This is a part of Disorder in the Court, a weeklong series on the legal press and the most explosive Supreme Court in generations: how we cover it, how we’ve failed, and how we can do better.
One day after his 19th birthday, Ray walked into a crisis pregnancy center in Cedar Rapids, Iowa. His boss had recommended it. Ray, a trans man who had recently aged out of the foster care system, had gotten a positive on a pregnancy test and wanted confirmation. (We are using only his first name to protect his privacy.) At the center, a woman invited him into a backroom. Before giving him the test, she spent several minutes praying for him, even pulling out a Bible and reading several pages aloud. She then gave him a pregnancy test. Ray recognized it as the exact brand he had purchased at the dollar store. It turned out positive.
She told Ray to come back in two weeks for an ultrasound. When he arrived, she spent some time urging Ray not to get an abortion. Then she did the ultrasound. It detected no heartbeat. It seemed strange to Ray, but the technician didn’t seem particularly concerned. She told Ray he was either miscarrying or earlier in the pregnancy than suspected and then sent him home.
Two days later, Ray began to experience excruciating pain. He raced to the hospital, which quickly determined that he had a ruptured ectopic pregnancy. The doctors immediately sent him into emergency surgery, which was followed by blood transfusions. They saved his life, but removed his left fallopian tube in the process. Had he waited five more minutes to go to the ER, the doctors told him, he probably would have died. Had he gone to a real medical professional at the start, they would have provided a diagnostic ultrasound, detected the ectopic pregnancy, and helped Ray terminate it before it ruptured.
But Ray didn’t go to a real doctor. He went to a crisis pregnancy center. By doing so, he unknowingly entered an unregulated pseudo-clinic where people with no medical expertise evangelize under the guise of providing health care. Ray’s visit occurred a year before the Supreme Court overruled Roe v. Wade. Yet his experience foreshadowed a spiraling problem in post-Roe America: Pregnant people in dire need of health care are being bamboozled into receiving proselytism instead of prognoses.
Crisis pregnancy centers, or CPCs, are designed to dissuade pregnant people from terminating their pregnancies. But their tactics often go far beyond persuasion and veer into trickery. They are typically designed to look like abortion clinics, and many set up shop near a real clinic to confuse and intercept patients who are trying to access abortion care. Most do not have a medical professional, like a doctor or nurse, on staff. Still, they position themselves to look like real medical centers: Staff may dress in scrubs to convey the appearance of medical professionalism, and some offer no-cost tests and ultrasounds that are presented as professional services.
A comprehensive 2022 analysis by The Alliance, which studies state-level access to reproductive care, found that virtually all CPCs give patients false information about pregnancy, abortion, and STIs; refuse to provide or promote contraception, including condoms; and fail to offer any actual prenatal care. Many claim that condoms do not work and that birth control is dangerous, promoting abstinence and “fertility awareness” instead; a large number also promote “abortion reversal,” an unproven, potentially dangerous experimental treatment.
And “keepsake” ultrasounds, like the kind Ray received, serve no diagnostic purpose, yet mislead patients into thinking a real health care professional has assessed their pregnancy.
Reproductive health clinics offer all of these services, including those vital to patients whose pregnancies are wanted. Yet CPCs currently outnumber legitimate clinics by a ratio of more than 3 to 1.
The issues with CPCs go beyond not providing genuine medical care—they pitch and frame their services as medical care even though it is not. Despite this deception, red, purple, and even some blue states don’t regulate or rein in these entities—in fact, many give them public money. Many states, such as Florida and Texas, have simultaneously refused to expand Medicaid under the Affordable Care Act, starving hospitals of the resources needed to maintain legitimate maternity wards. The upshot is that people seeking pregnancy-related health care, including maternal care for wanted pregnancies, frequently wind up at CPCs—which are unable to meet the most basic needs of patients.
How did all of this come to be? How could it even be legal to pose as a medical service when you are not giving medical advice? The backstory of these organizations—and the role they have come to occupy in today’s America—is one of the starkest examples of how Supreme Court decisions layer atop one another to change our society. Too often, we look at these rulings in isolation, missing their full impact. But Supreme Court decisions on religion, speech, states’ rights, and abortion all intersect. The path to how so many Americans live now—with dramatically restricted access to reproductive health care that often turns dangerous and even deadly—began well before the Supreme Court overturned Roe in 2022’s Dobbs v. Jackson Women’s Health Organization. It began when the increasingly conservative court facilitated an explosion in crisis pregnancy centers across the country.
The path to where we are now started decades ago. In 1967, a Christian activist named Robert Pearson opened America’s first CPC in Hawaii, ostensibly to help those facing unwanted pregnancies (by trying to talk them out of getting an abortion). Pearson was the type to refer to a woman seeking an abortion as a “killer.” Following his clinic’s success, Pearson wrote an influential manual explaining how these centers could operate elsewhere. The precise tactics varied, but the goal was always to prevent people from terminating their pregnancies. Pearson set up a foundation to help other activists launch CPCs around the country, creating a network of private donors—individuals, churches, religious organizations—to keep their doors open.
From the 1960s through the 1990s, Christian activists assumed that public funding would never flow into CPCs. The reason was that they thought such funding could not survive a legal challenge, given the Supreme Court’s admonition that the First Amendment’s establishment clause “forbids any appropriation, large or small, from public funds to aid or support any and all religious exercises.” And the centers are fundamentally religious: To obtain the much-vaunted “free” baby supplies, for instance, CPCs may compel individuals to attend Bible study or other proselytization sessions. For several decades, the Supreme Court barred state involvement in such evangelizing, and so the centers were unable to secure public funding. As long as CPCs relied on private donations only, their reach remained limited.
By the late 1990s, however, the court’s conservative majority had substantially weakened the First Amendment’s bar against state subsidization of religious exercise and coercion. CPC supporters saw an opportunity, and devised what was essentially a test case: In 1999, Florida passed a law allowing drivers to pay extra for a “choose life” license plate; the state then funneled that money into CPCs, often through an intermediary like Catholic Charities. The scheme survived legal challenges. A majority of states have since adopted similar programs.
This precedent paved the way for a massive infusion of taxpayer dollars into the CPC network. In 2001, President George W. Bush went a step further, redirecting federal funds to CPCs, sending $30 million to the centers in his first term. Most of that money came from Bush’s abstinence-only education program. The funding paused during President Barack Obama’s tenure. But it roared back under President Donald Trump, who redirected money from Title X, the federal family-planning program, to CPCs. At the same time, Trump cracked down on funding for health care providers who offered or even mentioned abortion, starving them of federal funds.
This discriminatory treatment, too, has its roots in a Supreme Court decision: 1991’s Rust v. Sullivan. Every Republican president since Ronald Reagan has withheld Title X funding from providers that so much as mention abortion—unless they oppose it, in which case they can say anything they want. The court upheld that restriction in Rust by a 5–4 vote. As a result, real clinics that support abortion as legitimate health care get no money, even if they do not offer abortion services. Anti-abortion activists, meanwhile, get a windfall of “family planning” funding to use in their battle against abortion.
Throughout the early 2000s, following the success of Florida’s “choose life” plate, more state legislatures got into the business of underwriting CPCs. Between 2012 and 2022, state funding for CPCs increased fivefold, infusing the centers with hundreds of millions of dollars. Some states fund them directly: Pennsylvania, for instance, has sent a total of more than $100 million to these centers, diverting much of this cash away from Temporary Assistance for Needy Families (TANF), a lifeline for impoverished pregnant people and children. Texas now sends $100 million a year to CPCs, and previously diverted $45 million from TANF to CPCs. It’s not just purple and red states, though: As of 2022, California had funded at least nine CPCs by allowing them to bill for services through the state’s Medicaid system.
In 2015, California tried to tackle the spiraling problem of fake clinics by passing the FACT Act, which would’ve imposed new regulations on CPCs. The law required licensed centers to notify patients about real clinics that provide genuine reproductive care. It also required centers that didn’t have medical licenses to disclose that fact. While drafting the statute, California lawmakers drew on extensive evidence that CPCs engaged in unethical duplicity to trick women out of going to real medical providers and obtaining basic services, including not only abortion, but contraception, STI treatment, and maternity care. California’s elected representatives enacted the FACT Act through the democratic process. Yet the Supreme Court decided the state had no authority to protect its residents against fake health care: In 2018’s NIFLA v. Becerra, the Supreme Court struck down the law by a 5–4 vote, holding that these disclosure rules violated the First Amendment. According to the conservative majority, James Madison thought free speech meant letting people play dress-up as doctors and lie about their medical credentials.
Four years later, of course, the Supreme Court issued Dobbs, abolishing the constitutional right to abortion. The decision accelerated an alarming trend: As CPCs have multiplied at a dizzying rate in America, abortion clinics and maternity wards have dwindled. The problem is especially acute in red states, whose abortion bans are driving away OB-GYNs who are fearful of receiving a prison sentence for providing obstetric care. Ironically, the states with the most stringent abortion restrictions have also declined to expand Medicaid—a decision they can make only because the Supreme Court let them opt out of Obamacare’s Medicaid expansion.
That decision is hastening the closure of maternity units in red states and depriving millions of pregnant people of affordable insurance—people who may turn to “free” CPCs for lack of any better options.
And so they are increasingly likely to end up at CPCs. Republican-controlled state legislatures appear to believe that crisis pregnancy centers provide the needed services. In Florida, for example, Gov. Ron DeSantis paired his six-week abortion ban with $25 million in new state funding for CPCs. This new model of Republican governance—criminalize abortion, then send funding to fake clinics instead of real health care providers—has been encouraged by the Supreme Court at every turn. The conservative majority has continuously offered extraordinary deference to the rights of activists who dress up as doctors to deprive patients of medical treatment. It appears to have no interest in the rights of people like Ray, who nearly died from an ectopic pregnancy because a CPC tricked him into thinking he had gotten a diagnostic ultrasound.
Look at any single Supreme Court opinion—as the press and the public usually do, for a maximum of one news cycle—and you’ll miss the cumulative impact of its jurisprudence. But the layers of decisions stack atop one another until they suffocate the rights of the most marginalized people. In one opinion, the court will say it has no power to protect people from state abortion bans, striking a pose of deference; in another, it will claim that states have no power to protect people from predatory CPCs, rejecting the work of the democratic process. If you string together these decisions, the court’s sweeping ideological project comes sharply into focus. If you examine them in isolation, you can get caught up in the minutiae: which side had a better reading of precedent, or more persuasive rhetoric, or better historical analysis, or whatever else distracts us from the court’s broader agenda. When the press covers cases this way, it loses sight of the real story: the arc that this court is most assuredly not bending toward justice.
Worse, this atomistic approach loses sight of the people who suffer great harm because of the court’s decree—people like Ray, whom CPCs target precisely because they are the most vulnerable. Ray realizes now, too late for it to help him, that he was ensnared in a trap set long before he took that first pregnancy test. “I was trying to find the best advice possible from the first person who offered it,” he told me. “It ended up costing me. I hadn’t once mentioned to anybody that I wanted to get an abortion because that couldn’t be further from the truth. There wasn’t anything that I wanted more in this world than that baby.”