Even in abortion ‘safe havens’ finding care can be challenging

In the aftermath of the leaked supreme court document fortelling the end to federal abortion protections, California geared up to fight.

“California will not stand idly by”, the state’s governor and legislative leaders said in a joint statement. As in other liberal-leaning states, officials and abortion providers vowed to ramp up abortion protections and turn California into an abortion safe haven.

Already, no other state does more to protect abortion access. The right to an abortion in California is guaranteed in statute and by the sweeping personal privacy rights enshrined in the state constitution. California health insurance plans cover the cost of an abortion for low-income residents, and the state has rejected waiting period requirements and most restrictions on the practice.

But even in the state with the best abortion protections in the US, abortions have long been inaccessible for many – especially those living in rural, conservative areas. Forty percent of California counties have no clinics providing abortions. Many people still have to travel far to get the appropriate care, or struggle to afford abortions, while language barriers and a lack of up-to-date information can make it difficult to find help.

Advocates say that the millions of dollars state leaders are promising for abortion care and extended legal protections are a start. But even more may be needed to care for those living within the state, and the thousands coming from afar. “As more and more people come in from out of state seeking abortions, it’s going to put more pressure on a system that’s already strained,” said Laura Jiménez, the executive director of California Latinas for Reproductive Justice.

Across the country, blue states seeking to become abortion sanctuaries are facing similar challenges. Even as Democrat-controlled legislatures from coast to coast convey millions into abortion funds, advocates are unclear on just how much money and resources will be required by abortion clinics and services that are already overextended. According to the Guttmacher Institute, a reproductive rights group, about 43% of Massachusetts counties had no abortion clinics, and 13% of Massachusetts women lived in those counties. In Vermont, 64% counties had no clinics, and about 38% of Vermont women lived in those counties.

Few options in rural areas

Jennifer Lopez, who lives in Visalia in California’s agricultural Central Valley, had to drive north over county lines to get a simple medication abortion. (The Guardian is withholding her last name because she worries about backlash in her community.)

“When you drive into Visalia from other parts of California, it’s like you’re going back in time,” said Lopez, 36.

Visalia has a small Planned Parenthood clinic, but it doesn’t provide abortion care. An effort by Planned Parenthood to expand recently inspired furor among conservative groups, and a public hearing on the proposal to build a clinic that would provide abortions was postponed several times this year over the controversy.

Lopez, who works at a domestic violence shelter, said she considers herself exceptionally lucky. Many of the clients she works with lack access to transportation or funding to travel for abortion care.

“This isn’t a new problem,” said Jessica Pinckney, executive director of Access Reproductive Justice, an organisation that helps secure financing and organize travel, lodging and childcare for people seeking abortions.

A woman stands next to a fence in a park wearing a shirt that says 'Everyon loves someone who had an abortion'.
Jessica Pinckney is executive director of Access Reproductive Justice, a group that helps secure financing and makes arrangements for those seeking an abortion. Photograph: Eric Risberg/AP

About a quarter of those seeking help from Access come from out-of-state, including from Texas, which enacted a near-total ban on abortions last year, Pinckney said. But the organisation has also helped many coming from states like Nevada – where abortion rights are protected, but clinics are sparse – and in remote regions within California.

“We have helped folks in rural parts of northern California travel four or five hours to the Bay Area to access abortions,” Pinckney said, adding that the few abortion clinics in the rural regions are unable to care for patients with complicated abortions or those who are farther along in their pregnancies.

‘There’s still work to be done’

Although a shortage of abortion clinics is felt most acutely in rural parts of California, people living in underserved parts of big cities can struggle to find care as well. Amelia Torres, 25, said she had to travel from the South Central neighbourhood of Los Angeles, where she lives, all the way across the city to Beverly Hills in order to get a surgical abortion.

Torres, thinking she was about five weeks along when she found out she was pregnant, initially sought a medication abortion at a nearby clinic. But the medication didn’t work, she said. When she went in for a follow-up appointment, it turned out she was about 18 weeks along and would need a surgical abortion, which more than half of abortion clinics in the state aren’t equipped to perform.

She didn’t have a car, but her partner was ultimately able to take time off work to drive her to the appointment, and her family was able to take care of her two daughters while she was being seen. “I was lucky,” she said. Though some in her family tried to dissuade her from terminating her pregnancy, they ultimately supported her choice. “But without that support, the money, the transportation,” she said, “even here in California getting an abortion can be very difficult.”

In addition to a lack of providers, language barriers and a lack of information can make it impossible for many to find abortion care, or the resources to help fund such care. “There’s always been an enormous stigma around seeking information about abortions,” said Ushma Upadhyay, a public health researcher at the University of California, San Francisco.

Advocates in recent weeks have become increasingly concerned about the spread of misinformation that implies abortions aren’t legal in California. The fear of criminalization or deportation may also keep California immigrants who lack legal status or are in the country with a temporary protected status from seeking abortions or public resources to help pay for care, they say.

Late-term abortions, once the fetus is viable, are still restricted in California and can be prosecuted, as can abortions performed outside a medical setting. “This might include a situation where there’s been rape and incest, and the person doesn’t realize that they are pregnant until much later in the pregnancy,” said Upadhyay. “These are extreme situations that apply only to a small number of patients.”

California could also do more to protect those who miscarry, or attempt self abortions, advocates said. Just this week, a district attorney in California’s conservative Kings county dropped the prosecution of a woman who spent four years in prison for giving birth to a stillborn child after using drugs. “California is definitely a leader in passing legislation to protect people seeking abortions,” said Jiménez. “But there’s still some work to be done in the decriminalisation of self-managed abortions”

And then there’s the cost. Even with insurance, Lopez had to pay about $550 out-of-pocket for each of the two abortions she sought over the past three years. “I managed to pay, but it was a big chunk out of my savings,” she said.

The median out-of-pocket cost of a first-trimester for those without insurance in California is about $700.

One resident of the Central Valley city of Dinuba, whom the Guardian is not naming because they fear stigma from their family, said they ended up paying about $1,000 for a first-trimester medication abortion last year because concerns about an ectopic pregnancy required them to seek multiple follow-up appointments.

A woman in blue scrubs and a medical mask sits in an exam room.
Dr Jessica Hamilton sits in a consultation room at the Planned Parenthood Health Center in Sacramento, California. Photograph: Carlos Barría/Reuters

California recently passed legislation eliminating co-pays for abortion care, and the state already covers abortion costs for those enrolled in the state’s public insurance option for low-income residents. The governor this week announced an additional $57m to prepare for an influx of people from other states seeking abortions in California, including $40m for abortion providers offering care to low-income patients without health insurance, and $15m to help community-based organizations with sexual and reproductive health outreach and education.

The funds “will go a long way” to protect abortion access “for those who live here and those who may be forced to seek care here”, said Jodi Hicks, president and CEO of Planned Parenthood Affiliates of California.

Telehealth visits could expand access

Researchers and advocates say that telemedicine clinics, which consult with patients online and mail abortion pills to clients, could be another way to quickly expand abortion access.

Telemedicine services typically charge about $300 for a simple service, and often don’t take public or private health insurance due to the logistical complications of securing reimbursements for care delivered across county lines, said Mai Fleming, a physician and researcher at UCSF who also works with an online abortion clinic.

The services aren’t right for everyone and infeasible for many in rural California who lack internet access, but they still could be a solution for some who live in areas without clinics, she said. “Going forward, I think expanding telehealth could be key to expanding access in rural parts of the state,” she said, adding that California should work to make it easier for online clinics to accept insurance.

Often, brick-and-mortar abortion clinics shy away from offering telehealth abortion services precisely because of how insurance reimbursements work. Public and private insurance services reimburse at higher rates for in-person appointments that include an ultrasound, which is often medically unnecessary – leading clinics to require patients to come in person in order to recoup operational costs, Upadhyay said.

In an attempt to ramp up the number of healthcare workers available to perform abortions, California and some other states are also moving to allow nurse practitioners to provide abortion care without the supervision of a physician. And ultimately, more primary care providers and family clinics could start providing abortion care, Fleming said – though as it stands, primary care and family medicine residencies still aren’t required to train doctors to provide abortion care.

“Despite its very progressive laws, hurdles and barriers to abortion care have existed for years,” she said. But now, especially, she added, “it’s important to remember that abortion, legality, abortion rights, don’t necessarily equal abortion justice or abortion access.”