The Potential Impacts of Texas’ Executive Order on Patients’ Access to Abortion Care

By: Kari White, Gracia Sierra, Elsa Vizcarra, Laura Dixon, Sarah Baum, Kristine Hopkins, Joseph E. Potter, and Daniel Grossman
March 2020

On March 22, 2020, Governor Greg Abbott of Texas issued an executive order stating that all surgeries and procedures that are not medically necessary to correct a serious medical condition or to preserve the life of a patient should be postponed because of the coronavirus pandemic.1 This order is to remain in effect until 11:59 p.m. April 21, 2020. In a follow-up press release,2 Attorney General Ken Paxton declared that abortion providers were not exempt from the executive order and must postpone “ any type of abortion that is not medically necessary to preserve the life or health of the mother.” Texas abortion providers subsequently suspended services, canceling hundreds of scheduled appointments.

Following the outbreak of COVID-19 cases in the U.S., the American College of Obstetricians and Gynecologists, along with seven other professional organizations specializing in women’s health, released a statement announcing that they do not support COVID-19 responses that cancel or delay abortion procedures.3 This statement deems abortion an “essential component of comprehensive health care” and asserts that delays may increase the risks associated with abortion or make it inaccessible.

In this brief, we estimate the potential impacts of patients having to wait until the executive order expires (at least April 22, 2020) to obtain abortion care at a Texas facility using existing survey data on the gestational age at which 600 Texas abortion patients first sought care. We also estimate the distance Texas patients would need to travel to obtain abortion care out-of-state and consider the logistical challenges of doing so if Texas facilities have to suspend services.

Results

Many women will no longer be eligible for medication abortion.

If Texas’ abortion facilities have to suspend all services while the executive order remains in effect, many patients seeking abortion care in early pregnancy will no longer be eligible for medication abortion because they will be pushed past the gestational age limit for the method (10 weeks from last menstrual period). Based on our patient survey, most clients seeking care (88%) were eligible for medication abortion at the time of their initial consultation and ultrasound visit. If patients have to wait 4 weeks until the executive order expires, fewer than half (48%) would still be able to get this method if they want it. (Figure 1, next page.)

Some of these patients may not be able to return for their abortion visit immediately after the order expires because of increased wait times at facilities and other scheduling challenges. We estimate that only 6% of patients who were seeking abortion when the executive order was issued would still be eligible for medication abortion if they are delayed and cannot return for their abortion for 6 weeks.

A growing percentage of people obtaining abortion care in Texas use medication abortion.4 Many patients prefer this method over a surgical procedure because they feel that it is more natural and the process can occur in the privacy and comfort of their home.

Many women seeking a first-trimester abortion will be delayed into the second trimester.

If patients are forced to delay their abortion while the executive order remains in effect, many will not be able to obtain care until the second trimester (after 12 weeks of pregnancy). In our patient survey, approximately 9% of patients were in the second trimester at the time of their initial consultation and ultrasound visit. However, after a 4-week delay between their ultrasound and abortion visits, more than one-third (35%) of patients would need second- trimester abortion care. (Figure 1.)

Second-trimester abortions are safe, although the risk of complications increases later in pregnancy. In addition, these procedures are more expensive, and fewer facilities offer the service. Indeed, after the order expires, it is unlikely that the existing second-trimester facilities in Texas will have the capacity to provide care for all the patients who will need it. This capacity constraint may lead patients to wait even longer for services and push some past the state’s gestational age limit for abortion (22 weeks from last menstrual period). These effects would fall disproportionately on Black and lower income patients, who are more likely to seek later abortion care.

The above projections apply to patients who would have already attended an initial consultation visit and then had their abortion visit canceled when the executive order was issued. Patients who call Texas facilities to schedule their initial appointment while the executive order is in effect would also experience delays obtaining care. Wait times for visits at Texas facilities may increase when services are re-established and staff work to see patients whose visits were canceled. Patients also may face delays as they identify and try to arrange travel to out-of-state facilities.

FIGURE 1: ESTIMATED CHANGES IN PATIENTS' ABILITY TO USE MEDICATION ABORTION AND NEED FOR SECOND-TRIMESTER ABORTION WITH INCREASING DELAYS IN ACCESS TO SERVICES

The majority of Texas counties are 200 miles or more from the nearest out-of-state abortion facility.

Before the executive order was issued, nearly half of Texas’ 254 counties were over 100 miles from the nearest U.S. facility providing abortion care. If Texas clinics are forced to suspend services while the executive order remains in effect, most counties (94%) will be 100 miles or more from a facility and approximately three-quarters (72%) will be over 200 miles away. (Figure 2.)

Since most of Texas’ neighboring states require a mandatory in-person consultation visit and 24-hour waiting period, many patients seeking care out of state would have to travel 800 round-trip miles or more to attend two separate visits. Some of these patients may be able to stay overnight and reduce their overall travel, but our prior research indicates that fewer than one in five patients do so.5

It is often difficult for patients seeking abortion to make the necessary arrangements to travel to a clinic, especially one that is far away. Finding child care, taking time off work and covering the cost of gas increase patients’ out-of-pocket expenses and are logistically challenging to arrange. Out-of-state travel may be more difficult for patients during the current pandemic because they face economic uncertainty from lost wages and need to care for children who are at home. People who are undocumented will be unlikely to travel at all because they will be unable to pass through interior border checkpoints.

It is likely that many people considering abortion will be unable to afford these travel costs and will end up continuing an unwanted pregnancy. Our previous research on the impact of clinic closures found that increasing distance from a facility following clinic closures was associated with a large decrease in the number of abortions.6 Those who are able to travel may have difficulties scheduling an appointment elsewhere because facilities in neighboring states are unable to meet the increased demand for care.

FIGURE 2: DISTANCE TO U.S. ABORTION FACILITY IF TEXAS CLINICS REMAIN OPEN AND IF THEY CLOSE DUE TO THE EXECUTIVE ORDER

Summary and Conclusion

Abortion is an essential part of reproductive healthcare and remains a necessary, time-sensitive service during the coronavirus pandemic. If Texas abortion facilities are forced to suspend services while the executive order is in effect, many patients who remain in Texas will have to delay care until later in pregnancy, and those who can obtain care out of state will be forced to travel considerably longer distances for services. This would create unnecessary economic hardships and increase the health risks for those who undergo second-trimester procedures or end up continuing an unwanted pregnancy.

Methods

Between June and December 2018, we conducted a survey with 603 patients seeking abortion at 12 Texas facilities. Patients completed a self-administered tablet-based survey and were asked to report their gestational age at their ultrasound visit. Among the 567 with valid data, we estimated gestational age and eligibility for medication abortion (≤10 weeks from last menstrual period) and need for second-trimester surgical abortion (12-21 weeks from last menstrual period) if they were required to wait 1 to 6 additional weeks to return for their procedure.

We estimated the distance from the population-weighted centroid of each Texas county to the nearest facility in Texas and neighboring states (Arkansas, Louisiana, Oklahoma, and New Mexico) using the georoute command in Stata 15.

Suggested Citation

White, K, Sierra, G, Vizcarra, E, Dixon, L, Baum, S, Hopkins, K, Potter, JE, and Grossman, D. The potential impacts of Texas' executive order on patients' access to abortion care. Texas Policy Evaluation Project. Research Brief. 2020.

References

1. Abbott, G. Executive order GA 09: Relating to hospital capacity during the COVID-19 disaster. March 22, 2020. https://gov. texas.gov/uploads/files/press/EO-GA_09_COVID-19_hospital_capacity_IMAGE_03-22-2020.pdf.

2. Paxton, K. Health care professionals and facilities, including abortion providers, must immediately stop all medically unnecessary surgeries and procedures to preserve resources to fight COVID-19 pandemic. Press release. March 23, 2020. https://www.texasattorneygeneral.gov/news/releases/health-care-professionals-and-facilities-including-abortion-providers- must-immediately-stop-all.

3. American College of Obstetricians and Gynecologists. Joint statement on abortion access during the COVID-19 outbreak. March 18, 2020. https://www.acog.org/news/news-releases/2020/03/joint-statement-on-abortion-access-during-the-covid- 19-outbreak.

4. Baum, SE, White, K, Hopkins, K, Potter JE, Grossman D. Rebound of medication abortion in Texas following updated mifepristone label. Contraception. 2019;99(5):278-280.

5. Gerdts, C, Fuentes, L, Grossman, D, et al. Impact of clinic closures on women obtaining abortion services after implementation of a restrictive law in Texas. Am J Public Health. 2016;106(5):857-864.

6. Grossman, D, White, K, Hopkins, K, Potter, JE. Change in distance to nearest facility and abortion in Texas, 2012 to 2014. JAMA. 2017;317(4):437-439.