By Claire Carlson for The Daily Yonder.
Broadcast version by Emily Scott for Big Sky Connection reporting for The Daily Yonder-Public News Service Collaboration

Reproductive rights activists who are fighting abortion restrictions in Montana say new state laws will have a disproportionate impact on reproductive care in rural communities.

The laws, currently awaiting a Montana Supreme Court decision, prohibit abortions after 20 weeks, require providers to offer ultrasounds to patients, and prohibit medication abortions via telehealth and mail prescriptions.

The telehealth and mail-prescription bans could have the biggest direct impact on the state's dispersed and remote rural populations, but all three laws work together to limit abortion services statewide, especially for underserved and rural populations, abortion rights advocates say.

"Each of these bills have their individual impacts, but together, they do what I call the 'squeeze,'" said Martha Stahl, CEO and president of Planned Parenthood of Montana. "They work together to make it a much more difficult process to access care early in pregnancy, which, for abortion patients, is something that people need in a timely manner."

Republican Governor Greg Gianforte signed four abortion bills into law in April. The only one currently in effect prohibits health insurance plans that are covered by the state's health insurance exchange from paying abortion expenses.

Planned Parenthood of Montana is suing the state of Montana over the bills, arguing that they breach Montanans' constitutional right of privacy.

"Legal precedent exists in a couple of places that actually show the court's belief that that right to privacy is directly applicable to access to sexual and reproductive care and to abortion," said Stahl.

District Judge Michael Moses put the three laws on hold just hours before they would have gone into effect in October to give the court time to consider Planned Parenthood's legal challenge.

The bill that most clearly affects rural communities is HB 171. Medication abortion by mail and telehealth consultation is often the only way an abortion seeker can receive care if they live in remote areas and don't have the ability to travel long distances for medical care.

However, abortion providers do recognize that this option doesn't guarantee access for everyone.

"Telehealth isn't always the amazing solution that it seems for rural America, simply because people's lack of broadband can get in the way," said Stahl. "But now that providers can actually bill insurance for these services, it really has changed the face of access for a lot of folks."

Telehealth services also include site-to-site patient care, which allows a patient to go to their nearest health center and connect via telehealth with an abortion clinic elsewhere to be prescribed medication abortion. This brings telehealth to people without broadband, but along with medication abortion by mail, this site-to-site patient care would also be banned under HB 171.

According to Planned Parenthood, medication abortion provides two medicines: mifepristone and misoprostol. These pills are taken within two days of one another and induce cramping in the uterus, creating a process similar to an early miscarriage. In Montana, medication abortion can be given up to 11 weeks after the last day of the person's period. The process is safe, effective, and common.

Between July 1, 2020 and June 30, 2021, Planned Parenthood of Montana provided 935 medication abortions and 255 procedural abortions, according to data from the organization. Of these medication abortions, 140 were direct-to-patient, meaning they were mailed. Had these patients been required to show up in person, 56% would have had to drive one to two hours one-way to reach the clinic, and 18% would have had to drive two to five hours one-way, according to Planned Parenthood.

In a state as large as Montana, being required to drive to a clinic can be a significant obstacle, which is why many patients use telehealth and direct-to-patient mailing services. Snow and icy road conditions in the winter can make drives even longer, which is another reason abortion providers say telehealth services have revolutionized abortion access for rural communities in the state.

There are just three abortion providers in Montana: Blue Mountain Clinic, All Families Healthcare, and Planned Parenthood. Their clinics are primarily concentrated in the western part of the state, which means that if patients were required to drive to an abortion clinic for in-person care, those living on the far eastern side of Montana could be forced to travel between seven and eight hours one-way.

(The Daily Yonder driving-time analysis at the top of this article is based on Google Maps estimates, which do not account well for terrain or road conditions in many rural areas. The Daily Yonder found that residents of eastern Montana were likely to drive five to 10 times longer to reach abortion services than residents of unserved counties in western Montana.)

By banning direct-to-patient medication abortion by mail and site-to-site care, people in rural areas without reliable transportation are left with few options.

This is where support from abortion organizations like the Susan Wicklund Fund can help.

The Susan Wicklund Fund is one of only two abortion funds providing financial support to people in Montana - the other is Indigenous Women Rising's fund, which supports Indigenous and undocumented people. Both of these funds rely on donations, usually from individuals, and the Susan Wicklund Fund is fully volunteer-run.

According to Kate Kujawa, chair of the Susan Wicklund Fund, the organization provides their callers with support with transportation costs and medical expenses. The fund provides support to anyone in Montana, even if they travel out of state to go to an abortion clinic. Activists say this might become increasingly common, even if the bans aren't enforced.

"We wouldn't be shocked if privacy and medical privacy is stripped in Montana," said Kujawa. "And if that happens, we do believe that abortion will become harder to obtain, and at that point, we are prepared to help people get out of state or out of country depending on what is easiest and best in order to help them retain their access to choice."

If the bans do go into effect, Kujawa believes they will only magnify financial and social disparities between abortion seekers. "If you don't have access to a car, if you can't coordinate childcare with family or friends, you're really just left without options," said Kujawa.

Requiring in-person care isn't the only issue activists believe will affect rural communities.

Stahl, of Planned Parenthood, is also concerned about HB 171's requirement for abortion providers to make public the demographics of their patients. The law would require clinics to report the patients' age, race, and number of previous pregnancies.

"If you think about Montana that has rural counties of less than 1,000 people, [being able to identify] a patient who's, say, been pregnant three times and is 24-years-old is not going to be that difficult for the people living in that county," said Stahl.

While HB 171 has the most direct impact on rural communities, all three bans work in concert to restrict rural access, according to Stahl. HB 140 requires in-person appointments so people can be given the opportunity for an ultrasound, and HB 136's 20-week ban decreases the amount of time a person has to get an abortion. If a person has to get an abortion before they are 20 weeks pregnant and they are required to drive to multiple appointments across state for in-person care, the process is challenging.

Some argue that complicating this process is the goal for Republican lawmakers who are closer to restricting abortion in Montana than they have been in years. This is thanks to Republican Governor Greg Gianforte, who was elected in 2020 after 16 consecutive years of Democratic governors.

"Republicans have the majority and are using these abortion access restrictions to demonstate their power and to fire up their voting base," said Helen Weems, nurse practitioner of All Families Healthcare, one of the three abortion providers in Montana, in an email.

Supporters of the bills believe these restrictions are a step in opposing Planned Parenthood as a whole, which has long been targeted by anti-abortion Republicans. Along with abortion services, Planned Parenthood provides other affordable reproductive health services - many to low-income or underserved communities - such as STD screening, contraception, and preventive reproductive care.

A state lawmaker who supports the restrictions said the measures would not affect health care services for rural areas.

"How can you call aborticide a health issue?" said state Representative John Fuller (R-8) from Whitefish, in northern Montana. "Banning aborticide through mail or through telehealth is not reducing health care to rural America [or to] rural Montana."

Reproductive rights activists say that these bills wouldn't stop abortion but would only stigmatize the procedure and put undue burden on low-income and rural communities.

There is no end date to the court injunction that halted the bills in October, which means that until the Montana Supreme Court makes a decision, abortion seekers won't face the restrictions the bills would enact.

"These laws do not represent the will of the majority," said Weems. "We will keep fighting and keep caring for our patients. We aren't going anywhere."

Claire Carlson wrote this article for The Daily Yonder.



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New Mexico saw record enrollment numbers for the Affordable Care Act this year and is now setting its sights on lowering out-of-pocket costs - those not reimbursed by insurance. More than 56,000 New Mexicans are enrolled in a medical health insurance plan on the state exchange - an increase of 12,000 people overall.

Colin Baillio, deputy superintendent with the state's Office of Insurance, said the state has boosted its outreach and made efforts to improve the overall consumer experience.

"We saw a 40% year-over-year increase, and New Mexico saw the biggest percentage increase during the open-enrollment period among all of the state-based marketplaces," he explained

Part of the enrollment increase is due to what's called the "unwinding" - a federal directive that required all states to redetermine Medicaid eligibility following a three-year pause on checks during the COVID pandemic. He said by using expanded tools made available by the federal and state government, 8% of New Mexico's population is now uninsured - down from 23% in 2010.

Following approval by lawmakers in the 2024 legislative session, the New Mexico governor signed seven health care-related bills into law - one of which requires annual reporting of prescription drug pricing. Baililo said the Affordable Care Act built the foundation that has allowed the state to pursue additional affordability initiatives.

"I'm really glad to see that there's so much interest in the next step of health reform, really leaning into these out-of-pocket cost issues and making it easier for people to afford to stay covered and see their doctors," he continued.

Two years ago, the state also passed a one-of-a-kind law that did away with behavioral health co-pays for people in certain insurance plans.

New York's medical aid-in-dying bill is gaining further support. The Medical Society of the State of New York is supporting the bill. New York's bill allows terminally ill people with only six months to live to use this option, with safeguards requiring two physicians' approval.

The bill's Assembly sponsor Amy Paulin, D-Westchester, said despite the growing support, other hurdles lie ahead.

"Now we have what I believe, if it came to the floor, a majority. There's still a hesitation on the part of leadership. You know, we need members to assure leadership that they no longer have reservations," she said.

Other newly resolved concerns center on making sure insurance companies and doctors who don't support this aren't held liable. She's optimistic the bill will pass after nine years in the Legislature. New York would be the 11th state along with Washington, D.C. to have medical aid in dying legislation.

Corinne Carey, senior New York campaign director with Compassion and Choices finds the pandemic drew a vivid picture of a person's end-of-life experience. There were images of people dying on ventilators, apart from loved ones, and unable to communicate. She said people began thinking about a "good death."

"And, what is a good death is being surrounded by loved ones, having some measure of control, experiencing the touch of your loved ones, and being the one in the driver's seat," she explained.

Now people have different options for end-of-life care, each of which presents various challenges. Polls show medical aid in dying has garnered considerable support since being introduced in 2015. A 2022 Compassion and Choices poll finds 57% of nurses support medical aid in dying professionally, although fewer support it personally.

The California State Assembly is considering a bill to require schools to have a cardiac arrest response plan. Assembly Bill 2887 would make sure schools update their safety plans to include CPR training and an automatic external defibrillator or AED onsite.

Dr. Stephen Sanko, a professor of clinical emergency medicine at USC, and a founding member of the Cardiac Arrest Survivor Alliance, is a volunteer expert for the American Heart Association. He said having a plan in place is critical.

"The American Heart Association is promoting that schools have a cardiac arrest response plan. A written protocol for what to do in order to decrease the likelihood that if somebody collapses, that they die," he said.

Two years ago, 15-year-old Cash Hennessy collapsed on the football field due to a previously unknown heart defect. Two off-duty medics in the stands gave him CPR. The school brought out its AED - but it was useless, because the batteries were dead.

Hennessy said the experience was traumatic.

"I feel blessed that I had people there for me, that could give me C-P-R. But I think about if those people weren't there and that was another kid, who knows what would have happened? Because there wouldn't have been an AED to save them," he explained.

An AED walks people through the steps to deliver a life-saving shock to a person's heart until an ambulance arrives. Studies show that 70% of kids who suffer sudden cardiac arrest at school recover if an AED is deployed correctly - whereas the survival rate for kids and adults not in the hospital is less than 12%.