxiety can wear on patients and staff.
“It’s exhausting and frustrating,” Gavin said. “Every time folks hear that there’s change, people think that it immediately goes into effect, and there’s a lot of chaos and confusion.” Patients often call with questions about keeping their appointments, and staff are worried about keeping their jobs, she said.
In some ways, operating under uncertainty has become the norm.
“We want to retain freedom to abortion care in the South, and we’re working to be that safe haven, but nothing is a certainty,” Scheinberg said. “With the political landscape, it’s very hard to tell exactly what’s going to happen next. I don’t think there is a safe place in the United States. We just have to be vigilant and keep working.”