Detroit’s iconic Herman Kiefer complex for decades was synonymous with public health in the eyes of many city residents. By the time the complex was abandoned in 2013, it had fallen into vermin-infested disrepair and housed a fraction of the dedicated employees who once walked its halls.

This article was published on Friday, August 6, 2021 in Kaiser Health News.

By Anna Maria Barry-Jester

If you were growing up in Detroit in the 1970s or ’80s, chances are you knew the city’s Herman Kiefer public health complex by both sight and reputation.

Opened at the turn of the century and later enhanced by renowned industrial architect Albert Kahn, the imposing brick complex was named after a local infectious disease doctor. As the city grew, so did the complex and the services offered within, becoming synonymous with public health in the eyes of many families and residents.

For decades, it was where you went to pick up birth records, get tested for tuberculosis, get vaccines or undergo discreet diagnosis and services for sexually transmitted diseases.  It was even a place some parents told their children to go to if they needed help — the way other parents tell their kids to go to the police if they’re in trouble.

That was before the lean years that led into the Great Recession of 2008. By the time the complex was abandoned more or less overnight in 2013, it had fallen into vermin-infested disrepair and held a fraction of the dedicated employees who had once walked its halls. City officials gave up on the building — and dismantled the public health department it had come to represent. Eventually, the city sold Herman Kiefer to an out-of-town developer, who has marketed it as a commercial complex.

Across the nation, public health departments have seen dramatic cuts over the past decade. It is a nationwide phenomenon, hitting communities big and small, rich and poor. When state and local government revenues falter, health departments are often the first to lose funding.

When politicians shutter a school or close a subway stop, the impacts are immediate and visible, sparking sharp public blowback. But when a health department fires its contact tracers or closes its infectious diseases lab or stops testing children for lead exposure, the impact is more subtle.

At least at first.

Detroit often experiences a magnified version of the nation’s economic and health woes, and the same holds true of its experiment to streamline and privatize public health services. A health department that had 700 employees in 2008 had just five by the end of 2012. Though it has slowly been rebuilding since 2014 — it now employs approximately 270 people — damage done during the leanest years has been on stark display amid the ravages of the covid-19 pandemic.

***

Vernice Davis Anthony loves thinking back on the good years. In the 1970s, she was one of dozens of public health nurses working for the Detroit Health Department. Originally from Pennsylvania, Davis Anthony moved to Detroit to attend nursing school at Wayne State University, where, as a young Black woman, she’d heard she could get a fair shot at an education and career in the majority-Black city.

She and her co-workers walked the neighborhoods building connections and trust, visited the home of every new mom, and worked in schools, tracking cases of infectious diseases and making sure kids got immunized. Wearing health department badges and uniforms, she particularly liked doing home visits in vibrant Southwest Detroit, then home to Puerto Ricans, Mexicans, Middle Easterners, Appalachian whites and Southern Blacks. The power dynamic captivated her: Unlike a hospital, where doctors and administrators ran the show, the families ultimately decided whether she could come in. “When you are in their home, the balance of power has shifted,” she said.

In those days, she said, the health department had resources to back up its mission, including a world-class laboratory and a pharmacy that provided discounted medicines to residents. It ran clinics throughout the city’s sprawling neighborhoods.

It also had political clout. When AIDS emerged as a devastating public health threat in the early 1980s, at the same time intravenous drug use had become rampant in some neighborhoods, the health department funded community groups to educate residents on the dangers of the human immunodeficiency virus and sharing needles.

George Gaines, then the city’s deputy health director, recalled a conversation in the 1980s when he pleaded with Mayor Coleman Young to let him hand out clean needles to drug users, a controversial topic even today. “Give them the needles,” he said Young told him. “Just keep your name out of the paper.”

For years, Gaines dedicated resources to drug treatment programs aimed at helping poor inner-city families, even as federal funding for drug addiction was slashed.

While there’s no way to prove those early efforts prevented an explosion of HIV, said Eve Mokotoff, who handled HIV data for Michigan from 1986 through 2012, that work was clearly vital in turning attention to the threat HIV posed in low-income Black communities even as much of the nation’s medical community focused primarily on the threat to gay white men.

The people leading the health department at the time had “a fierce love for that city, and fierce in the most positive sense of the word,” Mokotoff said. “When they saw this was going to happen, they weren’t going to close their eyes to it. They weren’t sitting ducks. They wanted to prevent it.”

Those were the gratifying years when Detroit health officials were often called in by other cities to teach strategies for lowering rates of child lead poisoning, HIV infections and Black infant mortality.

Gaines can hardly fathom how it all fell apart so fast.

***

In the final decades of the 20th century, white flight to the suburbs, the struggles of the auto industry and offshoring of manufacturing all hit Detroit hard. Then came the predatory lending that helped trigger the Great Recession.

From 2008 to 2010, with the city’s tax base shrinking, the health department shed more than 70% of its employees. By 2012, Mayor Dave Bing, a professional basketball player turned businessman, was preparing the city for bankruptcy. Told they had to cut costs further, leaders of the stripped-to-the-bone health department made a radical proposal: privatize and outsource services by handing nearly all their work to a nonprofit to be assembled from scratch and dubbed the Institute for Population Health.

Health departments around the country have survived perennial funding declines by turning to grants and private entities to carry out some of their work. What was unprecedented about Detroit was that it wasn’t just a few programs to be outsourced; it was essentially all of the city’s health services.

Those involved say it was a necessary step to save the department from the volatility of the municipal bankruptcy and the weight of union and pension obligations. In theory, it would allow the city to maintain its core health mission, even as it went through a financial overhaul.

But critics say the arrangement had nothing to do with the well-being of residents. “It was not a decision made to improve the health of people. It was purely an economic decision,” said Phyllis Meadows, director of the city health department from 2004 to 2009. “This was political health; it wasn’t public health.”

Though a messy battle over the plan ensued — by Michigan law, the city was obligated to provide certain public health services — Bing won. By October 2012, health services were no longer housed at Herman Kiefer and nearly all the department’s duties had been outsourced to the new nonprofit. The following year, the governor installed an “emergency manager” whose powers superseded those of elected officials.

Davis Anthony, who had moved on to other health agencies, initially supported the reorganization and returned to run the stripped-down, five-person city department that remained from 2012 to 2014. But her experience ultimately led her to believe public health at its very core must be a government function. The skeletal city staff was too small to provide proper oversight of public funds. “When you have public health funding that’s going directly from the state to a nonprofit without any accountability, that was a problem,” she said.

Community organizers and former employees say the nonprofit may have been well-meaning, but public health all but disappeared from many Detroiters’ lives. Residents had no say in funding priorities. And there was no government agency with expertise and political support to serve as a backstop for the health of residents.

A local health department is charged with prevention, protection and health promotion, said Robert Pestronk, former health officer for Genesee County, Michigan, home to Flint, and former executive director of the National Association of County and City Health Officials. “It’s not about conducting business. It’s to make sure there’s a place in our society where the roots are nourished by those concepts.” Underfunding undermines that role, he said. “We live in a culture where, if you have resources, you gain some respect.”

After the privatization, health officials lost the political influence needed to protect residents from basic threats, said former employees and city residents. That includes remaining largely silent as Detroit’s Water and Sewerage Department, struggling with its own bankruptcy filing, began shutting off water to the homes of people late paying their bills. From 2014 to 2020, an estimated 141,000 customers lost water at some point. The shutoffs were crushing for low-income residents, many of them Black families, living in neighborhoods already buckling under the weight of the city’s economic collapse.

“How are they going to use the restrooms? How are they going to cook? How are they going to prepare formula for babies?” said Dr. Kanzoni Asabigi, who held top public health positions with the city before abruptly retiring in May 2020 over disappointment at city officials’ response to the pandemic. “Everybody needs water to live.”

Gaines was so disgusted by the water shutoffs that at 90 years old he conducted research on the health effects in hopes elected officials would end the policy. Instead, it took a global pandemic. As officials nationwide advised Americans to wash their hands to fight the new coronavirus, Michigan Gov. Gretchen Whitmer issued a temporary moratorium on water shutoffs. In mid-December, Detroit Mayor Mike Duggan announced a plan to extend the moratorium through 2022.

***

It was Duggan who initiated the return of public health services to government control when he took office in 2014, less than two years after the department was all but shuttered. But rebuilding has been a painful process.

Duggan hired as executive health director Abdul El-Sayed, a native of the Detroit suburbs who was then a professor of public health at Columbia University. His first order of business was to move the department out of a conference room in the back of the city parking department. He then was tasked with revamping animal control, yet another of the department’s duties, to combat negative headlines generated by the shelter’s high kill rate.

From there, his job became contentious, as he got into public feuds with his boss over a range of health issues: refineries that were spewing toxic fumes in a city overburdened by asthma, sweeping neighborhood demolitions that communities believed were causing increases in child lead poisoning, and the water shutoffs to tens of thousands of Detroiters. He said he didn’t play the politics well but felt compelled to weigh in.

“There’s not that much money in making sure that babies have what they need to thrive. There’s not that much money in making sure that restaurants are up to code,” said El-Sayed. “If there was, private industry would hop to do it.”

After less than two years with the department, he resigned to wage an unsuccessful run for governor.

El-Sayed was succeeded in 2017 by Dr. Joneigh Khaldun. She had joined the department as medical director the previous year, coming home to Michigan after serving as chief medical officer in the Baltimore City Health Department, which has 900 employees for a population 10% smaller than Detroit’s. When Detroit was hit by an outbreak of hepatitis A in 2016 during her first week on the job, she recalled, the city had no public health lab; she didn’t know where to find its contact tracers, who were state employees, and there was no protocol for a vaccination campaign.

“That infrastructure of, how do you quickly respond to an outbreak? How do you stand up clinics? How do you get the communications out so that people know where to go? That was not there,” Khaldun said.

Khaldun left in 2019 to become the chief medical executive for Michigan’s Department of Health and Human Services. When covid arrived in March 2020, the fledgling system she had set up with colleagues was Detroit’s first line of defense. Amid the feeble response, the coronavirus cut a broad and deadly swath through the city, quickly overwhelming area hospitals and hitting hard in tightknit communities of health care workers, churchgoers and ballroom dancers.

In the year since, 1 in 10 Detroiters have been infected with covid and more than 2,400 have died — more than twice the number in Baltimore. Detroit’s covid death rate is roughly double the national rate.

The pandemic has raised the department’s profile, but officials are struggling to win back the community’s trust. When the Centers for Disease Control and Prevention updated its mask guidance in May, saying indoor masking was no longer necessary among fully vaccinated people, just 20% of Detroit residents met that definition. Nearly three months later, just 34% of the city’s residents are vaccinated, compared with 54% of Michigan residents and 50% of U.S. residents overall.

And with all hands on deck to fight covid, neglected public health issues have plunged into deeper obscurity. Programs to prevent and treat childhood lead poisoning were put on hold. The childhood vaccination rates against diseases like measles and mumps have dipped below 50%.

On nearly every health measure — HIV rates, health insurance coverage, drug-related deaths, smoking, STDs, vaccination rates, asthma and obesity — Detroiters are faring worse than Michiganders as a whole. While the average life expectancy in Michigan is 78, it is 72 in Detroit, with some neighborhoods falling as low as 62. Maternal mortality is nearly triple the state average, as is infant mortality. A 2018 health needs assessment found that 9% of children under age 6 have blood lead levels elevated above accepted thresholds, a figure that jumps to 22% in some neighborhoods.

For all the federal relief money that came pouring in for covid, the health department still lacks the resources for even the most basic services. In May, the Detroit City Council approved an $87,000 contract to outsource testing related to sexual and reproductive health. Residents who are tested at a city clinic for HIV, STDs or pregnancy-related concerns will have their labs sent to San Antonio for processing.

Today, Detroit’s health department has an operating budget of $41.7 million, money that mostly comes from state and federal funds or grants.

“The pandemic really put the issue of health care disparities in everybody’s face,” said Davis Anthony, and that gives her hope that the city and state will continue to reinfuse the department with resources. But even if that happens, restoring its place in city life after years of absence isn’t a given. “It’s going to be a difficult road to travel,” she said.

It's unclear what that means for the future of the Montana program.

This article was published on Thursday, August 5, 2021 in Kaiser Health News.

By Andrea Halland

Federal health officials will likely reject Montana's request to include work requirements for beneficiaries of its Medicaid expansion program, which insures 100,000 low-income Montana adults, state officials said.

Three years after the Trump administration encouraged states to require proof that adult enrollees are working a certain number of hours or looking for work as a condition of receiving Medicaid expansion benefits, the Centers for Medicare & Medicaid Services has reversed course under Democratic President Joe Biden.

"CMS has communicated to [the Montana Department of Public Health and Human Services] that a five-year extension of the Medicaid expansion waiver will not include work/community engagement requirements," health officials wrote in a Medicaid waiver amendment application out for public review.

It's unclear what that means for the future of the Montana program. In 2019, Montana lawmakers approved extending the 2015 program — the Supreme Court made the Medicaid expansion provision in the Affordable Care Act optional for states — as long as it included work requirements. Those requirements were a key condition for the moderate Republicans who joined Democratic lawmakers to muster enough votes to pass the 2019 bill over the objections of conservative GOP legislators.

The state's position officially remains that it wants "to condition Medicaid coverage on compliance with work/community engagement requirements," according to the amendment application. If state negotiators are proposing an alternative, they have not disclosed it.

If CMS does not approve the waiver with the work or community engagement requirements, the state health department will operate Medicaid expansion according to what is approved and await legislative review of the program, said department spokesperson Jon Ebelt.

The Montana Medicaid expansion program is scheduled to end in 2025 if the legislature doesn't renew it. State lawmakers meet every other year, giving them the 2023 and 2025 sessions to consider changes to the popular program, which enrolls 10% of the state's population.

Meanwhile, Republican-led lawmakers and Republican Gov. Greg Gianforte's administration have proposed other measures designed to trim the Medicaid expansion rolls and defray costs, including raising the premiums some enrollees pay and ending a provision that allows 12 months of continuous eligibility regardless of changes in income. Those proposals are also pending federal approval, and it was in the state's application for the 12-month continuous eligibility waiver that the status of the work requirement negotiations was disclosed.

In June, the number of Montanans enrolled in the expansion program passed 100,000 for the first time in its 5½-year history. The program provides health insurance coverage to adults who earn up to 138% of the federal poverty level, which is $26,500 for a family of four.

The negotiations between state and federal health officials involve what's called a Section 1115 waiver amendment application to CMS, which is made when a state Medicaid program seeks to deviate from federal requirements. CMS' deadline for acting on the application, originally submitted in 2019, was extended to Dec. 31, 2021, because of the COVID-19 pandemic.

The Trump administration approved work requirement waivers in 12 other states, though no states are implementing those requirements, either because of the pandemic or lawsuits, according to research by KFF. (KHN is an editorially independent program of KFF.)

Since Biden took office, CMS has withdrawn the Trump administration's approval of work requirement waivers in Arizona, Arkansas, Indiana, Michigan, New Hampshire and Wisconsin.

Asked to comment about the Montana negotiations, CMS officials said Medicaid is a lifeline for millions of Americans who would be put at risk by work requirements.

"The pandemic and uncertainty surrounding its long-term social, health, and economic effects exacerbate the risks associated with tying Medicaid eligibility to requirements that have been demonstrated to result in significant coverage losses and substantial harm to beneficiaries," an unattributed CMS statement said.

Montana health department officials said in their waiver application that they expect negotiations with CMS to be finalized in the fall and the Medicaid waiver to be extended for five years starting in January. That Jan. 1, 2027, end date of the waiver, presumably without work requirements, would be subject to the state's own 2025 sunset.

The 2019 state law granting a six-year extension to the Medicaid expansion included the condition that work and community engagement be part of it. The law states beneficiaries must work at least 80 hours each month or be engaged in a job search or volunteer work, unless they are exempt for specific reasons, such as pregnancy, disability or mental illness.

State Rep. Ed Buttrey (R-Great Falls), who sponsored both the 2019 bill and the 2015 bill that created the original Montana Medicaid expansion program, said lawmakers added the 2025 sunset so that they could assess and revise the program, if needed.

"So in a couple sessions we'll have to take another look at the program and the federal rules and find out how things are performing and how we want to move forward." Buttrey said.

He defended work requirements, saying the goal of Medicaid expansion has always been to create a healthy workforce to improve Montana's economy.

State Rep. Mary Caferro (D-Helena) said work requirements can cause unnecessary hurdles for people who qualify for the Medicaid expansion program. She said that 7 in 10 Montanans who gained Medicaid coverage under the expansion are already working and that the rest can't for various reasons, such as they are caregivers, have an illness or are going to school.

"Work requirements don't make sense for our particular population," Caferro said.

The disclosure of the ongoing work requirement negotiations was made in an application that seeks to eliminate 12-month continuous eligibility for Medicaid expansion beneficiaries plus a separate group of Medicaid beneficiaries with severe disabling mental illnesses.

Currently, those people are enrolled in the Medicaid expansion program for a full year regardless of changes in income or assets. The proposed change, included in the state budget passed by lawmakers earlier this year, would kick enrollees out of the program if their income rises — even if only temporarily because of a one-time payment or seasonal work.

The state also proposes increasing premium payments for certain expansion beneficiaries to up to 4% of their household income in the same waiver application that proposes work requirements.

Buttrey said the goal was to offset the costs of Medicaid so that the people benefiting from it bore some of the costs, and hopes CMS will approve the proposal.

The public comment period for the state's waiver applications is open until Aug. 31. A legislative committee is scheduled to meet Tuesday to review the proposals.

How about an economic argument? Get a COVID shot to protect your wallet.

This article was published on Wednesday, August 4, 2021 in Kaiser Health News.

By Elisabeth Rosenthal and Glenn Kramon

America's COVID-19 vaccination rate is around 60% for ages 12 and up. That's not enough to reach so-called herd immunity, and in states like Missouri — where a number of counties have vaccination rates under 25% — hospitals are overwhelmed by serious outbreaks of the more contagious delta variant.

The vaccine resisters offer all kinds of reasons for refusing the free shots and for ignoring efforts to nudge them to get inoculated. Campaigns urging Americans to get vaccinated for their health, for their grandparents, for their neighbors, or to get free doughnuts or a free joint haven't done the trick. States have even held lotteries with a chance to win millions or a college scholarship.

And yet there are still huge numbers of unvaccinated people. Federal, state and municipal governments as well as private businesses continue to largely avoid mandates for their employees out of fears they will provoke a backlash.

So, how about an economic argument? Get a COVID shot to protect your wallet.

Getting hospitalized with COVID in the United States typically generates huge bills. Those submitted by COVID patients to the NPR-Kaiser Health News "Bill of the Month" project include a $17,000 bill for a brief hospital stay in Marietta, Georgia (reduced to about $4,000 for an uninsured patient under a "charity care" policy); a $104,000 bill for a 14-day hospitalization in Miami for an uninsured man; and a bill for possibly hundreds of thousands for a two-week hospital stay — some of it on a ventilator — for a foreign tourist in Hawaii whose travel health insurance contained a "pandemic exclusion."

Even though insurance companies negotiate lower prices and cover much of the cost of care, an over $1,000 out-of-pocket bill for a deductible — plus more for copays and possibly some out-of-network care — should be a pretty scary incentive.

In 2020, before COVID vaccines, most major private insurers waived patient payments — from coinsurance to deductibles — for COVID treatment. But many if not most have allowed that policy to lapse. Aetna, for example, ended that policy Feb. 28; UnitedHealthcare began rolling back its waivers late last year and ended them by the end of March.

More than 97% of hospitalized patients last month were unvaccinated. Though the vaccines will not necessarily prevent you from catching the coronavirus, they are highly effective at assuring you will have a milder case and are kept out of the hospital.

For this reason, there's logic behind insurers' waiver rollback: Why should patients be kept financially unharmed from what is now a preventable hospitalization, thanks to a vaccine that the government paid for and made available free of charge? It is now in many drugstores, it's popping up at highway rest stops and bus stops, and it can be delivered and administered at home in parts of the country.

A harsher society might impose tough penalties on people who refuse vaccinations and contract the virus. Recently, the National Football League decreed that teams will forfeit a game canceled because of a COVID outbreak among unvaccinated players — and neither team's players will be paid.

But insurers could try to do more, like penalizing the unvaccinated. And there is precedent. Already, some policies won't cover treatment necessitated by what insurance companies deem risky behavior, such as scuba diving and rock climbing.

The Affordable Care Act allows insurers to charge smokers up to 50% more than what nonsmokers pay for some health plans. Four-fifths of states follow that protocol, though most employer-based plans do not do so. In 49 states, people caught driving without auto insurance face fines, confiscation of their car, loss of their license and even jail. And reckless drivers pay more for insurance.

The logic behind the policies is that the offenders' behavior can hurt others and costs society a lot of money. If a person decides not to get vaccinated and contracts a bad case of COVID, they are not only exposing others in their workplace or neighborhoods; the tens or hundreds of thousands spent on their care could mean higher premiums for others as well in their insurance plans next year. What's more, outbreaks in low-vaccination regions could help breed more vaccine-resistant variants that affect everyone.

Yes, we often cover people whose habits may have contributed to their illness — insurance regularly pays for drug and alcohol rehab and cancer treatment for smokers.

That's one reason, perhaps, that insurers too have so far favored carrots, not sticks, to get people vaccinated. Some private insurers are offering people who get vaccinated a credit toward their medical premiums, or gift cards and sweepstakes prizes, according to America's Health Insurance Plans, an industry organization.

Tough love might be easier if the Food and Drug Administration gives vaccines full approval, rather than the current emergency use authorization. Even so, taxpayer-financed plans like Medicaid and Medicare must treat everyone the same and would encounter a lengthy process to secure federal waivers to experiment with incentives, according to Larry Levitt, executive vice president of KFF, a nonprofit focusing on health issues. (Kaiser Health News, where Rosenthal is editor-in-chief, is one program under KFF.) These programs cannot charge different rates to different patients in a state.

KFF polling shows such incentives are of limited value, anyway. Many holdouts say they will be vaccinated only if required to do so by their employers.

But what if the financial cost of not getting vaccinated were just too high? If patients thought about the price they might need to pay for their own care, maybe they would reconsider remaining unprotected.

Elisabeth Rosenthal: erosenthal@kff.org, @rosenthalhealth

A tsunami of restrictive abortion regulations enacted by Republican-led legislatures and governors across the South have sent women who want or need an early end to a pregnancy fleeing in all directions.

This article was published on Tuesday, August 3, 2021 in Kaiser Health News.

By Sarah Varney

MEMPHIS, Tenn. — Just a quick walk through the parking lot of Choices-Memphis Center for Reproductive Health in this legendary music mecca speaks volumes about access to abortion in the American South. Parked alongside the polished SUVs and weathered sedans with Tennessee license plates are cars from Mississippi, Arkansas, Florida and, on many days, Alabama, Georgia and Texas.

Choices is one of two abortion clinics in the Memphis metro area, with a population of 1.3 million. While that might seem a surprisingly limited number of options for women seeking a commonplace medical procedure, it represents a wealth of access compared with Mississippi, which has one abortion clinic for the entire state of 3 million people.

A tsunami of restrictive abortion regulations enacted by Republican-led legislatures and governors across the South have sent women who want or need an early end to a pregnancy fleeing in all directions, making long drives or plane trips across state lines to find safe, professional services. For many women, that also requires taking time off work, arranging child care and finding transportation and lodging, sharply increasing the anxiety, expense and logistical complications of what is often a profoundly difficult moment in a woman’s life.

“Especially for women coming from long distances, child care is the biggest thing,” said Sue Burbano, a patient educator and financial assistance coordinator at Choices. “They’re coming all the way from Oxford, Mississippi, or Jackson. This is a three-day ordeal. I can just see how exhausted they are.”

The long drives and wait times could soon spread to other states, as the U.S. Supreme Court prepares this fall to consider a Mississippi ban on nearly all abortions after 15 weeks of pregnancy, with no allowances for cases of rape or incest. Under a law enacted in 2018 by the Republican-led legislature, a woman could obtain a legal abortion only if the pregnancy threatens her life or would cause an “irreversible impairment of a major bodily function.”

Mississippi’s ban was promptly challenged by abortion rights activists and put on hold as a series of lower courts have deemed it unconstitutional under the Supreme Court’s landmark Roe v. Wade decision. That 1973 ruling, in concert with subsequent federal case law, forbids states from banning abortions before “fetal viability,” the point at which a fetus can survive outside the womb, or about 24 weeks into pregnancy.

Tennessee, Texas, Mississippi and several other states have since passed laws that would ban abortions after six weeks. That legislation is also on hold pending legal review.

Groups opposed to abortion rights have cheered the court’s decision to hear the Mississippi case, believing the addition of Justice Amy Coney Barrett gives the court’s conservative bloc enough votes to overturn Roe, or at least vastly expand the authority of individual states to restrict abortion.

But, for supporters of reproductive rights, anything but a firm rejection of the Mississippi ban raises the specter of an even larger expanse of abortion service deserts. Abortion could quickly become illegal in 21 states — including nearly the entire South, the Dakotas and other stretches of the Midwest — should the court rescind the principle that a woman’s right to privacy protects pregnancy decisions.

“If we end up with any kind of decision that goes back to being a states’ rights issue, the entire South is in a very bad way,” said Jennifer Pepper, executive director of Choices in Memphis.

The decades-long strategy by conservative white evangelical Christians to chip away at abortion access state by state has flourished in the South, where hard-right Republicans hold a decisive advantage in state legislatures and nearly all executive chambers.

Though details vary by state, the rules governing abortion providers tend to hit similar notes. Among them are requirements that women seeking abortions, even via an abortion pill, submit to invasive vaginal ultrasounds; mandatory waiting periods of 48 hours between the initial consultation with a provider and the abortion; and complex rules for licensing physicians and technicians and disposing of fetal remains. Some states insist that abortion providers require women to listen to a fetal heartbeat; other providers have been unable to obtain admitting privileges at local hospitals.

“Everything is hard down here,” said Pepper.

The rules also have made some doctors reluctant to perform the procedure. While obstetricians and gynecologists in California, New York, Illinois and elsewhere routinely perform abortions at their medical offices — the same practices where they care for women through pregnancy and delivery — their peers in many Southern states who perform more than a small number of abortions a year must register their practices as abortion clinics. None has done so.

Texas offers an example of how targeted legislation can disrupt a patient’s search for medical care. In 2012, 762 Texans went out of state for abortions, according to researchers at the University of Texas-Austin. Two years later, after then-Gov. Rick Perry signed into law the nation’s most restrictive abortion bill, shuttering about half the state’s abortion facilities, 1,673 women left Texas to seek services. In 2016, 1,800 did so.

Similarly, in March 2020, as the coronavirus pandemic took hold, Gov. Greg Abbott issued an order prohibiting all abortions unless the woman’s life was in danger, deeming the procedure “not medically necessary.” The month before the order, about 150 Texans went out of state to seek abortion services. In March and April, with the order in effect, nearly 950 women sought care outside Texas.

There can also be an unsettling stigma in some parts of the South.

Vikki Brown, 33, who works in education in New Orleans, said she initially tried to end her pregnancy in Louisiana, calling her gynecologist for advice, and was told by a receptionist that she was “disgusted” by the request.

She sought out the lone abortion clinic operating in New Orleans but found it besieged with both protesters and patients. “I knew but didn’t understand how difficult it was to get care,” said Brown, who moved to Louisiana in 2010 from New York City. “The clinic was absolutely full. People were sitting on the floor. It was swamped.” It took her six hours to get an ultrasound, which cost $150, she said.

A friend in Washington, D.C., counseled Brown that “it didn’t have to be like that” and the pair researched clinics in the nation’s capital. She flew to Washington, where she was able to get an abortion the same day and for less than it would have cost her in New Orleans, even including airfare.

“No protesters, no waiting period,” she said. “It was a wildly different experience.”

Atlanta, a Southern transportation hub, has also become a key piece in the frayed quilt of abortion care in the region.

Kwajelyn Jackson, executive director of Feminist Women’s Health Center in Atlanta, said the clinic regularly sees patients from other states, including Alabama, Tennessee, Kentucky and the Carolinas.

These visits often involve long drives or flights, but rarely overnight stays because the state-mandated 24-hour waiting period can begin with a phone consultation rather than an in-person visit. Georgia has many of the same laws other states employ to make clinical operations more burdensome — requirements to cremate fetal remains, for instance, and that abortion providers adhere to the onerous building standards set for outpatient surgical centers — but its urban clinics so far have weathered the strategies.

Jackson said staffers at her clinic are aware of its role as a refuge. “We’ve had patients who were able to get a ride from Alabama, but they weren’t able to get a ride home,” she said. “We had to help them find a ride home. It is so much simpler to go 3 or 4 miles from your home and sleep in your bed at night. That is a luxury that so many of our patients can’t enjoy.”

Many women embarking on a search for a safe abortion are also confronting serious expenses. State Medicaid programs in the South do not pay for abortions, and many private insurers refuse to cover the procedure. In addition, the longer a woman’s abortion is delayed, the more expensive the procedure becomes.

Becca Turchanik, a 32-year-old account manager for a robotics company in Nashville, Tennessee, drove four hours to Atlanta for her abortion in 2019. “We got an appointment in Georgia because that was the only place that had appointments,” she said.

Turchanik said her employer’s health insurance would not cover abortion, and the cost of gas, food, medications and the procedure itself totaled $1,100. Her solution? Take on debt. “I took out a Speedy Cash loan,” she said.

Turchanik had a contraceptive implant when she learned she was six weeks pregnant. She said she was in an unhealthy relationship with a man she discovered to be dishonest, and she decided to end her pregnancy.

“I wish I had a child, but I’m glad it wasn’t his child,” she said. “I have accomplished so much since my abortion. I’m going to make my life better.”

But the emotions of the ordeal have stayed with her. She’s angry that she had to call around from state to state in a panic, and that she was unable to have her abortion close to home, with friends to comfort her.

Others turn to nonprofit groups for financial and logistical support for bus and plane tickets, hotels, child care and medical bills, including the National Abortion Federation, which operates a hotline to help women find providers. Last year, the federation received 100,000 calls from women seeking information, said its president, the Very Rev. Katherine Hancock Ragsdale.

Access Reproductive Care-Southeast, an abortion fund based in Atlanta, has trained over 130 volunteers who pick women up at bus stations, host them at their homes and provide child care. A study published this year in the International Journal of Environmental Research and Public Health examined 10,000 cases of women seeking assistance from ARC-Southeast: 81% were Black, 77% were uninsured or publicly insured, 77% had at least one child, and 58% identified as Christian.

“It’s amazing to see the scope of the people we work with,” said Oriaku Njoku, ARC-Southeast’s co-founder. “The post-Roe reality that y’all are afraid of is the lived reality for folks today in the South.”

A Texas law targets precisely this kind of help, allowing such organizations or individuals to be sued by anyone in the state for helping a woman get an abortion. It could go into effect Sept. 1, though abortion rights advocates are suing to stop the new law.

Despite the controversy surrounding abortion, Choices makes no effort to hide its mission. The modern lime-green building announces itself to its Memphis neighborhood, and the waiting room is artfully decorated, offering services beyond abortion, including delivery of babies and midwifery.

Like other clinics in the South, Choices has to abide by state laws that many abortion supporters find onerous and intrusive, including performing transvaginal ultrasounds and showing the women seeking abortions images from those ultrasounds.

Nonetheless, the clinic is booked full most days with patients from almost all of the eight states that touch Tennessee, a slender handsaw-shaped state that stretches across much of the Deep South. And Katy Deaton, a nurse at the facility, said few women change their minds.

“They’ve put a lot of thought into this hard decision already,” she said. “I don’t think it changes the fact that they’re getting an abortion. But it definitely makes their life harder.”