Life After Dobbs: An Objective Look At Navigating The Impact On Healthcare

Life After Dobbs: An Objective Look At Navigating The Impact On Healthcare

I've debated for a long time whether or not to speak on the topic of abortion for obvious reasons. I don't know it all. I am an imperfect person on a journey to seek understanding through educating myself and others. I am not proud that I took full advantage of my privilege and kept my head in the sand about many important issues for far too long. However, witnessing the tangible repercussions of the Dobbs decision, particularly the adverse broader impacts on women's healthcare, fueled a sense of responsibility to contribute to the dialogue. It became evident that the consequences demanded a thoughtful examination of the broader societal implications. Choosing to step into this challenging conversation stems from a commitment to shed light on the repercussions of legislative decisions, fostering empathy and understanding in pursuing a more inclusive and informed society.

I want to clarify that the focus of this article will deliberately steer away from delving into the intricacies of ethics, morality, or the political dimensions surrounding abortion. Instead, the objective is to provide an overview of the Supreme Court cases on reproductive rights and shed light on the tangible effects of the Dobbs decision, particularly its ramifications on healthcare. By narrowing the scope to these practical aspects, the intention is to provide an informative and objective analysis of the real-world consequences that individuals, particularly women, have faced because of this legal shift. Understanding the broader implications of legislative decisions is crucial, as they can significantly shape the landscape of individual rights in unexpected ways. Legislation targeting reproductive rights can set a precedent for other areas of women's rights. By understanding the interconnectedness of various issues, women can advocate for comprehensive policies that protect their well-being. This awareness is crucial for women of all political affiliations.

A Brief Overview of Supreme Court Cases Shaping Reproductive Policy

Roe v. Wade (1973)

In the realm of legislative decisions, few have resonated as profoundly as the Supreme Court's landmark ruling in Roe v. Wade. Norma McCovey brought the 1970 case under the pseudonym Jane Roe against her local district attorney in Texas, Henry Wade. McCorvey, who was pregnant with her third child, wanted to seek an abortion. Still, abortion was illegal in Texas except in situations where it was necessary to save the mother's life. The U.S. District Court ruled in favor of Roe, and the decision was appealed to the U.S. Supreme Court. In January 1973, The Supreme Court ruled in a 7-2 decision in favor of Roe to protect a woman's right to an abortion. This decision was made under the Due Process Clause of the Fourteenth Amendment to the United States Constitution, which provided the fundamental right to privacy. The Due Process Clause states, "nor shall any state deprive any person of life, liberty, or property, without due process of law." The Supreme Court decided that the right to privacy extends to control over pregnancy. While the right to privacy protected a person's right to choose whether to have an abortion, it was not an absolute right. That right had to be balanced against the government's interest in protecting health and prenatal life. That meant that states could put some regulations on abortions. The Court also created a framework to balance the state's interest with privacy rights. Acknowledging that the rights of pregnant people may conflict with the rights of the state to protect potential human life, the Court defined the rights of each party by dividing pregnancy into three 12-week trimesters:

• During a pregnant person's first trimester, the Court held, a state cannot regulate abortion beyond requiring that the procedure be performed by a licensed doctor in medically safe conditions.
• During the second trimester, the Court held that a state may regulate abortion if the regulations are reasonably related to the health of the pregnant person.
• During the third trimester of pregnancy, the state's interest in protecting the potential human life outweighs the right to privacy. As a result, the state may prohibit abortions unless an abortion is necessary to save the life or health of the pregnant person.

It is important to note that Roe v. Wade did not legalize abortion. It just changed the way states regulate abortion. While the decision was made in favor of Norma McCorvey (Jane Roe), it was not made in time for her to receive the abortion she had sought and she gave birth to a baby girl on June 2, 1970, who was later adopted.

Planned Parenthood v. Casey (1992)

In 1982, Pennsylvania Governor Robert Casey passed the Abortion Control Act in an attempt to tightly regulate abortions. The act included five provisions:

• Informed Consent- Those seeking an abortion had to give her informed consent prior to the procedure. The doctor had to provide specific information at least 24 hours before the procedure was to take place, including information about how the abortion could be detrimental to her health and about the availability of information about the fetus.
• Spousal Notice- A married woman was required to sign a statement declaring that she had notified her husband prior to having an abortion.
• Parental Consent- Minors were required to get the informed consent of one parent or guardian prior to having an abortion or seek a judicial bypass in lieu of consent.
• Medical Emergency Definition- Excused compliance of the Abortion Control Act in medical emergencies defined as "[t]hat condition, which, on the basis of the physician's good faith clinical judgment, so complicates the medical condition of a pregnant woman as to necessitate the immediate abortion of her pregnancy to avert her death or for which a delay will create serious risk of substantial and irreversible impairment of a major bodily function."
• Reporting Requirements- Mandated reporting and record keeping requirements on facilities providing abortion services.

Before the provisions could take effect, the American Civil Liberties Union representing Planned Parenthood (five abortion clinics, a class of physicians who provided abortion services, and one physician representing himself independently) filed suit to challenge the Pennsylvania Abortion Control Act of 1982, stating that the provisions were unconstitutional under Roe v. Wade.

In a plurality opinion, the Supreme Court reaffirmed the "essential holding" of Roe consisting of three parts: (1) Women had the right to have an abortion before viability and to do so without undue interference from the State; (2) the State could restrict the abortion procedure post-viability, so long as the law contained exceptions for pregnancies which endangered the woman's life or health; and (3) the State had legitimate interests from the outset of the pregnancy in protecting the health of the woman and the life of the fetus that may become a child. However, it modified the legal standard established by Roe v. Wade by introducing the "undue burden" standard. The decision maintained that states could regulate abortion, but such regulations could not impose an "undue burden" on a woman's right to choose before fetal viability.

The plurality decision in Planned Parenthood v. Casey also overturned the Roe trimester framework in favor of a viability analysis. The introduction of the viability standard also marked a shift in the legal framework surrounding abortion rights. The Court supported the state's interest in protecting potential life after the point of viability. Still, it affirmed that, before viability, the state could not place substantial obstacles or "undue burdens" on a woman's access to abortion. This nuanced approach aimed to strike a balance between preserving reproductive rights and allowing states some regulatory authority over abortion procedures.

The outcome of the case allowed states to impose certain restrictions on abortion as long as these regulations did not place a "substantial obstacle" or an "undue burden" on a woman's ability to access abortion services. This decision marked a departure from the strict scrutiny standard set by Roe and provided states with greater leeway in enacting regulations related to informed consent, waiting periods, and parental involvement, and redrew the line for fetus viability.

While the core right to choose abortion remained intact, the Planned Parenthood v. Casey decision allowed states to implement measures that could make access to abortion more difficult for women, leading to a more nuanced legal landscape in which the balance between protecting reproductive rights and permitting state regulations was recalibrated.

Dobbs v. Jackson Women’s Health Organization (2022)

The Dobbs v. Jackson Women’s Health Organization Supreme Court case originated from a challenge to Mississippi's Gestation Age Act that prohibited most abortions after 15 weeks of gestation, with exceptions only in cases of severe fetal abnormality or medical emergencies. The state's attempt to enact this law directly challenged the viability standard set by Planned Parenthood v. Casey, which protects a woman's right to choose an abortion until the fetus is viable, typically around 24 weeks. Within days of the Act's passage, Jackson Women's Heath Organization, Mississippi's only abortion clinic, sued the state health officer Thomas E. Dobbs to challenge the Act's constitutionality. The lower courts ruled in favor of Jackson Women's Health Organization, citing past precedence set in Roe v. Wade and Planned Parenthood v. Casey.

The Supreme Court took up the case and heard oral arguments on December 1, 2021. The central legal argument in Dobbs revolves around the question of viability and whether states have the authority to impose restrictions on abortion before fetal viability. Mississippi argued that advancements in medical technology have shifted the viability threshold, justifying their attempt to limit abortion earlier in pregnancy. While Politico leaked the Court's decision draft in the case on May 2, 2022, the Court didn't issue its official decision until June 24, 2022. In a 6–3 judgment, the Court reversed the Fifth Circuit's decision and remanded the case for further review. The majority opinion, written by Justice Samuel Alito and joined by Justices Clarence Thomas, Neil Gorsuch, Brett Kavanaugh, and Amy Coney Barrett, held that abortion was not a protected right under the Constitution, overturning both Roe v. Wade and Casey. The decision returned the authority regarding abortion regulations back to the states, marking a significant shift in the legal landscape. Justice Alito argued that the Constitution makes no reference to abortion, and the right was not deeply rooted in the nation's history.

The Immediate Impact

The Dobbs decision did not make abortions illegal nationally in the United States, but it did return the power to regulate abortion back to the states. Trigger bans immediately went into effect in Kentucky, Louisiana, and South Dakota, with many states working quickly also to ban abortion in their state. As of November 2, 2023, KFF.org reports that 13 states have banned abortion. Here is the current abortion status by state from KFF.org:

Source: https://www.kff.org/other/state-indicator/abortion-policy-tracker/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D

The Dobbs Impact on Healthcare

The Dobbs decision, handed down by the Supreme Court on June 24, 2022, marks a watershed moment in the healthcare landscape in the United States, particularly within the realm of reproductive rights. The ramifications of this decision extend far beyond the realm of abortion rights, resonating throughout the healthcare system. The Dobbs decision not only alters the dynamics of reproductive healthcare but also sets a precedent for the delicate balance between individual autonomy and state regulation. While not an exhaustive list, we delve into the multifaceted impact of the Dobbs decision on healthcare in the United States, its effects on reproductive rights and maternal health, and the broader implications for the future of healthcare policies.

Maternal Fatalities

One of the immediate and concerning consequences of state abortion bans is the potential increase in maternal fatalities. According to the Centers for Disease Control and Prevention, the number of Americans who die while giving birth or in the weeks after has risen 83% from 2018 to 2021.When access to safe and legal abortion is restricted, women may resort to unsafe alternatives, leading to a rise in complications and life-threatening situations. Studies have shown that women who were denied an abortion were more likely to experience serious pregnancy complications, poor longer-term health, chronic pain, and even death. The same study also found that these women were more likely to experience household poverty and stay tethered to an abusive partner. 

In the wake of the Dobbs decision, many women experiencing emergencies such as miscarriages, ectopic pregnancies, and other complications found themselves facing a maze of delays or denials of treatment over the swiftly changing restrictions. One of those women was Kate Cox from Texas. Kate and her husband discovered their unborn child had a severe genetic condition that causes severe developmental problems called trisomy 18. A 2016 study found 9 out of 10 infants with this condition won’t survive longer than one year. Medical professionals advised Kate that if she decided to move forward with the pregnancy, she would potentially risk infection, uterine rupture, the ability to have more children, and potentially her life.

Kate, along with her husband, decided that it was best to seek an abortion. However, abortion is illegal in the state of Texas. The Coxs sought legal assistance to sue the state of Texas and get a court order to say Kate could get an abortion in Texas, and that court order would protect her doctor and her husband. While a district court ruled in favor of Kate, the Texas Supreme Court overturned that ruling stating that Kate “wasn’t sick enough.” Kate had no other choice but to seek an abortion outside the state of Texas. The state of Texas has gone as far as to criminalize anyone who has an abortion, provided an abortion, or aided or abetted someone in getting an abortion. The legal challenges might only be beginning for Kate and her husband in the state of Texas.

Disproportionate Impact on Marginalized Communities

State abortion bans often exacerbate existing health disparities, disproportionately affecting Black, Indigenous, and other people of color, people with disabilities, people in rural areas, young people, undocumented people, and people who are low-income or living in poverty. In 1976, the Hyde Amendment banned federal funding for abortion in most circumstances. This amendment meant that public health insurance could not be used for abortion and disproportionately affects low-income and women of color. Women of color and those with limited financial resources may face heightened barriers to accessing healthcare services, including safe abortions. The intersectionality of race, socioeconomic status, and gender compounds the challenges, leading to increased health risks for individuals already facing systemic inequalities.

Exodus of Medical Professionals and Lack of Access to Adequate Healthcare

Abortion bans and criminalization of abortion have impacted the ability to access the full range of reproductive healthcare, including fertility care, miscarriage management and care needed for pregnancy complications.

In the year following the Dobbs decision, more than 66 clinics across the country closed, and many OBGYNs left states banning and criminalizing abortion. Access to obstetric services has declined for years in rural areas, with at least 89 obstetrics units in rural U.S. hospitals closing their doors between 2015 and 2019, according to the American Hospital Association. The March of Dimes found in their 2022 maternity care deserts report that 6.9 million women in the United States live in areas where there is low and no access to OB providers and hospitals/birth centers offering OB care. Since 2020, they have added 1,119 counties to their maternity care deserts list. The Dobbs decision is expected to magnify further and expand maternity care deserts nationwide. We are seeing this play out in real-time in the state of Idaho, where a hospital in Idaho was forced to close its labor and delivery unit over hostile abortion restrictions and a lack of qualified and available physicians. This closure requires patients to travel 45 minutes to the nearest city with a labor and delivery unit.

The bans, along with the criminalization of abortion, have also impacted students entering the medical field. A recent study among medical students found that 77% of respondents reported that access to abortion care, or lack thereof, affects the location of residency programs to which they apply. The study also determined that 58% of the respondents said they are unlikely to apply to a residency program located in a state with abortion restrictions.

According to the American College of Obstetricians and Gynecologists, abortion training is an essential part of reproductive health care and teaches skills like uterine evacuation that are used to manage miscarriages, remove polyps for cancer diagnosis, and for abortion. Medical students and residents are not able to receive the full hands-on training to provide patients with comprehensive care in states with abortion bans. As a result of this insufficient gynecological training, experts warn, a generation of doctors will be ill-equipped to meet their patients’ needs. A research study mapping US residency programs predicted that almost 44% of OB-GYN residency programs are located in states that have already banned or are likely to ban abortions. As more states prohibit or limit abortion, medical students may prefer to train in states where abortion is legal. Consequently, existing divides in healthcare access will deepen as many medical residents choose to practice where they are trained.

The Attack On Mifepristone

In November 2022, the Alliance for Hippocratic Medicine filed a suit against the U.S. Food and Drug Administration over its approval of the drug mifepristone. Mifepristone is the most common medication used in abortions and has a lengthy track record of safe and effective use. Legal attempts to ban the FDA approved drug mifepristone will further exacerbate the issue of reproductive healthcare access if the drug gets banned. If the Alliance for Hippocratic Medicine is successful in their lawsuit, the outcome would have a devastating impact on all states where abortion is legal. A report by the Guttmacher Institute reports, “Without medication abortion using mifepristone as an option, demand for procedural abortions could increase significantly—leading to overwhelmed clinics and providers, much longer wait times, further unnecessary delays, and more complicated and costly logistics for many patients. It would be difficult, if not outright impossible, for providers that only offer medication abortion using mifepristone to switch to offering procedural abortions instead.”

While this drug is being targeted for its use in abortions, it is also used in the treatment of uterine fibroids, Cushing’s syndrome, and clinical trials as a treatment for multiple forms of cancer and depression. There have also been reports of patients being denied prescriptions for methotrexate, a drug used to treat such conditions as cancer, rheumatoid arthritis and other autoimmune diseases because the medication can also be used to induce abortion. If the Alliance for Hippocratic Medicine is successful, it will have a broad sweeping impact on the healthcare system in the United States that extends far beyond the access of abortion.

Future Access To Contraceptives At Stake?

The Supreme Court cases Griswold v. Connecticut and Eisenstadt v. Baird paved the way for privacy protection around contraception. However, there is currently no federal right to contraception. Unfortunately, misinformation about contraceptives and how pregnancy is defined in state abortion bans may impact contraceptive access. Many people do not understand that emergency contraception methods (Plan B, Ella, and IUDs) do not terminate a pregnancy, stop the implantation of a fertilized egg, or affect a developing embryo. Emergency contraception prevents pregnancy by delaying or inhibiting ovulation and will not work if the pregnancy is established. (KFF Org) 

The misunderstanding of emergency contraceptives and the definition of abortion used in some state abortion bans could be used to limit access to contraceptives. The American College of Obstetricians and Gynecologists define pregnancy as beginning at the implantation of a fertilized egg, while several abortion bans define pregnancy as beginning at fertilization. Preventing the implantation of a fertilized egg could be construed as terminating a pregnancy in cases where abortion bans establish that a pregnancy exists from the moment of fertilization. Here are two problematic examples of definitions from Tennessee and Missouri:

• Tennessee defines pregnancy as “reproductive condition of having a living unborn child within [the pregnant person’s] body throughout the entire embryonic and fetal stages of the unborn child from fertilization until birth.”
• Issue: If pregnancy exists from the moment of fertilization, then preventing the implantation of a fertilized egg could be construed as terminating a pregnancy.
• Missouri defines abortion to outlaw “[the] termination of the pregnancy of a mother by using or prescribing any instrument, device, medicine, drug, or other means or substance with an intention other than to increase the probability of a live birth or to remove a dead unborn child.” It additionally defines unborn child as “the offspring of human beings from the moment of conception” — which they define as fertilization — “until birth.”
• Issue: The ban as written establishes personhood for fertilized eggs and the ban could be interpreted as banning anything that prevents the implantation of a fertilized egg on the uterine lining.

As of October 2023, only thirteen states have legal or constitutional protections for the right to contraception (California, Colorado, Florida, Illinois, Massachusetts, Michigan, Minnesota, New Jersey, New Mexico, Oregon, Rhode Island, Vermont, and Washington – and D.C.). The state of Maryland will vote in November 2024 to create a constitutional amendment to protect the right to contraception. Nevada must pass the measure twice in the legislature before it could be on the ballot in November 2026. Currently, none of the states with abortion bans in place have protected the right to use or obtain contraception. The Dobbs decision has brought renewed attention to the potential vulnerability of the Griswold and Eisenstadt decisions as well as future attempts to limit contraceptives.

Why Every American Should Be Concerned & The Urgency of Civic Participation

The Dobbs decision is not merely a legal verdict; it is a pivotal moment with far-reaching implications that extend beyond the realm of reproductive rights. Every American should be deeply concerned about the decision as it fundamentally alters the landscape of healthcare autonomy and individual freedoms. The Supreme Court's decision to overturn the precedents set by Roe v. Wade and Casey not only challenges the constitutional protection of a woman's right to choose but also sets a precedent that could affect a broad spectrum of personal liberties. The Dobbs decision raises critical questions about balancing individual autonomy and state intervention, with implications for healthcare policies, civil liberties, and constitutional rights. Regardless of one's stance on reproductive rights, the Dobbs decision underscores the need for widespread concern and engagement in shaping the future of healthcare policies, reaffirming the importance of civic involvement in safeguarding the principles of autonomy and personal choice.

The overturning of Roe v. Wade is a poignant example of why everyone, irrespective of their immediate concerns, should engage in the political discourse. Staying informed, paying attention to legislation, and actively participating in the democratic process through voting are crucial aspects of civic responsibility that resonate far beyond individual circumstances. Issues that may initially seem distant or unrelated can profoundly affect the fabric of society, shaping the rights and freedoms we often take for granted. The consequences of the Dobbs decision serve as a stark reminder that voting extends beyond the presidential elections; local and state elections play a pivotal role in shaping the legal landscape and influencing policies that touch our daily lives. By staying informed and participating in the democratic process, we contribute to the collective strength of a society that values inclusivity, justice, and the protection of fundamental rights. The implications of legislative decisions, such as those surrounding reproductive rights, extend beyond partisan lines, affecting the overall well-being of communities. Every vote at every level, every informed decision, becomes a building block for a society that upholds principles of equity and justice, safeguarding the rights not only of the present generation but of those to come.

Closing Thoughts

To all the readers who have journeyed through this blog, regardless of your stance on the controversial topic of abortion, I extend my heartfelt gratitude. This exploration was never intended to persuade or reshape opinions but aimed at providing a retrospective perspective on the profound impact of legislative decisions on our lives. If there's one takeaway from this blog, I hope it is the importance of exercising your right to vote at every level of government, particularly at the state and local levels. The choices we make at the ballot box influence the trajectory of our society, shaping policies that resonate with our values. Thank you for embracing this journey of introspection, and may it inspire a renewed commitment to active participation in our democratic process.