While clinics are being shut down throughout the country by restrictive and medically unnecessary state laws, patients may soon learn that their last hope - their own private physician - has lost his or her opportunity to provide abortion care, as well.
The Louisiana legislature has been debating a contentious abortion bill that could shut down three out of five clinics in the state, leaving just one city with a public abortion clinic, and at the same time dissuade the use of medication abortion by changing the rules around when, and how, the medication can be dispensed.
Reproductive rights groups have been rightfully opposed to a number of oversteps in HB 388, from demanding medically unnecessary hospital admitting privileges for doctors doing abortions to mandating dissemination of medically inaccurate information about abortion risks under the guise of "informed consent."
But there is an overlooked, subtle and very dangerous element in the new abortion bill that isn't getting as much notice, and that new rule is the latest attack in the offensive to cut all access to abortion, even without ever overturning Roe v. Wade. Tucked inside the bill is a dangerous redefining of who in fact is officially an "abortion provider," and this definition is meant to turn a family practitioner into an illegal abortionist even if he or she only does an occasional pregnancy termination.
In the days before abortion was made legal in all 50 states, the ability to terminate a pregnancy was dependent on a number of factors. For a person resourceful enough, both financially and socially, an abortion could usually be found, whether it meant telling lies to a hospital board, traveling out of state or out of country, or working through the whispered grapevine of contacts who eventually would lead you to a person - hopefully someone with a medical background - who was willing to take risks necessary to perform the procedure illegally.
That changed with Roe. With one court ruling, access to a safe, legal abortion was supposed to be a right to every person, not just those who lived in the right state, wanted an abortion for the right reason, had large amounts of money to finance it and happened to know the right doctors.
Due for the most part to Targeted Regulation of Abortion Provider (TRAP) laws . . . the provider landscape in many areas of the country has gone from sparse to mostly deserted
Now, once more, access is waning. Although abortion is still technically legal in all 50 states, the ability to actually have an abortion has again become determined by how far a person can travel, how much money she can spend, and how long that person can afford to be away from home, out of work, obtaining daycare or hotel rooms, and jumping through the hoops of waiting periods, face-to-face doctor's visits, protesters and ultrasounds with mandatory scripts.
Due for the most part to Targeted Regulation of Abortion Provider (TRAP) laws that are forcing clinics to shut down over medically unnecessary building regulations or hospital admitting privileges, the provider landscape in many areas of the country has gone from sparse to mostly deserted. With a few exceptions, such as Colorado or Illinois, non-coastal states are now down to a handful of clinics only clustered around highly populated rural areas, or, in some states, just one or two clinics all together.
As clinics disappear, those that are left are not only farther away, but also busier, as more pregnant people have fewer clinics from which to choose. Waiting periods, counseling sessions, ultrasounds that can be performed in clinic and by the doctor (while he or she is describing the embryonic or fetal heart tones and development only), all serve to make appointments more frequent and longer, and many patients are discovering their appointments must be made further out on the calendar, or farther away from their homes.
There is another choice, although it's not frequently talked about - asking your own physician for help. Stand-alone abortion clinics weren't always the go-to place for an abortion, and, in some cases, have been cited as part of the growing issue of abortion being segregated from the rest of health care, resulting in its stigmatization. Clinics increased their share of abortions as doctor office and hospital-based procedures plummeted, especially in the last decade.
In 2005, doctor's offices were responsible for a mere 2 percent of all procedures, and by 2011, the latest data offered, that number dropped to just 1 percent - a mere 286 private offices out of 1720 abortion providers.
It was private physicians who often offered abortion care pre-Roe, putting their own practices at risk to do so. Now, as clinics are being shuttered at an increasing rate, private physicians may be fielding more requests to terminate a patient's pregnancy, simply because a clinic abortion is too hard to obtain. Yet abortion opponents have subtly and silently removed that as a potential option, and with very little notice.
According to the Guttmacher Institute in March of this year, 16 states in the country have at least some sort of rule regarding the performance of first-trimester abortions in private offices.
Louisiana's HB 388 is taking a much more blatant swing at ending a private physician's ability to offer a first trimester, in-office abortion, a procedure that would take a few minutes only using a manual vacuum aspirator. Tucked into the rest of the massive regulatory changes around procuring an abortion is a new rule that would force any doctor who performs more than five abortions per year to be licensed as an abortion provider. Previously, physicians could perform up to 60 abortions per year without such restrictions being put upon them.
Louisiana isn't the first state to restrict the number of abortions a physician can perform without officially being considered an abortion provider, of course. According to a list obtained from the Guttmacher Institute in March of this year, 16 states in the country have at least some sort of rule regarding the performance of first-trimester abortions in private offices.
Arizona, Kansas, Missouri, South Carolina and Virginia all have the same 5-per-month limit Louisiana has currently, while Arkansas, Michigan and Mississippi allow 10 per month (Mississippi however, limits the overall number of yearly abortions to 100). On one extreme, Nebraska allows 10 per week, and on the other, Texas tops their upper limit at just 50 per year, just over 4 per month.
Effecting some sort of requirements on in-office abortions is not always an inappropriate move for legislators or health boards. In 2013, a purported doctor's office was opened at the site of a former Birmingham, Alabama, abortion clinic that had closed the previous year after its license was revoked by the state. The doctor providing abortions on site claimed that because he wasn't performing more than the 30 abortions per month in two consecutive months, which would define him as an abortion provider under state law, he wasn't officially operating a clinic.
The state disagreed, citing his continuing use of the address, signage and even the old website as a means of accessing new patients, as well as his not providing any additional medical services except as they related to the abortion patients, meant that he was, in fact, operating an unlicensed clinic. He was ordered to cease performing abortions, and a new rule was passed at the end of the calendar year that dropped the number of in-office abortions allowable in the state from the previous 30 to just 10 per month and a maximum of 100 per year, identical to Mississippi.
What Louisiana is doing, however, is much different. Officials are virtually eliminating the option altogether. And, if patterns hold true, as they have since 2010 and the beginning of massive amounts of model legislation regarding reproductive health, what may currently be an absolute extreme could quickly become the new standard.
Americans United for Life (AUL), the author of numerous pieces of model legislation regarding reproductive rights and end-of-life issues, has stated that the motive for TRAP laws, like admitting privileges for abortion providers, is patient safety. In the group's own model bill, "Abortion Providers' Privileging Act," it cites lack of doctor/patient relationship as a key issue in making abortion less safe for patients. Yet in the same bill that advocates admitting privileges for those physicians in clinics, AUL also sets a standard of limiting private physicians to just the 5 abortion-per-month cap that would cause them to otherwise be regulated as abortion providers.
If the real goal were to keep patients safer and using a physician that the pregnant person already has an established relationship with aids that, why would abortion opponents be seeking to limit those abortions, too?
One New York physician, speaking anonymously out of fear of harassment if her practice was identified as providing abortions, called rules and requirements meant to limit a physician's ability to offer abortion services in a private office setting "crackpot."
"I do provide abortions in my general practice, and I don't think it is right to say to a patient, 'Well, I can take care of you if you are pregnant, but if you are going to have an abortion, I need to send you to someone else,' " she said. "Obstetrical care is way more complicated. What sense does it make that there are greater barriers for me to provide abortion care than to provide obstetrical care?"
"All of these state regulations are trying to overturn Roe piece by piece by piece, and this is just the latest example of it."
The physician remarked on the number of benefits that can come from having your own doctor do an abortion, ranging from familiarity and availability to follow up in obtaining and using the right contraception after the procedure. "It's really helpful when she gets her care, her abortion, her follow-up all from her physician that has known her forever."
She said that although many doctors may be unlikely to do abortions in-office because they may be "petrified of all of the harassment that abortion providers undergo . . . Some regular doctors will try to come through for their patients."
"It's always with them just making another barrier and another barrier and another barrier," she added. "All of these state regulations are trying to overturn Roe piece by piece by piece, and this is just the latest example of it."
Ending safe abortion by closing clinics is an aggressive public campaign and one that will leave millions of pregnant people with little access or care. But closing off access through private doctors is a stealth attack on a patient's potential last option, and one antiabortion advocates are hoping no one will notice until it is too late.