State Legislation Related to Abortion Services, January 2017 to November 2020

Abstract

This survey study examines trends in abortion policies among states by analyzing legislation enacted between January 2017 and November 2020.

The 1973 US Supreme Court decision, Roe v Wade, simultaneously established the constitutional right to abortion and provided states with regulatory power over access to reproductive health services.¹ Since Roe v Wade, the Supreme Court has heard 43 cases related to abortion, nearly all from states that have restricted access.² To understand trends in abortion policies among states, we analyzed enacted legislation between January 2017 and November 2020.

Methods

We collected legislation through NexisUni, a database of legislation across all states, searching bill text for these keywords: abortion, abortion services, abortion provider, and abortion funding. The inclusion criteria were: (1) enacted legislation, (2) 2017 to 2020 legislative sessions, and (3) legislation substantively related to abortion policy. After identifying 736 pieces of legislation, we confirmed the relevance of each bill to abortion services and discarded unrelated legislation.

The final sample included 256 enacted laws from 45 states; a member of the research team (E.B.G.) coded each law, using inductive and deductive coding techniques.³ Prior to coding any legislation, we developed an initial set of anticipated codes, related to clinicians, patients, and financing of the procedure. After reading the bills, we expanded the codebook to reflect the nuances of policies. Subsequently, we combined previously distinct codes into parent categories to identify themes (Table 1 and Table 2). The University of Utah institutional review board deemed the study exempt from approval; the data were publicly available and there were no human participants.

Table 1. State Legislation Restricting Access to Abortion Services, January 2017 to November 2020.

Variable	Restrictions on clinicians and facilities			Restrictions on patients seeking abortion services			Restrictions on funding or insurance, and tax credits for opposition to abortion		Restrictions on abortions access prior to fetal viability and laws that trigger a complete ban if Roe v Wade is overturned
Subcategories	Laws that require higher levels of certification to perform abortions	Laws that dictate how clinicians practice medicine when they are providing abortion services	Laws that dictate what types of medical facilities can perform abortions	Laws that increase the number of steps a patient has to complete prior to having an abortion, and laws that dissuade a patient from having an abortion	Laws that establish a fetus’s personhood, including bans of abortions based on a fetus’ characteristics	Laws that limit abortion education	Laws that restrict insurance coverage for abortion services	Laws that prohibit funding for abortions or support money going to anti-abortion efforts	Gestational age bans	Dilation and Evacuation bans (most common surgical technique for second-trimester abortions)	Laws that would trigger complete abortion ban if Roe v Wade is overturned
Enacted laws, No.	18	59	9	48	15	6	13	35	12	4	8
States that have enacted laws, No.	7	23	8	24	12	5	9	19	10	4	8
Total enacted laws, No.	86			69			48		24
Total No. of states that have enacted laws	25 (Arkansas, Arizona, Florida, Georgia, Idaho, Illinois, Indiana, Kansas, Kentucky, Louisiana, Minnesota, Mississippi, Missouri, Nebraska, North Dakota, Ohio, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, West Virginia, Wyoming)			26 (Arkansas, Arizona, Colorado, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Michigan, Minnesota, Missouri, North Carolina, North Dakota, Nebraska, Ohio, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Utah, West Virginia, Wyoming)			22 (Alaska, Arkansas, Arizona, Colorado, Georgia, Illinois, Iowa, Kentucky, Louisiana, Maryland, Minnesota, Mississippi, Missouri, New Hampshire, Ohio, Wyoming, South Carolina, Tennessee, Texas, Utah, Virginia, Wisconsin)		14 (Alabama, Arkansas, Georgia, Iowa, Idaho, Indiana, Kentucky, Louisiana, Mississippi, Missouri, North Dakota, Ohio, Tennessee, Utah)

Table 2. States Legislation Expanding Access to Abortion Services, January 2017 to November 2020.

Variable	Expansion of scope of practice for clinicians and removal of restriction		Expansion of patient access and education about abortion services			Expansion of health insurance coverage		Affirmation of reproductive rights if Roe v Wade is overturned
Subcategories	Expansion to allow advanced practitioners to perform abortions	Removal of facility restrictions and criminal penalties directed at abortion providers	Removal of waiting periods and informed consent language	Expanding access to abortion services for college students and inmates	Increasing education about abortion services	Private insurance coverage of abortion services	Medicaid coverage of abortion services	Repeal of previous legislation that had outlawed abortion	Creation of new legislation that protects the right to an abortion
Laws enacted, No.	4	2	2	2	2	5	3	3	6
States that have enacted laws, No.	4	2	2	2	1	5	3	3	5
Total laws enacted, No.	6		6			8		9
Total No. of states that have enacted laws	5 (Illinois, Massachusetts, Maine, New York, Vermont)		4 (California, Illinois, Maryland, Nevada)			5 (Illinois, Maine, New York, Oregon, Washington)		8 (Washington DC, Delaware, Illinois, Massachusetts, Nevada, New York, Rhode Island, Vermont)

Results

During the study period, 35 states enacted 227 laws restricting access to abortion services (median of 4 laws; range, 1-20) (Table 1). Seven states—Arkansas, Indiana, Kentucky, Louisiana, Missouri, Ohio, and Utah—accounted for 119 (52.4%) of the laws. By comparison, 12 states and Washington, DC, enacted 29 laws expanding access to abortion services (median of 2 laws; range, 1-7) (Table 2). Two states (Illinois and Maryland) enacted laws that restricted and expanded access in various respects. Of the laws, 86 established restrictions for physicians, advanced clinicians, or facilities that provide abortions, typically involving medical records, required clinical specifications, available emergency services, and licensing as hospitals or surgical centers.⁴ In addition, 69 laws established restrictions on patients, for example by extending waiting periods for abortions to 24 or 72 hours or requiring patients to view information modules to dissuade them from having an abortion. Another 48 laws restricted state funding or insurance coverage of abortion services or established tax credits for donations to organizations that oppose abortion. Finally, 24 laws restricted abortion based on gestational limits, ranging from 0 to 18 weeks, or would trigger a complete abortion ban if the Supreme Court were to overturn Roe v Wade.

Although less frequently adopted, laws that expand abortion access are generally a direct counterpoint to laws that restrict access.⁵ Among the features of the 29 laws in this category are ensuring abortion access if Roe v Wade is overturned, expansion of abortion and contraceptive benefits in private and public insurance plans, and allowances for advanced clinicians to provide abortion care.

Discussion

Between January 2017 and November 2020, we found that 227 (88.7%) of the 256 state laws related to abortion services established new restrictions; only 29 of the laws (11.3%) expanded access. Limitations of the study include the time frame and the exclusion of legislation regulating broader reproductive health policies that could influence abortion services, such as public funding for contraception and access to primary care. At present, the variability of state laws means that access to abortion services is largely dependent on location. The numerous state restrictions on access to abortion services pose risks to women who are younger, of lower socioeconomic status, and racial minorities.