If your life is anything like mine, someone you know was vaccinated last week because someone else sat up all night, hitting refresh on an obscure website until they found an open appointment. Someone else you know probably just got their shot because their son or daughter sat on hold for hours on a phone line, until someone picked up and slotted them into a complex health system. Someone else you may know hopped in a car to drive across state lines, for several hours, to get a shot in some other jurisdiction. And someone else maybe received a phone call from someone they knew abruptly telling them to bundle their elderly parents or immunocompromised self into the car and just drive, because there were vaccines available someplace.
Kindly remember this experience—because what you are witnessing is precisely what happens whenever a woman’s reproductive health care facility shuts down. Access to vital, lifesaving health care becomes purely a function of whom you know, how fluent in English and how mobile you may be, and, of course, how much money you have. This may be a first for you, but for millions of women, especially in states that have closed virtually all of their abortion clinics in recent years, this is how reproductive health care currently works in America.
It’s hardly a controversial statement that while vaccine delivery is finally happening, the rollout has been chaotic and hyperlocalized. Every state and county and city may have different systems. The incomprehensible matrix of hospital and pharmacy websites, phone apps, and telephone hotlines assumes that everyone in America has ready access to technology, vast computer literacy, an email address, and hours of time to burn scaling the vaccine learning curve. (Here is an instructive example from the Washington Post’s Geoffrey Fowler guiding elderly Americans on navigating the systems.) You may be subject to fraudsters and grifters who prey on vulnerable people seeking health care in a crisis. Wealthy enclaves with big donors appear to have access that allows them to jump the queue, ahead of local seniors and the seriously ill. Learning to navigate these fragmented systems can take days. And if you aren’t fluent in English, computer-savvy, free to take time off work, and well connected, you will probably get vaccinated after those who are.
Nobody expected anything less, particularly given that high-end clients have received preferential treatment and resources throughout the pandemic. But at minimum we can learn from this natural experiment in scarce medical resources what will happen as several states continue their crusades to limit low-cost, accessible birth control and pregnancy care.
The state-level assault on abortion clinics, and particularly on independent clinics, long predated the COVID crisis. As Time magazine reported in December, “the number of independent abortion clinics in the U.S. has fallen 34 percent in recent years, from 510 in 2012 to 337 as of November. A total of 41 clinics have closed in the past two years alone.” Since 58 percent of people seeking abortions get them at independent clinics, the results have of course been catastrophic for women’s health. COVID itself has exacerbated the problem. Six states were down to a single clinic before the pandemic hit, but 11 states attempted to suspend abortion services this past spring, opportunistically citing the pandemic as justification. While these efforts were blocked in the courts, some clinics closed, and the attendant legal fees and the burden of COVID regulations have all been devastating for others. For the women who require their services, the cost of declining abortion access is immeasurable.
Since Brett Kavanaugh’s confirmation to the Supreme Court, state legislatures itching to end the protections of Roe v. Wade have passed regulations that are defiantly unconstitutional, in an effort to force the issue nationwide. TRAP laws designed to shutter clinics under the pretext of advancing maternal health have been sidelined in some states as they now try to ban abortion outright. Last week, Mark Joseph Stern interviewed professor Mary Ziegler about Arkansas’ new, near-total abortion ban. The state joins at least 11 others in passing complete or near-total bans in the hopes of becoming the case that will overturn Roe. Also last week, Republican Texas state Rep. Bryan Slaton introduced a bill to abolish abortion, allowing for the death penalty for women and physicians who carry out the procedure.
We already know exactly what happens in a state that closes virtually all of its clinics. And we already know that states with the worst maternal and infant health outcomes are leading that charge. Missouri Gov. Mike Parson’s yearslong harassment crusade to shutter the last remaining clinic in his state, admittedly undertaken to end all abortion there, was stymied in the courts but proved devastating to both the clinic and to women forced to travel out of state to obtain their abortions in Illinois. What we do know about states that impose onerous TRAP laws is that the public health impacts have always fallen disproportionately on people of color and the poor. As Jasmine Wang, Peter Jacobs, and Hannah Pugh recently detailed here, “clinic closures across the country have resulted in longer wait periods and travel times, which place additional strain on patients in rural areas. Logistical requirements that do not improve patient safety—such as 24-hour waiting periods, mandatory ultrasounds and counseling, and informed consent laws—require patients to make multiple, sometimes costly trips to clinics.” We also know how quickly each of those burdens and extra inconveniences is dismissed by those who want to blame people for failing to access health care that is nearly inaccessible to them.
When Texas passed its controversial omnibus clinic regulation, House Bill 2, in 2013, the number of clinics that could operate in the state briefly dropped from 42 to 7. Had the Supreme Court upheld the new restrictions, Texas would have been left with 10 clinics—all in major cities—to serve 5.4 million women of childbearing age. Even after the Supreme Court struck down that law in 2016, many clinics never reopened. The number of clinics operating in the state now is about half what it was in 2013. While the litigation was wending its way through the courts, Texas experienced a natural experiment in what happened to women who lost access to reproductive care. Overnight, women seeking to secure abortions were forced to endure longer wait times, unnecessary repeat visits, burdensome travel, costly hotel stays, and missed work. The longer the wait time, the pricier the procedure became. In some cases, longer waits eventually precluded an abortion altogether. In Lubbock, for instance, a woman would have had to travel nearly 300 miles to reach her closest provider. Studies showed that the “number of Texan women of reproductive age living in a county over 100 miles from the nearest abortion provider in Texas more than doubled to just over one million when the admitting privilege requirement of HB2 went into effect.” Wait times at the remaining open clinics quickly soared to 20 days and longer. Women began to cross state lines to obtain abortions, turned to dangerous self-managed abortions, black-market scammers, and drugs they could purchase in Mexico.
A sample CNN account at the time was representative of how this affected poor women in particular: Women traveling hundreds of miles needed gas money. Poor and rural and non-English-speaking women didn’t always have access to bus tickets, taxis, hotels. Some slept in their cars while awaiting procedures. Women missed procedures because their babysitters didn’t show up, their paychecks didn’t clear, time off work was denied, protesters blocked clinics. And yet, at oral argument over HB 2 before a federal appeals court in 2014, Judge Edith Jones suggested that the 300 miles round-trip between the Rio Grande Valley and Corpus Christi was a breeze: “Do you know how long that takes in Texas at 75 miles an hour? This is a peculiarly flat and not congested highway.” Spoken like someone who has never slept in her car.
Vaccine access as it’s rolled out across the country highlights the same problems that were laid bare when Texas shuttered clinics. It has been an example of what can happen when capitalism and scarce medical resources collide. Yet again we are witnessing the stark division between the medical haves and have-nots, and yet again it’s got nothing whatever to do with moral virtue or medical need. Vaccines will go—as reproductive care has always gone—to the wealthy and well-connected, to those with resources and networks, to those with work flexibility, ample child care, and the ability to travel. Eventually, everyone will “have access,” but the same burdens and worries, limitations and encumbrances, that make it all but impossible for poor or non-English-speaking women in Mississippi and Missouri to access lifesaving reproductive care will present again when it comes to lifesaving COVID protection care. For Americans who haven’t thought carefully about why that happens, this present moment affords us that clarity.
We are doubtless a few short months away from the time at which we will begin to hear that there is simply something “wrong” with those who haven’t been vaccinated yet, that they were too lazy or unmotivated or distracted. (Indeed, narratives about measles vaccination rates tend to focus on anti-vaxxers, but as my former colleague Dan Engber wrote in 2019, lack of access to vaccination seems to be just as significant a problem in the U.S.) That’s what was said about poor women seeking to terminate their pregnancies, too—they weren’t trying hard enough. So long as access to lifesaving health services demands what this rollout is demanding—access that privileges the well-connected and the internet-connected—unevenness will be the rule. Blaming individual behavior for a systemic problem has long been the way to avoid solving systemic problems. But long after the crisis of this particular pandemic has passed, we would do well to question exceptionalist claims that basic health care required by all Americans is available to all Americans. As abortion clinics continue to close around the country, the pandemic should remind us that the pattern is long-standing, and that basic health care is still largely for the wealthy and the lucky.