Texas Policy Evaluation Project
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Texas’ Executive Order during COVID-19 Increased Barriers for Patients Seeking Abortion Care

By: Emma Carpenter, Kristen Burke, Elsa Vizcarra, Asha Dane'el, Vinita Goyal, and Kari White

Download a PDF of this Brief
January, 2021

Following the onset of the COVID-19 pandemic, Texas Governor Greg Abbott signed an executive order on March 22, 2020 that prohibited surgeries and procedures that were not medically necessary, claiming that this would preserve personal protective equipment and reduce demands on hospital-based care.1 Attorney General Ken Paxton interpreted the order to include abortion. This interpretation ran counter to professional medical associations’ recommendations that access to abortion care during the pandemic should not be delayed or compromised2 and prompted legal challenges.

During the 30-day period in which the executive order was in effect, there were 6 different court rulings, which quickly changed whether clinics could offer services. Clinics canceled and rescheduled hundreds of appointments to comply with the order and the changing provisions surrounding abortion. This created considerable uncertainty until the order expired on April 21, 2020.3

To learn more about people’s experiences seeking abortion care during the executive order, we conducted in-depth interviews with 10 individuals who had contacted an abortion facility while the order was in effect. Five of the 10 were ultimately able to obtain an abortion, 4 continued their pregnancy, and 1 remained unsure of their plan. In this brief, we summarize how the executive order affected participants’ ability to get timely abortion care.

Key Findings

The March 22, 2020 executive order negatively affected those seeking abortion care. The order:

• Created unnecessary barriers to access.
• Increased the risk of exposure to COVID-19.
• Took a significant economic and emotional toll.

Results

The Executive Order Exacerbated Existing Barriers to Abortion and Delayed Care
The executive order created confusion about whether abortion services were available or not and made it difficult for people to get care when they needed it. Participants reported making numerous attempts to reach Texas clinics in order to schedule their initial appointment for an ultrasound or reschedule their abortion visit when facilities re-established services. In some cases, patients made appointments only to have facilities cancel them the same day, when a new decision was issued by the court.

A 25-year-old reported trying to get an abortion before the executive order was enacted, and she was still trying to get enough money together to pay for the abortion when the order went into effect. Knowing the cost of an abortion increased later in pregnancy, this participant described what it was like to try to get care during this chaotic time:

I went online every single day to see if anything had changed. One day in April, I noticed the judge [had] temporarily stopped the ban, so I called them and tried to make an appointment. [The clinic] was going to make me an appointment, and then the next day it just went right back to the way it was. It made things really confusing.

Existing abortion restrictions (Box 1) exacerbated the scheduling difficulties and logistical challenges created by the executive order, resulting in further delays and increasing costs. For example, Texas mandates the same physician providing one’s abortion also perform an ultrasound at least 24 hours in advance. This existing restriction made scheduling even more difficult and sometimes precluded individuals from accessing the care they needed.

Box 1: Existing Texas Abortion Restrictions

  • Require a mandatory ultrasound ≥24 hours before an abortion, which necessitates 2 in-person
    visits (unless the patient lives ≥100 miles away); the ultrasound must be performed by the same physician who provides the abortion.
  • Restrict medication abortion (the “abortion pill”) by prohibiting the use of telemedicine, limiting provision to ≤10 weeks from last menstrual period (vs. recommended ≤11 weeks)4, and requiring an in-person follow-up visit.
  • Limit abortion to <22 weeks from last menstrual period; patients needing care later in pregnancy must travel out of state for services.
  • Prohibit coverage of abortion in state insurance plans and Medicaid, forcing patients to pay out of pocket for care.

One participant, who was unemployed and unable to find work due to the pandemic, reported that she could not come up with enough money in time for her abortion visit. She asked the clinic to reschedule her procedure. However, in order to do that, she would have had to see a different physician, which meant that she would need another ultrasound:

They said "No, you have to come in the next week and redo the whole process and get another ultrasound and do everything all over again." And I'm like, I don't want to pay an extra hundred dollars.

Unable to afford the escalating costs and overwhelmed by having to restart the process, she ultimately resolved to carry her pregnancy to term.

Delays Caused by the Executive Order Resulted in Hardship and Distress
Most participants had to delay their abortion visits until they were past the 10-week limit for medication abortion, which many women prefer, and therefore needed a procedural abortion, which can be more costly. While only 5 of the 10 people we interviewed ended up getting an abortion, all of them described added emotional and financial hardship due to their constrained choices.

Participants reported that the uncertainty during this period of delay led to feelings of anxiety, depression, and hopelessness. One participant, a 35-year old with 2 children who was able to get an abortion by traveling nearly 750 miles one way to New Mexico, reported the following feelings while figuring out her next step:

I don’t think that I’ve ever been more depressed in my life, to the point where I didn’t see a future for myself, because I said, "Well, I just have to deal with this. This is just going to have to be what it is. I’m either going to have to parent this baby or adoption." I think every day I sat there, it just got worse and worse and worse and worse, and I felt like I didn’t have any options since they had closed down... I went to Google and to the [clinic] Facebook pages, and they had a dark post about how they were closing down for a while, and that’s when I thought that I didn’t have any options.

The participants who ultimately resolved to carry their pregnancy to term cited economic barriers that further contributed to delays in care. Despite attempts to get care early in pregnancy, the executive order made it too difficult for these participants to obtain an abortion. A 26-year-old with 2 children wanted a medication abortion but was pushed past the gestational age limit after earlier appointments were canceled. Unable to travel out of state for care, this participant reflected on having to continue a pregnancy after getting divorced and closing her new business:

I feel a little depressed... I have anxiety from not knowing what's going to happen in the future. I'm worried about how hard things are going to be just money-wise. I don't know. I'm afraid. I'm definitely afraid of what's going to happen. It's weighing a lot on me too that just knowing that I didn't want to go on with this pregnancy and here I am now going on with it.

All participants unable to obtain an abortion reported stress related to the physical toll of carrying an unwanted pregnancy to term, the emotional toll of having their autonomy undermined (i.e., feeling like they had no choice), and the financial and emotional challenges they would face raising additional children.

The Executive Order Intensified New Concerns Brought On by COVID-19
Texas patients seeking abortion often report cost and logistical challenges related to both the procedure and expenses such as child care, but the majority of participants reported that the executive order and unprecedented circumstances following the onset of the coronavirus pandemic exacerbated these barriers in a number of ways.

For example, nearly all participants we spoke to had lost their jobs or had their working hours reduced due to the pandemic, making it difficult to cover the increased cost of care when appointments were delayed or pay expenses needed to travel to another facility. Participants reported spending down their savings, borrowing money from family if they could, and seeking extensions on other bills in order to afford their abortion. A few were able to get financial assistance from abortion funds, non-profit organizations dedicated to providing financial and logistical support (e.g., travel assistance) to individuals seeking abortion care.

Yet, even with financial assistance, economic uncertainty during the pandemic heightened participants’ stress about being able to afford an abortion. A 28-year-old with 2 children was able to receive some funding from a local abortion fund. However, she was still unable to cover the $300 in remaining costs for her abortion after the company she worked for laid off employees in response to the pandemic and she lost her job:

I would just have to pay like 300 dollars, but that's still too much. It's too much when you don't know what is your next income.

Although some people in Texas need to travel to other counties or states to obtain abortion care,5 service suspensions during the executive order forced people to consider traveling even greater distances. Participants had to think about their risk of exposure to the coronavirus if they had to stay at a hotel or stop along the way, in addition to challenges such as arranging childcare, if they sought care at a facility in another state. These concerns led a 29-year old with 2 children to decide that out-of-state travel was too risky:

At one point, I was even thinking of going to Atlanta and just taking a Greyhound bus—16 hours on a Greyhound bus. That would be like putting myself at risk, 16 hours transportation—times two—to and from. But that's not an option. I guess I was just being desperate at that time.

Unlike the participant above, 2 people we interviewed were able to overcome the logistical and financial barriers and travel out of state for their abortion. One of these patients, a 30-year old nursing student coping with learning her fetus had significant anomalies, arranged to travel over 700 miles one way to New Mexico. She worried she was exposed to the coronavirus after feeling feverish on her way home from a 4-day trip:

This week I need to go get my COVID test because [the nurse] is like, “You traveled. You were in and out of gas stations and hotels, and in and out of the clinic. You were just around a whole bunch of people, and you don't know if somebody gave you something.”

Maria Isabel's Story

Maria Isabel (pseudonym) is 23 years old and lives in South Texas. She found out she was pregnant at the end of February and decided to have an abortion in March when she was about 8 weeks along. When she initially called a clinic near where she lived, the clinic told her they could not schedule an appointment and recommended she travel to Colorado. However, she could not take the time off work or afford to travel out of state.

Once she finally got an appointment in Texas, roughly 8 weeks later, she was told she was too far along for a medication abortion at that facility and would need to schedule an appointment for a procedural abortion elsewhere. She was finally able to have an abortion at a different clinic in her city. Overall, she spent 9 weeks trying to get care and paid $1,200.

In describing the added stress and cost that came with having to wait so long for an appointment, she said, “I just feel like it was definitely unnecessary. It could have been avoided.”

Participants Disagreed with Abortion Being Included in the Executive Order
Although participants recognized that the service disruptions they experienced were related to the COVID-19 pandemic, about half understood that their appointment cancelations were specifically due to the executive order, having been informed by clinic staff or following coverage in the news. Several participants who were aware of the executive order voiced their disagreement with the order’s designation of abortion as not “essential.” As this 23-year old participant says:

I feel like the government made the wrong decision because people should be able to have abortion whenever they want to. I think it is medically necessary.

Additionally, these participants were angry that their options for care were so limited. A 26-year-old participant contrasted the relatively low risk of medication abortion to other medical visits, stating:

I didn't see how it was okay for an abortion clinic to be closed when all it is is going in for a sonogram and a medication and that was it, you're out of there. Now, going to [a] doctor's office you don't know what these people are sick of and they could possibly have the COVID-19, and you're sitting in a room with them. It was just confusing to me.

Summary and Conclusions

Texas’ executive order halting most abortion services contributed to emotional, financial, and logistical barriers for people seeking abortion, including unnecessary delays and out-of-state-travel. Some felt that the delays imposed by the order, in combination with other barriers to abortion and concerns around contracting COVID-19, forced them to forgo care all together. Regardless of whether or not participants obtained an abortion, the process of seeking care during the executive order caused confusion, distress, and hardship that exacerbated the incredible disruptions to daily life that were taking place because of an unprecedented global health crisis.

Major medical associations agree that during a pandemic, pregnant patients needing abortion care should be able to access timely, evidence-based, and patient-centered services, such as telemedicine, and that medically unnecessary visits should be eliminated (Box 2).2 As the pandemic continues to impact day-to- day life and medical care, policy makers and public health professionals should ensure that health care innovations and other strategies to deliver essential services include abortion care.

Box 2: Evidence-based Abortion Care During a Pandemic6,7

  • Telemedicine for evaluation, counseling and consent in order to limit time in clinic
  • Most procedural abortions performed at a single visit to limit exposure
  • Medication abortion provided up to 11 weeks' gestation via telemedicine or a "no test" protocol that does not require an ultrasound
  • Follow-up appointments conducted via telephone or telemedicine

Methods

Between May and June 2020, we conducted interviews with 10 Texas residents who tried to get abortion care while the executive order was in effect. Participants were recruited from clinics in Texas and New Mexico where they had sought care, and they completed an in-depth interview by phone about their experiences seeking abortion. We compensated participants with a $40 gift card for their time. Interviews were audio-recorded with participants’ consent, transcribed, and coded by four researchers. Participants included 4 people who self-identified as Hispanic, one who self-identified as Black, and 3 who self-identified as White; 2 participants did not provide race/ethnicity information. Nine of the 10 participants had children, and 7 lacked health coverage.

References

1Abbott, 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

2The American College of Obstetricians and Gynecologists. Joint statement on abortion access during the COVID-19 outbreak. Press release. March 18, 2020. https://www.acog.org/news/news-releases/2020/03/joint-statement-on-abortion-access-during- the-covid-19-outbreak.

3Paxton, 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

4Creinin, M. D., & Grossman, D. A. (2020). Medication abortion up to 70 days of gestation: ACOG practice bulletin, number 225. Obstetrics & Gynecology, 136(4):e31-e47.

5Grossman, D, White, K, Hopkins, K, Potter, JE. (2017). Change in distance to nearest facility and abortion in Texas, 2012 to 2014. JAMA,317(4):437-439.

6Raymond, E. G., Grossman, D., Mark, A., Upadhyay, U. D., Dean, G., Creinin, M. D., ... & Gold, M. (2020). Commentary: No-test medication abortion: A sample protocol for increasing access during a pandemic and beyond. Contraception,101(6):361-366.

7Cohen, M. A., Powell, A. M., Coleman, J. S., Keller, J. M., Livingston, A., & Anderson, J. R. (2020). Special ambulatory gynecologic considerations in the era of COVID-19 and implications for future practice. American Journal of Obstetrics and Gynecology, 223(3):372-378.


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