by Kristen Schorsch, WBEZ Chicago, KFF Health News

Credit: Unsplash/CC0 Public Domain

When she was around 22 weeks pregnant, the patient found out that the son she was carrying didn't have kidneys and his lungs wouldn't develop. If he survived the birth, he would struggle to breathe and die within hours.

The patient had a crushing decision to make: continue the pregnancy—which could be a risk to her health and her ability to have children in the future—or have an abortion.

"I don't think I stopped crying for an entire two weeks," she said. "The whole world felt heavy. … It's not something anybody should have to go through. It's not easy losing somebody you love."

KFF Health News is not disclosing the woman's name or the name of the community where she lives, because she fears harm if her identity becomes known. She lives in Missouri, which has one of the strictest abortion bans in the nation. KFF Health News confirmed details of her experience.

After the fetal diagnosis, the patient's Missouri doctors told her that her life wasn't in immediate danger, but they also pointed out the risks of carrying the pregnancy to term. And in her family, there's a history of hemorrhaging while giving birth. If she started to bleed, her doctors said, she might lose her uterus, too. The patient said this possibility was devastating. She's a young mom who wants more children.

So she chose to get an abortion. Her Missouri doctors told her it was the safest option—but they wouldn't provide one.

The patient had to leave Missouri and cross the border to Illinois, which has become a legal haven for abortion rights. Because of her complicated pregnancy, she received the abortion in a hospital.

Since the Dobbs decision overturned Roe v. Wade on June 24, 2022, determining who can get an abortion and where has been complicated by medically ambiguous language in new state laws that ban or restrict abortion. Doctors in those states fear they could lose their medical licenses or wind up in jail.

Amid these changes, physicians in abortion havens such as Illinois are stepping up to fill the void and provide care to as many patients as possible.

But getting each medically complex patient connected to a doctor and a hospital has been logistically complicated. In response to the growing demand, Illinois Gov. JB Pritzker, a Democrat, recently launched a state program with a goal to get patients who show up at clinics, yet need a higher level of abortion care, connected more quickly with Illinois hospitals. Providers will call a hotline to reach nurses who will handle the logistics.

There is little concrete data on how many more patients are traveling to other states for abortions at hospitals. The Centers for Disease Control and Prevention tracks some abortion data regarding out-of-state patients but doesn't collect it based on the type of facility they're performed in.

Hospitals are a "black box" for abortion-related data, according to Rachel Jones, a longtime researcher at the nonprofit Guttmacher Institute.

Even before Roe fell, it was hard to wade through the hospital bureaucracy to understand more comprehensively how abortion care was provided, Jones said. Guttmacher has tracked hospital-based abortions in the past but doesn't have updated figures since Dobbs.

#WeCount, widely considered a reliable tracker of shifts in abortion care over the past year, doesn't break out hospital data separately. #WeCount co-chair Ushma Upadhyay said the data would have gaps anyway. She said it's been difficult to get providers in banned states to report what's happening.

The uncertainties behind life exceptions

All 15 states that ban abortions do allow exceptions to save the life of the pregnant person, according to tracking from the health policy nonprofit KFF. But exactly when the person's life is considered at risk is open to interpretation.

"It's very, very difficult to get an exception," said Alina Salganicoff, director of women's health policy at KFF. "It's like, "How imminent is this threat?" And in many cases, patients can't wait until they're about to die before they get an abortion."

The latest ban—in Indiana—took effect at the end of August.

In 2020, when Roe was still the law of the land, only 3% of abortions typically occurred in hospitals. Now, OB-GYNs in Chicago and other places across the U.S. that protect abortion rights say out-of-state patients are increasingly showing up to get abortion care at hospitals.

Those more complex procedures and hospital stays often bring higher medical bills. More patients now need help covering the expensive price tag of the procedures, according to medical providers and abortion funds that provide financial assistance.

The patient from Missouri made her way to Laura Laursen, an OB-GYN at Rush University Medical Center in Chicago, in May. The number of out-of-state abortions at Rush has quadrupled since Roe was overturned, Laursen said.

Laursen received the patient's consent to discuss her case with NPR and KFF Health News. She recalled the patient was frustrated about having to jump through so many hoops to get the abortion, and stressed about the cost of being in a hospital.

"The biggest thing was just making space for her to express those emotions," Laursen said. "Making sure that she felt comfortable with all the decisions she was making. And trying to make her feel as empowered as possible."

The patient's life wasn't immediately threatened, but it was safer for her to have an abortion than remain pregnant, Laursen said.

"I'm constantly hearing stories from my partners across the country of trying to figure out what counts as imminent danger," Laursen said. "We're trying to prevent danger. We're not trying to get to the point where someone's an emergency."

Sending patients over state lines for care

Jennifer McIntosh is an OB-GYN in Milwaukee who specializes in high-risk patients. Because of Wisconsin's abortion ban, she's referring more patients out of state.

"It's really awful," McIntosh said, recalling difficult conversations with patients who wanted to be pregnant, but whose babies faced dire outcomes.

She would tell them: "Yes, it's very reasonable to get an abortion. But oh, by the way, it's illegal in your own state. So now on top of this terrible news, I'm going to tell you that you have to figure out how to leave the state to get an abortion."

In some cases, McIntosh can provide an abortion if the medical risk is significant enough to satisfy Wisconsin's life-of-the-mother exception. But it feels legally risky, she said.

"Am I worried that someone might think that it doesn't satisfy that?" McIntosh said. "Absolutely, that terrifies me."

Jonah Fleisher's phone is often ringing and buzzing with texts. An OB-GYN who specializes in abortion and contraception at the University of Illinois health system, near Rush hospital in Chicago, Fleisher is frequently asked to see how quickly he can squeeze in another patient from another state.

Since Roe fell, Fleisher estimated, the health system is treating at least three times as many patients who are traveling from other states for abortion care.

He worries about the "invisible" patients who live in states with abortion bans and never make it to his hospital. They may have medical problems that complicate their pregnancies yet don't know how to navigate the logistics required to make their way over state lines to his exam room, or don't have the financial resources.

"I know that some number of those women are not going to make it through birth and postpartum," Fleisher said. "More than the stress of somebody who's actually making it to see me, that's the thing that causes me more stress."

Medical costs, in addition to travel, are a big obstacle for high-risk patients seeking abortion care at hospitals. The patient from Missouri owed around $6,000 for her hospital stay, Laursen said. Her bill was covered by local and national abortion funds. Some hospital bills can reach into the tens of thousands of dollars for more complicated procedures, according to the funds.

The Chicago Abortion Fund pledged to cover just over $440,000 in hospital bills for 224 patients in the year following Dobbs, according to Meghan Daniel, CAF's director of services. Those bills were primarily for out-of-state patients. By comparison, in the year that preceded Dobbs, CAF helped cover just over $11,000 for 27 patients.

This increase in patients needing financial help for out-of-state abortion care is happening across the nation.

In many cases, patients have a hard time accessing abortion care, and the delays push them further into their pregnancies until they need to have the procedure in a hospital, said Melissa Fowler, chief program officer at the National Abortion Federation. And that costs much more.

"We're seeing more cases right now [of] people who are later in gestation," Fowler said. "More adolescents who are later in gestation, who are showing up at hospitals because this is really their last resort. They've been referred all over."

All of this raises questions about how long these funds can afford to help.

"The current financial way in which people are paying for their abortions I fear is not sustainable," Fleisher said.

Nonprofit hospitals could help. In return for getting tax breaks, they have financial assistance policies for people who are uninsured or can't afford their medical bills. But the policy at UI Health in Chicago, for example, covers only Illinois residents. UI Health spokesperson Jackie Carey said that for other patients, including those who live in other states, the hospital offers discounts if they don't have insurance, or if their insurance won't pay.

Laursen argues out-of-state Medicaid plans and insurance companies should be picking up the tab.

"Whose responsibility is this?" she asked.

Not ready to let go

Back in Missouri, the patient has a special room dedicated to her son. She brought home a recording of his heartbeat and keeps his remains in a heart-shaped casket. She talks to her son, tells him how much she loves him.

"I'm just not ready to let him go," the patient said. "Even though they're not here on Earth anymore, you still see them in your dreams."

She's working on healing emotionally and physically. And while she's thankful that she was able to travel to Illinois for care, the experience made her angry with her home state.

"There's a lot of good people out there who go through a lot of unfortunate situations like me who need abortion care," the patient said. "To have that taken away by the government, it just doesn't feel right."

2023 KFF Health News.
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