The outside of the Planned Parenthood Reproductive Health Services Center in St. Louis, Mo., as seen on Tuesday, March 8, 2022. The clinic is the last location in the state of Missouri performing abortions.(Photo by Neeta Satam for The Washington Post via Getty Images)

Crossing the Abortion Line

The Interstate Tug-of-War Over Reproductive Freedom

The Planned Parenthood Reproductive Health Services Center in St. Louis on March 8, 2022. Photo: Neeta Satam/The Washington Post via Getty Im

Editor’s Note: On June 24, the Supreme Court overturned Roe v. Wade. Within an hour, Missouri’s attorney general issued an opinion triggering the state’s abortion ban.

The last remaining abortion clinic in Missouri is blocks west of the famed Gateway Arch National Park, which hugs the Missouri side of the Mississippi River. The sliver of water, just three-tenths of a mile wide, divides downtown St. Louis from the suburbs and small cities of southern Illinois.

The clinic, run by Planned Parenthood, is housed in a brick building surrounded by a tall metal fence. Anti-abortion protesters gather along the perimeter, attempting to stop people from driving in. Hanging from the side of the building is a sign with big block letters that reads “STILL HERE.”

Still being there, being open, is no small feat. For more than a decade, an increasingly conservative Missouri legislature has tried to legislate abortion out of existence. It passed a slew of draconian measures that led to the closure of the state’s other clinics. It passed a near total ban on abortion at eight weeks, a point at which many people don’t know they’re pregnant. To that measure, lawmakers affixed a so-called trigger law, which will outlaw abortion altogether when — imminently — the U.S. Supreme Court knocks down nearly a half-century of precedent acknowledging the right to terminate a pre-viability pregnancy. And although the eight-week ban was blocked by the federal courts as unconstitutional, at least by present standards, the state was undeterred, weaponizing its regulatory system in an attempt to revoke the clinic’s license.

“I describe practicing in Missouri as providing some of the most basic and not super-complicated health care with my hands behind my back, in handcuffs, and blindfolded,” said Dr. Colleen McNicholas, an OB-GYN and chief medical officer for Planned Parenthood of the St. Louis Region and Southwest Missouri. “And then tomorrow, I get to go provide the same health care in Illinois, where it is centered in science.”

While lawmakers in Missouri have worked furiously to constrict reproductive health care, politicians and providers in Illinois have been working to increase access. The state made birth control available over the counter, expanded Medicaid to include abortion coverage, repealed a parental notification requirement for minors seeking abortion, and enshrined reproductive freedom into state law. The abortion clinics on the Illinois side of the river — including an 18,000-square-foot facility in Fairview Heights operated by the same Planned Parenthood affiliate that runs the St. Louis clinic — have expanded capacity. Thousands of Missouri residents now make the trip across the river every year for services.

Simply living on the Illinois side of the river cuts a person’s likelihood of pregnancy-related death in half, notes Dr. Erin King, an OB-GYN who serves as executive director of the Hope Clinic for Women in Granite City, Illinois, also just across the border from Missouri.

With Roe about to fall, Illinois will be thrust into an even bigger role: 22 states are expected to swiftly outlaw abortion, a list that includes nearly every state in the South — and every one of Illinois’s neighbors. The state is poised to become an oasis of access in the heart of an abortion desert. In the first year post-Roe, the Fairview Heights clinic anticipates treating 14,000 additional patients; 15 miles away, the Hope Clinic estimates that its patient volume will nearly double.

Illinois is poised to become an oasis of access in the heart of an abortion desert.

Outlawing abortion won’t diminish the need for care, but it will make navigating access more complicated and costly and hit those with the least resources and mobility the hardest. Nationally, 60 percent of abortion patients are already parenting; nearly 50 percent live below the federal poverty line; a majority are patients of color. It was with this reality in mind — months before Politico published the leaked Supreme Court draft opinion that would eliminate abortion rights — that providers were joined by Illinois Gov. J.B. Pritzker in January as they unveiled their latest bid to help facilitate the looming exodus: the Regional Logistics Center.

A $10 million partnership between the Fairview Heights clinic and the Hope Clinic for Women, the RLC was designed as a one-stop shop for any patient traveling to Illinois. Patients calling for appointments at either facility are connected to the nation’s network of financial aid and practical support groups; case managers help arrange transportation and lodging or line up cash for food and child care. It is a first-of-its kind operation — and couldn’t come online a minute too soon.

Just across the river from Missouri’s last remaining abortion clinic is the Regional Logistics Center. Designed as a one-stop shop for patients traveling to southern Illinois, it is housed in Planned Parenthood’s Fairview Heights clinic through a partnership with the Hope Clinic for Women.

Credit: The Intercept

“Today’s announcement is a shining example of what is possible when elected leaders like you work to shape policy that allows providers to center patients and not politics when delivering abortion care,” Yamelsie Rodriguez, CEO of the regional Planned Parenthood affiliate, said during an online ribbon-cutting ceremony. “Together we are breaking down the silos anti-abortion politicians created.”

The reproductive freedom tug-of-war that has been playing out across this stretch of the Mississippi River opens a window into what is to come after Roe falls: a jockeying for control among the states that will only intensify. As states like Illinois work to expand access for people across the country, others, like Missouri, will escalate their assault, attempting to bind residents to their anti-abortion laws.

There is a common anti-abortion talking point that claims returning control over abortion rights to the states will take the courts out of the mix — in other words, that “abortion law will become simpler,” note the authors of “The New Abortion Battleground,” a forthcoming article in the Columbia Law Review. But that, they write, is “woefully naïve.”

Missouri has already offered a potent example of what the future will look like. This spring, one lawmaker crafted a measure based on Texas’s notorious sue-thy-neighbor law that would allow lawsuits against anyone who helped a Missouri resident obtain care across state lines. While the legislation went nowhere, experts like David Cohen anticipate that measures like it are likely to become the norm.

“Thinking about Missouri is spot on,” said Cohen, a professor at Drexel University’s Kline School of Law and co-author of the new law review article. The state has regulated abortion so severely that there are already very few being performed. “Think of a state legislator in Missouri who, after Roe v. Wade is overturned, says, ‘OK, I have the green light to ban abortions.’ So they’re going to ban abortions,” he said. But if residents can leave the state, anti-abortion lawmakers haven’t really nailed their target. “Are they going to feel good about what they’ve done if they are a true pro-life believer? No, because it’s really kind of having no effect.”

So, he said, they’re going to pursue what will have an effect — and that is bound to unleash a new landscape of cross-border fights that will inevitably end up in the courts. “And those things are going to be the things that … involve interstate travel and crossing state lines or trying to prosecute someone for performing an abortion on a Missouri resident.”

Providers like McNicholas, King, and Rodriguez have long been readying for the fight ahead. “In our bi-state region,” Rodriguez said, “the post-Roe reality arrived years ago.”

Pro-choice supporters and staff of Planned Parenthood hold a rally outside the Planned Parenthood Reproductive Health Services Center in St. Louis, Missouri, May 31, 2019, the last location in the state performing abortions. - A US Court on May 31, 2019 blocked Missouri from closing the clinic. (Photo by SAUL LOEB / AFP)        (Photo credit should read SAUL LOEB/AFP via Getty Images)

Supporters and staff of Planned Parenthood hold a rally outside the abortion clinic in St. Louis on May 31, 2019.

Photo: Saul Loeb/AFP via Getty Images

Missouri’s Extreme Evolution

Growing up on Chicago’s South Side, McNicholas knew she wanted to be a doctor. Initially, the ambition was to be a forensic pathologist. She’d worked in the local coroner’s officer during college, “and I just loved it,” she said. It was more than medicine; it was also problem-solving. “That’s actually why I went to medical school,” she said. But that would soon change.

For med school, McNicholas landed in Kirksville, Missouri, a small, rural, conservative city roughly 40 miles from the Iowa state line. The culture shock was immediate: The traffic lights were only on for a few hours a day, she recalled, and there were deer running around town. “Honestly, I had never seen a deer in my whole life.” As she and her classmates settled in, they decided to start a chapter of Medical Students for Choice, an organization that promotes training in reproductive health, including family planning and abortion. “We thought that there would be some value in our medical school classmates having some exposure to just some more progressive or less judgy sexual reproductive health stuff,” she said. This is no small issue. Reproductive health education that includes abortion is not part of the curriculum in many U.S. medical schools, even for students training to become OB-GYNs.

McNicholas and her friends followed the school’s protocol for initiating the group. “We checked the boxes and we’re like, ‘OK, here we go,” she recalled. The reaction was not what she expected. In school meetings about whether the club should be allowed, “there were classmates crying about having to learn about abortion,” she said. “It was really quite shocking.” The lessons they’d planned were composed of basic stuff, like learning how to take a patient’s sexual history. “It wasn’t even about abortion.” And no one was required to participate. While the school eventually approved the chapter, “that was sort of like, maybe dead people is not the place where I’m going to be best using my talents and voice,” McNicholas said.

She reimagined herself as a “crunch-nugget” OB-GYN who would facilitate water births and provide abortion for her patients when they needed them. She did a residency at Washington University in St. Louis, the only program in the state to provide abortion training. It was there that she realized just how tricky abortion access in Missouri could be. “My training sort of collided with the really extreme evolution that was happening.”

It was the early 2000s, and legislatures across the country were beginning to ramp up their restrictions on abortion. There were laws creating waiting periods, which meant that getting an abortion would require multiple clinic trips. There were mandates for the provision of medically inaccurate “informed consent” materials designed to shame people seeking abortions. There were targeted restrictions of abortion providers, known as TRAP laws, which used safety as a pretext to shut down clinics. There were laws limiting health insurance coverage of abortion and access to medication abortion, which now accounts for more than half of all abortions in the country. Missouri would enact all these restrictions and more.

Amid the dimming landscape, McNicholas undertook research and policy work. She did media training. And she began to testify at the legislature. “If you think about it, the legislature generally doesn’t know anything about building railroads, right? So you would think if they were going to build a railroad, they would ask somebody about that,” she said. But they don’t do that where health care is concerned. “It’s both terrifying and disappointing,” she said. “More than anything, I think the thing that pushed the advocacy piece of my work was around feeling like I put all this time and money into learning how to take care of people, and this dude who has a farm — which, farming is important, great — but what do you know about what I do?”

Missouri politicians have displayed egregious ignorance concerning reproductive health issues. In the most recent legislative session, state Rep. Brian Seitz penned legislation that would ban the “trafficking” of medications or “instruments” used in abortion — the same medications used in miscarriage management and instruments used in routine gynecological procedures. The bill would also make it a felony punishable by life in prison to perform an abortion on a patient with an ectopic pregnancy, a nonviable, life-threatening condition. After public backlash, Seitz claimed the bill had been misrepresented. A subsequent version omitted the language about instruments and ectopic pregnancies.

In 2019, during the growing crisis of access, McNicholas decided to leave a faculty position at Washington University to become chief medical officer for the Planned Parenthood affiliate that operates the St. Louis clinic. That year, lawmakers passed the bill criminalizing abortion as early as eight weeks. Meanwhile, the state was simultaneously pursuing a regulatory strategy that nearly resulted in the clinic losing its license and Missouri becoming the first state in the country without a single abortion provider.

Under state law, the clinic is subject to inspection by Missouri’s Department of Health and Senior Services as part of its annual license renewal. Typically, these would be several-day affairs. But the inspection that year was protracted, spreading over several months. It seemed like the inspectors were on a “quest to find anything and everything,” McNicholas said. “Standing up on chairs and putting your finger across the ceiling tile to see if there is dust or trying to lift off the laminate of something because that could somehow be a violation.”

For the first time, the clinic was cited for not following a regulation regarding pelvic exams. According to the state, the clinic was required to provide an internal pelvic exam during the patient’s first visit — or 72 hours before the abortion would take place, thanks to Missouri’s mandated waiting period. Providers routinely conducted pelvic exams for patients receiving procedural abortions, but not three days ahead of time. Following the regulation meant patients would be subjected to an additional pelvic exam for no medical reason. The state was also imposing the same protocol for medication abortion, where a mandatory pelvic exam runs counter to best practices.

At first the clinic acquiesced, but the result was traumatic. “We explained to the patients that this was not our doing,” Kawanna Shannon, then-director of surgical services, later testified while fighting back tears. “We have patients who have been abused, raped, and you are putting them through an invasive, unnecessary pelvic exam … something they already have to do on procedure day. And you have patients apologizing to us saying, ‘I’m sorry you have to do that to me.’”

Planned Parenthood told the state that it would not comply. “We want Missourians to have access to abortion. But also, you’re not going to push us beyond our ethical boundaries,” McNicholas said. When clinic officials began to suspect that the state was plotting to revoke their license, they decided to be proactive and sued to prevent that from happening.

The state fired back in a press release suggesting the clinic had something to hide. Several weeks later, Dr. Randall Williams, then-head of the health department, told reporters that regulators had decided not to renew the clinic’s license. He said they had identified four patients who had “adverse outcomes” — including one who lost “half her blood” during an abortion — and accused the clinic of failing to file complication reports.

The whole matter ended up before the state’s administrative commission. Over the course of a multiday hearing, it became clear that Williams’s dire characterization was not supported by the evidence. And there were additional revelations, including that regulators had created a spreadsheet for tracking patients’ menstrual cycles in an effort to find failed abortions that the clinic hadn’t reported. The spreadsheet made national headlines. “Here’s the state digging into these people’s medical history trying to make something of nothing,” McNicholas recalled. “The whole picture is really disturbing on many levels.”

Ultimately, the administrative commission sided with Planned Parenthood. In an exhaustive opinion, Commissioner Sreenivasa Rao Dandamudi wrote that the clinic had “demonstrated that it provides safe and legal abortion care” and the state had not found anything amiss that would justify license revocation. Dandamudi ordered the state to pay the clinic’s legal fees. Three months later, Gov. Mike Parson replaced Dandamudi.

While the St. Louis clinic remains open, the heft of restrictions required to access abortion in Missouri have caused patient numbers to fall significantly. In 2015, the clinic provided a total of 4,647 abortions, including 1,177 medication abortions. In 2020, it provided just 51. Notably, none of those were medication abortions; the state refused to exempt them from the invasive pelvic exam requirement, so the clinic no longer provides them.

Meanwhile, just across the river in Illinois, abortion is available without restriction. As the Missouri numbers have dropped, the Illinois numbers have risen significantly. In 2020, the Fairview Heights clinic alone provided over 5,000 abortions — more than triple the previous year.

The Regional Logistics Center is operated jointly by Reproductive Health Services of Planned Parenthood of the St. Louis Region and Hope Clinic for Women, seen in June 2019, a clinic in Granite City, Illinois. (Erin Hooley/Chicago Tribune/Tribune News Service via Getty Images)

A sign for the Hope Clinic for Women in Granite City, Ill., in June 2019.

Photo: Erin Hooley/Tribune News Service via Getty Images

Illinois Is Right Here

Inside the Hope Clinic for Women in Granite City is a framed copy of Senate Bill 25, the Illinois Reproductive Health Act, and a pen Pritzker used to sign the legislation into law back in June 2019. King, the clinic’s executive director, was there behind the governor for the signing ceremony.

The RHA enshrines the right to reproductive freedom into state law and requires private insurers to cover abortion. “This act sets forth the fundamental rights of individuals to make autonomous decisions about one’s own reproductive health,” it reads, including “the fundamental right of an individual who becomes pregnant to continue the pregnancy and give birth to a child, or to have an abortion.”

As Missouri’s health department had the St. Louis clinic in its crosshairs, lawmakers from Georgia and Missouri had traveled to the Capitol in Springfield to urge their Illinois colleagues to pass the measure, which they said would send a positive message across state lines. “The idea of the … very last provider losing their license by the end of this week just really drives home the importance of what’s going on here in Illinois for people in the Midwest region,” then-Missouri Rep. Cora Faith Walker told Capitol News Illinois. “I want to let the people of Missouri know that Illinois is right here. There are people who are supportive of them and will help them if they need help.”

King, who practices medicine in both Illinois and Missouri, thinks the pleas from out-of-state legislators really resonated with their Illinois counterparts. She was out to dinner with her husband and father the night lawmakers were debating the bill and listened for updates through a single earbud. When it finally passed, she said, “There were tears streaming down my face.”

“I went into gynecology because I think reproductive health care is the most important public health measure you can pay attention to,” she said. “It’s actually a medical fact.” That’s because ready access to the full spectrum of reproductive health care — including birth control, prenatal and postpartum care, and abortion — leads to declines in troubling metrics like rates of maternal and infant mortality. This in turn strengthens families and the broader community, King said. “All sorts of things down the stream.”

Missouri has one of the highest maternal mortality rates in the country. In December, King took to the stage for a TEDx talk in St. Louis and laid it all out. “Simply by living in this state, your risk of dying from pregnancy is higher than in 42 other states,” she said. “This information is terrifying.”

The state had convened a multidisciplinary maternal mortality committee to address the problem and had issued two reports. But when you “apply the search terms of ‘contraception,’ ‘birth control,’ ‘abortion,’ or any family planning-related search term, there are no hits,” she told the audience. In states that have been successful in lowering their death rates, “their reports include family planning over and over and over again.”

“Missouri, ignoring this will continue to be our recipe for disaster,” she concluded.

As the state’s lawmakers have waged their war on abortion, they have also refused to exercise their power in ways that would support pregnant people and children. In the most recent legislative session, they failed to pass a measure that would expand postpartum Medicaid coverage to 12 months, for example, but included in the state’s budget an item that would bar low-income residents on Medicaid from receiving preventive reproductive health care — including cancer screenings and birth control — from Planned Parenthood.

“It just reminds you every day about how reproductive health access can get chipped away so slowly, and no one really notices until it’s just not there.”

King said it can be hard to connect her patients to the birth control they want or the postpartum care they need. “When I’m practicing in Missouri, I feel like I kind of bump up against all these different hurdles all the time,” she said. “It just reminds you every day about how reproductive health access can get chipped away so slowly, and no one really notices until it’s just not there.”

Of course, King, McNicholas, and Rodriguez did notice — they’d seen it happening for years as more and more patients were finding their way to Illinois. The Hope Clinic and the Fairview Heights Planned Parenthood had long been allies, but as their proportion of out-of-state patients increased, they wanted to see what more they could do. From that, the Regional Logistics Center was born.

Rodriguez came up with the idea about a decade ago, while working for another Planned Parenthood affiliate that runs clinics in the northern half of Illinois. Even though the state had scant abortion restrictions, surrounding states were ramping up theirs and Rodriguez regularly encountered patients who were struggling to access care. Since Roe was decided, states have passed more than 1,300 restrictions on abortion. For many people, the right to abortion conferred by Roe has long been out of reach.

“Everyday life poses challenges for people of color, people with low incomes,” Rodriguez said. “I would hear patients say something like, ‘Well, I’m going to have to figure out how do I pay my rent.’ People would say that they were trying to sell stuff in order to come up with the fees. Clearly, transportation has always been a challenge.”

Rodriguez thought there had to be a way to simplify things and hit on an idea: What if patients could make a single call to get an appointment and get hooked up with financial aid? What if the person on the other end of the line could arrange for transportation and lodging, or put money in the patient’s pocket for food and child care? “My goal was to become a connector of those services,” she said. “Not just health care appointment needs, but also all of the wraparound services and practical support that was going to enable them … to actually make it to that appointment.”

The idea didn’t get much traction at the time, but Rodriguez held on to it. By 2019, the clinics just over the river from Missouri were regularly seeing patients from at least seven states; the Supreme Court was changing; Missouri was continuing its relentless ambition to push abortion out of reach — which meant that area clinicians were already assisting patients with logistics. “I think that really helped us sort of move this vision of the Regional Logistics Center forward,” McNicholas said. “Acknowledging that there’s going to be a real problem with managing logistics when half the country … loses access.”

According to the Guttmacher Institute, 22 states are poised to ban abortion almost immediately after Roe falls. An additional four are likely to follow suit. Meanwhile, access to medication abortion — used up to about 10 weeks in pregnancy — is expected to become even more important, a fact hostile states have picked up on. Just this year, 117 restrictions on medication abortion have been introduced in 22 states, including seven that would ban medication abortion outright.

The southern Illinois providers hoped that the Regional Logistics Center could serve as an example for other parts of the country. They’d long heard from patients that “what they really needed was not necessarily another physical space,” McNicholas said. “Like, ‘Fine, if this is the physical space to get to in Illinois, or this is the physical space to get to in Colorado, I’ll get there. Help me get there.’”

King said they sat down and worked it all out. “It doesn’t sound like rocket science,” she said, “but it is a game-changer.”

40 Days for Life protestors wave at passing cars outside the  Planned Parenthood clinic in Fairview Heights, Ill., on Tuesday, March 8, 2022.  40 Days for Life is a religious anti-abortion movement that holds protests and prayer vigils outside abortion clinics across the US during Lent. (Photo by Neeta Satam for The Washington Post via Getty Images)

Anti-abortion demonstrators outside the Planned Parenthood clinic in Fairview Heights, Ill., on March 8, 2022.

Photo: Neeta Satam for The Washington Post via Getty Images

Uncharted Legal Territory

The driveway of Planned Parenthood’s Fairview Heights clinic has a simple message painted in yellow block letters: DO NOT STOP. It’s a good reminder because the driveway is often flanked by individuals wearing colored vests, the kind usually worn by escorts at clinics across the country who help patients wade through anti-abortion protesters. The difference here is that the people wearing the vests are anti-abortion protesters.

Inside, Kawanna Shannon, sporting a leopard-print sweater and matching sneakers, is ready to give a tour. Shannon was previously director of surgical services for the St. Louis clinic. In Fairview Heights, she’s director of patient access and oversees the RLC.

Shannon’s phone rings day and night. It’s often patients looking for help to get to their appointments, but sometimes they just want to talk. “You build relationships,” she said. “They may just call and say hi. … They let you know they made it home safely.” One patient was undecided about whether she wanted an abortion. She called repeatedly to schedule and then cancel her appointment. I’m sorry I’m wasting your time, Shannon recalled the patient telling her. “You’re never wasting my time,” she replied.

Winding her way through the building, Shannon opens a door into a big room where staff, including Alexandria Ball, sit in front of computers wearing headsets. Behind Ball is a screen that shows incoming calls in real time, along with a rolling tally for the day. In front of her are two computer monitors. On one, she pulls up a spreadsheet with information about abortion funds and practical support organizations across the country. These are the funds that provide financial support for abortion itself — which can cost anywhere from several hundred to several thousand dollars, depending on the method — or money for other practical needs. Some, like Indigenous Women Rising, focus on specific populations, Ball noted. But like many others, it also offers “solidarity” funding, “which means you may not fit the bill for that particular funder, but they will help you anyway.” Ball matches individual patients to funding organizations. “That’s when I put on my little thinking cap and go to work,” she said.

Although the RLC was slated to open this summer — when the Supreme Court is expected to deliver Roe’s death blow — the clinics had to significantly accelerate their plans after Texas’s Senate Bill 8 took effect in September. Lawmakers sought to shield the six-week ban from legal challenge by outsourcing its enforcement, allowing private individuals to bring civil suits against health care providers or anyone else they believe may have aided a patient seeking an abortion in violation of the law.

After the U.S. Supreme Court shrugged its shoulders and declined to intervene, the law had an immediate impact, chilling abortion providers in Texas and emboldening other hostile states to follow suit. Patients who could afford to travel for care fled the state in droves. The Fairview Heights clinic saw a more than 50 percent increase in out-of-state patients after S.B. 8 took effect. In the first four months of 2022, the RLC provided funding and logistical support for nearly 1,000 patients.

Ball’s job also includes a significant amount of emotional labor, dealing with patients who are anxious, stressed out, or skeptical. She recalled a man from Texas who was trying to line up care for his partner. She told him the procedure would cost $3,600. He said they only had $500. “OK. You got $500. That’s great. I’ll take it. I can find the rest,” Ball responded. She told him she was going to go ahead and book a flight and hotel room. “And he was like, ‘Uh, so what’s the catch?’” There’s no catch, she replied. “And he was like, ‘Why are you doing this?’ And I was like, ‘Well, unfortunately, it shouldn’t be this hard to receive care. But unfortunately, it is, and we just want to make this as easy as possible.’”

Ball says she’s skeptical by nature, so she gets it: The patients scrambling to find a clinic are simultaneously waiting for the other shoe to drop. But the fact that her job is even necessary frustrates her. “People aren’t having abortions as some sort of righteous political act. They’re doing it because they need care,” she said. “No one is thinking, ‘I’m going to get pregnant so I can have an abortion. Really stick it to those legislators.’ No one’s thinking that.”

Conservative lawmakers, however, are trying to stick it to patients seeking abortions. Take Missouri state Rep. Mary Elizabeth Coleman, who offered a new spin on S.B. 8 with a measure that would unleash vigilantism on anyone who performs an abortion on a Missouri resident or helps them cross state lines for care. Coleman’s goal was for Missouri to own its residents. “If your neighboring state doesn’t have pro-life protections,” Coleman told the Washington Post, “it minimizes the ability to protect the unborn in your state.”

The measure would cast a wide net, targeting anyone providing financial support or even referrals for abortion care. That would include the abortion funds that help patients travel to Illinois, for example, and the staff of the RLC. It would also empower individuals to sue internet service providers and website hosts that “allow Missouri residents to access any website” that “encourages or facilitates efforts to obtain elective abortions.” And it declared medication abortion drugs “contraband” and would make it illegal to “mail, transport, or deliver” the pills to anybody in Missouri.

Coleman offered her measure as an amendment to several anti-abortion bills but found no takers. In fact, in an unusual turn, the Missouri legislature failed to pass any anti-abortion laws during their 2022 session — but this says less about policy priorities than it does about a legislature floundering under the weight of its own dysfunction.

Coleman has been ridiculed for what seems like blatant overreach. One advocate told the Washington Post her idea was “bonkers.” But Cohen, the Drexel law professor, says it’s precisely the kind of measure he expects will proliferate in the post-Roe landscape: “Missouri, and a lot of other states that are in similar positions, you’re going to see them getting very creative in approaches to try and limit or stop residents of their state from getting abortions elsewhere.”

To many, it’s an absurd idea that a state would have the power to control a resident’s actions beyond state lines. But whether that’s the case is a sort of gray area, says Cohen. “Most people think that if I travel across country, as long as I’m following the laws of the state where I am, then I’m doing the right thing,” he said, like a person buying marijuana in Colorado or gambling in Nevada. “Unfortunately, that sort of commonsense understanding is not reflected clearly in the case law.” Instead, he and his colleagues Greer Donley and Rachel Rebouché argue that there is enough debate about the contours of the law that “there’s an opening for an anti-abortion Supreme Court to sort of push the law in the direction of giving states broader authority … to control their citizens across state lines,” he said.

Even if, for example, Missouri can’t control a resident’s actions in Illinois, it could still say “at a minimum” that it can control those actions in Missouri. “So if you start doing things to travel out of state to get an abortion, you start that process in the state of Missouri,” he said.

Where limitations on access to medication abortion are concerned — like Coleman’s measure that would brand the medications as contraband — Cohen said he and his colleagues believe this should be preempted by federal law. “Because the federal FDA says that these are allowed and these are approved and safe, then states should not be able to act contrary to that,” he said. But that too “has not been tested in court yet.”

On the other side of the coin, a host of states are looking to insulate themselves from interstate overreach. To date, 19 measures to protect abortion have been passed in 11 states. California, Connecticut, New York, and Washington have passed laws or are considering measures that would shield doctors and patients from out-of-state interference. This too raises legal issues that will need to be sorted out.

The demise of Roe is going to jumpstart an interstate power struggle that will see questions of abortion access dropped right back into the courts.

In all, the demise of Roe is going to jumpstart an interstate power struggle that will see questions of abortion access dropped right back into the courts. “We’re entering a situation where states are going to start really taking extreme measures to ban abortion that threaten jurisdictional issues, and then other states are going to try and protect their abortion providers and patients, threatening classic expectations of cooperation,” Cohen said. “It’s this new territory that we’re going to enter.”

King says that even if a law like Coleman’s is unenforceable, it will nonetheless create uncertainty and intimidate people — which is what the myriad abortion restrictions across the country have already done. “When you’re confusing patients, you’re also confusing health care providers. So health care providers all of a sudden feel very uneasy in a state that has even proposed legislation like that. They feel very uneasy about talking about all options with a patient,” she said. “Which is really, really bad for health care in general: You’re not giving someone all the options because either you don’t understand it or you’re scared. And, obviously, that just limits patients’ access more.”

“I’m someone who is deeply immersed in abortion access,” she said. “I live in Missouri, I have a medical license in Missouri … and I’m still confused.”

Shannon has experienced the vast difference between providing health care in Missouri and Illinois. In Missouri, “It’s just so many unnecessary T’s and unnecessary I’s that you have to cross and dot,” she said. “Even before we’re talking about overturning Roe, these are struggles people have been going through for years, just trying to get basic health care.”

“It’s strenuous, and it is stressful on the patients unnecessarily. And it’s just the difference: You drive 15 minutes across that river, you’re just like, ‘Wow,’” she said. “Such a breath of fresh air and freedom for patients.”

Shannon says that she and her colleagues are determined to help people exercise their reproductive autonomy, free from government surveillance and overreach. Just making it across the river from Missouri into Illinois feels “like freedom. It’s really sad to say, but it is just like making it to a free land, where you’re able to make the choice that you want to make without being stressed out, ridiculed,” she said. “And it’s going to get down to the wire of the states that are left. And we will have to band together to help every other patient be seen.”

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