Like many places in America where abortions are performed, the Blue Mountain Clinic, in Missoula, Montana, has faced a litany of threats. Protesters have routinely harassed patients since the facility opened, in the late seventies. In 1993, a firebomb gutted the premises. The clinic eventually reopened at a new location, in a building fortified with bulletproof windows and thick concrete walls. On June 24th of last year, staff members gathered there to console one another following a different sort of attack: the Supreme Court had just issued a final ruling in Dobbs v. Jackson Women’s Health Organization, overturning Roe v. Wade and eliminating the constitutional right to abortion. Working at an abortion clinic requires stoicism and resolve, yet the employees felt overcome. “We all just had a good cry,” Nicole Smith, Blue Mountain’s executive director, recalled.
As disheartened as Smith and her co-workers were, they also had reason to feel fortunate, at least compared with peers elsewhere. Soon after Dobbs was announced, fourteen states began enforcing sweeping new bans on abortion. Had the matter been left to the Republican Party in Montana—which holds a super-majority in the state legislature and in 2022 adopted a platform calling for a prohibition on abortion—the Blue Mountain Clinic would have encountered similar restrictions. But in 1999 the Montana Supreme Court had ruled that the right to privacy inscribed in the state constitution applied to medical judgments affecting bodily integrity, including the decision to terminate a pregnancy. This legal backstop insured that clinics like Smith’s could continue operating even if the state legislature passed regressive new laws.
Smith was also determined to serve patients from states without protections, among them Montana’s neighbors Idaho and South Dakota, where laws soon went into effect criminalizing abortion at any stage of pregnancy. In the months before the Dobbs ruling, Smith discussed post-Roe scenarios with counterparts at two peer institutions: All Families Healthcare, a reproductive-health clinic in Whitefish, Montana, and Planned Parenthood, whose facilities in Billings, Great Falls, and Helena offered abortion care. Now she assumed that they would all work together to accommodate the patients who might inundate the state.
A week or so later, Smith informed Helen Weems, the director of the Whitefish clinic, about an e-mail that Martha Fuller, the C.E.O. of Planned Parenthood of Montana, had written to her staff. In the e-mail, which had been leaked online, Fuller announced that Planned Parenthood, which offers an array of sexual-health services, had decided not to provide medication abortions—now the most common way to terminate a pregnancy—to out-of-state patients, in order to avoid legal hazards. “As a healthcare provider, we must identify and mitigate risks constantly,” the e-mail stated. “The risks around cross-state provision of services are currently less than clear, with the potential for both civil and criminal action for providing abortions in states with bans.”
Smith and Weems felt blindsided. Smith was particularly dismayed that Planned Parenthood had not consulted them before making the decision. Her consternation deepened after various media reports suggested that all abortion providers in Montana had adopted this policy. On NPR, the director of a pro-choice group in South Dakota said, with disappointment, that Montana had been “a state that we were hoping was going to be available” for patients seeking services. Smith was appalled; at the same time, Planned Parenthood’s decision made her wonder whether treating out-of-state patients might indeed be reckless or unwise. Fuller’s e-mail indicated that the group had arrived at its position after consulting with legal counsel, and that the decision had been “based on protecting our providers and patients.” Smith, worried about jeopardizing her colleagues at Blue Mountain, consulted some lawyers herself. They reassured her that, according to the Montana state constitution, the clinic was not in violation of the law. Smith summoned the clinicians on her staff to a conference room, to see if anyone had qualms about treating out-of-state patients. “What do you all want to do?” Smith asked. One by one, they said that they were willing to accept the risks.
Fuller’s leaked e-mail went viral on Twitter, and, in the weeks that followed, Smith and Weems repeatedly conveyed how upset they were. “We are failing our patients, the ones that need us the most,” Weems wrote in an e-mail urging Fuller to reconsider the policy. After a month or so, Fuller gave a television interview announcing that Planned Parenthood of Montana had reassessed the legal landscape and was reversing its decision: it would offer medication abortion to patients from other states.
Smith was happy about the change, but told me that Planned Parenthood has not gone as far as other providers have to accommodate out-of-state patients who lack the resources to travel to a clinic in Montana. To enable such patients to access care, both she and Weems have begun mailing abortion pills anywhere in the state, including to motels and FedEx offices near the borders of Idaho, Wyoming, and the Dakotas. Planned Parenthood also has a meds-by-mail program, but it is reserved for Montana residents, who can have pills sent to their home address. Out-of-state patients have to drive to one of its clinics, complete an intake process, and take their first abortion pill on site. In theory, this approach protects Planned Parenthood from legal risks, but Smith feels that it imposes burdens on patients. And shouldn’t pro-choice organizations trust patients to decide for themselves when and where to take the medication? Determining this for them, Smith said, is “about control—making sure it’s done within the parameters of what they think is risk-tolerant.” As she sees it, Planned Parenthood has been running scared.
Long before Roe was overturned, providers’ desire to avoid risk—from professional ostracization to picketing to shootings—shadowed abortion care. This is why medical schools often refrained from offering training in terminating pregnancies, and why abortion procedures were not regularly performed in the vast majority of public hospitals. Since Dobbs, some medical institutions have gone further, hesitating to provide care to women such as Christina Zielke, who was rushed to a hospital in Painesville, Ohio, last September after experiencing heavy bleeding from a miscarriage. Instead of performing a dilation-and-curettage procedure to remove the pregnancy tissue from her uterus, the hospital staff discharged Zielke, apparently in response to a six-week abortion ban that had been passed by the Ohio state legislature. Zielke was soon lying in a bathtub in a pool of blood, wondering if she would die. After she lost consciousness, her family called 911, and paramedics eventually took her back to the hospital, where a doctor performed the procedure.
Such horror stories are a predictable consequence of the fear that criminalizing abortion has spread through the medical community. For fifty years, Roe protected providers from legal risks like the ones taken on by the Jane Collective, an underground network of women in Chicago. Collective members arranged more than eleven thousand illegal abortions in the late nineteen-sixties and early seventies, until a team of detectives raided their makeshift clinic and charged them with multiple counts of “conspiracy to commit abortion.” (Just before their cases went to trial, the Supreme Court legalized abortion.) Arguably, providers face greater legal dangers now than they did before Roe. Carole Joffe, a sociologist who has written about the history of abortion, told me that doctors who performed illegal procedures in the past “typically received sentences of a few years,” whereas physicians today face “an aggressive anti-abortion movement that, in some states, is calling for life imprisonment.” Abortion opponents have also targeted organizations such as Planned Parenthood with spurious lawsuits and violent attacks, in an effort to shut them down.
Planned Parenthood’s motto is “Care. No matter what.” These words suggest an uncompromising commitment to serving patients. Yet some pro-choice advocates feel that the group, along with other large organizations that have shaped the modern abortion-rights movement, has lately seemed more focussed on self-preservation than on taking bold risks. Tracy Weitz, a reproductive-rights scholar who directs the Center on Health, Risk, and Society, at American University, told me she is worried that these groups are being guided too strongly by attorneys whose priority is to shield them from lawsuits. The mission of Planned Parenthood is not “institutional survival,” Weitz said. “Their entire goal, their mission, is to serve patients.” If caution supersedes this goal, she warns, not only will patients suffer but the pro-choice movement will fall into a familiar trap. “One of the critiques of the abortion-rights movement is that we put too much faith in the law, believing that it would protect the right to abortion,” she said. “I think it’s ironic that all of a sudden we have turned over this movement to a whole new group of lawyers—not constitutional lawyers but risk managers.”
In the fall of 2021, a preview of how these dynamics could play out in a post-Roe era unfolded in Texas, after Governor Greg Abbott signed the Texas “heartbeat” bill. Better known as S.B. 8, the law banned abortion after six weeks of pregnancy, and it offered a ten-thousand-dollar bounty to any private citizen who successfully sued someone involved in such a procedure. In the view of some analysts, S.B. 8 was plainly unconstitutional—Roe v. Wade was then still federal law—and designed to intimidate both patients and providers. (Indeed, Planned Parenthood joined the A.C.L.U. and other groups in a lawsuit to block S.B. 8.) One might imagine that Planned Parenthood and other large pro-choice organizations, including the National Abortion Federation, which funds and supports many independent clinics, would have responded to this threat by urging providers to continue offering care and by pledging to defend anyone named in a lawsuit. Vicki Saporta, who served as the N.A.F.’s president until 2018, believes that such a strategy would have been both feasible and effective. “There could have been a legal-defense fund set up to pay out various ten-thousand-dollar suits while S.B. 8 was being challenged, and, in the meantime, care could have continued to be provided,” she said. Planned Parenthood and its affiliates, whose net assets exceed two billion dollars, have “the wherewithal to raise the legal-defense money,” she added.
Instead, Planned Parenthood’s South Texas affiliate instructed its providers to stop performing all abortions, even before six weeks. The affiliate’s apparent anxiety about lawsuits was shared by Planned Parenthood’s leaders and by its attorneys in Washington, who warned that Republicans in Texas could weaponize S.B. 8 to try to bankrupt the organization. Meanwhile, the N.A.F. announced that it would stop funding any providers and patients who didn’t comply with S.B. 8—and even pressed clinics to perform a second ultrasound after patients had endured Texas’s mandatory twenty-four-hour waiting period, in case a heartbeat could be detected then. Many Texas doctors refused to adhere to the N.A.F. directive. In fact, some physicians had the impulse to publicly flout S.B. 8. Shortly after the law took effect, Alan Braid, a provider in San Antonio, published an op-ed in the Washington Post in which he acknowledged having performed an abortion after the six-week limit. He explained that in the early seventies, while completing his ob-gyn residency, he had seen several women die from illegal abortions. “I understand that by providing an abortion beyond the new legal limit, I am taking a personal risk, but it’s something I believe in strongly,” he wrote. Braid told me recently that, at the time, he’d talked to several physicians who shared his feelings and who, like him, were willing to defy S.B. 8. If doctors were willing to fight, he wondered, why were institutions designed to protect women’s rights capitulating?
Planned Parenthood has forty-nine affiliates, which have broad discretion to set their own policies, and some of them have long been run by staunch advocates of abortion rights. For much of its history, however, the organization has hedged its commitment to these rights. Margaret Sanger, who founded the group, in 1916, decried abortion, maintaining that it wouldn’t be necessary if all women could access birth control. In the first two decades after Roe v. Wade, a strain of opposition to abortion remained within the group. In 1978, Faye Wattleton became the first Black president of the Planned Parenthood Federation of America. Congress had recently passed legislation barring Medicaid from covering abortion at the federal level, and Wattleton soon announced that one of her priorities would be restoring abortion access for poor women. Her agenda sparked such an uproar, she said, that a faction within Planned Parenthood tried to organize a vote of no-confidence in her leadership. Wattleton told me that, during this period, most of the group’s affiliates didn’t provide abortion services. Her own commitment to abortion rights had been cemented when she did clinical training in Harlem while getting a master’s in maternal and infant health; a teen-ager admitted to the hospital where she was working died after trying to end a pregnancy with bleach and Lysol. Even after Roe, the lingering stigma around abortion meant that it was never fully integrated into the broader constellation of reproductive-health services—a development for which Planned Parenthood shares some blame, Wattleton told me. “We contributed to that,” she said.
By the time Wattleton left Planned Parenthood, in 1992, attitudes within the organization had shifted, thanks in part to the launch, a few years earlier, of the Consortium of Abortion Providers, which offered technical assistance, consulting services, and funding to affiliates. Lynne Randall, who directed the consortium from 1999 to 2011, told me that, at the start of her tenure, some affiliates still feared that providing abortion services would strain relations with their communities. Most were in conservative areas. By the time she left, Randall said, such resistance was rare, in part because in 2000 the Food and Drug Administration had approved mifepristone—one of two drugs normally taken during a medication abortion. Affiliates were much more willing to dispense medication than they were to expend the resources necessary to do surgical procedures. Also helpful was a surge of support from the Susan Thompson Buffett Foundation, named after the late wife of the investor Warren Buffett, which has given billions of dollars to pro-choice groups.
Saporta, the former president of the National Abortion Federation, worked closely with Planned Parenthood during these years, training providers to do medication abortions and, later, dispensing “justice funds”—financial assistance for abortion care. At the time, she said, Planned Parenthood “couldn’t have been a better partner,” even though its activism made it a prime target of the right, fuelling attacks on affiliates and leading Republicans to try to cut off funding to the organization.
Planned Parenthood’s mission and identity is now synonymous with abortion—including to the many pro-choice donors who write it checks. But the group did not always stand out for its daring. Abortion advocates were often irked by the organization’s messaging, which emphasized that abortion constituted “just three per cent” of the services Planned Parenthood offered, and evasively referred to “comprehensive women’s care.” Such coyness also rankled clinicians. From 2003 to 2013, Marc Heller served as the medical director of Planned Parenthood Mohawk Hudson, which oversaw facilities in thirteen mostly rural counties in New York. He described this period as “the highlight of my career,” but told me that he bristled at the meek language his employer used to describe abortion, particularly as conservative opponents seized the moral high ground by calling themselves “pro-life” (while making the lives of his staff miserable). “I and the staff faced daily harassment and fear because of our commitment to abortion,” he said. “I felt, ‘Own it and back us up!’ ” Randall, the former Consortium of Abortion Providers director, recalled other Planned Parenthood medical directors voicing similar complaints: “The people who were involved in abortion care would say, ‘This is near and dear to our hearts, and we’re just not feeling that you’re representing that in the messaging.’ And, yeah, that was true.”
Peg Johnston, the former executive director of Southern Tier Women’s Health Services, an independent reproductive-health clinic in Vestal, New York, told me that Planned Parenthood’s timid rhetoric was a vestige of Sanger’s negative attitude toward abortion. “Independent providers got into abortion work because it was abortion work,” Johnston said. “It seemed to me that people from Planned Parenthood saw abortion as a failure because they hadn’t prevented it. It’s sort of baked into who they are.”
Johnston was among the founders of the Abortion Care Network, an association of independent clinics. Such clinics provided most of the abortion services in America, as they still do, but over time, because of the violence they faced, fewer and fewer doctors were willing to work at them or to integrate abortion into their practices. Between 1982 and 2000, the number of clinics declined by more than thirty per cent. By the early aughts, there were vast swaths of the country with no abortion providers, creating insurmountable barriers for women who lacked the means to travel long distances. Planned Parenthood had the resources to broaden access by offering services in remote, underserved communities. But this is not, by and large, what the group’s affiliates chose to do. Instead, many moved into places that independent clinics already served. In any given area, Planned Parenthood maintained, having more providers offered patients greater options and made it more likely that they would seek abortion care—a view that some reproductive-rights advocates I spoke to shared. And some large metropolitan areas clearly needed more providers. Nonetheless, independent providers sometimes felt that Planned Parenthood treated them as competition, rather than working collaboratively to expand access to abortion. As the pattern played out, few providers complained publicly about it—not least because they knew that any tensions would likely be exploited by opponents of abortion. Privately, though, some providers came to feel that Planned Parenthood operated less like a mission-driven nonprofit than like an aggressive franchiser indifferent to the fate of smaller operations.
Southern Tier Women’s Health Services, the center Johnston ran, was among the facilities that felt outmaneuvered by their ostensible ally. Southern Tier served an area that stretched across New York into parts of Pennsylvania. For many years, it was the only facility between Buffalo and New York City providing abortion care, which made it both a crucial destination for patients and a target for protesters, who picketed its landlord and drove around town in a truck bearing a sign that called it a place to “kill a baby.” The center offered both medication abortions and surgical procedures. (Mifepristone and the drug used in tandem with it, misoprostol, can be dispensed only in the first eleven weeks of pregnancy.)
In 2012, Johnston learned that a Planned Parenthood health center in Binghamton, ten miles from her facility, was looking into providing abortions. Southern Tier served thousands of women every year, but, like many independent clinics, it operated on a narrow margin, in part because insurance-reimbursement rates for abortion were low. Additionally, money had to be spent on security measures, such as bulletproof sheetrock and glass, and a call bell for the police. If women in the area started going to Planned Parenthood for medication abortions—which were comparatively inexpensive to provide—Johnston’s center might be forced to close.
Some Planned Parenthood officials were sympathetic to Johnston’s concern. Debra Marcus, then the C.E.O. of Planned Parenthood of South Central New York, which oversaw the center in Binghamton, reached out to her. Marcus didn’t want her organization’s actions to decrease over-all access to care, especially since her facility lacked the capacity to serve anywhere near the volume of patients that Johnston’s clinic did. But, by this point, abortion had become a “core service” that every Planned Parenthood affiliate (though not every location) was required to offer. Marcus consulted her affiliate’s board and then requested a waiver for this requirement from the national office, explaining on an internal form that proceeding with medication abortions “could have the truly unfortunate effect of decreasing the existing high-quality provider’s business enough to cause her to leave the community.” Marcus submitted the request on September 25, 2012. The same day, a recommendation was made to deny the waiver. Marcus was disappointed but not surprised: before sending it, she’d spoken to peers at other Planned Parenthood affiliates who’d wanted to avoid encroaching on clinics in their communities. Some of them had also asked for waivers; all the requests had been denied.
Marcus concluded that she had no choice but to disaffiliate from Planned Parenthood—a decision she described to me as “wrenching.” She recalled that, as a young girl, she used to send her allowance money to the organization, which she’d learned about from her mother, who taught family studies at SUNY Oneonta and once pulled down the shades in her classroom to teach her students comprehensive sex education, in violation of a “chastity” law on the books since the nineteenth century. “It was painful because we thought of ourselves as Planned Parenthood, and we thought our values were their values,” Marcus said. Not everyone on her affiliate’s board supported Marcus’s decision, but her anguish was shared by one member, Melinda Hardin. In a letter to Cecile Richards, then the national office’s president, Hardin cited the group’s mission statement, affirming that “the heart of Planned Parenthood is in the local community.” In Binghamton, she felt, it had behaved as ruthlessly as Walmart. “To believe in—to revere—an organization for decades, only to watch it turn into a top-down, rigid corporate bully is devastating,” she wrote. “I am saddened by P.P.F.A.’s decision and hope that you and your board will reconsider.” Hardin told me that she sent copies of her letter to several other Planned Parenthood officials. She says that she never received a response.
As Marcus sees it, one reason Hardin’s appeal was ignored was that Planned Parenthood had steadily grown more centralized, merging affiliates and becoming less attuned to small communities. Another possibility is that, when the interests of Planned Parenthood and the needs of patients diverged, the former sometimes took precedence.
In 2008, a physician named Susan Wicklund published a memoir about her career as an abortion provider, which had involved travelling to clinics across the Midwest, from St. Paul to Fargo. She eventually settled in Montana, and began working at Planned Parenthood facilities in Billings, Helena, and Kalispell. Some patients in rural areas, she discovered, had to drive several hundred miles to attend their appointments. Wicklund decided that a clinic should be opened in Livingston—a small town in southwestern Montana, not far from where she was living. She told me that when she proposed this idea at a meeting, Stacy Cross, then the C.E.O. of Planned Parenthood of Montana, reacted coldly, informing her that it was not in Planned Parenthood’s financial interest to take such a step. Wicklund responded by saying that she would open a clinic in Livingston on her own. According to Wicklund, Cross said that she would “do everything possible to shut me down, because I was taking patients away from Planned Parenthood.” (Cross, who now presides over a Planned Parenthood affiliate headquartered in California, said, “The assertion that we would try to shut her down is patently false.”) Deborah Erdman, a doctor and a Planned Parenthood donor who attended the meeting, told Cross that she would never give the organization another dime. “She was so angry,” Wicklund recalled. (Erdman died recently, but a close friend of hers confirmed this account.)
In Wicklund’s memoir, she writes of working at a clinic in Minnesota and trying to help an indigent woman who spoke no English and did not know how far along her pregnancy was. Wicklund wanted to perform an ultrasound, which would pinpoint how advanced the fetus was, but another staffer stopped her, because the woman couldn’t pay the fee. Wicklund slammed the door and went ahead with a pelvic exam instead, which she conducted for free. The next Monday, an administrator informed her that her contract had been terminated, “effective immediately.” Although Wicklund doesn’t say so in the book, it was a Planned Parenthood clinic. “I never turned a patient away,” she said.
Wicklund opened a clinic in Livingston in 2009. Some of her patients there told her that they’d first gone to Planned Parenthood but were unable to get care because they couldn’t afford it. This happened often enough that Wicklund began keeping a file of such cases. “Was given a hard time by Billings PP,” she wrote about a nineteen-year-old patient who said she’d been asked, “Do you think you should get free abortion?” Another patient told Wicklund that she’d heard about the Livingston clinic from Planned Parenthood because she “couldn’t afford $1,000.”
In 2013, Wicklund, facing significant health complications, was forced to close the Livingston clinic. Not long afterward, local activists created the Susan Wicklund Fund—a nonprofit that helps poor Montanans access abortion care—in her honor. In recent years, she has received fund-raising letters from Planned Parenthood featuring the “Care. No matter what” slogan. The first time she saw this, she told me, “I just came unglued—I was so livid.” She went on, “When I was a very young woman and would go to Planned Parenthood, it was a feminist organization. At some point, it changed into a business.”
Providing services to patients isn’t the only way that Planned Parenthood defends abortion rights. The group has arms devoted to advocacy and political organizing which push for pro-choice laws and policies; every election cycle, they perform an array of functions—including mobilizing and educating voters—that most abortion providers cannot undertake but from which they benefit. Last year, Planned Parenthood helped defeat anti-abortion ballot initiatives in numerous states, including Kansas and Kentucky. The organization’s national office, meanwhile, files lawsuits across the country to challenge restrictions. With Roe gone, the stakes of such battles have never been higher, which explains why so many people who care about abortion rights have donated to Planned Parenthood since the Dobbs decision—and why some providers I spoke to didn’t want to air their grievances about the group, saying that it was now more important than ever to band together.
Not everyone feels this way, however. In March, I had coffee with Katharine Morrison, the medical director of Buffalo Women Services, an abortion facility and birthing center in western New York. In October, 1998, a physician working there, Barnett Slepian, was murdered in his home, by an assassin who then fled. Afterward, Morrison told me, the police stopped by her house and advised her and her family to leave immediately. (The police also visited my parents’ house, because my father, Shalom Press, was working as an abortion provider in the area.) Morrison, who had three young children, quit her job, but she returned a few months later, intent on keeping a low profile. One day, a complication required her to transfer a woman to a local hospital, where a nurse who opposed abortion spotted her. A few weeks later, a bridge near Buffalo Women Services was spray-painted with the words “Morrison Murders Babies!” She relocated her family to Brooklyn and started flying to Buffalo once a week to keep the clinic open. Five years after Slepian’s killer, an anti-abortion zealot named James Charles Kopp, was arrested, she moved back to Buffalo with her family.
Until 2003, Planned Parenthood did not offer abortion care in Buffalo. That year, it began providing medication abortions in Buffalo and Niagara Falls, half an hour to the north. Today, medication abortions are available at Planned Parenthoods throughout western New York; surgical procedures are also done two days a week. Michelle Casey, the C.E.O. of Planned Parenthood of Central and Western New York, told me that this wasn’t enough to meet demand. “We need more access than we have in Buffalo,” she said, explaining that there was a two-week waiting list for surgical procedures now that patients were coming from Ohio and even Texas. Casey said that her organization viewed independent providers in the area as “collaborators with the same mission of having people have access to the care they need.”
Indeed, in some communities, Planned Parenthood affiliates have fostered solidarity with other providers. One independent clinic owner in Florida told me that two decades ago, after her facility suffered an arson attack, Planned Parenthood invited her counsellors to use the phones in its office to schedule appointments. But, she noted, the organization’s generosity did not last; it eventually started offering abortion services right down the road, imperilling her operation.
Morrison, the Buffalo provider, told me that her clinic, which now focusses on surgical procedures, may not remain open much longer, owing to a steady decline in the number of patients coming in. There were multiple reasons for this, including broader access to contraception, which has led to an over-all decline in the demand for abortion, including at Planned Parenthood centers. But the biggest factor, she told me, was Planned Parenthood. To illustrate the problem, she Googled “Buffalo abortion clinic” on her phone. The top two search results were for Planned Parenthood facilities. Google did not tell users, she noted with dismay, that those facilities did not offer comprehensive second-trimester care, and that Buffalo Women Services was the only local provider these patients could rely on. Morrison explained that although some second-trimester abortions were done in Buffalo hospitals, a medical board had to approve the procedures, and they required a justification, such as clear evidence of fetal anomalies. The vast majority of second-trimester patients went to Morrison’s clinic.
Michelle Casey had told me that Planned Parenthood did not offer care after the fourteenth week of pregnancy because “such a small number of people” needed it. Morrison disputes that the number is small. During our conversation, she randomly selected dates in her clinic’s log book: on February 28th, ten patients had come in for second-trimester procedures; on another recent day, six had done so. The real reason the local Planned Parenthood facilities don’t offer such care, Morrison told me, is that it is far more difficult and expensive, and involves potential complications. “You have to have staff, an ultrasound-sonographer, equipment, an R.N.,” she said. Medication abortion, by contrast, mainly involves dispensing pills. “It’s a great business model,” she said.
I asked Morrison if, given her clinic’s role in the abortion fight and the ordeals she’d been through, anybody at Planned Parenthood had ever reached out to discuss how its operations might affect the broader ecosystem of abortion care in Buffalo. “Nope,” she said. We were sitting in a café in Brooklyn, and Morrison, who is sixty-six, with short brown hair flecked with gray and a wry sense of humor, told me that, to keep Buffalo Women Services afloat, she’d started working at a clinic in New York City. She was now commuting every week to the city from Buffalo—the opposite of her old trek. “I’m doing it in reverse,” she said, with a smile. When I asked her if she could imagine a time when the patients she served would also have to travel to New York City, because her Buffalo clinic had closed, the smile vanished. “Definitely,” she said. She noted that some second-trimester patients wouldn’t be able to make the trip—a six-hour drive—because most of her clients were poor. “The younger you are and the poorer you are, the greater your gestational stage,” she said. “Because you were afraid to tell your mom, or because you were hoping you weren’t pregnant, or because you thought you were pregnant but if you don’t show up at work you’re gonna lose your job, and if you lose your job you’re gonna get evicted.” Such patients were also disproportionately people of color, Morrison added. She’d recently treated an undocumented immigrant with no medical insurance, and a thirteen-year-old Black girl who she suspected had been raped. Although various funds now exist to help patients in need cover travel and lodging, “people are living a paycheck away from disaster,” she went on. “Even if you say it will be covered, they can’t take off a day to travel, spend two or three days in New York, then take another day to come back.”
Since the Dobbs decision, the media has taken note of a dramatic increase in the number of medication abortions, which now constitute a little more than half of all pregnancy terminations. It stands to reason that this figure will continue to rise, because pills make it easier to evade barriers to care. But, as these barriers proliferate, causing more patients to encounter delays, the demand for procedural abortions later in gestation is also likely to grow. Buffalo is hardly the only place where independent clinics provide such care. According to the Abortion Care Network, sixty-two per cent of the clinics in the U.S. that perform abortions after thirteen weeks are independent. For procedures after twenty-two weeks, the figure is seventy-nine per cent. Nikki Madsen, the network’s co-executive director, told me, “When people need abortion care after the first trimester, they rely on independent clinics. This is the most expensive abortion care to provide, and it’s done at clinics that lack the institutional support, visibility, name recognition, and fund-raising capacity of national health centers and hospitals, making it especially difficult to secure the resources to keep the doors open.” Independent providers, she added, also deliver a disproportionate amount of care “in the most hostile states.”
In March, I drove to Casper, Wyoming, with Julie Burkhart, the founder of an abortion-care nonprofit named Wellspring Health Access, to visit a clinic that she was planning to open there. Burkhart lives in Colorado and co-owns a clinic in southern Illinois, but in 2021 two abortion-rights advocates from Wyoming had urged her to expand her operation, and she’d agreed to take on the challenge. Originally, the facility was scheduled to begin seeing patients last June, but shortly before opening day an assailant broke in, poured gasoline onto the newly refinished floors, and torched the place. After the Dobbs decision, the Wyoming legislature banned abortion in virtually all cases. The law has been temporarily suspended, because Wellspring Health Access filed an injunction claiming that it violated the state constitution’s protections for matters of bodily integrity.
These developments could have led Burkhart to rethink her plans. She told me why she’d decided to persist on the way to Casper—a nearly four-hour drive from the town in Colorado where she picked me up. Burkhart, who is plainspoken and was wearing bluejeans and leather boots, said that she was still motivated by what had happened to George Tiller, an abortion provider in Wichita whose clinic she had joined in 2001. She’d worked for him until 2009, when an anti-abortion extremist murdered him in the foyer of his church. When a friend called Burkhart to deliver the news, she thought that he was joking. After the reality sank in, she started to think about who could provide care to the women who’d relied on Tiller’s clinic. There was a Planned Parenthood in Wichita, but it didn’t offer abortion services. Burkhart decided to reopen Tiller’s clinic herself, even though pro-choice allies warned her that it would only bring more violence to the community. Abortion opponents waged a fierce campaign to stop her. She received death threats. More than once, Burkhart told me, she contemplated abandoning the project, but on April 3, 2013—nearly four years after Tiller’s murder—the new clinic began seeing patients. In the first week, just three women showed up. Eventually, the facility was seeing nearly two thousand patients a year. Burkhart had formed a nonprofit, Trust Women Foundation, that aimed to improve access to abortion in underserved communities. Its next project was in Oklahoma City, where it took two and a half years to open a clinic.
As Burkhart spoke, we continued driving through a windswept landscape dusted with snow. We passed cattle herds and a Budweiser factory. At one point, she pulled over at a truck stop to get coffee. Before she stepped out of the car, her phone rang: it was the chief operating officer of the Illinois clinic, calling to tell her that the facility had just been invaded by anti-abortion protesters. The woman’s voice was trembling, and I overheard her tell a police officer who arrived on the scene, “We’re all scared! These are actual terrorists and they want to hurt us, and they forced their way inside of our building.”
“How many of them got in?” Burkhart asked calmly, as though nothing could be more routine. She spent several minutes explaining to her colleague how to download the clinic’s security-camera footage onto a flash drive. Then she hopped out to get her coffee.
We got back on the road, and Burkhart’s phone rang again. This time, it was the contractor who was finishing up the repair work at the clinic in Wyoming. He agreed to meet us there, along with another worker. An hour later, we pulled up to a tan stucco building next to a gas station. The newly built white fence around the clinic swayed whenever the wind kicked up, and Burkhart wondered if the person who’d installed it had intentionally done a shoddy job. She wondered the same thing about a generator in the basement, which, the other worker told her, had been wired so haphazardly that it could have exploded if someone had turned it on.
Piles of wood molding were stacked on the floors. In one room, a half-melted window screen—a remnant of the arson attack—was propped against a wall. The clinic was supposed to open in six weeks, but staffing the project had been challenging, which the contractor attributed to the fact that no one in Casper wanted to be associated with the place. “I’ll be honest—they just don’t want to do the building,” he told Burkhart. I asked him if this was for political reasons. He nodded. “See that knucklehead out there?” he asked, pointing to a man in a green parka on a bench outside. It was a protester who’d been coming every day. “When the weather is nice, there’ll be three hundred people out there,” he said. He then confided that he’d refrained from hanging a sign out front indicating that he was the contractor, as he usually did on projects. “It’s a small town,” he explained.
Afterward, Burkhart told me that the contractor was an avid Trump supporter, but that they got along regardless. She’d grown up on a farm in Oklahoma, she said, and it troubled her that the pro-choice movement seemed to be giving up on places like her home state, as if the country were permanently split into camps: urban versus rural, blue versus red. So many people were overlooked by this divide—Burkhart had lots of friends in Oklahoma who lived on farms and were passionately pro-choice. More important, people in conservative rural areas needed access to abortion just as much as the residents of New York or San Francisco did. “People who get pregnant unintentionally—they’re not thinking, ‘I’m a Democrat,’ or ‘I’m a Republican,’ ” she said. “They just either want to be pregnant or they don’t.”
Lynne Randall, the former Consortium of Abortion Providers director, told me that some Planned Parenthood affiliates had made efforts to reach patients in remote rural areas, only to be stymied by political opposition within the community or by an inability to retain qualified staff. “The obstacles are so great,” she said. But others told me that such efforts did not seem like a priority at the affiliates where they worked. Susan Wicklund, the retired abortion provider in Montana, said that in the nineties, when she was working at a Planned Parenthood in eastern Wisconsin, it became obvious to her that the organization should open a clinic in the northern part of the state, which was an abortion desert. As she recalled it, “Administration told me it wasn’t going to happen”—not only because the counties up north were deeply conservative but because too few people lived in them to make it financially viable. Burkhart found this reasoning self-defeating. “I feel like that’s one of the reasons we’re losing,” she said. She also believed that it was unethical. “It’s not right for us to say that we are champions of social justice but yet we are not going to go the full stretch for folks in places where it is less hospitable,” she said. “It feels disingenuous to say, ‘Well, it’s kind of tough here, so we’re not going to throw our hats into the ring.’ ”
In conservative states, attorneys general are moving swiftly to ban the sale and marketing of abortion pills. (In March, Wyoming became the first state to do so.) Some pro-choice advocates believe that, in the near future, the only way to provide abortion care to people in such states will be to mail or smuggle pills to them. As abortion bans spread, some of the most daring risks will be taken not by clinic employees but by people in networks like Just the Pill, which uses innovative methods, such as pop-up clinics, to deliver abortion medication to patients in remote areas. But pills are not a panacea, not least because they sometimes fail; when they do, patients may need to see a doctor in a hospital or a clinic. Moreover, in April a federal judge in Texas invalidated the F.D.A.’s decades-old approval of mifepristone. Although the Supreme Court subsequently decided to temporarily preserve access to the drug, the matter is far from settled, and an unfavorable ruling in the Texas case could force providers across America to rely solely on misoprostol, a method that is less effective.
Such obstacles have only made Burkhart more committed. She told me that she understood why a large organization like Planned Parenthood might be more cautious than she is. It hadn’t escaped her notice, though, that the group sometimes relied on the most vulnerable providers to take the greatest risks. On April 20th, Burkhart’s clinic in Casper finally opened. She texted me triumphantly, “We are beginning to schedule patients now!!” But she still had plenty of concerns—including a fear that, if the clinic was successful, Planned Parenthood might see that it was serving a viable market and begin offering abortion services there, too. Burkhart had witnessed this dynamic firsthand. A few years after she reopened Tiller’s clinic in Wichita, she learned that Planned Parenthood had started offering abortion services at its health center in the city. Nobody from the group had consulted her, she said. Not long after she opened the clinic in Oklahoma City, the same thing happened there. (Last year, both her clinic and Planned Parenthood stopped offering abortion services in Oklahoma, because of new bans.)
Burkhart preferred to do her work quietly, to avoid attracting more menacing attention. In Wichita, she told me, protesters often gathered outside her home, holding up signs that read “Prepare to Meet Thy God” and—in a sinister reference to George Tiller’s murder—“Where Is Your Church?” Yet she sometimes wished that she got more acknowledgment from donors. “I don’t have the same name recognition as Planned Parenthood,” she said. “The way it works out is ‘We’re gonna give them a hundred thousand dollars, and we’ll give you a thousand.’ ”
A representative for Planned Parenthood recently told me that it is the sole health-care provider for many patients, and cannot therefore endanger its entire operation just to protect abortion. Nonetheless, the organization has taken numerous steps to help patients in states where abortion has been banned or is under threat. Some of this work has been carried out by its pool of “patient navigators,” who coördinate with partner organizations to help people travel to appointments. Since June, navigators at Planned Parenthood North Central States—which oversees the group’s operations in Minnesota, Iowa, Nebraska, North Dakota, and South Dakota—have enabled more than a thousand patients to get care. A fifth of them were from outside the region. Planned Parenthood has also provided its affiliates with grants that encourage them to expand care in areas with restricted access, and it has supported AbortionFinder, a Web site that allows patients anywhere in the country to find an up-to-date list of the closest providers.
In a phone interview, Alexis McGill Johnson, the C.E.O. and president of Planned Parenthood, told me, “We’ve been making investments to open and expand access.” She noted that in southern Illinois—where the demand for abortion has surged, owing to bans that went into effect in neighboring states—Planned Parenthood recently launched a mobile clinic that can travel along the border. The organization, she said, has redoubled its commitment to “stand with our front-line staff” in the face of unprecedented physical and legal intimidation. “Planned Parenthood has long been targeted by security threats,” she said. “In addition to these threats, I think that we are now seeing the ways in which the opposition is just methodically continuing to enact laws that target providers and patients.”
The organization’s new initiatives are welcome, but they represent only a fraction of the combined annual budgets of Planned Parenthood ’s national and global offices and its affiliates, which is $1.7 billion. The Abortion Care Network has launched a fund-raising drive to support independent providers: it has raised just five million dollars in the past year. An abortion provider in Missoula named Joey Banks told me that after Dobbs she and her peers hoped that, because Planned Parenthood had the largest budget, it would be “the first to stand up and say, ‘Well, we have to close these three clinics that are redundant—we are going to find the biggest wasteland of abortion access and we’re gonna put some clinics there.’ ” Instead, she said, all the new brick-and-mortar clinics she knew of were independently run by people who, despite their more limited resources, were willing to act in a time of crisis.
The irony of this was not lost on Nicole Smith, the Blue Mountain Clinic executive director, whom I visited one morning in Missoula. At the entrance to the clinic, a cluster of signs had been placed: “Abortion Is Healthcare,” “We Support Your Choice.” Inside, the walls were decorated with art and memorabilia. I spotted a cover of “Our Bodies, Ourselves” that had been framed in glass. The book’s edges were visibly blackened; it had been salvaged after the 1993 firebombing.
Smith, a river-rafting enthusiast with clear blue eyes and a forthright manner, was born in Helena. She began serving as Blue Mountain’s executive director in 2021—only a year before Roe was struck down. She is thankful that Planned Parenthood of Montana reversed its decision not to provide medication abortions for out-of-state patients, but she said that the controversy has had lingering effects. Some of Blue Mountain’s donors, believing that the clinic had similarly decided to stop serving out-of-state patients, had threatened to pull their support. “It was weeks and weeks of damage control,” she said. “And, to this day, when I am interacting with people who want to donate, I say, ‘Please know, we continue to serve any patient, including those who travel in from other states.’ ” Losing a few donors might not have been a big deal for Planned Parenthood—as Smith noted, the national office and twenty-one affiliates received a two-hundred-and-seventy-five-million-dollar donation from MacKenzie Scott last year. But the negative press was potentially devastating to her clinic, a family-medicine practice that struggles financially. “I have to fund-raise a gap of about three hundred thousand dollars a year to keep my doors open,” she said.
Smith acknowledged that an out-of-state patient who received abortion pills from her clinic could theoretically be prosecuted, with Blue Mountain exposed as the source. She was not cowed. “I’m not going to be afraid of some hypothetical,” she said. “For us, we have been trying to find a balance—how do we take on more of the risk as providers versus putting that risk on the patients? There is this level of risk that either gets placed on the patient or on the provider. As much as possible, I think we’re trying to take on that risk.”
She hopes that Planned Parenthood of Montana will adopt her clinic’s policy about mailing pills. When providers are timid, Smith told me, it makes patients afraid of coming to the state to get an abortion. I spoke to one such patient, a woman from Idaho who drove nearly five hours to Missoula with her husband and two kids. She made the trip because she was too poor to raise another child and because she was ill, suffering from lupus and sharp pain in her pelvic area. Before she found out that she was pregnant, she was so lethargic that she could barely get out of bed. Then she had a seizure. “I felt like I was going to die,” she told me. After the procedure, the pain stopped. She felt relieved and energized. But, when she returned to Idaho, she was terrified that the authorities might come after her. “Are they going to send somebody who will ask me, ‘Are you still pregnant?’ ” she asked. “The legality is haunting me.”
Montana has not yet seen the flood of out-of-state patients that some activists expected Dobbs to unleash. Meanwhile, Republicans are passing a flurry of state legislation, from a ban on public funding for abortion to a measure that removes abortion from the state constitution’s privacy protections. “They’re coming at us from all angles,” Smith said. Montana’s politics kept pushing rightward, which made it all the more essential for abortion providers to “be united.” She added, “We care so much about being in good partnership with Planned Parenthood.” Despite the flare-up over serving out-of-state patients, Smith viewed the organization as an ally and spoke often with Martha Fuller; still, there were some tensions that she found perplexing. Planned Parenthood, she said, was sometimes unwilling to refer patients to independent clinics even when it was obviously in their interest—by reducing travel times, for example, or enabling them to get seen faster. “They can have a two-week wait list,” Smith explained. “We see patients five days a week and can get them in the next day.” One case that particularly bothered Smith involved a woman she’d spoken to while volunteering at the Susan Wicklund Fund. The woman was thirteen weeks pregnant and said that she’d tried to get an appointment at Planned Parenthood, only to be told she’d have to wait three weeks. Smith asked her if anyone had told her about the Blue Mountain Clinic, given that she lived close to Missoula. No, the woman said. “Would you like to be seen sooner?” Smith asked. Absolutely, she replied. The patient got an appointment the next day. Afterward, Smith told me, she called Fuller and said, “Martha, this is not patient-centered care.”
Fuller told me that Planned Parenthood often refers patients to other clinics. Its scheduling teams even meet with counterparts at All Families Healthcare and Blue Mountain. Fuller described the decision not to provide medication abortions for out-of-state patients as a temporary precaution taken because Montana had an “extremely hostile” political environment: its governor, Greg Gianforte, is an evangelical Christian, and its attorney general, Austin Knudsen, is rabidly anti-choice. When I asked Fuller whether the decision had been made by doctors or by lawyers, she said that it had been a “collaborative conversation.” Fuller noted that Planned Parenthood had filed several lawsuits challenging restrictions in Montana, including a bill virtually banning abortion after fifteen weeks. The organization had also joined forces with pro-choice allies on various advocacy initiatives, including a campaign that led to the defeat of a Montana ballot measure that would have given a fetus the legal status of a person.
As Smith acknowledged, such political battles could be unwinnable without the involvement of Planned Parenthood, whose support she valued more than ever. She told me that she admired the way the organization’s new medical director in Montana, a doctor named Samuel Dickman, prioritized patient needs. But many reproductive-rights advocates still believe that Planned Parenthood’s agenda is too narrow and too cautious. Why hadn’t the group used its enormous muscle to announce that it would be opening clinics in abortion deserts and along the borders of states with bans—and then clamored for donors to help fund them?
In recent years, activists in Minnesota have spearheaded a more aggressive agenda. In 2018, Megan Peterson, the executive director of an organization called Gender Justice, began strategizing about ways to shore up abortion rights in the state. She told me that she was particularly intent on removing various restrictions—a mandatory twenty-four-hour waiting period, a parental-notification law—that “created barriers for people to get care, especially young people, low-income people, people of color, and immigrants.”
Gender Justice, in conjunction with the Lawyering Project, filed a lawsuit opposing these restrictions. It also launched UnRestrict Minnesota, a grassroots campaign that sought to galvanize support for overturning them. Elianne Farhat, the executive director of TakeAction Minnesota, a multi-issue advocacy group, told me that, at the time, the “Democratic Party gospel in Minnesota was that you can’t talk about abortion,” because the issue would alienate some centrist voters. The UnRestrict campaign, which Farhat decided to join, challenged this perception. An array of organizations that view abortion as part of a broader struggle for reproductive justice—such as Our Justice, a Black-led group that raises funds for patients who cannot afford abortion care—also joined the lawsuit.
Planned Parenthood North Central States did not. The reason, various sources informed me, is that it feared the lawsuit would backfire, distracting attention from the more important goals of electing a pro-choice governor and defeating President Donald Trump. Tim Stanley, a Planned Parenthood executive who oversees its advocacy work in Minnesota, told me that the group’s strategy was complementary to the UnRestrict campaign, explaining that pro-choice lawsuits cannot succeed if liberal governors aren’t in place to appoint sympathetic judges. Planned Parenthood had helped secure what Stanley called “a pro-choice trifecta”: Minnesota’s governor, Tim Walz, and both chambers of the state legislature are all supportive of abortion rights. These victories have enabled aligned groups to pursue different tactics.
But Planned Parenthood didn’t just refrain from participating in the lawsuit that Gender Justice filed, I was told: it tried to sabotage it. Kelli Clement, a minister at the First Unitarian Society of Minneapolis, which became a plaintiff in the lawsuit, told me that her organization received a call from Planned Parenthood North Central States discouraging it from being involved. The call shocked her, she said, because it came from an institution she respected. “It did not feel appropriate,” she added. Other groups were also pressured not to join. “It was bad,” Peterson, of Gender Justice, told me. “I felt completely under attack by my own side.” (Planned Parenthood denies that the calls were coercive.)
Though Planned Parenthood was absent from the UnRestrict campaign, Clement told me, “this remarkable coalition, which is now more than thirty grassroots groups, came together to create change.” In July, 2022, seventeen days after the Supreme Court issued the Dobbs decision, a ruling was announced striking down abortion restrictions in Minnesota and turning the state into a beacon of access in the Midwest. Thomas Gilligan, a district-court judge, declared, “The right to choose to have an abortion . . . would be meaningless without the right to access abortion care.” ♦
