A Citadel of Choice

The text message simply read, “Fuck Texas.” Rebecca Cohen looked up from her phone, took a sip of her chai latte, and said, “I get a lot of these in my line of work.” Still, Cohen, a Denver OB-GYN, thought this particular expletive, received in mid-February, might’ve been about more than another pregnant person being denied health care in the Lone Star State. The 42-year-old abortion clinician pulled up Google. “I wonder if maybe the mifepristone ruling came through,” she said.

Cohen searched for a breaking news story detailing whether a Donald Trump–appointed Texas judge had decided to force a major abortion drug off the market despite longtime Food and Drug Administration (FDA) approval and a 23-year safety record. “If the judge bans mifepristone,” Cohen said, “it would be baseless and inappropriate, but appeals would go to the conservative Fifth Circuit Court of Appeals and then to the Supreme Court, which is, of course, what they want.”

5280 June 2023
More From The Issue

Her emphasis on the word “they” was a not-so-subtle reference to the American anti-abortion movement that has, over the past 22 months, made significant progress in restricting the practice across the country. That momentum includes the U.S. Supreme Court overturning Roe v. Wade, the 1973 landmark decision that, for 50 years, had protected an American’s freedom to have an abortion. The reversal of Roe in June 2022 led to trigger laws and legislative action at the state level, which resulted in a U.S. map where 14 states have banned the practice and others have enacted varying levels of restrictions.

The Texas case, Alliance for Hippocratic Medicine v. FDA, which wasn’t ruled upon until early April, did ultimately become the most consequential anti-abortion win since Roe fell. The decision, which would’ve amounted to a ban, was immediately appealed by the FDA. A subsequent ruling by the Fifth Circuit Court of Appeals did not remove mifepristone from the U.S. market, but it put into question future access to a medication used in roughly 54 percent of abortions in this country each year by rolling back policies the FDA had put in place to expand access to the drug. Also in early April, a judge in Washington state ruled in another lawsuit that the FDA must keep the drug available in certain states, including Colorado. The discordant decisions, plus the Justice Department’s distaste for the Texas ruling, sent the question of mifepristone’s availability to the U.S. Supreme Court. On April 21, SCOTUS said mifepristone could remain on the market with the FDA’s current policies in place as appeals proceed. That decision sent the question back to the Fifth Circuit, where, at press time, arguments were scheduled to have begun on May 17. Experts suggest that the losing party will undoubtedly appeal, once again sending the case to SCOTUS. Whatever happens, the banning or restriction of mifepristone could have even further-reaching consequences than the repeal of Roe—consequences that could disproportionately affect Colorado, as the need for surgical abortions would likely increase.

Photograph by Rachel Woolf

Colorado is one of only 15 states generally considered to be protective of reproductive rights, so rulings at the federal and state levels have had an outsize impact here. Nearly encircled by neighbors that have limited, if not outright denied, abortion, the Centennial State has not only continued its history of serving those who need care regardless of their home addresses (the state was the first to decriminalize abortion in 1967), but it has also further burnished its position as a beacon of choice.

In the months after the passage of Texas’ 2021 Senate Bill 8—a law that banned abortions except in the earliest weeks of pregnancy and set up a bounty system in which Texans could sue other Texans for aiding those who receive abortion care anywhere—the Colorado Legislature guaranteed abortion access for Coloradans by passing the Reproductive Health Equity Act, and Governor Jared Polis issued an executive order to protect out-of-state patients and Colorado providers alike from prosecutions in other states. Then, after Dobbs v. Jackson Women’s Health Organization reversed Roe, Colorado legislators passed a triad of bills—the Safe Access to Protected Health Care package—in April 2023. The measures prohibited deceptive practices at pregnancy crisis centers; created a shield law for abortion providers and patients; and forced an increase in insurance coverage for reproductive health care.

The governor and the Legislature don’t operate independent of influence, though. They’ve been prompted to act by Coloradans who have not only seen the in-real-life aftermath of the Texas law and the fall of Roe, but who are also trying to provide Colorado-based solutions to Americans who have become refugees from their home states. Doctors, midwives, nonprofits, reproductive rights advocates, and everyday folks in the Centennial State—a place where voters have consistently protected the right to abortion—have been working over the past two-plus years to ensure that abortion care endures and that it’s as accessible as possible to those who need it. Here’s what they’ve been up to and what they think you need to understand.

Fragile State

A by-the-numbers breakdown of abortion in Colorado.

13,856: Abortions performed in Colorado in 2022

2,345: Texans who received abortions in Colorado in 2022; that number accounts for 60 percent of all out-of-state abortion patients. Rounding out the top three: Nearly 300 patients came from Wyoming, and almost 200 came from Oklahoma last year. (For context, only 35 Oklahomans traveled to Colorado for abortions in the three previous years combined.)

82: Percentage of abortions performed in Colorado in 2022 that were at 10 weeks or fewer in gestation

170: Late abortions, loosely defined as abortions after 20 weeks, performed in Colorado in 2021

487: Late abortions performed in Colorado in 2022; that accounts for four percent of that year’s 13,856 abortions

85: Percentage of Colorado’s 2022 abortions that were performed by Planned Parenthood of the Rocky Mountains

14: Percentage of Planned Parenthood of the Rocky Mountains’ Colorado health care services that involved abortion care before the repeal of Roe; that percentage is now hovering at 22

13.5: Percentage of 2021’s 11,580 abortions that were performed in Colorado on non-Colorado residents

28: Percentage of 2022’s 13,856 abortions that were performed in Colorado on non-Colorado residents

20–24: Patient age range that represented the most abortions in Colorado in 2022, at 31.5 percent

The Definition of Sanctuary

The laws and protections that make Colorado a haven.

  • Abortion is not restricted based on gestational age.
  • Qualified health care professionals—not just physicians—can perform abortions.
  • The 2022 Reproductive Health Equity Act codified a person’s right to use or refuse contraception and to continue or end a pregnancy; the act declared that a fetus does not have independent rights under state law.
  • The state provides protections from harassment and physical harm for anyone entering an abortion clinic.
  • Passed in April, the Protections For Accessing Reproductive Health Care bill protects patients, providers, and assistors of politically targeted health care—including abortion—from interstate criminal justice threats. This bill shields these individuals from criminal prosecution and imprisonment; court summons, subpoenas, and arrests; interstate investigations, divulging information, or assistance with investigations; and professional delicensing.
  • Passed in April, the Deceptive Trade Practice Pregnancy-related Service bill makes it illegal for so-called pregnancy crisis centers—which are typically anti-abortion—to falsely advertise that they provide abortions, emergency contraceptives, or referrals for abortions if they actually do not.
  • Passed in April, the Increasing Access To Reproductive Health Care bill requires most health insurance plans to cover the cost of medication abortion.

Those Who Can Least Afford It

For some, the cost of traveling to get an abortion can mean forgoing the procedure—unless they find assistance.

Amanda Carlson grew up in rural northern Colorado, where having extra anything is rare. Today, Carlson says understanding financial hardship helps her relate to the clients she serves as the director of Cobalt Abortion Fund, Colorado’s largest independent provider of financial assistance to those seeking abortions. “It’s hard for people to understand that not everyone has a credit card,” she says. “Many of the people we help need help with everything. They sometimes can barely afford food, but the state where they live thinks they can somehow afford to have a child.”

Funded entirely by donations, Cobalt Abortion Fund’s coffers had, since 1984 (when it was called the Women’s Freedom Fund), mostly been directed toward assisting people with the cost of abortion procedures—and most of those people were Centennial Staters. “Texas’ SB 8 law was a litmus test for us,” Carlson says. “Colorado was inundated with Texans. Around that time, we also realized that Roe could actually fall, so we made a decision to shift more heavily into practical support.”

When the Supreme Court did overturn Roe, Cobalt Abortion Fund’s caseload tripled in fewer than 24 hours, which is perhaps not surprising considering recent national surveys that suggest 57 percent of Americans cannot afford a $1,000 emergency expense. “We were getting 25 to 30 requests a day at that time,” Carlson says. Nearly overnight, staffers at the fund became personal concierges, assisting those who needed abortion care but could not afford to travel to Colorado with airfare, hotel stays, and DoorDash gift cards. In 2021, the fund spent $6,054 on practical support; that number exploded to $221,881 in 2022. “The challenges these folks face speak to larger injustices in society,” Carlson says. “The barriers really should elicit compassion.”

Financial Barriers

  • Medication abortion: $400–$800
  • Abortion procedure in first trimester: $600–$800
  • Abortion procedure in second trimester: $715–$2,000
  • Abortion procedure later in pregnancy: $10,000–$25,000
  • Average domestic round-trip airfare: $384
  • Average nightly stay at a Denver-area hotel: $160–$180

Situational Barriers

  1. Some health insurance plans don’t cover abortion, especially out of state.
  2. Many people seeking abortions already have children, which can mean incurring childcare costs while one or both parents are traveling.
  3. Some procedures take two or three days to complete, meaning travel expenses can double or triple.
  4. Many employers do not offer vacation policies; one missed shift can mean the loss of a job.
  5. Those who need financial assistance have often never been on an airplane.
  6. Abortion funds do not cover lost wages.
  7. Even if driving to Colorado were an option—which sometimes it’s not, based on available procedure appointments and gestational time frames—many people do not have their own vehicles.
  8. Finding help in languages other than English can be next to impossible.
  9. Not having citizenship documentation or a state-issued ID can make interstate travel precarious.
  10. Abusive or controlling partners can make out-of-state travel difficult for those experiencing domestic violence.

Fund Finding

The National Network of Abortion Funds exists to connect people who have unwanted or unviable pregnancies with organizations that can help offset the financial outlays. The network suggests calling your insurance carrier to see if it covers some costs; making an appointment at a clinic and letting clinic staffers know you’re looking for financial assistance; determining what you can cover for the procedure and for travel on your own; searching for abortion funds in the state where your procedure will take place as well as any funds that might exist in your home state, if it’s not the same; and searching for abortion funds that provide assistance nationwide. In Colorado, Cobalt Abortion Fund, the Colorado Doula Project, and the Boulder Valley Women’s Health Center offer varying levels of financial assistance and practical support.

It’s Complicated

Since 1975, Boulder Abortion Clinic has served as a refuge for the desperate. Today’s despair is even more palpable.

Bullets ripping through his office windows. Stalkers creeping around his house. Protestors scaring his patients. Anti-abortion groups putting his name on hit lists. Dr. Warren Hern has experienced it all since he began performing abortions in Boulder in 1973, the year of Roe v. Wade. Five decades later, the 84-year-old says he’s undeterred. “Every day that I do this work,” he says, “I feel more committed to it and see it as a critical need for women.”

As a physician who will perform an abortion into the third trimester, Hern is an outlier among outliers. He is one of only a handful of U.S. doctors capable of delivering the complex medical treatment necessary for a late abortion. For decades, that has made him a hero to those who find themselves in tragic situations: wanted pregnancies that have been found to have catastrophic fetal anomalies or complications that are threatening the lives of the mothers. Pregnancy, Hern explains, is not a benign condition. “Women die from pregnancy,” he says.

Photograph by Rachel Woolf

For two reasons, Hern says, that has been his biggest concern since the passage of SB 8 in Texas and the trigger bans that went into effect after the repeal of Roe. First, without easy access to abortion services in their states and with long wait times at health clinics in unrestricted states, Americans with undesired or unviable pregnancies are struggling to schedule abortions in the first trimester, when the procedure is comparatively safe and easy. “The more advanced the pregnancy,” Hern says, “the greater the risk to the woman’s life.”

Hern’s second worry is that the restrictions and bans have hindered physicians’ abilities to do their jobs when a pregnant person’s life is in danger. “[These laws] mean that women cannot get basic medical care for pregnancy,” Hern says. “If a woman has ruptured membranes at 16 to 20 weeks in any pregnancy, for example, her life is at immediate risk, and her pregnancy must be terminated immediately. There is no justification for this not happening. The laws across the country now prevent doctors from performing this relatively simple life-saving operation.”

In February and March of this year alone, Hern says he and his staff cared for several out-of-state patients who had to travel to Boulder to receive adequate care. The issue, of course, is that Hern cannot practice forever. Although he says he has no plans to stop working, he’s already well past the average retirement age for American physicians.

Hern, however, is planning for the future. He has already recruited and trained two OB-GYNs who work regular hours at the clinic—and he’s looking for others to join his practice. Hern is also hoping to expand his facilities and office staff to meet the increasing demand from patients from other states in a post-Roe world. “I love my work,” the veteran doctor says, “but I am trying to work myself out of a job”—while still making sure pregnant Americans have a place to turn.

Anatomy Scan

For expectant parents, the 20-week ultrasound is a big one. It’s the first image where the parents-to-be can count all the fingers and toes—as well as have the doctor check for anomalies. Things like heart conditions, missing limbs, abnormal brain development, and genetic conditions can be diagnosed at roughly 20 weeks. Each year, about 120,000 American babies come into the world with birth defects, many of which are treatable and/or are unlikely to dramatically affect the child’s lifespan or quality of life. However, there are dozens of fetal anomalies that can only be detected at the 20-week ultrasound—or later—that could cause someone to consider ending a pregnancy. With the restrictions and bans that are currently in place, pregnant people in 26 U.S. states can find out their baby has a disastrous birth defect later in pregnancy but are then required to go through labor and delivery anyway. “The highly successful national assault on reproductive rights is cruel, stupid, medieval, and catastrophic for women across the board,” Dr. Warren Hern says.

Legal Doctrine

For 50 years, most Americans believed the right to an abortion was settled law. Most Americans also think that equal protection, as ruled by Brown v. Board of Education in 1954, is permanent and that innocence until proven guilty, buttressed by Taylor v. Kentucky in 1978, is here to stay. “Based on what the Supreme Court did with Roe,” says Dani Newsum, director of strategic partnerships for Cobalt, a Colorado-based reproductive-rights advocacy group, “we’d be crazy to think they won’t trash other ‘settled law.’” In the wake of the Dobbs v. Jackson Women’s Health Organization decision, Newsum is concerned about one liberty in particular: the freedom of movement between states, which was defined by Corfield v. Coryell as a constitutional right in 1823 and again by Crandall v. Nevada in 1868.

Why worry about a right that’s been accruing precedent since James Monroe was president? “Because states like Missouri and Oklahoma have already tried to pass laws that attempt to exert jurisdiction over you and your provider wherever you are,” Newsum says. “They are trying to extend state laws beyond their borders.” That, Newsum says, makes her wonder why, for example, states where cannabis is illegal have not tried to pass laws preventing their residents from traveling to Colorado to smoke weed. “It’s a concern,” she says, “that Americans could lose the right to travel freely, simply because some people want to exert control over women and don’t want them to travel to receive what should be considered basic health care. It hasn’t happened yet, but it could.”

Plane Old Resistance

Elevated Access is a 14-month-old, Illinois-based nonprofit that harnesses a network of 350 volunteer pilots to provide no-cost access to abortion and gender-affirming care, no matter where patients live. Roughly six percent of the organization’s pilots live in and fly from Colorado. 5280 spoke with Charles,* who uses his personal jet to fly volunteer missions, about why he feels called to ferry people from (typically) the Deep South to the Centennial State.

“I was interested in Elevated Access because I think, for me, there’s a marriage of an important mission and my unique capability to help. First, we have a bunch of people in this country trying to remove rights. These are often the same people in the same political party that purports not to like the Chinese government’s way of life, yet that party is taking away rights from Americans. They’re using anti-democratic methods to do things that are not in the will of the people. This kind of care—abortion care—is wildly popular. Most Americans believe it should be legal. Second, people deserve access to health care. Women particularly. Not just white men like me. I understand that me flying one person to get health care is a drop in the bucket, but then again, that’s how you start to fill a bucket. I want to help in some small way. And, I guess, third, I’m very lucky. I’m a private pilot and have my own plane, a plane that not everyone has—it’s fast and all-weather—and I’d like to use it for things that are important. I pay for the fuel and maintenance and all of those things for each flight. For my plane, that’s about $1,500 an hour. I also miss time at my job and leave my wife and kids to do this volunteer work, but I am helping people who are much less fortunate than me. If Elevated Access weren’t doing this, I can’t imagine what would happen to some of the people I fly. It’s nice to live in a state, despite being an island of blue surrounded by red, where there are good clinics with good doctors who care. I look at my flying as political resistance, really.” —as told to Lindsey B. King

*Name has been changed

Illustration by Hanna Barczyk

Going The Distance

Medication abortion is under threat, but Just The Pill’s Colorado-based pilot program still plans to deliver.

March 17 was a difficult day for Dr. Julie Amaon. The medical director for Just The Pill—a three-year-old nonprofit that has helped more than 5,000 people access medication abortions in Minnesota, Montana, Wyoming, and Colorado—knew the news was coming, but that didn’t make it less problematic. On that Friday, the governor of Wyoming signed a medication abortion ban that made the state the first in the nation to explicitly prohibit the use of any drug for the purpose of ending a pregnancy.

For Just The Pill, that ruling, along with the subsequent mifepristone decisions out of Texas and then the Fifth Circuit on April 12, created a near-existential crisis. Founded with a mission to use telemedicine and snail mail to help rural and underserved populations more easily procure the two-drug regimen that induces abortion up to 11 weeks in gestation, the organization had begun considering how it would pivot to a single-drug protocol (using a medication called misoprostol) to continue providing medication abortion by mail in Montana, Colorado, and Minnesota if the Fifth Circuit dials back access to mifepristone. Meanwhile, a one-year-old pilot program the Minnesota-based nonprofit started in Colorado should allow it to continue helping Wyomingites despite their state’s medication abortion ban.

In the days after SCOTUS repealed Roe, Just The Pill launched a delivery van with the purpose of plying Colorado’s borderlands, where residents of states such as Oklahoma, Texas, and South Dakota could drive to pick up medication. Now, residents of the Equality State will join pilgrims from those farther-flung locales when the medication ban goes into effect on July 1. “When and if the ban takes effect,” Amaon says, “we are looking at all options, including deploying more vans in Colorado.”

The logistics of what Just The Pill does with a staff of only 30 are mind-bending—plus the nonprofit plans to launch two mobile clinics in the Centennial State or Minnesota for surgical abortions by the end of 2023—but Amaon took the time to explain, in step-by-step detail, how a patient from a state with severe restrictions can take advantage of Just The Pill’s Colorado-based pharmacy on wheels.

Coming to Colorado

Step 1

Make an appointment on justthepill.com. You’ll watch a short video, provide personal information, give your medical history, and complete some consent forms.

Step 2

If you live in a restricted state, you’ll have to get yourself to an area in Colorado served by Just The Pill’s delivery van. Once inside Colorado’s borders, you’ll need to do a 15-minute telehealth appointment with a Just The Pill–approved health care professional from wherever you can access Wi-Fi (many clients do this at a hotel).

Step 3

After the telehealth appointment, during which the clinician will explain how to take and what to expect from the medication, Just The Pill will let you know where the van—staffed by Just The Pill employees—will be parked. You’ll be given a pin code to access the medication lockers in the back of the van, which Just The Pill guarantees will be within an hour’s drive of your location within 24 hours.

Step 4

If mifepristone ever becomes unavailable or its use too restricted (a real possibility because the Fifth Circuit’s original April decision banned its prescription via telehealth), Just The Pill will deploy misoprostol, a drug that, while highly effective, has slightly higher failure rates and more side effects than the mifepristone-misoprostol combo. As a result, Just The Pill will explain the possible side effects and the risks to patients so they know what to be aware of.

Step 5

Drive home. Just The Pill will follow up seven to 14 days later and then again four to five weeks after you take the medication. The nonprofit has a clinician on call 24/7 in case patients have questions.

These Are Their Stories

Clinicians and patients explain, in their own words, what they’ve seen and experienced since Americans lost their constitutional right to abortion.

“I am a physician and a practicing high-risk obstetrician. This is a scary time to be practicing medicine and an even scarier time to work in women’s health. Lauren Miller…contacted me…shortly after her diagnosis. She was reeling from this devastating information, but instead of grieving with her family, she was tasked with navigating a health care system in Texas that was intent on limiting her information and options. Lauren came to Colorado not for a groundbreaking treatment or an exclusive research trial. She came here to receive the standard of care…. What should have been a 15-minute procedure for Lauren in a doctor’s office in Dallas instead became a traumatic experience of her gathering resources, getting on a plane, and flying to Colorado for health care. The abortion ban in Texas meant Lauren’s physicians in her home state couldn’t communicate with her honestly about her own health care.… Abortion is health care. In Lauren’s case, it was needed to save the life of her surviving twin.” —Dr. Jonathan Hirshberg, Denver metro area

Lauren Miller. Photograph by Nitashia Johnson

“I had to travel to Colorado for an abortion. There’s a certain terror to being hunted by your home state when all you’re trying to do is access health care. I have a 19-month-old son and had always wanted three kids, so I was ecstatic to learn that I was pregnant with twins. That happiness was short-lived. Ultrasounds showed a series of heartbreaking issues with one of our twins, and testing revealed that he had trisomy 18. Multiple doctors and genetic counselors could only tell us the same thing: This baby will die. And every day that he continued to develop, he put his twin and [me] at higher risk. But that’s where health care ends in Texas these days…. We had to scramble to make plans to travel to Colorado for an abortion for our unviable twin. Being able to get straightforward answers to our questions from doctors in Colorado helped to relieve at least one burden. I am grateful for that. Texas lawmakers didn’t even want us to have that level of dignity and sound health care.… Politicians in Texas have gone to unprecedented lengths to turn people against one another. Our health care is haunted by a bounty system. For a long time, we only shared with a few trusted people what we had done, fearful of what it meant for ourselves, our family, our friends, and anyone—inside or outside of Texas—who had helped us along the way.” —Lauren Miller, Dallas, Texas

Dr. Warren Hern. Photograph by Rachel Woolf

“In the last few weeks alone, I have seen the following situations: a woman with a desired twin pregnancy with twin-to-twin transfusion syndrome, which is generally fatal for both twins, and the treatment that she received to alleviate this problem failed. She had several other complications with the pregnancy, and her life was at risk. Ending her pregnancy and saving her life took four days and all my skill from 50 years of doing this…. [Next, I cared for] a woman who was raped by a person known to her who is a criminal sociopath and who threatens her life in spite of extensive efforts to protect herself and her children from him. She is terrified and horrified by the thought of carrying this pregnancy to term. She said it “feels like the devil within her.” [I had another] woman from Texas with an advanced pregnancy in which the fetus was anencephalic—it had no skull or brain and zero hope for survival…. She could not get help in Texas to end this pregnancy.” —Dr. Warren Hern, Boulder Abortion Clinic, Boulder

“Recently, I spoke extensively to a woman with a desired pregnancy whose membranes ruptured early and who was refused treatment at the first emergency room she went to in Texas. Treating her safely and completely in my office would have taken no more than an hour, and she could have been on her way home fully recovered within a few hours. This woman was refused treatment time after time. She called my office, and we helped her receive the correct emergency treatment [at a hospital] in Denver, but it was five days too late. Because her treatment was unnecessarily delayed by the Texas abortion laws, she became septic and had to be hospitalized for several days. She almost died.”  —Dr. Warren Hern, Boulder Abortion Clinic, Boulder

Kelsey Lauer. Courtesy of Kelsey Laurer

“Around Halloween, I had a patient from Texas in my clinic who was seeking a medication abortion. She didn’t have time for a surgical procedure, as her flight was departing and she needed to be home to take her children trick-or-treating. The patient explained that she had a heart condition, one requiring surgery that was already scheduled. Pregnancy was not advised for the sake of her health. Yet these extenuating circumstances mattered little in her home state of Texas, which now mandates that patients like mine risk their lives in an attempt to carry a medically dangerous pregnancy. How can this be happening in a nation that purports to be so committed to individual liberty? My patient took the mifepristone that I prescribed and returned home to her family to have her abortion while taking her children out for trick-or-treating.” —Kelsey Laurer, certified nurse midwife, Denver

“One of our providers recently saw a patient with a diagnosis of aggressive, recurrent cancer. Already a mother of a young daughter, she timed her second pregnancy to coincide with her cancer’s remission. However, in her second trimester, the cancer recurred, and immediate chemotherapy and radiation was the recommended treatment. However, she was not permitted to receive these interventions while pregnant and was unable to obtain abortion care in her home state. She drove 13-plus hours each way to access the health care needed to begin her cancer treatment. She brought along her husband and her daughter, who spent the day at the zoo while she spent the day with us in the health center.” —Fawn Bolak, spokesperson for Planned Parenthood of the Rocky Mountains, Denver

“I had a 15-year-old patient who came to Colorado from Texas after getting a positive result on an at-home pregnancy test. She and her mom were afraid to go to the doctor in Texas to get a second test to confirm the pregnancy. They drove 14 hours to come to Colorado to get an abortion, and when we administered the pregnancy test, it was negative. It was excellent and terrible news at the same time. This is what happens when laws make people scared to go to the doctor.” —Dr. Rebecca Cohen, Comprehensive Women’s Health Center, Denver

Dr. Rebecca Cohen. Photograph by Rachel Woolf

Straining to Care

Colorado’s abortion clinicians need a break that’s not coming.

Rebecca Cohen estimates that she used to have one bad case a month. “Someone was in a bad social situation, maybe with their significant other,” she says, “or someone had a really scary medical issue.” Now, the OB-GYN, who spends most of her days performing abortions, says she’s seeing multiple distressing cases each week. She attributes that to a dramatic change in caseload spurred first by SB 8 in Texas and then by the undoing of Roe last June. “About five percent of our cases were from out of state before [Texas’ law]; now that’s at 30 percent,” she says. “Additionally, only about 15 percent of patients we used to treat were in their second trimesters; that’s now at 30 percent. And the number of patients we’re treating overall has increased by about 33 percent.”

Numbers can’t fully express what that means to Cohen and her staff at Denver’s Comprehensive Women’s Health Center, though. They’re working longer hours because, as Cohen says, “We can’t in good conscience turn anyone away.” They’re managing far more complicated procedures, which typically would require more planning, but the time for preparation is being condensed because out-of-state patients have travel constraints and are often coming in with more advanced pregnancies. They’re trying to care for people appropriately, but they can’t reach out to their patients’ doctors for proper medical histories or lab results or prior imaging because lawsuits could follow. They treat people, send them home, and cross their fingers that there are no complications that could send them to the ER, where they could encounter a system hostile to abortions. “I’ve become an emotional support gynecologist,” Cohen says with a sad laugh. “Jokes aside, the injustice of it all is hard to handle day in and day out for us.”

Perhaps the most difficult part, Cohen says, is that patients are hurting in ways they shouldn’t have to. “People who come here from states where abortion is banned are coming here alone, and they’re scared,” she says. “It’s too much of a legal burden to tell a friend. We have to hold their hands instead.”

Cohen and her team know the extra hand-holding they’re having to do isn’t going away any time soon. In fact, the long hours could get longer depending on what happens with abortion rights in nearby states. Wyoming passed a near-total ban, but it has been blocked from enforcement pending a legal challenge. Ditto for Utah. The Guttmacher Institute, a research and policy nonprofit that aims to expand reproductive rights worldwide, considers Montana at risk for passing a ban as well. “There is a hero narrative,” Cohen says. “We know this is something we can still do that other people can’t. We are feeling that and take it seriously. But there is a lot of sadness. And exhaustion.”

Drug Trials

For more than 20 years, U.S. clinicians have used a two-drug regimen—mifepristone and misoprostol—to induce at-home abortions in early pregnancy. The combo of drugs has been shown to be between 95 and 99 percent effective and has a 99 percent safety record (better than either Tylenol or Viagra). Despite that, rulings in April from a Texas judge and a federal appeals court could ultimately force changes to the drug’s accessibility and usage, which the FDA had been working to expand over the past seven years. At press time, mifepristone could still be distributed via mail, could still be used after seven weeks of pregnancy, could still be prescribed via telemedicine, and could still be prescribed by a clinician other than a physician. That all could change, though.

If mifepristone were to be restricted, clinicians would switch to misoprostol. The safety and effectiveness of a misoprostol-only course, which is widely used in Europe, are still high enough that health care providers could feel good about the substitution. However, Dr. Rebecca Cohen says the drug’s higher failure rate and higher risk of dangerous bleeding mean “that we anticipate more people would opt for surgical rather than medication abortion and that more people traveling from out of state for medication abortion would need to stay in Colorado longer. Currently, out-of-staters take the mifepristone here—because it starts the abortion process—and then use the misoprostol after traveling home. If that changes, everything will have to take place in a state where abortion is legal.”

Taking the Initiative

In a state where anti-abortion ballot initiatives have been soundly defeated in 2008, 2010, 2014, and 2020, abortion-rights advocates are ready to try their hands at taking their agenda to Coloradans in 2024. “Colorado can be a leader in this area,” says Karen Middleton, president of Cobalt. “We’re already talking with other states, like Kansas and Michigan, and giving them a copy of our plans.” Those plans include asking Colorado voters to approve two changes to the state constitution. The first would be to ask them to overturn a 1984 amendment that cut off public funds for abortion care, a law that impacts public employees such as teachers and firefighters. “This amendment is a relic of days gone by,” Middleton says. “It disproportionately affects the people who work for us in government because they can’t use their insurance for basic health care.” The second request would update existing language in the constitution with wording from 2022’s Reproductive Health Equity Act. “This would create a fundamental right to abortion in our state constitution,” Middleton says, “which is what Coloradans clearly want.”

Mind The Gap

If Colorado is going to be a refuge for abortion seekers, it’s going to have to increase its capacity and adapt its personnel to be able to treat them. Here, what clinics, hospital systems, and nonprofits have already done, plus what likely will happen next.

Colorado Organization for Latina Opportunity and Reproductive Rights (COLOR)

How Are They Getting It Done?

Knowing that the Latina population is disproportionately affected by abortion bans in states like Texas, COLOR reached out to local abortion funds, advocacy organizations, and health care providers after the fall of Roe to make sure they had plans to provide resources in Spanish. “Colorado protects abortion,” says Aurea Bolaños Perea, strategic communications director for COLOR, “but legality doesn’t mean access. Finding abortion care is hard enough; we want Latinas to be offered services in their language.”

What’s Next?

Bolaños Perea says COLOR will help with the 2024 ballot initiative push and continue aiding abortion-rights groups and health clinics with language support: “Our role is not only to remind our partners that this is important,” she says, “but also to help them. We can assist them with some of our volunteers, many of whom simply reach out to us and say they want to use their language skills for something important. Well, this is it. Give us a call.”

Kaiser Permanente Colorado

How Are They Getting It Done?

After the Dobbs decision in June 2022, Kaiser Permanente Colorado, which has about 507,000 member patients, began offering abortion care services when wait times at external partners, like Planned Parenthood of the Rocky Mountains, increased dramatically.

What’s Next?

“Dobbs changed everything, and it’s clear we need to expand abortion access capacity statewide,” says Cobalt’s Karen Middleton. “We are having conversations within our medical advisory committee and across the state on how best to do this.” Increasing access will be a challenge because many local hospitals and health care systems have long been averse to providing abortion care. In the Denver area, HealthOne, Centura Health, and all but one of SCL Health’s facilities (Platte Valley Medical Center) do not currently offer abortion services.

Advanced Practice Providers (APPs)

How Are They Getting It Done?

Colorado is one of only a handful of states that allow physician’s assistants, nurse practitioners, and certified nurse midwives to perform abortions. At clinics around the state, APPs are stepping up. “I’m part of a trio of midwives who started training at Comprehensive Women’s Health Center in October,” says Kelsey Laurer, 32. “We learned medication abortion first. We’re now training on the surgical procedure and hope to help with volume because the doctors are stretched so thin.”

What’s Next?

Laurer says that APPs can be a solution—but only if the health care system can find a way to marshal their skills. “There’s not a coalition that’s working to mobilize APPs,” she says. “More APPs need to be trained [in abortion care].” APPs also need to be made aware that they are allowed to perform abortions in Colorado; a recent survey at the University of Colorado College of Nursing suggested only 12 percent knew they could do so.

Planned Parenthood of the Rocky Mountains (PPRM)

How Are They Getting It Done?

Since the implementation of Texas’ SB 8 and the subsequent repeal of Roe, PPRM’s Colorado facilities have accommodated a 63 percent increase in patients seeking abortion care. The regional branch—which serves Wyoming, Nevada, New Mexico, and Colorado—has been hiring to keep wait times reasonable (nine days, at press time) and access to other reproductive health care (e.g., appointments for birth control) accessible. Roughly two out of five patients PPRM sees for abortion care are from out of state.

What’s Next?

With more than 70 percent of its patients selecting medication abortion in 2022, PPRM is monitoring the ongoing mifepristone case. PPRM spokesperson Fawn Bolak says it’s possible that if mifepristone is banned or limited there could be an uptick in requests for surgical abortions. “We just won’t know for sure until it happens,” she says. “Our health centers are prepared to switch to misoprostol if mifepristone is restricted. Right now, we are just focused on responding to the changing situation and providing safe, effective, and legal care.”

Misinformation Nation

Whether they’re getting it from pregnancy crisis centers or TikTok, people who seek reproductive health care are bombarded with bad 411.

Illustration by Hanna Barczyk

Tara Thomas-Gale sees it every day. As director of family planning at Denver Health Community Health Services, she lives in awe of the falsehoods being distributed about reproductive health. “We hear patients quote TikTok all the time,” Thomas-Gale says. “What they say is almost always inaccurate and often portrays reproductive health care negatively.” Her assessment is backed up by a study published in Obstetrics & Gynecology in January that looked at how the hashtag “IUDs” was depicted on TikTok. Roughly 24 percent of posts contained inaccurate information, and 97 percent had a negative tone. “So many people, especially young people, are not getting information from traditional news or reputable sources,” she says.

Another unreliable source? So-called pregnancy crisis centers, which are often nonprofit organizations set up by anti-abortion groups primarily to dissuade pregnant people from getting abortions. “These fake clinics target Spanish speakers and other populations that are already at an economic disadvantage,” says COLOR’s Aurea Bolaños Perea. “They talk about things like abortion pill reversal and how there are so many resources that will help a new mother. It’s forced parenthood.”

In Colorado, the Deceptive Trade Practice Pregnancy-related Service bill made some of the tactics used at pregnancy crisis centers illegal. Unless Congress decides to ban TikTok nationwide, though, the misinformation from that social platform will continue to proliferate. Here, we dispel some of the most common myths reproductive health care professionals are hearing from Coloradans and out-of-staters every day.

Myth: Emergency contraception—often called the morning-after pill or Plan B One-Step—can cause an abortion.
Truth: The morning-after pill will not induce an abortion in a person who is already pregnant, nor will it harm a developing embryo. Emergency contraception prevents pregnancy and helps prevent the need for abortion.

Myth: Using contraception can make a person infertile.
Truth: Hormonal birth control does not directly affect a person’s fertility. Birth control can, however, mask other health problems that can impact fertility, such as endometriosis and polycystic ovary syndrome.

Myth: Intrauterine devices (or IUDs) are painful and frequently lead to dangerous complications.
Truth: The insertion of an IUD, a type of birth control, can be uncomfortable for some patients; however, the pain is usually relegated to several minutes during and immediately after insertion. Some people experience cramping for several days post-insertion. Complications like an IUD falling out or perforating the uterus are rare. IUDs are 99 percent effective against pregnancy and can actually lead to reduced menstrual bleeding and cramping over time.

Myth: Abortion pill reversal is effective for stopping the termination of a pregnancy if a person takes progesterone within 24 hours of ingesting mifepristone, the first medication in a two-drug regimen that results in an abortion.
Truth: The so-called abortion pill reversal protocol is not promoted by mainstream medical organizations; it is not approved by the FDA; and it has never been tested in a randomized controlled trial. The American College of Obstetricians and Gynecologists specifically rejects abortion pill reversal.

Conduct Unbecoming?

One of the goals of Colorado’s Deceptive Trade Practice Pregnancy-related Service bill that Governor Jared Polis signed in April was to declare the administration of abortion pill reversal as unprofessional conduct. However, the law contains an amendment that requires the state medical, nursing, and pharmacy boards to evaluate the practice of abortion pill reversal by October 1; the state says it will not enforce the ban until the boards make their determination. On the day the bill became law, Englewood-based Bella Health and Wellness, a Catholic health care clinic, filed suit in U.S. District Court, saying the law infringes upon staffers’ First Amendment rights. The judge granted a temporary exemption for Bella Health and Wellness but not for other pregnancy crisis centers. That exemption was rescinded on April 28 by a U.S. District Court judge, who said the state’s promise not to enforce the ban until the boards weighed in was a “generally accepted standard of practice.”

Dr. Leilah Zahedi-Spung. Photograph by Rachel Woolf

The Journey Taken

As an OB-GYN, Dr. Leilah Zahedi-Spung says the coolest thing she does is deliver babies. But the 35-year-old physician has advanced training that also allows her to safely end pregnancies, a skill she believes she should be able to use freely to help her patients. When Roe fell, Zahedi-Spung was living and working in Tennessee—a state that quickly banned abortion, with no exceptions, and made the practice a felony for clinicians. Zahedi-Spung knew she couldn’t stay in the Volunteer State. After only 18 months in Tennessee, she moved her family to Colorado in January. In February, she spoke with 5280 about what she’s learned as a doctor who performs abortions in America today.

I’ve lived, worked, and trained in Georgia, Missouri, and Tennessee—all states that have had and currently have some of the country’s strictest abortion laws. I’ve seen how those laws affect care, and it’s not good for anyone.

After training to be an OB-GYN, I wanted more training. I knew going into fellowship for maternal-fetal medicine that I wanted to do abortion care. I knew being that kind of doctor would be an uphill battle, but I was OK with that. That was before 2022.

I don’t think I really thought Roe would fall. It just wasn’t something my mind could wrap itself around.

In Tennessee, I was in private practice in Chattanooga. I was trained to do abortions into the second term, but Chattanooga was the only major city that didn’t have an abortion clinic, so I drove to Memphis once a month to keep my skills up. I saw devastating fetal anomalies and situations where the mother was at risk. As a high-risk obstetrician, I would walk that grief path with them, and then I was able to actually help them. Until Roe fell.

It’s really awful to tell a patient who has just found out that their baby isn’t viable—has some terrible fetal anomaly—that I can’t help them. They would ask: If the baby isn’t going to live, why do I have to go out of state to get help? People had a hard time understanding “no exceptions.” I couldn’t blame them. I was so grateful for the doctors in North Carolina, South Carolina, and Virginia who took care of my patients.

Tennessee’s law offers no exceptions for rape, incest, or health of the mother. It also is a state that requires an affirmative defense, meaning I would have to go to court and prove that an abortion I performed—and was automatically charged with a felony for performing—met the criteria for a legal abortion.

People with felonies don’t get to be doctors, and I worked really hard to be a doctor.

I was worried that if I tried to help someone, I could go to jail. I would be sent there not by a jury of my peers, because it’s very likely that none of the jurors would be doctors. They wouldn’t have the medical knowledge to know what’s medically necessary in certain situations.

When the Supreme Court draft leaked in May 2022, I got a call from a friend in Colorado. She asked if I needed a job someplace where people still respected choice and freedom. I realized I did.

I felt guilty leaving Tennessee. I left patients who really needed me. But now I’m here, and it’s overwhelmingly refreshing to be in a place where people believe in science.

Here’s the thing: No one thinks they need abortion care until they need it.