In 2023, the first full year since the US Supreme Court overturned Roe v. Wade, state legislatures took key action on sexual and reproductive health. While many states increased access and piloted new policy solutions to expand and protect abortion and other sexual and reproductive health care, others sought to further curtail access.

The landscape of abortion access in the United States is fractured: Fourteen states enforce total bans, and seven more restrict access under limits that also would have been unconstitutional under Roe. As of December 13, 2023, another 22 states and the District of Columbia had enacted 129 measures to protect abortion access this year—the highest number of protections ever enacted in a single year.

The Guttmacher Institute’s latest research shows that the number of abortions has increased in many states where care remains legal compared to the number in 2020, the most recent year of data from Guttmacher’s Abortion Provider Census. This increase was especially prominent in states that border those where care is banned and in those that have enacted protective policies, like Illinois, New Mexico and Colorado. All three of these states expanded access for in- and out-of-state residents and experienced huge influxes of patients traveling from out of state in the first half of 2023, compared with a similar period in 2020. These states offer a pathway to other states seeking to improve abortion access in the face of increased restrictions.

Counts of State Legislation in 2023 (as of December 13, 2023):

Reproductive health and rights overall

• 2,393 provisions introduced that would protect reproductive rights or expand access to reproductive health
  • 417 provisions enacted
• 1,098 provisions introduced that would restrict access to reproductive health or curtail rights
  • 148 provisions enacted

Abortion

• 754 provisions introduced that would protect or expand access to abortion care
  • 129 provisions enacted
  • 1 blocked
• 675 provisions introduced that would restrict access to abortion care
  • 80 provisions enacted
  • 13 blocked
• 4 provisions enacted that expanded or added exceptions to abortion bans

Gender-affirming care

• 36 provisions introduced that would protect or expand access to gender-affirming care
  • 20 provisions enacted
• 157 provisions introduced that would restrict access to gender-affirming care
  • 34 provisions enacted

Contraception

• 315 provisions introduced that would protect or expand access to contraceptive services
  • 56 provisions enacted

 

Information on legislation and enactments on specific topics can be found in our State Policy Update, which is updated twice a month.
 

Attacks on Sexual and Reproductive Health and Rights

Eighty abortion restrictions were enacted in 2023, and in combination with bans enacted in 2022, have resulted in access to care being restricted for millions of people. This year, many of the same policymakers also restricted reproductive health and bodily autonomy more broadly, specifically by enacting bans on gender-affirming care. The interconnectedness of these attacks highlights the need for policy that expands and protects access to all health care.

Abortion bans

In the chaos and confusion that erupted after the US Supreme Court overturned Roe in June 2022, abortion trigger bans that many states had on the books soon went into effect; many other states moved quickly to restrict care. As of mid-December 2023, 14 states are enforcing total bans with limited exceptions, including two new bans enforced this year. As a result, almost 18 million women of reproductive age, in addition to transgender and nonbinary people who may need an abortion, no longer have access to abortion care in their state of residence.

Anyone denied abortion access in their state is forced to either overcome the enormous logistic and financial hurdles of traveling out of state, self-manage an abortion or carry an unwanted pregnancy to term—scenarios that are most difficult and carry the greatest consequences for those marginalized by economic insecurity and structural racism.

 

View interactive version of the map.

 

Abortion care was unavailable in Wisconsin for most of the year because of legal uncertainty, but abortions resumed there in September. However, two other states banned abortion in 2023:

• North Dakota: The sole abortion clinic relocated to Minnesota shortly after Roe was overturned, so care was already unavailable, but a new ban that went into effect in April reinforced that North Dakotans do not have access to abortion in their state.
• Indiana: After almost a year of litigation, Indiana’s abortion ban went into effect in late August, although providers had stopped providing care on August 1 as a result of legal uncertainty. The impact was dramatic; in August there were an estimated zero abortions provided within the formal health care system in the state, compared with almost 700 abortions in July.

Gestational limits

As of mid-December 2023, seven states are restricting abortion at gestational limits that also would have been unconstitutional under Roe. Three of these states (South Carolina, North Carolina and Nebraska) enforced new gestational bans in 2023.

Policymakers in these states used anti-democratic maneuvers to advance their bans. There have also been efforts to frame these bans as “compromises” rather than violations of reproductive autonomy. Gestational bans are stepping stones to total bans, and Guttmacher’s data show they harm abortion provision, especially in regions where multiple states are enforcing bans.

• Nebraska: A six-week abortion ban failed when one Republican legislator voted against it; however, a ban on abortion at 12 weeks passed as an amendment to a ban on gender-affirming care and took effect in May, demonstrating the interconnectedness of attacks on gender-affirming care and abortion care.
  • The number of abortions in Nebraska has not decreased by much since May, but the increase of out-of-state patients obtaining care in neighboring states like Colorado, where the proportion increased from 13% in 2020 to 31% in 2023, suggests some Nebraskans may have been forced to travel to access essential care.
• North Carolina: A 20-week ban was in effect at the end of last year. After a series of closed-door maneuvers by anti-abortion politicians, a 12-week ban went into effect on July 1, along with a 72-hour forced waiting period between in-person counseling and the abortion appointment.
  • After these two restrictions were enforced, abortions in North Carolina dropped by 31% from June to July 2023. While the impact was sustained through August, the number of abortions rose slightly in September, following the enactment of South Carolina’s six-week ban. The fluctuations demonstrate how the rapidly shifting landscape of bans and restrictions impacts providers and patients.
• South Carolina: A six-week ban was stopped this year by a bipartisan group of legislators, after which the governor called a special session and the ban was rushed through the legislature and signed into law. The state supreme court upheld the ban in late August.
  • Before the ban went into effect, South Carolina was a reliable source of abortion care in the Southeast. From January to June 2023, abortion increased by 124% in the state compared with the same time period in 2020, and care for out-of-state residents accounted for 75% of that increase. Following implementation of the six-week ban, there was a 79% drop in the number of abortions from August to September 2023.
• Florida: Abortion bans are clustered in the South and Southeast, and Florida is now the only state in the region offering care after 12 weeks. The number of abortions increased by 15% for the January to June 2023 period compared with a similar time frame in 2020. Increased travel from out-of-state individuals accounted for 65% of the overall increase.
  • Florida’s position as a place for people throughout the region to obtain abortion care is at risk as a result of a six-week ban that was signed this year, but this prohibition is not in effect as the Florida Supreme Court litigates challenges to a 15-week ban. If the state supreme court upholds the 15-week ban, the six-week ban will go into effect after 30 days and will further devastate access across the region.

States with abortion bans that were already in effect at the end of 2022 have also experienced sustained changes in the number of abortions:

• In Arizona (15-week ban) and Georgia (six-week ban), the number of abortions decreased in 2023 compared with similar periods in 2020. There have been large increases in out-of-state patients receiving abortion care in neighboring states such as New Mexico, and Florida, respectively.
• In Utah, where an 18-week ban is in effect, the number of abortions has increased slightly. The state’s governor has indicated he wants to further restrict care; he signed a law in March that would have mandated the closure of all abortion clinics in the state once the current clinic licenses expired, which would end access to virtually all abortions across the state. A court blocked this ban from going into effect.

Pauses and resumptions in abortion care

The abortion policy landscape remains chaotic and confusing, which is detrimental to providers, as well as to patients seeking care and information.

• Care was disrupted briefly in Wyoming (total ban) and Iowa (six-week ban) this year as a result of prohibitions that went into effect and were subsequently temporarily blocked. As of mid-December, care remains available in both states, but any lapses in access to essential services are traumatic to patients and pose significant challenges for providers.
• Abortion care resumed in Wisconsin up to 22 weeks in September 2023 at two Planned Parenthood clinics, after more than a year of providers in the state not offering care as a result of legal uncertainty surrounding an 1849 ban.

Court cases on exceptions

More than a year after Roe was overturned, exceptions to abortion bans continue to be exposed as cruel and harmful.

This year, three states amended the medical exceptions to their bans. Cases brought by the Center for Reproductive Rights in various states on behalf of patients and providers seek to ensure that those experiencing pregnancy complications can access abortion care and providers have clarity on “medical emergency” exceptions. While abortion rights advocates won a case this year in Zurawski v. State of Texas that could have provided clarity to providers in emergency situations, the decision was subsequently blocked when Texas appealed the case. The appeal is being heard by the Texas Supreme Court. The testimonies in this case—along with others filed by people seeking abortion care in states like Texas and Kentucky—highlight that the only way to guarantee abortion access for everyone is to eliminate any and all restrictions to care.

Gender-affirming care restrictions

Legislation to ban or restrict gender-affirming care, particularly for young people, increased dramatically in 2023, as anti-abortion policymakers broadened their attacks on reproductive health and autonomy. Nineteen states enacted 20 bans on gender-affirming care this year out of a total of 22 bans ever enacted—an increase that further dehumanizes the transgender community.

Every credible medical organization opposes these bans on gender-affirming care and recognizes this type of care’s vital role in improving the physical health and mental well-being of transgender individuals. The tactics, including placing restrictions on providers, demonizing the people who make these decisions and elevating regret narratives of some people who have received gender-affirming care, mirror those the anti-abortion movement has spearheaded for decades. These restrictions are also linked to an ongoing nationwide push against LGBTQ+ rights, such as bans on transgender youth in sports participation and bans on LGBTQ+–inclusive school curricula.

Proactive Policies

In the face of restrictions, some states took actions in 2023 to protect access to abortion, contraception and gender-affirming care.

Abortion

In 2023, state policymakers across the country enacted 129 measures protecting abortion access. These protections included policies protecting the legal right to abortion, improving and expanding patient access, supporting the health care workforce, improving clinic safety and security, and expanding insurance coverage for abortion access. 

 

 

In 2023, four states—Minnesota, New Mexico, Ohio and Oregon—affirmed or established the legal right to abortion in their state constitutions or state statutes. Ohio did so through a ballot measure, as voters declared their support for reproductive autonomy. There are now seven states that have protected the right to abortion since the Supreme Court’s Dobbs v. Jackson Women’s Health Organization decision (including California, Michigan and Vermont, all of which did so in late 2022).

States have also taken additional steps to protect abortion by protecting patient access and supporting the health care workforce through grants and financial support:

• New York granted $25 million for abortion providers to expand capacity and ensure that patients have access to timely care.
• Oregon created the $15 million Reproductive Health Equity Fund.
• Massachusetts allocated more than $26 million for sexual and reproductive health services such as abortion, adolescent sex education, comprehensive family planning services, HIV counseling and testing, and gender-affirming care support; $2 million for grants to improve access to abortion and other reproductive health services; and $1 million to reimburse public universities for the provision of medication abortion.
• Maryland, New Jersey and California allotted $3.5 million, $5 million and $20 million, respectively, for programs aimed at training health care providers in abortion care.

In total, 23 provisions related to funds for improving abortion access have been enacted since Dobbs, with 12 of those enacted in 2023.

Increased concern around anti-abortion violence at clinics has also become a focus for some state legislatures:

• New York provided $10 million in grants for reproductive health centers for safety and security measures against hate crimes and attacks.
• California allocated $15 million for clinic security.

States continued to make strides related to insurance coverage for abortion care:

• Rhode Island’s Equality in Abortion Coverage Act allowed state Medicaid funds to be used for abortion care.
• Two states (Colorado and Vermont) enacted laws that expand private insurance coverage for abortion care with no cost-sharing. The Vermont law extends the same requirements to gender-affirming care as well. In addition, New Jersey issued regulations requiring insurance coverage of abortion care with no cost-sharing.

Contraception

In 2023, state advocates continued to push for contraceptive access and protection of the legal right to contraception. Overall, 76 provisions expanding or protecting contraceptive access have been enacted since Dobbs, with 56 of those enacted in 2023. Five states passed measures to legally protect access to contraception (Colorado, Minnesota, New Mexico, Oregon and Ohio).

Other states also expanded access to contraception:

• Four states expanded access to emergency contraception (Connecticut, Illinois, Maryland and Vermont).
  • Policies included making over-the-counter emergency contraception available through increasing the number of vending machines; giving pharmacists authority to order, prescribe and administer emergency contraception; and making emergency contraception more available on college campuses.
• Nine states expanded access to contraception through pharmacies (Connecticut, Indiana, Maine, Massachusetts, Montana, New Jersey, New York, Rhode Island and Vermont).
• Six states authorized extended supplies of contraception (Colorado, Montana, Nevada, Oregon, Texas and West Virginia), which helps eliminate gaps when people are unable to pick up their prescription as soon as they need a refill.
• Three states protected coverage for contraception (Colorado, Minnesota and Nevada), which eliminate cost barriers to access.

Gender-affirming care

In a year filled with devastating attacks on gender-affirming care, nine states took proactive steps to protect access to this type of care. Since Dobbs, 20 provisions protecting gender-affirming care have been enacted, all of them in 2023.

• Three states (Oregon, Vermont and Massachusetts) expanded coverage or funding for gender-affirming care.
  • Oregon required health plans and state employee health plans to cover gender-affirming care.
  • Vermont required both public and private health plans to cover both abortion and gender-affirming care without cost-sharing.
  • Massachusetts's $26 million allocation for reproductive and sexual health services includes gender-affirming care.
• New Mexico protected the right to both gender-affirming and reproductive health care and barred discrimination on the basis of receiving that care.
• Nine states (California, Colorado, Illinois, Maryland, New Jersey, New Mexico, Oregon, Vermont and Washington) included gender-affirming care in their shield law protections, and three states included gender-affirming care in data protection laws (California, Vermont and Washington).

New Policy Solutions

In 2023, many states also enacted new, proactive policy solutions that other states are likely to adopt in 2024.

Combating anti-abortion centers

Anti-abortion centers seek to dissuade patients from seeking abortion care, while deceptively portraying themselves as health care clinics. These centers do not provide comprehensive health care services or have any licensed health care professionals on-site.

• In 2023, three states—Vermont, Colorado and Illinois—passed legislation that would prevent anti-abortion centers from deceptively advertising their services.
• In addition, Colorado’s legislation called upon the state’s professional medical societies to determine whether prescribing “abortion pill reversal,” a dangerous and unproven method of attempting to “reverse” medication abortion, was considered unprofessional conduct.
• The efforts in Vermont, Colorado and Illinois all faced litigation after the laws were enacted.

Shield laws

Guttmacher’s latest research shows that states bordering those with complete bans have seen an increase in out-of-state patients traveling for care. “Shield laws” protect health care providers and in some instances, volunteers and patients, from legal or professional consequences enforced by states banning abortion while providing or seeking care that is legal in the protective state.

These laws have been established via legislation and executive order. The latter—which are legal documents issued by governors to immediately declare or enact a policy—have some benefits, but they are not enshrined in state statutes or in state constitutions and can be rescinded by succeeding governors.

• Twenty-two states and DC have some type of shield law protection, whether by executive order, statute or both. In 2023, eight new states implemented shield laws, in addition to DC: Arizona, Connecticut, Maryland, New York, Illinois, Oregon, Vermont and Washington. These laws came in addition to the protections implemented by 14 other states in 2022 (California, Colorado, Delaware, Hawaii, Massachusetts, Maine, Michigan, Minnesota, Nevada, New Jersey, New Mexico, North Carolina, Pennsylvania and Rhode Island).
• These laws are intended to protect providers who treat out-of-state patients in person or via telehealth.
• These laws have not yet faced legal challenges.
  
   

Data privacy

Laws related to data privacy for sexual and reproductive health care services increased in 2023. The threat of criminalization of abortion, which existed pre-Dobbs as well, led state advocates and legislators to advocate for increased data privacy protection.

• Six states (California, Connecticut, Maine, Maryland, Vermont and Washington) passed laws that aim to protect data privacy for reproductive and sexual health care services.
• Three of these states (California, Vermont and Washington) explicitly protect gender-affirming care in their laws as well.

 

Three states (California, Connecticut and Washington) passed laws that prohibit geolocation and geofencing—which refer to any technology that uses cell towers, Wi-Fi or other form of location detection to establish a virtual boundary—near health care clinics. Anti-abortion organizations may use geofencing to target people who visit health care facilities that provide abortion care.

• A California law prohibited the retention or sale of geolocation data of people who visit family planning centers; Connecticut and Washington prohibited geofencing within certain areas near health care clinics.

Elections and Ballot Initiatives

Abortion rights and access prevailed in every state election this year where abortion was a major factor.

A measure expanding and protecting access was explicitly on the ballot only in Ohio, where voters enshrined reproductive freedom in their state constitution with an amendment that includes protections for abortion, contraception, continuing pregnancy and more. The amendment took effect in early December 2023 and is expected to permanently block a six-week abortion ban that was in effect briefly after the Supreme Court overturned Roe, although anti-abortion politicians in the state are determined to mute the impact of this amendment. In addition, voters in Kentucky, Pennsylvania and Virginia backed state and local candidates who supported abortion rights.

Opportunities and Threats in 2024

With a national election looming next year, more states may find innovative ways to both restrict and protect sexual and reproductive health care and rights, especially abortion and gender-affirming care.

Two states (Maryland and New York) already have measures on the 2024 ballot that could bolster protections for reproductive autonomy, and many more campaigns are underway to place abortion-related measures on state ballots, including in Florida, where a six-week ban is imminent. As they did in the past two election cycles, abortion rights and access are likely to garner broad voter support in 2024.

Laws that restrict interstate travel are preeminent threats, as our data show that abortion patients are determined to get the care they need. In Idaho, a ban that criminalizes adults who support a minor to obtain an abortion out of state without parental knowledge or consent was in effect for months before a federal judge blocked it in November. In Texas, several counties have passed local ordinances banning people from supporting abortion seekers traveling out of state.

These types of restrictions create a chilling effect to dissuade people from seeking care or assisting others in doing so. Criminalizing a variety of pregnancy outcomes, such as self-managing an abortion and using drugs while pregnant, was already on the rise before Roe was overturned, and any encroachment of law enforcement in people’s sexual and reproductive health care will carry the worst consequences for people subject to systemic racism and economic injustice.

Calls for a national abortion ban and the baseless case seeking to withdraw Food and Drug Administration approval of mifepristone (one of two drugs used in the most common medication abortion regimen) demonstrate that anti-abortion advocates always had higher aims than overturning Roe. In the absence of federal protections or executive actions, innovative state solutions are more critical than ever to protect and expand the full spectrum of sexual and reproductive health care.