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It's been four years since the Supreme Court overturned Roe v. Wade, ending the constitutional right to abortion.
"Roe was egregiously wrong from the start," Justice Samuel Alito wrote in the Dobbs v. Jackson Women's Health majority opinion on June 24, 2022. "And far from bringing about a national settlement of the abortion issue, Roe and [Planned Parenthood v.] Casey have enflamed debate and deepened division."
Reversing Roe didn't calm debate or heal division. A confusing patchwork of state laws began to take shape hours after the Supreme Court ruled — which was, perhaps, predictable. States had passed "trigger laws," ready to restrict abortion as soon as the high court allowed.
But other developments have been surprising, including the role of the internet and the mail in increasing access to abortion, even in those very same states. This year, voters will again consider ballot measures to protect or restrict abortion access across the country. Dramatic stories of medical care denied to pregnant patients continue to unfold across the country.
Here are four things to know about the state of abortion access in America today.
1. The number of abortions continues to rise
You might have guessed that when more than a dozen states banned abortion, there would be fewer abortions happening in those states and that the overall number of abortions would go down.
That's not what has happened. The number of abortions nationally has increased each year since the national right to abortion was overturned.
Part of the reason is that access has become easier in states that support abortion. Policy changes have allowed more residents of those states to have abortion access without barriers like waiting periods or parental permission requirements. These lowered barriers have helped people who live in restrictive states to travel for care.
"Shield laws" have also emerged as a major force in the abortion access landscape. States that support abortion access have created legal shields to allow clinicians to provide abortion to residents in states with bans, even without patients traveling. Clinicians can prescribe medication abortion via telemedicine — online or over the phone. Pills can then be mailed or picked up at local pharmacies.
That's led to the surprising fact that the number of abortions in states with bans have actually increased in recent years, as telemedicine abortion has grown. And this has not escaped Justice Alito's notice.
"What is at stake is the perpetration of a scheme to undermine our decision in Dobbs," Alito wrote in a recent dissent related to abortion pills, "which restored the right of each state to decide how to regulate abortions within its borders."
2. Anti-abortion politics have gotten complicated
President Trump is pulled in two directions on the issue of abortion. His appointees to the Supreme Court overturned Roe vs. Wade, a huge victory for conservatives, but he and his administration have become notably quiet on the issue in this midterm year. Why? The coalition that elected Trump in 2024 included independent voters, who support abortion rights.
Meanwhile, anti-abortion politicians and activists want to see more action to restrict abortion, like reviving the Comstock Act. That's the 19th century law that says you can't use the mail to send "obscene" materials including pornograpy and "every article or thing designed, adapted, or intended for producing abortion." If enforced, it could create a de facto national abortion ban without requiring Congress to pass a new law.
Last month, Justice Clarence Thomas asserted in his dissent to the abortion pill case that the Comstock Act was in force and that drug companies manufacturing and distributing FDA approved medications were therefore engaged in a "criminal enterprise."
And states are also actively pursuing more restrictions, including bills that would charge women who get abortions with homicide. Texas passed a law that allows private citizens to sue out-of-state prescribers of abortion pills for $100,000. Louisiana scheduled mifepristone and misoprostol, the two medications used for abortion, as controlled substances.
Louisiana also is suing the Food and Drug Administration, aiming to force the agency to roll back the rules change that allowed telemedicine access to mifepristone. That case is likely headed for the Supreme Court. If the justices decide the case in Louisiana's favor then mifepristone would no longer be available via telemedicine nationally. Other lawsuits against mifepristone are also pending.
3. Supporters say abortion pills are "unstoppable"
Abortion rights advocates are pushing beyond the status quo, too. Researchers at University of California San Francisco recently published a study examining the feasibility of making abortion medication available over-the-counter in the U.S., no doctor's appointment or prescription needed. A Planned Parenthood affiliate started offering abortion medication to patients who aren't pregnant, to keep at home in case they need it. And telemedicine abortion providers have contingency plans to be able to continue sending misoprostol alone through the mail even if access to mifepristone is restricted.
The post-Roe era has seen some closures of brick-and-mortar reproductive clinics that offer abortion, in part because Republicans in Congress withheld millions of dollars for Planned Parenthood and other organizations that provide abortion in 2025. Efforts to maintain access to in-person abortion care include training more primary care physicians to offer abortion, and turning to health facilities like urgent care clinics to fill in gaps.
In the meantime, the use of medication abortion continues to grow. "Abortion pills are everywhere, they're safe, they're effective, and they're pretty much unstoppable," Elisa Wells of Plan C, a website about medication abortion, told NPR last month. "The genie is out of the bottle."
4. Privacy and stigma around abortion are evolving rapidly
Abortion was legal for nearly 50 years under a right to privacy based in the constitution. In the first trimester, according to the majority opinion in Roe, "the abortion decision and its effectuation must be left to the medical judgment of the pregnant woman's attending physician."
Ironically, since that right has been revoked, women can have abortions in far more privacy than was possible under Roe. Patients can fill out an online form and have abortion pills delivered to their homes, avoiding protesters that still gather outside some reproductive health clinics. At the same time, people embrace talking freely about the experience, eschewing shame, with hashtags like #ShoutYourAbortion.
Some women who have shared their own painful stories about being denied medically necessary abortion and miscarriage care have become public figures. Samantha Casiano, whose story was first reported by NPR, was pregnant for months knowing that her baby wasn't going to survive, and went on to testify in court and be featured in a documentary about the consequences of Texas' abortion ban.
As more and more people have shared their stories, that's had a snowball effect — it empowers more people to speak out. Kate Cox appealed to the Texas Supreme Court for access to abortion while pregnant. Her picture was in the news as she was living through a pregnancy complication and seeking help. In the end, Texas denied her request, and she traveled out of state for an abortion.
Still, the increasingly online experience of seeking abortion also opens up new privacy issues. Just months after the Dobbs decision, police in Nebraska used Facebook messages to bring felony charges in a successful case against a woman who gave her teenage daughter abortion pills. And many Americans track their periods in apps that have raised concerns among privacy experts.
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