Florida’s latest anti-abortion law snares women and clinics in ever-tighter restrictions

TRAP laws

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Florida’s latest anti-abortion law snares women and clinics in ever-tighter restrictions and is a classic example of targeted regulation

Her husband had already moved on to his new life when Amanda found out she was pregnant.

At 23, the Melbourne woman thought she had a loving marriage – until the day last September when her husband informed her they didn't. Now she was single, and life was a fast-paced blur: getting a job that would support her 4-year-old and 1-year-old sons, filing divorce papers, finding a baby-sitter, deciding whether to attend nursing school, scheduling parental visits, making home payments and bills, and finding the fleeting hours in between to hold her baby tight.

And now, a missed period. Another mouth to feed. Amanda (last name withheld to protect her privacy) says she called her ex-husband, who by that time had moved to a different state to be with someone else. When she told him she was pregnant, Amanda remembers he told her, "OK. Do what you want."

So she made a choice for herself and her family.

Amanda was about six weeks pregnant when she scheduled an appointment at the Planned Parenthood clinic in downtown Orlando. Her sister Chelsea drove an hour and a half from Altamonte Springs to Melbourne to pick her up and drive up to Orlando. They were running late, so Amanda called the clinic to let them know she would still be coming.

"No, you're just getting an ultrasound today," the clinic receptionist told her. "You have to wait 24 hours."

The sisters listened in shock as the receptionist explained the law. The day before, Feb. 26, a law went into effect mandating that women must wait 24 hours after an ultrasound before undergoing the abortion procedure. The receptionist told Amanda and Chelsea that clinic staff had spent all day Friday trying to call their patients to let them know that they couldn't have the abortion they scheduled on Saturday and would have to come back on Wednesday, the other day the clinic does abortions. When the sisters finally arrived at the clinic, they waited with a room full of other upset women who had collected the funds, arranged days off work and traveled from different cities only to be denied by the state. Florida law requires women seeking an abortion to undergo an ultrasound, which they don't have to look at, but must sign off on. Amanda says the doctor had to zoom in five times to show her the embryo, which looked like a tiny line on the ultrasound picture. Conservative lawmakers and Gov. Rick Scott supported the 2011 measure, theorizing that women would make a different decision after seeing the image.

"It's the biggest bunch of bullshit I've ever heard," Amanda says. "Some of the girls waiting were telling the nurses, 'We will pay you more, can you please just do it today?' If you've already mustered up the courage to call Planned Parenthood, show up, go through the ultrasound, what makes you think a couple of hours will change my mind?"

But despite the mandatory ultrasounds and 24-hour waiting period, Florida's lawmakers weren't quite done. Three weeks ago, on March 25, Scott signed into law House Bill 1411, a seemingly innocuous bill that increases regulations on the 62 abortion clinics across the state. The bill is similar to laws in other states, most notably Texas, that critics call Targeted Regulation of Abortion Providers (TRAP) laws because they place onerous and medically unnecessary restrictions on abortion providers in an effort to close clinics. The Guttmacher Institute, a research organization that promotes reproductive rights and health, says as of 2016, 24 states across the country have some form of a TRAP law. Last year, almost 400 restrictions on abortion services were introduced into state legislatures, the Institute finds.

The 2013 Texas law, which supporters say was meant to improve the standard of care and protect women (not make it so inconvenient to get a legal abortion that women will give up), is currently being challenged before the United States Supreme Court. Opponents argue it places undue burdens on women who want to end a pregnancy. If the Texas law stands, that would leave nine abortion clinics in that state.

Anti-abortion activists and conservative lawmakers argue these laws are trying to protect women, not stopping the practice. But Laura Goodhue, executive director of the Florida Alliance of Planned Parenthood affiliates, says the laws are an extremely coordinated attack on women's health care. In 2014, roughly 72,100 abortions were performed in Florida according to state health records, the Associated Press reports.

"None of this is medically necessary whatsoever," she says. "Women have the legal rights to obtain a medical procedure and when you punish providers, women are punished regardless."

Dawn Porter says she was one of the many people who had no idea that TRAP laws were being enacted all over the country. For her 2016 documentary, Trapped, the filmmaker followed abortion clinics in Mississippi, Texas and Alabama for two and a half years as they fought to stay open.

"The most common reaction from people after they watch the film is 'I'm so angry' and 'I had no idea,'" she says. "It confirms what I suspected, which is people are not aware of how the laws are actually working in practice. It's hard to explain why something that sounds good, like 'The Women's Health and Safety Protection Act,' is troubling."

At first glance, TRAP laws might seem easy to comply with, like the law that requires abortion clinic doctors to obtain admitting privileges, which are the rights to admit patients at nearby hospitals. But hospitals can refuse these doctors, which can then lead to the closure of clinics. In Mississippi, seven local hospitals refused to provide admitting privileges to two doctors in the state's only abortion clinic. When the law went into effect in Texas, multiple clinics closed. A similar thing happens with transfer agreements, which require abortion clinics to get an agreement that a hospital will admit emergency patients. Hospitals are already legally required to do that, but if they refuse to issue a formal agreement, clinics can be forced to shut down. Another TRAP law that might seem like a good idea is requiring abortion clinics to act as ambulatory surgical centers. Some states tried to force clinics to make costly renovations, such as Kansas, which tried to regulate janitor closets, or Virginia, which tried to force one clinic to widen its doorways and hallways to fit a hospital stretcher.

The American Congress of Obstetricians and Gynecologists says the Texas law sets a higher standard for abortions than for other procedures, such as colonoscopies, wisdom tooth removal or tonsillectomies – all of which have statistically higher risks of complication than abortion.

"The fact is that abortion is one of the safest medical procedures," the organization says in a press release. "The risk of complications from abortion is minimal, with less than 0.5 percent of abortions involving major complications."

In the current case before the U.S. Supreme Court, Texas officials argued HB 2, the 2013 Texas bill that increased restrictions on abortion clinics and that lawmakers said would improve women's health, didn't have much of an effect.

But the Texas law did have a profound impact on women's health, says Dan Grossman, an investigator with the Texas Policy Evaluation Project and a professor at the University of California, San Francisco.

Since 2013, the number of abortion providers in Texas has dropped from 41 to 18, according to TxPEP. The remaining facilities couldn't keep up with demand, and TxPEP found that some Texas women were waiting up to 20 days for the procedure – which, given the 20-week limit, in some cases made the procedure illegal. Before HB 2, the average one-way distance to the nearest abortion clinic was 17 miles. After HB 2, it was 70 miles.

That, Grossman says, has led to anecdotal reports of women self-inducing their abortions.

"I'm not hearing about invasive things like coat hangers, but women have tried a variety of things," he says. "There are reports of women calling clinics asking what herbs they can use to induce an abortion and crossing the border to get misoprostol [the medical abortion pill] at Mexican pharmacies."

It's hard to know the exact number of women who have tried to end their pregnancies on their own as TRAP laws pass across the country, because it's a sensitive topic, but there are other ways to know what women are doing. The New York Times analyzed Google searches and found that last year, there were more than 700,000 nationwide searches looking into self-induced abortions. That included: 160,000 searches asking how and where to buy abortion pills; 4,000 searches asking how to do coat-hanger abortions; tens of thousands of searches into self-inducing abortions through high doses of parsley or vitamin C; and a few hundred asking how to end a pregnancy by introducing bleach into the uterus or punching a pregnant woman in the stomach.

Porter says that while she was making Trapped she heard that some women had started an underground network and were training people on how to do abortions. Porter adds there was some insight into the reasoning behind these laws after Republican presidential front-runner Donald Trump's recent comment that "there has to be some form of punishment" for women who get abortions (a legal medical procedure), and then his rapid reversal when even anti-abortion activists disagreed on actual criminal penalties for women.

"I am thrilled Trump said that because it points to the real, logical conclusions of the laws that they're enhancing," she says. "If abortion providers don't comply with the law, there are criminal penalties. There's no crime if the woman doesn't seek the abortion. Women have been put in jail for trying to self-abort. ... If you think that's what the law should be, then say it. Say you want to regulate it. It's all a very underhanded way of behaving."

The Republican-led Florida Legislature went even further than Texas when they passed HB 1411, says Elizabeth Nash, the senior state issues associate at the Guttmacher Institute.

In addition to requiring that abortion clinics be treated more like surgical centers and have admitting privileges or transfer agreements with nearby hospitals, Florida's version blocks Planned Parenthood clinics from receiving nearly $200,000 in Medicaid reimbursement for preventative services like cancer screenings, STD tests and contraception. (Under the federal Hyde Amendment, using Medicaid funds for abortion is already banned.) This affects all 22 Planned Parenthood clinics in the state, including the seven that don't do abortions at all.

The reasoning behind this, according to Republican state Sen. Rob Bradley, is that "the idea that those taxpayer dollars would go to an organization that performs abortions is simply intolerable," the Tampa Bay Times reports. CBS Miami reports a spokesperson for the U.S. Centers for Medicare & Medicaid Services notified Scott after he signed HB 1411 that Florida has an obligation to "ensure Medicaid beneficiaries continue to have access to services provided by any willing provider."

The law also changes Florida's definition of the first pregnancy trimester. Like other states, Florida launched an investigation into Planned Parenthood clinics in the state after highly edited, altered (and since debunked) videos about the use of fetal tissue were released by anti-abortion activists. Florida's Agency for Health Care Administration alleged three Planned Parenthood clinics in the state performed second-trimester abortions without proper licenses. After Planned Parenthood pointed out that AHCA was using a different definition than doctors do of what the first trimester is, HB 1411 created a legal definition.

The law also toughens restrictions on improper disposal of fetal remains, requires the state to inspect at least half of clinic records every year, forces clinics to submit monthly reports detailing abortions and requires abortion referral or counseling agencies to register with AHCA.

It's not clear yet what impact the law will have on the clinics. But some, Nash says, will almost certainly close.

"What we saw before Roe v. Wade was handed down was laws that straight-out banned abortions," she says. "Now we're seeing laws that make abortion difficult to access. The impact is similar in that it reduces the availability of women to obtain an abortion. But it does nothing to prevent the need for abortion. If you would be interested, you would see states heavily investing in family planning and sex education."

Florida Sen. Kelli Stargel and Rep. Colleen Burton, both Republicans from Lakeland, sponsored the Senate and House versions of the law, respectively. Stargel says nothing in the bill is going to close down clinics. She argues that lawmakers modeled it to be "constitutional." In Planned Parenthood v. Casey, the U.S. Supreme Court said the state can regulate abortion, but those regulations must not impose an undue burden on a woman's constitutional right to an abortion.

"Abortions will continue; the clinics will just have oversight on them to do it properly," she says. "The nature of the regulations means inspecting them more frequently. None of these are huge leaps for them, not to the level they're saying. What will happen is it will hold them to a higher standard, and that's a welcome burden. They need to be held to the same standard as other clinics."

Stargel says the bill doesn't punish anybody, but affects women in positive ways. She adds that abortion is just as invasive a procedure as liposuction, and that Florida "shouldn't have a double standard" when it comes to clinics.

Florida Rep. Lori Berman, D-Lantana, says the bill's supporters argued there were more than enough places women could go to instead of Planned Parenthood. Stargel says Florida Family Policy Council, a group that is "pro-life, pro-family," according to its website, provided a list claiming there are 636 federally qualified health center sites and rural health clinics in the state of Florida.

When Berman asked Burton for the list, she was dismayed to find it included 67 schools with nurses; optometrists, like Arcadia Family Optometry Center; dentists, like Apopka Dental Care; the Salvation Army; and podiatrists, like Riverview Foot and Ankle Specialists – nowhere you could actually get reproductive health care.

Stargel says the list is not accurate, but there are local health clinics that can accommodate people and the state has increased funding to those facilities. Orlando Weekly reached out to Florida Family Policy Council for comment, but did not receive a response by press time.

Mara Gambineri, communications director for the Florida Department of Health, says the department's current contracts with clinics are in place through the end of the fiscal year on June 30.

"The department is reviewing our options," Gambineri says. "Family planning is a core function of public health and there will be no interruption in services."

Dr. Sujatha Prabhakaran, vice president of medical affairs at the Planned Parenthood of Southwest and Central Florida, says local clinics don't know what the impact of HB 1411 will be, but she predicts women at or below poverty level will feel the brunt of the burden.

"I do this work because I've worked in countries where abortion access is limited," she says. "It doesn't decrease the number of abortions, but it vastly increases medical complications. In many countries where abortion is illegal and access is difficult, abortion-related deaths are one of the highest reasons young women die."

Laurie Roberts has heard it all.

The president of the Mississippi Reproductive Freedom Fund gets stories from women who try to end their pregnancies with herbal remedies, vitamin C flushes or by having someone push them down the stairs. She's heard of women who've accidentally overdosed on misoprostol or tried to pay someone to beat them up. Mississippi has one abortion clinic for the entire state, and its restrictive abortion laws disproportionately affect poor women of color, Roberts says.

"One of the earliest messages I remember, because I was so horrified," Roberts says, "was we got a message from a woman asking us to please help her friend because the boyfriend had told her to drink bleach to end her pregnancy and she thought her friend would."

Abortion fund organizations, like the one Roberts runs and the Central Florida Women's Emergency Fund, exist across the county. The Mississippi fund uses private donations to send Mississippi women to facilities in Florida, Alabama and other states, sometimes paying for the abortion, the plane ticket and a hotel.

"Just like before Roe v. Wade, women with means could always find a safe abortion," says Joan Lamunyon Sanford, executive director of the New Mexico Religious Coalition for Reproductive Choice, which helps women secure abortions in the Southwest. "It's women living on margins, then and now, who don't have the credit card, don't have paid leave or extra income, that are really being hurt by this legislation."

Back in Florida, Amanda says she thought about ending her pregnancy on her own for a second, but accidentally bleeding to death was not something she could risk with two kids depending on her. Her procedure was $375, a price that includes a discount but doesn't take into the account the extra costs incurred because of the 24-hour waiting period.

After waiting four days, Amanda and Chelsea took another day off to repeat the same process later that week. The procedure was quick, and soon she was back home in Melbourne with her children.

"It doesn't bother me," Amanda says about the procedure. "It's my body. I did what's best for my family. I just wanted to ask these people who were outside the abortion clinic yelling at us to have the baby, are you going to pay to send my child to college in 18 years? Groceries? Diapers? These are the same people who complain about paying for food stamps, Medicaid, yet they're going to force me into poverty?"

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