Republican politicians owe the pro-choice community a thank you card for saving the right from the worst impacts of their policies. After the Supreme Court overturned nearly five decades of abortion rights in the infamous Dobbs v. Jackson Women's Health case, the fallout has been terrible: women nearly bleeding to death in hospital parking lots, women having to be airlifted to safer states for abortions, and, unfortunately, a few highly publicized deaths because abortion bans prevented timely care. Still, the impacts have fallen far short of what anti-choice activists hoped and what pro-choice activists feared. There haven't been hospitals filling up, as they did in the days before Roe v. Wade, with patients mutilated from botched abortions. It's not because women have, en masse, given up and submitted to forced childbirth. On the contrary, the birth rate continues to decline while the abortion rate went up after the Dobbs decision.
Sociologist Carole Joffe and law professor David Cohen explore a major reason why in their new book "After Dobbs: How the Supreme Court Ended Roe but Not Abortion." (Full disclosure: I blurbed the book.) Both abortion providers and activists reacted to the Dobbs decision by rising up and creating, almost overnight, an infrastructure of helpers to make sure that women in red states still had access to safe abortion, despite the bans Republicans were rapidly passing. Even though it's shielded Republicans from the political consequences of their hateful policies, this small army of pro-choice patriots has managed to protect women's health, despite the often-daunting obstacle before them.
Joffe and Cohen spoke with Salon about these often unsung heroes, and the ongoing Republican war to take this crucial healthcare access away. This interview has been edited for clarity and length.
In your previous book "Obstacle Course," you wrote about the hoops that women have had to go through to get abortions, even in the pre-Dobbs era. This book is "After Dobbs." What changed in the years since Roe vs. Wade was overturned?
Joffe: It's like before Roe, but on steroids. People have to travel further. Before Dobbs, 1 out of 10 patients had to go out of state. Now it's 1 out of 5. But even though things are harder, many people are surprised that the number of abortions has risen in the United States since Dobbs. Our book helps explain that. It's because of the extraordinary efforts of the abortion-providing community, the advocacy community, the activist community. There's been a huge amount of money and organization that mobilized right after Dobbs. For some, abortion became more feasible. Not necessarily easier, but more feasible. Obviously, some people were still left behind.
Even though our book, in some respects, tells a surprisingly upbeat story, we have no illusions. We end the book on a note of caution. Everything boils down to sustainability. Will the donations keep coming? Will the activists and providers still keep working their butts off? And of course, what will the Trump administration do?
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Cohen: One of the big differences is that Dobbs mobilized pro-choice states to do things that they've been asked to do for decades, which is to take an inventory of their laws, see what restrictions are on the books, and get rid of them. There were so many restrictions, even in good states, and the legislators didn't seem to care. Dobbs made them care. And so you saw states that got rid of, for instance, physician-only requirements or waiting periods or minors restrictions. They started paying under Medicaid and funding clinics through other ways. Dobbs got people to pay attention, who should have been paying attention. Now, in a lot of states, abortion is more accessible than it was before.
Providers are taking a lot of risks under threat, such as red states demanding they be extradited if they help women get abortions. But there's also an army of activists and donors connecting women to those providers.
Cohen: Many providers in blue states are under telehealth shield laws that allow them to mail pills to people in other states. It's not many, but they can mail out pills in large numbers. There are about 10,000, maybe more, pills mailed every month from these telehealth shield providers. They are providing abortion care to people in abortion ban states, so those people don't have to travel.
The other part of the equation is the activists, the everyday people who want to help. They're helping in small to huge ways. The drive for someone who needs to get from an airport to the clinic a couple of miles away, after they've traveled from Florida? That 10 or 15 minutes changes someone's life. But others are driving patients cross country or accompanying people on flights several states away. They're housing people overnight, coordinating their travel, or donating money to fund it. It's unjust. It should not be this way, but while it is this way, they're going to do everything they can to help the people who need care right now. We have to fight for the long term to change this, but in the meantime, there are still people who need care. We have a chapter about folks like that in the book, showing the extraordinary lengths they go to to get people care.
Joffe: We report on a patient who got rerouted because of a snowstorm. The patient navigator rebooked the patient at another appointment at a clinic in Las Vegas, changed her flight, and got her a hotel. All within a couple of hours. It's just extraordinary how the system worked on very short notice.
It's inspiring to see how many people are helping women get the care they need. What impact is it having on patients themselves?
Joffe: Most people don't have to worry about getting on an airplane for basic healthcare. In some cases, patients have literally never been in an airport before. They don't know how to deal with TSA, didn't know what you could bring and could not bring. The staff at the National Abortion Federation told us patients who brought two bigger suitcases or tried to pack a whole bottle of shampoo. They have to be talked through even this process. Then there are ones left behind. These are people so poor, they don't even have a computer. They don't even know that there are organizations to help or about abortion funds. There are single parents with three or four kids. There's no way in hell they can get on a plane.
One story that struck me in the book was the group of Texas ministers helping patients fly from Dallas to New Mexico. Can you tell me more about that?
Joffe: Before Roe, Dr. Curtis Boyd was a very active abortion provider, with a clergy consultation service. He had a clinic in Dallas as well as in Albuquerque, and he had a long-standing relationship with the Unitarian church in Dallas. I mean, Dr. Boyd himself was, at one point, a minister. After Dobbs, his patients who qualified for medication abortions were helped by a minister group in Texas. They were met by a minister who flew with them, and once they got to New Mexico, would accompany them to the clinic. Since then, things have gotten a lot tougher, in terms of legal surveillance. So that program sadly no longer exists to our knowledge.
Because activists and doctors have been so good at filling in the gaps, anti-choice forces are reacting. Texas and Louisiana are going after a New York doctor who sent abortion pills out of state. The governor of New York said, basically she'd extradite this doctor over her dead body. What does the current legal situation look like? What should readers know about the dangers?
Cohen: There's almost no criminal risk for people who are providing care physically located in a state where abortion is legal and someone travels to them. There is a risk that the patient goes home and an angry boyfriend or ex or parent tries to sue the doctor, even though the abortion took place out of state. Still, that's a very low-risk proposition. The providers who are at the highest risk are the ones we talked about before, the shield providers who are mailing pills into states where there are abortion bans. The anti-abortion movement is, right now, flummoxed about what to do about that. The numbers are so high, almost 10,000 abortions per month. Antis are trying different attacks, because, as we all know, they don't just want to stop abortion happening by providers in their borders.
Joffe: They wanna stop as much abortion as they possibly can. Louisiana wants New York to extradite a doctor, so they can prosecute her for mailing abortion pills into their state. New York has a shield law, however, so the governor and the Attorney General of New York have said they will protect the doctor. Eventually, will probably wind up in federal courts, maybe the US Supreme Court. Right now the doctor is still, to the best of my knowledge, providing care to people and mailing pills. And to the best of my knowledge, it hasn't stopped any of the shielded providers from doing so. They understand the risk, but they think it's important to take this risk because there are so many people who need care in the states where abortion is banned. One of the inspiring stories of the post-Dobbs era is people who know that they are needed. They have the training to do it. They have the technology to do it. There's some risk, but they're doing it anyway because people need the care they can provide.
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This is too recent for your book to cover, but there's a whole new case in Texas. The state's attorney general is accusing a midwife of illegally providing abortions. We don't yet know if there's any truth to these charges, but what's your sense of how much red-state abortion is happening outside of the channel of doctors mailing women abortion pills? What are the risks of people offering this more direct care?
Cohen: We know there are informal networks of people distributing pills not as part of a medical clinic, just volunteers. They're like mutual aid groups who have gotten pills through one way or another. To the best of my knowledge, that's happening in every state with abortion bans. I've heard varying estimates of the volume they're doing, from just a few to quite a lot. It's really unknown. The studies from the Society of Family Planning and Guttmacher do not include informal network distribution of pills.
As far as what [Texas Attorney General] Ken Paxton is alleging, first of all, I don't trust a word that comes out of his press office. For all we know, this midwife was providing miscarriage management, and Paxton thinks it was an abortion. We must be super skeptical of everything he says.
Joffe: The similarity with the pre-Roe era is that law enforcement was more likely to go against people under the rank of physician: nurses, midwives, and lay people who had learned to perform abortions. And we know that the accused is a woman of color. Like David, I am deeply, deeply, deeply skeptical of anything Ken Paxton says.
Cohen: Maybe the big story here isn't that Texas midwife was charged with alleged illegal abortions, but that Texas closed three clinics providing prenatal care for low-income Spanish speakers. Those clinics are now closed and people aren't getting care.
Anti-choicers were ecstatic after Dobbs. You heard highfalutin' rhetoric about how they were going to end abortion in the U.S. forever. Project 2025 has language about "ending" abortion. What does your research tell us about how realistic that goal is?
Joffe: Even if the FDA manages to withdraw the approval of mifepristone, the first pill used in a medication abortion, they're not going to withdraw approval of misoprostol, which is widely used in other medical procedures. [Note from the editor: While both pills are recommended, misoprostol by itself will usually terminate a pregnancy.] Now that these networks exist, even if there's a national ban, there always are going to be these pills available. There are also groups sending them over the border from Mexico, or ordering the pills from Aid Access. You can but these pills in Europe. However, there will likely be more cases like what happened to this midwife in Texas. There will be more prosecutions, I assume, but they will never stop abortion.
Cohen: We've seen this historically. We've seen this around the world. Where abortion is banned, people still get abortions. If they crack down even more, there will be more prosecutions. But there will always be people who are committed to making sure people have the freedom to live the life they want and have their bodily autonomy. People who say, "I am so committed to that principle that I'm going to use my time, my money, my skills, my license." Whatever someone has to offer, they will help people access this form of care.
As much as the anti-abortion movement was saying this is going to end abortion, everyone in the abortion rights and justice movement feared Dobbs would dramatically cut back on the number of people getting abortions. But they were wrong. We should have known better, because the people we interviewed for the book, we've known how committed they are for a long time. We knew they would find some ways. I never thought it would be as successful as it's been. Yes, there are people left behind. We need to make sure fewer people are left behind, but they're doing their best to care for the people they can see.
The anti-abortion movement, like you said, were so excited. A year later, the reports were that they were depressed at their conferences. They haven't been able to stop abortion. Abortion is never going to be ended, because people are going to fight for it. People who need it will seek it out and find ways to get it.
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