Why states are always dangerously close to losing their last abortion clinics

"Today it's Missouri, tomorrow it could be all of America."

An exam room sits empty in the Planned Parenthood Reproductive Health Services Center on May 28, 2019 in St Louis, Missouri. In the wake of Missouri recent controversial abortion legislation, the states' last abortion clinic is being forced to close by the end of the week. (Photo by Michael B. Thomas/Getty Images)
An exam room sits empty in the Planned Parenthood Reproductive Health Services Center on May 28, 2019 in St Louis, Missouri. In the wake of Missouri recent controversial abortion legislation, the states' last abortion clinic is being forced to close by the end of the week. (Photo by Michael B. Thomas/Getty Images)

“Today it’s Missouri, tomorrow it could be all of America,” Planned Parenthood President Dr. Leana Wen said on Tuesday, referring to the likelihood that Missouri will be left with zero clinics offering abortion by the end of the week.

Missouri’s health department is refusing to renew the license for the St. Louis Planned Parenthood clinic after imposing additional regulations, one of which the clinic is unable to meet. Planned Parenthood announced Tuesday that it is suing the state so that it can continue to offer abortion care. Should a court not intervene, Missouri will be the first state to have zero abortion providers since the 1973 decision in Roe v. Wade legalized the procedure. 

But as Wen noted, this isn’t particular to Missouri. In fact, what’s unfolding in the state now has happened before.

Two years ago, Kentucky almost became the first state with no abortion providers. In January 2017, the state’s second-to-last clinic, in Lexington, closed amid a licensing dispute. Three months later, another licensing dispute threatened the last clinic in Louisville.


Like St. Louis’ Planned Parenthood clinic, the Kentucky health department nearly shuttered EMW Women’s Surgical Center in Louisville for failing to meet additional licensing criteria. And like the St. Louis clinic, the Louisville clinic met all the new goalposts except for one.

In Missouri, the health department notified the Planned Parenthood clinic last week that it must meet three additional regulations, according to CBS News. The clinic agreed to two of them: adding pelvic exams for patients receiving surgical abortions and altering who at the clinic provides the state-mandated counseling. The last one — to have state officials interrogate seven doctors at the clinic — was out of Planned Parenthood’s hands, as the clinic doesn’t employ all of them directly.

In Kentucky, EMW Women’s Surgical Center couldn’t arrange “transfer agreements” to work with local hospitals and ambulances should a medical emergency arise. Many hospitals are Catholic and thus anti-abortion, but regardless, the Louisville clinic maintained it was unnecessary as neither can turn patients away for emergency care.    

“We are not suggesting abortion clinics shouldn’t be licensed or shouldn’t meet requirements every year in order to get their licenses renewed — that makes sense for health care providers,” Heather Gatnarek, a staff attorney at the American Civil Liberties Union (ACLU) of Kentucky, told ThinkProgress.


“The difference, or the difficulty, is the licensing requirements for abortion clinics in Kentucky have become so incredibly onerous and so incredibly burdensome — much more for the abortion clinic even though outpatient abortion care is much safer than a lot of other outpatient clinic procedures. So it became very obvious that the abortion clinic licensing schemes were being applied differently because… the Kentucky General Assembly and the governor’s administration have certainly made it a point and have said publicly they want to see the abortion clinic shut down.”

The ACLU sued on behalf of EMW Women’s Surgical Center in April 2017. The clinic got immediate relief in the form of a restraining order. Later, in September 2018, a federal judge ultimately struck down Kentucky’s requirement, saying “scant medical benefits… are far outweighed by the burden on Kentucky women seeking abortions.”

Missouri is hoping the courts intervene in a similar fashion. But even in Kentucky, the legal fights are continuing two years later.

Kentucky appealed the district judge’s decision, and so legal proceedings continue. The clinic has been able to get its licensed renewed in the years since and it’s on course to get it again this year, said Gatnarek, as she knocked on wood.

In addition to Kentucky and Missouri, there are four other states where there’s one clinic left: Mississippi, North Dakota, South Dakota, and West Virginia. The same risks exist there.

“I’m definitely always concerned about that,” said Shannon Brewer, clinic director of Jackson Women’s Health Organization in Mississippi, which was at risk of closing three years ago.


Sharon Lewis, the executive director of the Women’s Health Center of West Virginia, said they “wait to see when that particular type of regulation or obstacle to access care comes to our state.”

It’s challenging for clinics to stay open. The red tape makes it hard, with clinics — depending on the state — having to meet standards comparable to surgical centers and ensure the room where the abortion takes place is a specific width. There are also financial obstacles, with insurance not always covering abortion services, so clinics aren’t reimbursed. The number of abortion providers fell from 780 in 2017 to 755 in 2018 nationwide, according to researchers at the University of California, San Francisco and University of California, Berkeley. 

A Mississippi law also nearly shuttered Jackson Women’s Health Organization in 2016. The law required all physicians at the clinic to have admitting privileges at nearby hospitals. The Supreme Court blocked enforcement at the last possible minute, the evening before the clinic was scheduled to stop offering abortions for failing to meet the requirement.

“It’s a scary feeling,” Brewer told ThinkProgress, recalling that night. Patients were calling to ask if they could still schedule appointments and she didn’t know what to tell them. Thinking about if it happened again now, she wouldn’t know what to say because, as she puts it, “it’s going on in so many states, you almost don’t know where to refer them.”

Many states that already had severe abortion restrictions have passed near-total abortion bans this month. Though none of them are in effect yet, the strategy with these bills is to trigger a challenge to Roe and have the conservative Supreme Court eliminate the constitutional right to abortion. The bills’ sponsors have been very upfront about this.   

“The folks who oppose abortion are looking for and using every tool in their toolbox, whether that’s outright bans, six-week bans, eight-week bans, [procedure bans], let’s get the state involved, let’s inspect, let’s not renew a license — doing anything and everything that they can to stop legal abortion,” said Tammi Kromenaker, of Red River Women’s Clinic in North Dakota. “We know that doesn’t stop abortions from happening, that just makes it much more unsafe.”

Meanwhile, patients are confused about the law, with some assuming abortion is already illegal. The second patient to visit Red River Women’s Clinic on Wednesday asked Kromenaker to explain what’s going on and how bans elsewhere affect North Dakota. Another patient called on Tuesday, asking if the procedure is legal.

“I said, ‘no, abortion is legal in all 50 states, you can get an abortion in all 50 states,'” said  Kromenaker. She said she heard this from patients in 2013, when there was a surge of abortion bans. When a person is pregnant and doesn’t want to be, they’ll do their best to access abortion, she added.