What’s going on with abortion? Most of the action is happening in the states.

Good morning. Since President Trump took office, the biggest changes to abortion policy have happened at the state level.

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TODAY’S STARTING POINT

Talk about abortion dominated the 2024 election. Kamala Harris promised to restore Roe v. Wade‘s protections and warned that Donald Trump would ban abortion nationwide. Yet since Trump took office, abortion policy has largely taken a back seat, with no new federal laws or major policy changes restricting access.

But things are happening at the state level. In some ways, it’s pretty much as the Supreme Court’s 2022 decision overturning Roe predicted: Blue states are expanding abortion access and red states are restricting it. Yet legal disputes between states also suggest that the implications of Roe‘s demise remain unsettled nearly three years later.

“This is still uncharted territory,” said Ingrid Duran, who tracks state-level abortion-related bills for the National Right to Life Committee, an antiabortion group. Today’s newsletter explains four broad ways in which state abortion laws are changing that you might have missed.

What constitutes an ‘emergency?’

After Roe fell, Republican-controlled states passed abortion bans that would punish doctors — with fines, loss of their medical license, even prison — for violating them. But some of those laws were written ambiguously. Women suffered illness , risked infertility , or died after doctors, fearing legal penalties even in medical emergencies, delayed or denied pregnancy-related care.

Antiabortion activists like Duran argue that such cases reflect “a misinformation campaign” from the laws’ opponents. Yet last week, the Texas Senate unanimously passed legislation aimed at clarifying when doctors can perform abortions under the state‘s strict ban.

Texas isn’t alone. Kentucky Republicans enacted a bill in March that listed emergencies in which doctors can legally terminate pregnancies, overriding the Democratic governor’s veto . And last fall, South Dakota released a video meant to clarify emergency exemptions, although some physicians say the rules are still too ambiguous and such medical decisions should be left to doctors.

Targeting ballot initiatives

The 2024 election revealed a surprising pattern: Red states that voted for Trump also voted for ballot measures to protect abortion access. Some Republicans are now trying to undo or preempt their own voters’ efforts to protect abortion.

Last November, about 52 percent of Missouri voters backed an amendment to the state constitution protecting abortion access until fetal viability (about 24 weeks of pregnancy), reversing that state‘s near-total ban. But Republicans lawmakers are now working to overwrite it by placing a new amendment on the ballot .

Their proposal would once again ban almost all abortions in Missouri. Yet the summary language that would appear on the ballot doesn’t explicitly mention a ban , instead asking Missourians if they support “women’s safety during abortions” and allowing “abortions for medical emergencies, fetal anomalies, rape, and incest.” If the state senate approves the measure, it could appear on ballots next year.

Other Republican-dominated states seem to be trying to prevent future abortion-related ballot measures from ever passing. Some Idaho GOP lawmakers favor requiring more signatures for initiatives to appear on the ballot. In South Dakota, some Republicans want to raise the threshold to pass a ballot measure from a simple majority to 60 percent .

Abortion pills

Most abortions in the US today happen not via a medical procedure, but by using medication that doctors prescribe. Women can get them at a pharmacy or through the mail to take at home. “That access is really important,” said Anna Bernstein of the Guttmacher Institute, a research organization that supports abortion rights, “especially in areas where brick-and-mortar clinics aren’t accessible.”

Peer-reviewed studies have repeatedly found that the pills, called mifepristone and misoprostol, are safe and effective. The FDA approved mifepristone a quarter century ago, and the Supreme Court preserved access to it last year. Yet some Republicans claim that the pills are dangerous.

According to Guttmacher, 28 states restrict access to the pills. Attorneys general from Idaho, Kansas, and Missouri are suing the FDA to further limit access, including by barring patients from getting mifepristone via telehealth. The administration is set to file a brief in that case today.

Interstate fighting

Abortion pills have also triggered unresolved legal wrangling between states.

In January, Louisiana accused a New York-based doctor of breaking its abortion ban by prescribing pills to a Louisiana patient. But New York is one of several states — including Massachusetts — with “shield laws,” which protect providers who prescribe and mail abortion pills into states with abortion bans. New York has refused to extradite the doctor.

The impasse will likely lead to court battles testing the shield laws’ legality, which could eventually reach the Supreme Court.

What’s next?

Under Republicans this year, the federal government has so far played a limited role on abortion. The Trump administration has rolled back modest Biden-era efforts to protect access, and Republicans’ narrow majorities make it unlikely that Congress will pass a nationwide abortion ban. Some lawmakers want to strip Medicaid funding from Planned Parenthood in a party-line bill, but a similar effort failed during Trump’s first term.

Yet both proponents and opponents of abortion access think there‘s more the federal government could do. Besides the pending mifepristone case, Guttmacher’s Bernstein argues that the administration’s efforts to freeze federal grants — and the other Medicaid cuts that congressional Republicans are weighing — would hamper abortion access.

“Even without an abortion ban through Congress, there‘s a lot of ways that they can really decimate access,” Bernstein said. “ We expect this administration to continue to use all avenues that they can.”

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