10 US States Would Be Hit Especially Hard by a Nationwide Ban on Medication Abortion Using Mifepristone

Updated on February 7:

This analysis has been updated to clarify that a pending federal court case has the potential to revoke the approval of mifepristone’s use for medication abortion, but it would not ban all forms of medication abortion. While 98% of medication abortions in the United States in 2020 used a regimen of mifepristone and misoprostol in combination, misoprostol can be used on its own to end a pregnancy. If mifepristone becomes unavailable, it is unclear whether all current providers using the two-drug regimen would offer abortion care using only misoprostol and to what extent patients would take up this method. The fact remains that revoking approval of mifepristone would go against an overwhelming body of scientific evidence that the drug is safe and effective. Banning mifepristone would cause massive disruptions to abortion provision in the United States and patients’ ability to get the timely care they need and deserve.

Originally published on February 7:

Despite overwhelming evidence that medication abortion is safe and effective, a federal court ruling from a judge known for his anti-abortion views could soon ban access to medication abortion using mifepristone across the United States. New findings from the Guttmacher Institute document that such a decision could have especially harsh impacts on people in 10 states—even though half of these states are considered to be protective of abortion rights and access.

To be sure, the impact of ending access to medication abortion using mifepristone would be devastating across the entire country. However, in these 10 states, medication abortion plays a particularly critical role in ensuring access to care.

About 10% of all US counties have an abortion provider that offers either procedural or medication abortion, or both. In about 2% of US counties, medication abortion is the only option offered by providers. Without medication abortion using mifepristone, the share of US counties with an abortion provider could drop from 10% to as low as 8%, and access to abortion would be compromised—or possibly disappear altogether—in about one in five US counties that currently have an abortion provider. 

The impact becomes even more stark when looking at counties where medication abortion is the only option for women—as well as individuals who do not identify as women—who are seeking abortion. About 35 million women of reproductive age—55% of the US total—live in a county that has an abortion provider. Without medication abortion using mifepristone, this number could drop by as much as 2.4 million women, or 51% of the US total.

A Baseless Court Case

Anti-abortion activists filed a lawsuit in November 2022—Alliance for Hippocratic Medicine v. U.S. Food and Drug Administration—that seeks to revoke the agency’s approval of mifepristone, which is used, along with misoprostol, in the most common medication abortion regimen. Mifepristone was approved by the FDA in 2000 following a rigorous review process and has amassed a lengthy track record of safe and effective use.

The use of medication abortion in the United States has steadily increased in the last 20 years. Since its approval, medication abortion has been used over four million times and has become so widely accepted by patients and providers that it now accounts for more than half of all US abortions—492,210 of the 930,160 abortions (53%) provided in 2020 were done with abortion pills.

Because medication abortion using mifepristone is such an important counterpart to in-clinic procedural abortion, it has long been targeted by the anti-abortion movement. A newer line of attack involves weaponizing the federal judiciary to end or limit use of the method by partially or fully revoking mifepristone’s approval.

The same anti-abortion group behind the Mississippi abortion law that was ultimately used by the US Supreme Court to overturn Roe v. Wade is also behind the legal attack against mifepristone. Fully aware of the weakness of their lawsuit and the scientific evidence stacked against them, the Alliance Defending Freedom went “court shopping” in hopes of finding a judge who might ignore the evidence and reach a decision based on ideology. That’s why the organization filed its case in a specific federal district court in Texas—a state where abortion, including medication abortion, is already banned. The case was heard by Judge Matthew Kacsmaryk, who was appointed by Donald Trump and has a history of close relationships with far-right religious groups. He is set to rule as early as February 10.

If the baseless lawsuit were to result in mifepristone’s use being banned or sharply curtailed, what is already a severe crisis in abortion access provoked by the US Supreme Court overturning Roe v. Wade would get dramatically worse. As of February 6, abortion is banned in 12 states and unavailable in an additional two, with more states expected to follow.

All States Where Abortion Is Available Would Be Impacted… 

All states where abortion is currently legal and available would be hit hard if providers were only able to offer in-clinic procedural abortions or had to switch to offering the misoprostol-only medication abortion regimen. Patients would be denied access to the safe and effective two-drug regimen, which they can now obtain from a clinic, are increasingly able to receive as pills shipped through the mail after being prescribed by their provider via telehealth and soon may be able to pick up from a participating pharmacy. 

Without medication abortion using mifepristone as an option, demand for procedural abortions could increase significantly—leading to overwhelmed clinics and providers, much longer wait times, further unnecessary delays, and more complicated and costly logistics for many patients. It would be difficult, if not outright impossible, for providers that only offer medication abortion using mifepristone to switch to offering procedural abortions instead. Some of these providers will pivot to offering medication abortion using only misoprostol, while others will be forced to stop offering abortion services entirely.

All of this would affect not only people in states where abortion is available, but also those traveling from states where it is not.

…But Some States Would Be Hit Much Harder Than Others

The impact of eliminating access to medication abortion using mifepristone would differ greatly from state to state and could be especially pronounced in rural counties and regions of any state. In addition, the consequences of losing the use of mifepristone for medication abortion would reach far beyond individual counties, extending to neighboring counties, the entire state or across state lines. Some providers would shift to offering a misoprostol-only option, while others would likely stop offering medication abortion altogether.

These 10 states could experience the most severe impact if mifepristone were banned, as they could have a particularly sharp drop in the share of women of reproductive age who live in counties with an abortion provider if medication abortion–only providers do not begin offering a regimen with misoprostol alone:

• Colorado
  • The share of counties with an abortion provider would drop from 22% to as low as 14%.
  • The share of women of reproductive age living in a county with an abortion provider would drop from 82% to as low as 56%.
  • Colorado is considered to be “Protective” of abortion rights and access based on policies in effect as of February 6, 2023.
• Georgia
  • The share of counties with an abortion provider would drop from 5% to as low as 4%.
  • The share of women of reproductive age living in a county with an abortion provider would drop from 45% to as low as 29%.
  • Georgia is considered to be “Very Restrictive” of abortion rights and access based on policies in effect as of February 6, 2023.
  • Abortion is banned in Georgia after six weeks of pregnancy. Since medication abortion is especially important for ending an early pregnancy, disruptions to facilities’ medication abortion protocols or wait times for an appointment for a procedural abortion could push many patients past the state’s gestational age limit.
• Indiana
  • The share of counties with an abortion provider would drop from 5% to as low as 3%.
  • The share of women of reproductive age living in a county with an abortion provider would drop from 34% to as low as 26%.
  • Indiana is considered to be “Restrictive” of abortion rights and access based on policies in effect as of February 6, 2023.
• Iowa
  • The share of counties with an abortion provider would drop from 4% to as low as 2%.
  • The share of women of reproductive age living in a county with an abortion provider would drop from 31% to as low as 24%. 
  • Iowa is considered to be “Restrictive” of abortion rights and access based on policies in effect as of February 6, 2023.
• Maine
  • The share of counties with an abortion provider would drop from 88% to as low as 19%.
  • The share of women of reproductive age living in a county with an abortion provider would drop from 84% to as low as 46%.
  • Maine is considered to be “Protective” of abortion rights and access based on policies in effect as of February 6, 2023.
• Montana
  • The share of counties with an abortion provider would drop from 9% to as low as 7%.
  • The share of women of reproductive age living in a county with an abortion provider would drop from 53% to as low as 45%.
  • Montana is considered to have “Some Restrictions/Protections” for abortion rights and access based on policies in effect as of February 6, 2023.
• New Mexico
  • The share of counties with an abortion provider would drop from 9% to as low as 3%.
  • The share of women of reproductive age living in a county with an abortion provider would drop from 52% to as low as 34%.
  • New Mexico is considered to be “Very Protective” of abortion rights and access based on policies in effect as of February 6, 2023.
• Pennsylvania
  • The share of counties with an abortion provider would drop from 19% to as low as 15%.
  • The share of women of reproductive age living in a county with an abortion provider would drop from 63% to as low as 54%.
  • Pennsylvania is considered to be “Restrictive” of abortion rights and access based on policies in effect as of February 6, 2023.
• Vermont
  • The share of counties with an abortion provider would drop from 29% to as low as 21%.
  • The share of women of reproductive age living in a county with an abortion provider would drop from 57% to as low as 48%.
  • Vermont is considered to be “Very Protective” of abortion rights and access based on policies in effect as of February 6, 2023.
• Washington
  • The share of counties with an abortion provider would drop from 41% to as low as 28%.
  • The share of women of reproductive age living in a county with an abortion provider would drop from 90% to as low as 80%.
  • Washington is considered to be “Protective” of abortion rights and access based on policies in effect as of February 6, 2023. 

Impact on People Needing Abortion Care

Like all abortion bans and restrictions, eliminating access to medication abortion using mifepristone would disproportionately impact already marginalized populations. Even before Roe was overturned, economic inequality was a key factor in determining who had access to abortion care and information. In addition to the cost of an abortion, averaging $550 in the first trimester, individuals seeking an abortion also face indirect expenses, such as travel, unpaid time off work, and child and family care. 

These financial burdens are exacerbated by intentionally burdensome abortion restrictions, like forced waiting periods or insurance coverage bans, placing timely care even further out of reach for many people with few financial resources. Structural racism, including a history of exploitation and neglect by the US medical system, means that Black, Brown and Indigenous people seeking an abortion are more likely than their White counterparts to lack insurance or live below the federal poverty level. 

Medication abortion using mifepristone offers several benefits that might make it a preferable option over procedural abortion for people with few financial resources. Because the regimen can be prescribed via telehealth in many areas and safely taken in the privacy and convenience of one’s own home, it can help reduce costs associated with transportation or child and family care, and it allows for more flexible scheduling. Banning mifepristone and potentially forcing patients to receive in-clinic procedural abortion care would create significant additional burdens that could delay or deny care.

Methodology

For this analysis, we used data from the Guttmacher Institute’s 2020 US Abortion Provider Census linked with 2020 US census data. Hospitals were excluded from this analysis. We made several updates to our 2020 data on facilities: 

• We updated the number of providers to reflect that 14 states currently have no abortion providers of any type: Alabama, Arkansas, Idaho, Kentucky, Louisiana, Mississippi, Missouri, North Dakota, Oklahoma, South Dakota, Tennessee, Texas, West Virginia and Wisconsin. Twelve of these states have a near-total ban on abortion in effect, North Dakota lacks any abortion providers and providers in Wisconsin stopped offering abortion care because of legal uncertainty over the state’s abortion ban. 
• In cases where data on type of abortion provided at a facility in 2020 were missing, we classified the facility as providing both procedural and medication abortion. Most facilities with missing data on type offered were in counties that had other providers offering procedural abortion; if some of those facilities offered only medication abortion, our analysis would underestimate the prevalence of counties that contain solely medication abortion providers. Therefore, our estimates about the impact of a mifepristone ban are conservative.

For each county, we tabulated the number of facilities that provided abortion using any method and the number that offered medication abortion only. If no providers in that county offered procedural abortions, the county was classified as having only medication abortion provision.

For facilities identified as medication-only providers and located in a county with no procedural abortion providers, we checked websites and called the clinics to verify that they were still open and not offering procedural abortion. Among those sites, 14 were no longer offering abortion services and four had begun offering procedural abortions, so they were removed from the medication-only provider category.

The authors thank Marielle Kirstein for updating the data used in this analysis.