Transcript | Ep. 99: How to Protect Abortion Clinics
Cristen: I am blown away. Like, it's not it's not news to me that that anti-choice folks are, you know, out there watching kind of ready to pounce. I did not realize the extent of it, though. How are they able to do this?
[Theme music]
Caroline: Cristen, at the time we’re recording, this episode comes out the week that the Supreme Court confirmation hearings for Amy Coney Barrett are scheduled to get underway.
Cristen: Heaviest of sighs, yes yes.
Caroline: And of course, if confirmed, she’ll fill Ruth Bader Ginsburg’s seat.
Cristen: Also as of this recording, the central debate around Coney Barrett’s appointment is whether it would mean the end of Roe v Wade. But the reality, y’all, is that a 6-3 conservative Supreme Court doesn’t really have to fuck with Roe to fuck with abortion rights.
Caroline: Exactly. Abortion rights are meaningless without abortion access, and for quite a while now, anti-abortion groups have been exploiting that fact with reckless abandon.
Cristen: Yep. Caroline, I don’t think I fully grasped just how mobilized the anti-abortion movement really is until hearing from today’s guest about what it’s actually like to build and open an abortion clinic in the US these days.
Amy: Abortion is still legal in the books. It's still protected by the Constitution. So their strategy has pivoted to chipping away at people's access to abortion, to making it much more difficult to obtain and to making it much more difficult for clinics to provide by figuring out really strategic and smart ways to disrupt the services and to make services more expensive to provide.
Caroline: Nowhere else do public health and private politics collide like they do at abortion clinics, and today’s guest, Amy Hagstrom Miller, works smack dab in the middle of it. She's the CEO and founder of Whole Woman’s Health, a network of eight abortion clinics in some of the most conservative areas of the country, like Texas.
Cristen: This episode, Amy’s is taking us beyond Roe v Wade to give us a firsthand reality check of what it takes for abortion clinics to survive
Caroline: Then next week, we’ll find out why “pro-life” crisis pregnancy centers now easily outnumber abortion clinics in the US.
Cristen: But it’s not all terrible news y’all! Today, Amy is also going to tell us about how she took the state of Texas and its bullshit abortion restrictions all the way to the Supreme Court — and won.
[Stinger]
Cristen: Amy Hagstrom Miller grew up in a very HGTV-esque family. Her dad was a custom home builder, and her brother is an architect. So when she founded Whole Woman’s Health in 2003, she took an active role in designing her clinics.
Caroline: Amy thinks a lot about how physical spaces influence patients, from lighting to layout.
Amy: People are very affected by physical environments. People are very affected by smell and by light and by color. I think some of our emotional reactions to those things are are really, really deep in, you know, in our psyche. And I think similarly, people have very strong reactions to unplanned pregnancy and specifically abortion in this country.
Caroline: For Amy, creating a warm and inviting clinic doesn’t just help her patients feel safe and comfortable; it’s part of her mission to destigmatize abortion
Amy: You know, that stigma is something that's really used oftentimes as a weapon where people are shamed and made to feel isolated and separated. And so I think one of the things that I have really tried to do is create clinic environments that can break down some of those stigmas, that can be warm, that can be inviting, that can have sort of areas in the clinic where people can build connectivity and can be together because that connectivity and togetherness is one of the sort of premier things that really reduces stigma where people stop, start to feel less alone and they realize there are other people who who share similar experiences.
Cristen: When you walk into a Whole Woman’s Health clinic, you’ll wait for your appointment in a comfy chair, surrounded by soft light and lavender walls. If you’re there for an abortion, you’ll get a fleece blanket and herbal tea afterward. Even the exam rooms have a pleasantly unladylike ring to them!
Amy: The rooms are named after different women. So you may instead of saying, you know, “We're going to do your ultrasound in exam room two,” we may be, you know, offering your ultrasound in Maya Angelou or Sojourner Truth or Angela Davis or, you know, Eleanor Roosevelt.
Caroline: Amy has also gotten creative about destigmatizing abortion outside her clinics.
Amy: And so in two of my clinics, I've had local muralists. I've hired them to come and paint beautiful murals on the side of the clinic. And one of the clinics, in McAllen, Texas, is right on Main Street, like there's only a sidewalk that patients have to walk on. And so they're like physically encountering protesters in order to get in the front door. And we've just painted this beautiful mural with like local faces that says beautiful things like justice and dignity on the mural. And it's this great sort of artistic way to, like, step into that conversation. And just like the protesters just look like big meanies next to this beautiful mural. Right.
Cristen: Protestors aren't the only big meanies who pose safety concerns for abortion providers. The National Abortion Federation has been tracking violence against clinics since the 70s - including murders, bomb threats, arson, kidnapping and harassment. And in 2018, they found that attacks on abortion clinics and providers had reached an all-time high.
Caroline: Despite all of the safety threats, abortion clinics LEGALLY cannot block the public — aka protesters — from getting near the front doors.
Cristen: Right. So, in 2007, Massachusetts passed a law creating a 35-foot buffer zone around abortion clinics where anti-abortionists wouldn't be allowed to protest or harass clinic patients or staff. But it didn't take long for an anti-abortion group to the sue the state, claiming the law violated their First Amendment rights to free speech.
Caroline: Seven years later, the lawsuit reached the Supreme Court, which unanimously agreed that the law went too far and was unconstitutional. In other words, anti-abortionists' free speech outweighed protesters’ right to privacy, safety and access.
Cristen: Simply securing an affordable clinic space is extremely difficult, too. For example, when Amy needed to relocate a clinic in Minneapolis, the process took more than 18 months. She had to look at 80 different locations.
Amy: You know, landlord after landlord — even even people who would have described themselves as pro-choice or progressives — just said, “Oh, we don't want to take that risk. We don't want to have protesters. We don't want to -” you know, they're they're thinking about, oh, that clinic could be vandalized or bombed or, you know, they may also be thinking about their stereotype. Who knows? But I'm pretty sure that part of the variable is the stereotype of “What kind of customers might they have?” Right. Because part of the stigma that's been sort of manufactured around abortion is that there's a certain kind of woman that may have an abortion or that there's a certain kind of doctor who would provide abortions when in fact, you know, one in three women in this country have an abortion in their lifetime. And, you know, almost 60 percent of those people who have those abortions are already parents. You know, the majority of them are not teenagers. And, you know, I mean, the actual facts are very different from the narrative that's been perpetuated.
Cristen: Amy encountered a similar problem in Austin. An anti-abortion organization swooped in and offered her landlord five years of rent upfront IN CASH for both the clinic space and the office next door.
Caroline: Now, Amy was able to block the lease, but then the anti-abortion folks got sneakier … with a new offer.
Amy: It didn't look like an anti-abortion organization at first, and so the landlord kind of fell for it because it was turns out it was like a board member from this organization that used his private business to secure the building. So it was like some hedge fund or mutual fund, kind of like financial business that it sounded like that's who was going to take over the building. And then as soon as they secured the lease, they started building a crisis pregnancy center in the former flagship clinic of Whole Woman's Health.
Cristen: In other words, her abortion clinic was replaced by a center that actively discourages abortion...which we'll get into next ep..
Caroline: Yeah. And it would have cost $250,000 to match that group’s offer, money Whole Woman’s Health simply didn’t have. After nine months, they secured a new space for the clinic, but that relocation still ended up costing them $100 grand.
Amy: The amount of time and energy that myself and my sort of leadership team spend looking at 80 properties, having these intense conversations with landlords and bankers, all of that energy and time could be, you know, devoted to direct patient care, but we have to do all this surrounding work in order to just even keep the clinic open.
Caroline: Once folks like Amy secure a location for the clinic, anti-abortion groups make it nearly impossible to build it. For instance, it took about five years to open the Whole Woman’s Health clinic in South Bend, Indiana.
Amy: I'm not kidding. Our project there was disrupted numerous times by anti-abortion folks who intimidated, like, screamed and yelled at any contractor who went into the building, the plumber, the carpenter, electrician. They would follow them. They would follow them to their other jobs. They would tell other companies that maybe hired the same contractor, “You know, these people are also building that new abortion clinic over there. You shouldn't use them.” That's the kind of stuff that they do.
Cristen: But that’s not all they do!
Caroline: Yeah, if only harassing plumbers were the worst of it. In just the last decade, anti-abortion organizations also managed to get HUNDREDS of new LEGAL abortion restrictions passed in 32 states.
Cristen: How that's happened, and what it's meant for abortion clinics in those states ... after a quick break.
[Stinger]
Cristen: We’re back with Amy Hagstrom Miller of Whole Woman’s Health abortion clincs. Amy has not only had to hustle to secure spaces for her clinics, but she’s also had to fend off relentless legal challenges.
Amy: For decades since the passing of Roe v. Wade, the anti-abortion folks have really been trying to figure out how either to reverse it or to narrow it. And they have challenged Roe a few different times with some big cases you might’ve heard of, basically trying to, you know, chip away at the effectiveness of Roe.
Cristen: Like we mentioned before our last break, that chipping away has happened through HUNDREDS of state laws restricting abortion access in various ways.
Caroline: So how were all those states allowed to do that? Well, today's anti-abortion legal strategy really took off after the Supreme Court decision in the 1992 case Planned Parenthood v. Casey.
Cristen: Here's a clip of Kate Michaelmen, executive director of the National Abortion Rights Action League, or NARAL, reacting to that Supreme Court ruling on PBS Newshour back in 1992
[PBS Newshour clip]
Kate: Well I think when you cut through all the legal technicalities, what we see is the court giving states much more sweeping power to create obstacles for women choosing abortion
Cristen: Casey was the first time the Supreme Court accepted a case challenging Roe v. Wade. At issue was whether it was unconstitutional for Pennsylvania to require married women seeking abortions to provide written consent from their husbands. The majority agreed that, yes, it was unconstitutional, and the Court reaffirmed Roe
Caroline: BUT — and this is a big BUT — the Casey ruling also introduced a slippery measuring stick into abortion law called “undue burden.” Specifically, it said that states could pass new laws regulating abortion as long as abortion restrictions don't present an “undue burden” for women who want to terminate.
Cristen: Here's Kate Michaelmen of NARAL again on PBS Newshour
[PBS Newshour clip]
Kate: I mean, before today a woman could decide. After today, more and more politicians and government can intrude in this decision. I really think it was a devastating blow to women and their freedom of choice...
Cristen: Devastating, indeed. In states across the country, anti-abortion networks set about using that Supreme Court ruling to create two major types of obstacles to abortion access. The first type of obstacles are focused on the patient — things like banning insurance coverage for abortion or enforcing mandatory waiting periods
Amy: The waiting periods are sometimes 24 hours or 72 hours, or they require parental consent or parental notification, or they'll require certain tests that you get like a forced ultrasound that you have to have. And then you have to wait 24 hours and you can't come back until you have - that kind of like restriction on the patient.
Caroline: The other set of barriers? TRAP laws, or targeted regulations on abortion providers. Nearly half of US states have TRAP laws in place, and typically they center around forcing abortion clinics to meet the same standards as same-day surgery centers.
Cristen: Those design standards included wildly specific stipulations for things like hallway widths, HVAC systems, janitor closet drainage ...
Amy: These regulations are targeted against abortion providers specifically and not for other medical providers who provide a similar procedure to abortion. So like if you're doing a colonoscopy in your office, which is like 20 times more risky than an abortion, you don't have to comply with the regulations that they're putting forward for abortion. So they're not regulations based on science or medicine. They're regulations based on people's feelings and beliefs about abortion. But they're sort of couched under this sort of notion that they care about women's health and safety.
Caroline: To be clear: Abortion has a .5% complication rate and is medically safer than having your tonsils removed!!!
Amy: So one of the sort of manufactured sort of falsities about abortion is that it's it's surgery and that it's super risky and then it's difficult and dangerous. Right. Abortion is actually a procedure. It's not a surgery. There's no cutting. There's no incisions. The procedure can be very safely performed in a doctor's office or clinic setting. The actual procedure usually takes somewhere between five and 10 minutes. People can you know, they're ambulatory, they can be awake, they can walk and talk and do just fine afterward.
Cristen: Those scientific facts totally contradict the burdens imposed by TRAP laws. IN FACT! The AMERICAN MEDICAL ASSOCIATION and the American College of Obstetricians and Gynecologists both emphasize that TRAP laws have NO medical benefit.
Caroline: Nevertheless, TRAPs persisted — especially in the Southeast and the Midwest. According to the Guttmacher Institute, between 2011 and 2017, TRAP laws effectively closed down half the abortion clinics in Arizona, Kentucky and Ohio, as well as the two largest abortion providers in Virginia.
Amy: Every one of our clinics at that time, I had six in Texas, was over a million dollars to either retrofit or build a new facility. Keep in mind that we charge about $500 for an abortion. The vast majority of our patients have abortions for economic reasons. And in Texas specifically, they do not have health insurance. And Medicaid doesn't cover abortion. So there's no way. If you think about the health care business side, there's no way for us to recoup that cost.
Cristen: In 2013, the Lonestar State passed its own Texas-sized TRAP law, known as HB2. On top of existing state laws restricting abortion access, HB2 took aim at Texas providers and clinics in three main ways: Number one: No abortions past 20 weeks.
Caroline: Number two: Doctors who perform abortions had to have admitting privileges at a hospital within 30 miles of where the abortion was taking place.
Cristen: And number three: Abortion clinics had to be retrofitted to meet all the safety and design standards of same-day surgery centers we mentioned.
Caroline: In reality, these restrictions can delay or cut off women’s safe access to reproductive healthcare. By requiring clinics to make massive, expensive renovations, they also drive up abortion costs
Cristen: Amy also noticed how TRAP laws tax the patient experience. Pretty pastel walls had to be covered up with sterile white paint, and nurses had to unnecessarily suit up for abortion procedures as if they were entering a surgical theater — kinda like wearing a covid hazmat suit instead of a mask.
Caroline: Not surprisingly, most abortion clinics in Texas weren’t able to comply with the HB2 regulations. For instance, at one clinic, the cost of beefed-up refrigeration and HVAC systems, plus new staffing requirements, made it 40% more expensive to run.
Cristen: So, when HB2 was enacted, it shut down 38 of the state’s 44 abortion clinics.
Amy: And so the effect is the anti-abortion movement has not successfully overturned Roe, but they've made Roe meaningless in more and more communities across the country. So the right to abortion exists on paper. But what does it mean if there's no clinic near you and you can't travel anywhere and you have to wait so many days and and, you know, you can't use your Medicaid? Like, so what? It's an abstract right that actually has no meaning in your your life. That's been their strategy over the last few decades. And it worked for a long period of time, really, until Whole Woman's Health knocked ‘em down in the Supreme Court in 2016.
Cristen: Yeah that’s right, Amy Hagstrom-Miller and her Whole Woman’s Health clinics in Texas weren’t going down without a fight.
Caroline: We’re gonna take a quick break, y’all
Cristen: When we come back, Amy gloves up and goes to Washington … Cue the Rocky theme ...
[Stinger]
Caroline: We’re back with Whole Woman’s Health CEO and lifelong reproductive-rights advocate, Amy Hagstrom Miller.
Cristen: Now y’all, in the intro, we promised you a Supreme Court victory. But before Amy found herself in the highest court in the land, she was wading through HB2’s new building regulations that her Texas abortion clinics had to comply with
Caroline: Now, the woman knows her way around a set of blueprints, but figuring out how and whether her clinics could be renovated to meet the new standards — and what that would all cost — was above her level of expertise. So in 2014, she called up an architect who’d designed abortion clinics before.
Cristen: The architect concluded that adhering to HB2 was implausible. Many Texas clinics were inside small buildings and locations where it would be physically impossible for providers to tack on an addition. Getting clinics up to code would also cost providers millions, and most would likely have to close.
Caroline: Rather than give in and shut down, Amy took that information from the architect and began building a legal case to take Texas and HB2 to court ...
Amy: We were able to show how it had a disproportionate effect on women of color, on rural women and young people. Over 150,000 people of reproductive age had to drive more than 150 miles to get access to abortion. There was a lot of facts that were strong in our case, but the facts came from like horrible things that happened to people in those three years. So it was good evidence for the case. But the the detrimental effect it had in the state of Texas, it basically crumbled the fabric of care for abortion services in the state over that time period.
Caroline: Can y’all say ‘undue burden’?
Cristen: Amy said it … with a lawsuit! Armed with data to prove how HB2 actively harmed women’s reproductive healthcare, Whole Woman's Health sued the state of Texas.
Caroline: And in March 2016, the case made it all the way to the highest court in the land.
[NBC Nightly News clip]
Lester Holt: High drama at the Supreme Court today as the justices took up the biggest abortion case in 25 years. It’s a fight over a tough new Texas law, one that many other states are looking to copy.
Amy: I got to tell you, as we get to the Supreme Court and there's nothing I mean, there's nothing like sitting in the courtroom, which I got to do. And hear our court, our case argued. And hear the liberal justices, y’know, Kagan, Sotomayor, Breyer, Ginsburg, like, quote, the evidence from our case chapter and verse. You know, they had just read it all, and they were just like, “Well, Mr. Texas attorney. So what you're saying is …” And there was a time when, like, Sonia Sotomayor, just like leaned back in her chair and was like, really, you know? And just like watching not only the mastery they had of the evidence, which to me was like so personal. Right. These stories that we had told of the patients that were affected and the clinics that had to be closed and how far people had to drive, but also just seeing them, you know, be able to argue these points so strongly and so powerfully and knowing that that that was our work.
Cristen: In June of 2016, the Court ruled in Amy’s favor. In her concurrence with the majority opinion, Justice Ruth Bader Ginsburg - rest in power - wrote, “It is beyond rational belief that H.B. 2 could genuinely protect the health of women … When a State severely limits access to safe and legal procedures, women in desperate circumstances may resort to unlicensed rogue practitioners … at great risk to their health and safety.”
Caroline: In fact, y'all, RBG herself was never a Roe v Wade stan. She recognized that our constitutional right to privacy is a pretty flimsy legal protection for such a divisive issue. She also understood that not only are abortion rights meaningless without access, but that anti-abortionists could easily figure that out, too, and TRAP accordingly!
Cristen: That’s also why the Whole Woman’s Health ruling in 2016 was such a big fucking deal!
Amy: I'm told it's the biggest, you know, legal win in the reproductive health, rights and justice field in a generation. We were able to demonstrate how this law had an undue burden on people in Texas, that that burden this law put forward, you know, greatly outweighed the benefits. And so we had a huge win on paper. But still to date, we only have 21, I think, or maybe 22 clinics open that provide abortion in the state of Texas because the law effectively shuttered pretty much every rural clinic in the state except my clinic in McCallan. And so even though we had this huge legal win, that law effectively crumbled, still to this day, half of the clinics that provided abortion in the state prior to that.
Caroline: There’s a silver legal lining though. As Amy told us, one of the most significant aspects of the Supreme Court win was that abortion providers in at least a dozen other states have successfully used the precedent set in Whole Woman’s Health v. Texas to either repeal or block TRAP laws from going into effect — including the Supreme Court ruling earlier this year that struck down an extremely similar TRAP law in Louisiana.
Amy: It’s been used in a whole bunch of places. And that's just like incredibly meaningful that our work in Texas could, you know, could could have that kind of life and that are that our case could, you know, you know, be referred to in case law. You know, I had - my niece had her fiancé’s in law school and she called me the other day, she’s like, “He just read your case, like it's part of, like it's in the textbooks,” you know. And, you know, for me, that's it's super personal. For other folks, it's like, you know, one of the big abortion cases. But that stuff is just like, you know, super meaningful.
Cristen: Y’know Caroline, our convo with Amy Hagstrom Miller reminds of something Ruth Bader Ginsburg wrote that was unrelated to abortion. So, in her dissenting opinion in the 2013 Supreme Court case that severely weakened the Voting Rights Act, she quoted Dr. Martin Luther King Jr.: “The arc of the universe is long, but it bends toward justice.” And she added: “but only if there is a steadfast commitment to see the task through to completion.” So for me, at least, I’m just trying to reframe all of my pro-choice anxiety into a steadfast commitment. Like yes, shit is dire. But we have to keep on pushing back.
Caroline: Exactly, and pushing back on every front — not just protesting in the streets, but also in the voting booth, because y’all it’s our state legislators who stand between us and a bunch more TRAP laws.
Cristen: And it’s also our state legislators who are helping anti-abortion crisis pregnancy centers THRIVE. And that’s what we’re tackling in our next episode. Be sure to tune in to find out why crisis pregnancy centers have been springing up all over the place, the services they actually provide … and why it’s so easy to accidentally end up at one.
Caroline: To learn more about Whole Woman's Health, head on over to wholewomanshealth.com or follow Amy Hagstrom Miller on Twitter. She’s @AmyHM.
Cristen: You can find us on instagram, facebook and Twitter @unladylikemedia. You can also support Caroline and me by joining our Patreon; you’ll get weekly bonus episodes, listener advice and more fun at patreon.com/unladylikemedia.
Caroline: Nora Ritchie is the senior producer of Unladylike. Gianna Palmer is our story editor. Shruti Marathe transcribes our tape. Special thanks to Lori Brown for her insight on this episode. Our music is by Flamingo Shadow, Amit May Cohen and Sarah Tudzin. Mixing is by Andi Kristins. Sound design and additional music is by Casey Holford and Andi Kristins. Executive producers are Chris Bannon, Daisy Rosario and Unladylike Media.
Cristen: This podcast was created by your hosts, Cristen Conger
Caroline: And Caroline Ervin of Unladylike Media.
Cristen: Next week … we’ll find out why crisis pregnancy centers outnumber abortion clinics in the US 3 to 1 and how you could easily end up at one..like our guest Beth Vial.
Beth Vial: I realized I was probably in a crisis pregnancy center when I was, like, waiting. And I could see some of the books had some, like, religious leaning titles. And I was like, oh, fuck, I know what this is. Oh, shit.
Cristen: Like, we don't have any treatments, but we do have a lot of prayer.
Beth: Yeah.
Cristen: You don’t want to miss this episode — or any episode this season!! Make sure you’re subscribed to Unladylike. Find us in stitcher, spotify, apple podcasts or wherever you listen to podcasts.
Caroline: And remember, got a problem?
Cristen: Get unladylike. And FIND OUT WHETHER YOUR STATE AND LOCAL LEGISLATORS HAVE SUPPORTED TRAP LAWS AND VOTE THEM THE FUCK OUTTTTTTTTTTTT
