Despite a strong showing of support for abortion rights on Election Day, the abortion access landscape in the United States won’t change immediately. And under President Donald Trump’s second term, it will remain heavily fragmented — and vulnerable to future restriction.
Voters in seven states – Arizona, Colorado, Maryland, Missouri, Montana, Nevada and New York – passed pro-abortion ballot initiatives at the polls this week. About a fifth of abortions in the US – an average of about 19,000 each month – occur in those states, according to data from the Society of Family Planning.
In most of those states – Colorado, Maryland, Montana, Nevada and New York – abortion is already legal, and the ballot measures maintain access by enshrining the right to abortion in the state’s constitution.
In only two states did voters approve measures to expand abortion access: in Arizona, where there is currently a 15-week gestational limit, and in Missouri where abortion is currently banned. The measures in both states allow for the right to an abortion to be enshrined in the state constitutions up to fetal viability, which doctors say is around 22 to 24 weeks of pregnancy.
Still, what these new pathways will mean in terms of practical change for women seeking an abortion remains to be seen.
Policy change takes time
However, “adding constitutional protection does not automatically repeal bans or restrictions; litigation is often necessary to overturn pre-existing state laws,” according to the Guttmacher Institute, a research and policy organization focused on sexual and reproductive health that supports abortion rights.
On Wednesday, Planned Parenthood’s two providers in Missouri filed a suit to restore abortion access in the state.
Still, it will take time to ramp up resources to support broader access, experts say.
“We don’t know how soon the clinics in the state will be able to expand their services, even after they receive the legal green light to extend their limits,” said Dr. Ushma Upadhyay, a professor at the University of California, San Francisco’s Advancing New Standards in Reproductive Health.
There were no abortion providers in Missouri even before the Dobbs decision, so a new clinic would have to be established. But greater accessibility is “likely to have important impacts,” she said.
“Currently, our best estimates are that about 13,000 people in Missouri are obtaining abortions per year – either through out-of-state travel or by ordering medications through telehealth services,” said Upadhyay, who also co-chairs #WeCount, a project from the Society of Family Planning that tracks abortion trends in the US. “So there is certainly large amounts of unmet need for abortion care in the state of Missouri.”
The impact in Arizona may not be as large when it comes to volume, but it’s no less important, Upadhyay said. And expanding access there by scrapping the gestational limit could require time and resources to train more providers in second trimester abortions.
More than 171,000 people traveled to a different state for an abortion last year, according to Guttmacher data, and expanded access in Arizona and Missouri could help reduce barriers for women living in other states. The vast majority of abortions provided in Arizona already were provided to out-of-state patients, and Missouri borders multiple states with bans.
Broad restrictions remain
Even if the ballot measures in Arizona and Missouri improve access in those states, about 40% of women of reproductive age – more than 26 million women ages 15 to 44 – will still be living in states with abortion bans or restrictions.
And pro-abortion measures failed to pass in three other states with restrictions: South Dakota, which currently has a near-total ban; Nebraska with a 12-week gestational limit; and Florida, where tighter policies have already reverberated across the broader region and country overall.
Florida had become a key abortion access point for the South in the years since the US Supreme Court’s Dobbs decision revoked the federal right to an abortion in 2022; In 2023, more than 1 in 10 abortions in the US happened in Florida, with thousands of people traveling from other states, according to Guttmacher estimates.
But when the state’s more restrictive abortion policy took effect in May – limiting abortion after six weeks of gestation, before most women know they’re pregnant – monthly abortions in Florida were cut by more than 30% and national abortion rates dipped, too.
Advocates were hopeful that Tuesday’s ballot measure would help patch some of the gaps that 6-week ban created, but the measure fell three percentage points short of the 60% support needed to pass.
“Like so many Americans, Floridians are living under an abortion ban they didn’t ask for and don’t want. As the majority of Florida voters made clear tonight, they want their reproductive freedom back,” Nancy Northup, president and chief executive officer of the Center for Reproductive Rights, a legal advocacy group, said in a statement on Tuesday.
“But due to the high 60% threshold and the state’s disinformation campaign, they must continue to live with the fear, uncertainty, and denial of care caused by the reversal of Roe. So too will countless women in the southeastern U.S., which will remain for now a virtual abortion desert.”
Florida Physicians Against Amendment 4, a group of Ob-Gyns in Florida who opposed the ballot measure because they said it lacked “maternal health and safety regulations,” called the proposal’s defeat a “win for women.“
Now, we physicians can stay true to our Hippocratic oath to do no harm to our patients,” Dr. Christina Peña, an Ob-Gyn practicing in Miami and member of the group said in a statement
The Tampa Bay Abortion Fund, which helps cover costs for people seeking an abortion locally and those who have to travel, says that Florida’s 6-week ban has led to a rise in the number of callers requesting aid – and a 26% jump in the average amount pledged per caller.
“While we and abortion funds around the state are doing our best to fill the gaps, the need is currently outpacing our resources,” Bree Wallace, Tampa Bay Abortion Fund’s director of case management said in a statement this week. “Without financial support, people can’t afford their appointments or to travel to their appointments, forcing them to continue pregnancies they don’t want or that put them at risk.”
Key vulnerabilities
It’s not clear what a new Trump administration’s strategy will be around abortion. Trump said during the campaign that he would veto a federal abortion ban if elected, but his positions on the issue have shifted many times over the years.
Despite the widespread bans and restrictions enacted by more than 20 states in the years since Dobbs, the number of abortions in the US is trending up. But a key factor driving these numbers up — the increased use of medication abortion, especially those provided through telehealth — is perhaps the most vulnerable to significant change.
More than half of all abortions in the US are medication abortions, and about 1 in 5 women who have an abortion receive their pills through the mail. This spring, about half of all telehealth abortions — or about 1 in 10 abortions overall — were provided to women living in states with abortion bans or restrictions under shield laws, #WeCount data shows. Shield laws offer some legal protections for providers who practice in some states where abortion remains legal to prescribe medication abortion drugs via telehealth to people living in states with bans or restrictions.
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Medication abortion has faced heavy litigation, with the Supreme Court ruling just this June to preserve access to the abortion pill mifepristone. But there are a few ways that could change under the incoming administration.
For example, new leadership at the US Food and Drug Administration could implement regulations that restrict access to the medications. Or, the administration could enforce a particular interpretation of the 19th century Comstock Act, which would prohibit the mailing or delivery of any abortion-related items by classifying them as obscene.
“The re-election of Donald Trump raises new and serious concerns about the safety of those needing reproductive health care. This outcome reflects a stark setback for science-based medical care in a nation where many already live in reproductive health deserts,” Dr. Daniel Grossman, an Ob-Gyn and director of the University of California, San Francisco’s Advancing New Standards in Reproductive Health said in a statement.
“We’ve seen first-hand how previous Trump-era policies undermined patient care, leaving many without essential services that protect their fertility, health, and lives. We need health decisions to prioritize science and the well-being of patients, rather than political agendas, to ensure a safer future for everyone.”