The United States is knee-deep in what some experts call the opioid epidemic’s “fourth wave,” which is not only placing drug users at greater risk but is also complicating efforts to address the nation’s drug problem.
These waves, according to a report out today from Millennium Health, began with the crisis in prescription opioid use, followed by a significant jump in heroin use, then an increase in the use of synthetic opioids like fentanyl.
The latest wave involves using multiple substances at the same time, combining fentanyl mainly with either methamphetamine or cocaine, the report found.
Nurse midwife Beverly Maldonado recalls a pregnant woman arriving at Ascension Saint Agnes Hospital in Maryland after her water broke.
It was weeks before the baby would have any chance of survival, and the patient’s wishes were clear, she recalled: “Why am I staying pregnant then? What’s the point?” the patient pleaded.
But the doctors couldn’t intervene, she said.
The fetus still had a heartbeat and it was a Catholic hospital, subject to the “Ethical and Religious Directives for Catholic Health Care Services” that prohibit or limit procedures like abortion that the church deems “immoral."
Chloe Bell is a case manager at the National Abortion Federation. She spends her days helping people cover the cost of an abortion and, increasingly, the interstate travel many of them need to get the procedure.
“What price did they quote you?” Bell asked a woman from New Jersey who had called the organization’s hotline seeking money to pay for an abortion. Her appointment was the next day.
“They quoted me $500,” said the woman, who was five weeks pregnant when she spoke to Bell in November. She gave permission for a journalist to listen to the call on the condition that she not be named.
“We can definitely help,” Bell told her. “We can cover the cost of the procedure. You just tell them you have a pledge from the NAF.”
Bell is one of a growing network of workers who help people seeking abortions understand what’s legal, where they can travel for care, and how to get there.
These “navigators” can often recite from memory the names and locations of clinics throughout their region that offer abortion services at a given point in a pregnancy. Often, they can then name the hotel closest to the clinic. And some are so familiar with the most common airports for connecting flights that they can help patients find their next departure gate in real time.
State abortion laws have always varied, so helping people access legal abortion services isn’t new, but the amount of travel needed to get care has risen sharply.
In the first six months of 2023, nearly 1 in 5 abortion patients traveled out of state to get care, compared with 1 in 10 in 2020, according to an analysis by the Guttmacher Institute, a national nonprofit that supports abortion rights. That increase in travel, even for early-pregnancy abortions, has sparked a corresponding rise in the need for case managers like Bell.
Most callers are like the woman from New Jersey — people in the early stages of a pregnancy who can’t afford the $500 cost of a medication abortion. But with elective abortion banned almost entirely in 14 states and after six weeks in two more, the logistics of ending a pregnancy at any stage have become more complicated.
“People are being forced later into pregnancies to access care” because of the difficulty of arranging travel over long distances and the chilling effect of the bans, said Brittany Fonteno, president of the NAF, a nonprofit professional organization of clinics that provide abortions. “It increases the cost of care and has a devastating impact on people.”
After hanging up with the woman from New Jersey, Bell told a woman from Georgia that she likely wouldn’t need to pay the $4,800 bill for her 24-week abortion. Half the money would come from the National Abortion Federation and Bell would contact local organizations that have their own abortion access funds to find the rest. Once the money was sorted, the woman told Bell she couldn’t decide whether she should drive more than 14 hours to Washington, D.C., for her care or buy a plane ticket. Her appointment was the following week.
“I was looking at flights, but most of them won’t be there at the time that I need to be there,” she told Bell, a former librarian who talks to as many as 40 callers a day. The Georgia woman said she had $1,200 saved for the trip. Because of the length of a second-trimester abortion procedure, she would likely have to stay in Washington for three nights.
“Sometimes we can help with travel,” Bell told the Georgia caller. “Book the flight and hotel to see if the $1,200 covers those things, also meals and ride-shares from airport to hotel. Factoring in all of those expenses, if you feel like $1,200 doesn’t cover that, reach back out to me immediately.”
Since July 2022, NAF case managers like Bell have helped patients pay for nearly three times the number of hotel rooms and plane, train, and bus tickets each month as they did before the Supreme Court overturned Roe v. Wade, which had recognized a constitutional right to abortion. The most requests for financial assistance have come from people in Texas, Georgia, Florida, and Alabama — populous states with strict abortion laws. Calls are also longer and more involved. The nonprofit now spends $200,000 a month (up from $30,000 a month before Texas instituted a six-week-ban in 2021) and is still not meeting the need, Fonteno said.
In 2020, Fonteno’s organization employed about 30 full-time hotline operators. That number rose when Texas passed its six-week ban. And since the Dobbs decision overturning Roe, the line has employed 45 to 55 people, said Melissa Fowler, the NAF’s chief program officer.
Other reproductive health organizations — at the local, regional, and national levels — have also added staff like Bell. Planned Parenthood affiliates, including some in states with full bans, now employ 98 people known as patient navigators. Most were hired after Dobbs, said Danika Severino Wynn, vice president of abortion access for Planned Parenthood Federation of America. She estimates 127,000 people have relied on these navigators since July 2021.
Planned Parenthood Columbia Willamette in Portland, Oregon, has hired three abortion patient navigators since Roe was overturned, according to spokesperson Sam West. Abortion is legal in Oregon, with no restrictions, but that doesn’t mean everyone has equal access to services. One of the new navigators speaks Spanish and focuses on the rural parts of the state, where services are sparse.
The clinic declined a request for a journalist to listen in on calls with its navigators, citing patient privacy. The two other navigators focus on helping callers who are from out of state (usually Idaho), are younger than 15, or are in their second trimester.
Lawyers contacted for this story who are familiar with current state laws said patient navigators are unlikely to be at legal risk for their work helping people connect with abortion services, though it could matter which state they are sitting in when they offer help. For example, an Idaho law stating that adults in Idaho are not allowed to “recruit” minors to get an abortion could apply to navigators if they answered the phone in Idaho. That law, along with many others in states with bans, is being challenged in court.
Back at her desk in Georgia, Bell took a call from a 20-year-old woman in North Carolina named Deshelle, who was seeking financial support for a second-trimester abortion. Deshelle talked with KFF Health News a few days later, speaking on the condition that only her middle name be used, to protect her privacy.
On the day Deshelle became pregnant, it was legal to get an abortion in North Carolina at up to 20 weeks of pregnancy. About six weeks later, when she discovered she was pregnant, she went to a nearby clinic to have a medication abortion. She went to the first appointment to fill out paperwork. She was required by state law to wait 72 hours before returning to get the abortion pills. She was also given an ultrasound she didn’t want. The image of the embryo rattled her and she skipped the second appointment.
By the time Deshelle decided again to go ahead with an abortion, she was nearly 15 weeks pregnant and the North Carolina law had changed. By July 1, nearly all abortions after 12 weeks were banned. She would have to go out of state.
With the help of NAF navigators, Deshelle made an appointment at a clinic in Virginia, where a 15-week abortion is legal. Her mother drove but did not support Deshelle’s decision to end the pregnancy. Then there were protesters. By the time Deshelle got inside, she was crying. She met with a provider but decided once again not to go through with the abortion.
None of that came up on her call with Bell in November. By that time, Deshelle was 26 weeks pregnant. It was her second time calling the hotline and her third time trying to get an abortion. She just wanted to know if she could still get financial assistance. The cost of her care had escalated from about $500 when she could have gotten a medication abortion to $6,500 for a multiday abortion procedure.
Bell took her cue from Deshelle and stayed focused on logistics. She approved funding to cover half the cost of the procedure and secured a donation to cover the rest. She confirmed that Deshelle had a place to stay and the required companion to go to the clinic with her each day. Then they hung up. The rest of the journey was Deshelle’s alone.
“This isn’t what I want, but I think it’s the best choice for me,” Deshelle said from just outside the waiting room on the first day of the procedure. She read aloud from a pamphlet about the medications she’d be given and the timing of it all. Then her name was called.
A week later, after it was all over, she still felt she’d done the right thing.
“You literally have to be really strong to abort your baby and be OK,” she said she’d tell anyone else in her situation, “and you also have to be really strong to be a single mom.”
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
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