After more than five years working together in reproductive health clinics in the Washington, D.C., area, nurse-midwife Morgan Nuzzo and ob-gyn Dr. Diane Horvath realized they could do it better. They started fantasizing about a clinic of their own, where clinicians of different backgrounds would provide compassionate, high-quality care; employees would be fairly compensated and patients met with respect; and abortion would be treated as essential medical care that everyone should be able to access.
Partners in Abortion Care, their all-trimester clinic, is set to open this fall in College Park, Md., a location they hope will be convenient not only for themselves as D.C.-area residents, but also for patients in Maryland and beyond. After the leak of a draft decision suggesting that the Supreme Court could soon overturn Roe v. Wade, which would likely result in the ban or significant restriction of abortion in 26 states, that location became more crucial than ever.
College Park is within 40 miles of three major airports and close to several highways, making it a relatively easy destination for travelers. And if nearby states like West Virginia and Ohio crack down on abortion as expected, Maryland could become a magnet for people who need to travel for care—even more so if neighboring Virginia enacts stricter policies in the future, as some advocates fear will happen. Unlike those states, Maryland is expanding abortion access. It allows abortions up to the point of fetal viability (around 24 weeks of pregnancy) and permits later procedures if the parent’s health is at risk or the fetus is diagnosed with a serious health issue. Plus, starting July 1, nurse-midwives, nurse practitioners, and physician assistants—in addition to doctors—can perform abortions there, which will expand the pool of potential providers and may therefore increase the number of patients clinics can serve.
A reflection of Horvath and Nuzzo seen in an empty space where they plan to start their abortion clinic in College Park, MD.
Shuran Huang for TIME
“We know that the volume of patients is going to go up in Maryland,” Horvath says. “There is no possible way to increase capacity at existing clinics to take on the number of people who are anticipated to need to travel.”
Many people already have to travel to get an abortion, due to state-level restrictions and dwindling numbers of clinics. In 2017, 74% of abortion patients in Wyoming, 57% in South Carolina, and 56% in Missouri left their home state to get care, one study found. But if the Supreme Court’s draft decision is similar to the final one, that inconvenience is about to affect a lot more people. Across swaths of the South, Midwest, and Southwest, people would have to travel out of state or find a way to access abortion pills if they needed to end a pregnancy. Clinics in “abortion islands” like Illinois—states with strong abortion protections in place, but surrounded by those likely to ban it—are already bracing for a post-Roe onslaught of new patients.
New clinics like Partners in Abortion Care, situated in geographically strategic areas where they can absorb as many patients as possible, may help ease that bottleneck—but they’re not likely to be enough on their own, says Caitlin Myers, an economics professor at Middlebury College who studies abortion access. New facilities “will improve appointment availability. They will reduce travel distances. They will have an impact,” Myers says. “But there are going to be women who want abortions and can’t get them because of these bans, no matter how many clinics open.”
Nuzzo and Horvath store furniture and equipment they purchase at a storage unit.
Shuran Huang for TIME
The cost of an abortion, either through pills or a procedure, can range from hundreds of dollars to more than $1,000. If someone also has to travel for that care, they must shoulder the financial and logistical costs of transportation, lodging, missed work, and child care. Local abortion funds have long provided practical support like money for travel and assistance finding child care. (At Partners in Abortion Care, a local investor is considering buying an apartment near the clinic to use as an “abortion Airbnb,” Nuzzo says, where people could stay for free before and after their procedures.)
But even with this type of aid, research suggests travel is a deterrent for many people seeking abortions. In a paper published last year, Myers estimated that about one in five people seeking an abortion in the U.S. would not get one if they had to travel 100 miles to do so. Her research suggests around 100,000 people in the U.S. will not be able to get a desired abortion in the year following a theoretical repeal of Roe v. Wade due to increased distance from providers.
“Middle-income or wealthy people, particularly white people, living in banned states will always still be able to get abortion care,” as long as they can hop on a plane, says Liza Fuentes, senior research scientist at the Guttmacher Institute, a reproductive rights nonprofit. For many other people who need an abortion—who, Guttmacher research shows, tend to be lower-income and already parents—it’s not that simple.
Some clinicians are leaving states that are likely to ban abortion and setting up shop elsewhere to help minimize the distance that patients must travel. Shannon Brewer, the director of Mississippi’s last remaining abortion clinic—which is at the heart of the case that caused the Supreme Court to reexamine abortion issues—recently said she may start practicing in New Mexico, a state with no major abortion limits that is sandwiched between Texas (which already bans most abortions after around six weeks of pregnancy) and Arizona (one of the states expected to crack down on abortion if Roe is rolled back).
Nuzzo and Horvath stand for a portrait in an empty exam room
Shuran Huang for TIME
Jennifer Pepper, executive director at CHOICES Memphis Center for Reproductive Health, is also planning to open a clinic in a new state if and when hers is forced to stop offering abortion care. (Tennessee has a “trigger law” in place, which would ban most abortions within a month of Roe being overturned.) She and her team found a space in Carbondale, a city in southern Illinois about a two-hour drive from St. Louis and a three-hour drive from both Memphis and Nashville. They’re preparing to open in August.
CHOICES provided 3,900 abortions in its Memphis clinic last year and expects to exceed that number in Illinois. But they can’t serve everyone. If Roe is overturned, multiple Tennessee clinics would have to stop offering abortion services, and there’s no way CHOICES could absorb all of those patients with one new facility. “It’s just a math problem that doesn’t work out,” Pepper says. Modeling that Myers conducted for TIME suggests the Carbondale facility could reduce travel requirements for about 3 million women, mostly in Kentucky, Tennessee, and Arkansas.
Other advocates are eyeing Illinois, too. Dr. Douglas Laube, an abortion provider in Wisconsin, told local news outlets that he is thinking of opening a new clinic just over the state border. Planned Parenthood is also expanding operations in Illinois, as the Washington Post has reported.
Julie Burkhart, a longtime reproductive health advocate and founder of the nonprofit Wellspring Health Access, is fighting hard to keep abortion accessible further West—but not without significant opposition.
In 2020, Burkhart started talking with local advocates who wanted an abortion clinic in Casper, Wyo. At the time, Wyoming had few legal barriers to abortion care and a clear need for more providers. Abortion services were only available in Jackson, just over the Idaho border, so opening one in Casper, a city less than 200 miles from Nebraska and South Dakota, would expand access across the region. “Wyoming was just a perfect state,” Burkhart says.
Then, in March 2022, Wyoming Governor Mark Gordon signed a trigger law that would ban most abortions five days after a Supreme Court overrule of Roe v. Wade. With the Casper clinic set to open around the same time the Supreme Court makes its final ruling, Wellspring may only be able to offer abortions for a matter of days or weeks—if it opens at all.
Horvath consults with contractor Reuben Pemberton about renovating the clinic.
Shuran Huang for TIME
In late May, the clinic’s building was damaged in a suspected arson. The damage is still being assessed, but it may be necessary to gut the building’s interior and replace its electrical system, possibly forcing Wellspring into a temporary space.
Burkhart says she knows it sounds crazy to move ahead despite these obstacles, but she’s doing it anyway. “These things cannot go unchecked,” she says. “It’s important for good people, people who want social justice and equality, to stand up even taller.”
New clinics can help keep abortion accessible, but more tools are needed. Abortion pills—which can be prescribed remotely, then sent to patients by mail for use early in a pregnancy—could be a workaround for some people, but their legal status varies by state. Some states don’t allow the pills to be prescribed via telehealth, limiting their utility for people who don’t live near abortion providers, and legislators in 22 states have advanced bills that would either ban or restrict access to the drugs. At least for now, however, the reproductive rights group Plan C helps people across U.S. states and territories find information about how to get the pills.
Appointment capacity is another major issue. Patients already face long waits in clinics across the country, even in abortion-friendly states like New York and California, Myers’ research shows. To help ease those backlogs, Myers says more states should permit non-physician providers to offer abortion care, as states like Maryland, Connecticut, and Delaware are doing.
For Nuzzo, that point is personal. As a nurse-midwife, she says she’s long been doubted by the medical community or treated as lesser than a doctor. “My profession is this punching bag, and everybody’s punching down,” Nuzzo says. Maryland Governor Larry Hogan, for example, vetoed the law that will allow non-physicians to provide abortions in Maryland, citing fears that it would reduce the quality of care. (He was overruled by state lawmakers.)
Nuzzo and Horvath are determined to prove that doing things differently can improve care. They believe theirs will be the only all-trimester abortion clinic in the country owned by women, as well as the only one operated by a physician and a midwife together, in one of the few states actually expanding abortion access—not restricting it.
Horvath and Nuzzo during a walk-through of their future clinic space.
Shuran Huang for TIME
Getting their clinic ready to open hasn’t been easy. Horvath and Nuzzo have contributed thousands of their own dollars and bought a vintage ultrasound machine and exam table on Craigslist and Facebook Marketplace, to hold them over until they can afford newer versions. They’re constantly worried about the security of their clinic and of their future patients, even in an abortion-friendly state and with enough community support to crowdsource almost $260,000. Living in uncertainty about the future of their profession has also taken a mental toll.
But if their model works, they hope to work with other abortion providers and advocates to open clinics in other parts of the country, with the goal of keeping care as accessible as possible even in a post-Roe reality. “We want to start from a place of abundance,” Horvath says, “and think of what abortion care could look like even in this time where everything is so dire.”
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