Amy Hagstrom Miller fired 34 people in November. “It’s hard to look people in the eye and say they don’t have a job anymore, not because of anything they or we did incorrectly or because we weren’t caring for women in a fabulous way,” she says. “It’s illogical.” Miller, founder and chief executive officer of Whole Woman’s Health, based in Austin, had to stop or sharply curtail abortions at four of her six Texas clinics because a new state law requires doctors performing the procedure to have admitting privileges at local hospitals. To get an abortion, the mostly poor women who relied on Miller’s establishment in McAllen, on the state’s border with Mexico, will now have to drive 150 miles to Corpus Christi or to the local flea market, where illegal, do-it-yourself drugs start at $15 a pill.
At least a dozen clinics in Texas have closed their doors or stopped offering the procedure in the past month after a federal appeals court and the U.S. Supreme Court let the new statute take effect. The Texas law is emblematic of a shift in the tactics of abortion opponents: State-level laws targeting women and providers have become a more effective tool than the past noisy clinic blockades and violence against doctors. Since 2011, legislatures in 30 mostly Republican-controlled states have passed 203 abortion restrictions, about as many as in all of the prior decade. At least 73 clinics have closed or stopped performing abortions. New laws are responsible for roughly half of the closures, while declining demand, industry consolidation, and crackdowns on unfit providers have also contributed to the drop.
Laws aimed at the clinics, such as mandates to widen hallways and install high-tech surgical scrub sinks, are proving more powerful than those aimed at patients, such as waiting periods or parental notification requirements. “People who don’t have power protest on the street,” says Cheryl Sullenger, senior policy adviser for Operation Rescue, an anti-abortion group based in Wichita. “People who have influence work from within to enact change.”
In 1992 the U.S. Supreme Court ruled states could pass restrictions that don’t present an “undue burden” to women seeking abortions, made legal in all 50 states by the 1973 Roe v. Wade decision. Courts are now clogged with challenges to recent state laws testing what “undue burden” means. The number of clinic closings would probably be higher were it not for legal fights that have prevented some laws from taking effect.
Nearly half the 6.7 million pregnancies in the U.S. each year are unintended, and almost half of those end in abortion. Rates of both unintended pregnancy and abortion are higher among minorities and the poor. The abortion rate hit 19.4 per 1,000 women in 2005, the lowest since Roe v. Wade, and has remained steady since. The ranks of clinics have been thinning since the late 1980s, when the number of large nonhospital providers—those that performed 400 or more abortions per year—peaked at 705, according to the Guttmacher Institute, a New York-based reproductive health research organization. By 2008, the most recent year for which data are available, the number had fallen to 591.
Both sides in the debate have a stake in the proposition that restricting access to clinics is holding abortion rates down. Social scientists say that’s not the whole story. Increasing cultural acceptance of single motherhood, the decline in pregnancies that accompanied the recession, and more prevalent use of contraceptives, which are more effective than they have ever been, are also factors. A 2012 paper from the National Bureau of Economic Research found that if 31 states outlawed abortion tomorrow, the majority of women would still travel to states where it remained legal. But the impact on those unwilling or unable to travel could produce a 15 percent decrease in abortions nationally and as much as a 4.2 percent rise in the birthrate.
Photograph by Jared Moossy for Bloomberg Businessweek
Miller scored a small victory at the end of November when her doctors in the Fort Worth area won hospital admitting rights, allowing her to resume abortion services. (No such prospects exist in McAllen, where Miller says one hospital even refused to provide an application.) Some big battles still lie ahead, though. A provision of the Texas law that takes effect in September requires abortion clinics to become hospital-like outpatient surgical centers—complete with wider hallways, janitors’ closets, and backup generators. That will force Miller to find new quarters for five of her clinics or make costly upgrades. “I’m just sort of stunned,” she says. “I don’t have the convenience of having time to grieve.”