FAIRVIEW HEIGHTS, Ill. — When the woman called Planned Parenthood to schedule her abortion, Alexandria Ball picked up the phone and explained exactly what would happen next.
And they would pay for her 15-year-old son to come along.
“Is this a dream?” asked the pregnant mother from western Missouri.
Attached to an abortion clinic on the Missouri-Illinois border, this first-of-its-kind call center offers a window into the splintered future of abortion care in the United States if the Supreme Court decides this summer to roll back Roe v. Wade, the landmark decision that established a constitutional right to abortion. Since the call center opened in December, Ball and her colleagues have been laying the groundwork to turn their operation into a blue-state abortion refuge for patients from across the South and Midwest, whose more conservative home states are poised to restrict abortion access if Roe falls.
The emerging red-blue abortion map has prompted a new level of tactical maneuvering — with abortion providers envisioning a proliferation of clinics a stone’s throw from red-state territory and conservative lawmakers exploring measures to prevent abortion patients from crossing state lines for care.
Nowhere is this dynamic more pronounced than southern Illinois, where Planned Parenthood and the Hope Clinic for Women, each located just over the Mississippi River a few miles from the Missouri state line, have been serving thousands of out-of-state patients for years as Missouri residents have sought to avoid the more restrictive laws enacted by their conservative state legislature.
In response to a strict ban imposed last year by Texas and in anticipation of a transformative high court ruling, the two clinics have partnered on a novel program to make Illinois a destination for those who live in Republican-dominated regions — a model, clinic leaders say, for abortion providers in other Democratic states.
“The expectation is that if the South falls — again — you will have Illinois … a blue boat in a red sea,” said Amy Redd-Greiner, the front desk supervisor at Hope Clinic. “You have Michigan and Wisconsin, but they are not as accessible.”
Inside the Planned Parenthood call center, which helps coordinate funding for patients at both clinics, close to a dozen staff members sit at attention, logging their calls on brand new black monitors with still-shiny keyboards.
Each time she picks up the phone, Ball leans back in her chair and smiles like she’s talking to a friend.
“You don’t have to worry,” she tells each patient at the end of the line. “We’ve got you.”
Abortion providers on the Missouri-Illinois border have spent years preparing for life after Roe.
Missouri, with a long list of unusually strict laws imposed by the state’s conservative legislature, has among the lowest abortion rates in the country. The restrictions include a 72-hour waiting period and a requirement that doctors who perform abortions are certified to admit patients at a local hospital. That credential, considered unnecessary by leading medical associations, can be difficult for doctors to obtain in a conservative region where hospitals may be reluctant to associate themselves with abortion clinics.
There were just 167 abortions performed in Missouri in 2020, according to preliminary data from the state health department. That same year in Arizona, which has a similar population size and a Republican-led legislature, doctors performed more than 13,000 abortions.
In response to Missouri’s restrictions, Planned Parenthood in October 2019 opened its 18,000-square-foot Fairview Heights clinic, where the organization says it has provided abortion care for over 10,000 Missouri residents. Although the Planned Parenthood facility serves mostly Missouri and Illinois residents, the clinic has always attracted patients from other states, too, said Ball, because it performs abortions up to 26 weeks of pregnancy, later than most other states in the region allow.
Until recently, Ball said, those patients mostly had to pay their own way to the clinic. Ball could offer a small amount of financial assistance from Planned Parenthood for the actual procedure, but if a patient didn’t have the money to get there, Ball said, “there wasn’t a whole lot we could do.”
Then Texas enacted its restrictive abortion law in September, banning abortions after six weeks of pregnancy, before most people know they’re pregnant. Texas patients started showing up on the Illinois-Missouri border almost immediately, traveling at least 600 miles. Donations began pouring into abortion rights organizations established to help low-income patients fund their procedures.
Suddenly, events were catching up to plans that had been in the works for years. Yamelsie Rodríguez, the president of Planned Parenthood of the St. Louis Region and Southwest Missouri, had long envisioned a Planned Parenthood program that would help abortion patients book hotels, flights, cabs, child care and anything else they needed to make it to their appointments.
“After what happened in Texas,” Rodríguez said, “we felt compelled to put all our plans on steroids.”
Starting in December, Ball’s job changed completely: Instead of simply scheduling appointments for patients who call Planned Parenthood in the Missouri-Illinois region, she and a small group of colleagues now also help coordinate travel and raise the money patients need to access the procedure, calling abortion funds across the country and patching together donations.
“Darlin’,” she’ll say to patients, “how much are you comfortably able to put toward your procedure today?”
Ball subtracts that number from the total cost, then gets to work finding the rest. The call center has yet to turn any patients away, according to Planned Parenthood. The clinic says that, since it started, it has been able to find enough funding for everyone.
While some Texas patients are traveling all the way to Illinois, many more are finding care closer to home, in Oklahoma, Louisiana or New Mexico.
If the Supreme Court overturns Roe in June — and 13 states immediately ban abortion through “trigger laws” already on the books — the abortion clinics here expect to be inundated with calls from all over the country. Six additional states are considering trigger bans this year, while 13 others have introduced measures that mirror the restrictive Texas law.
Meanwhile, lawmakers in at least 12 states have introduced measures to further protect abortion rights and, in some cases, encourage patients to travel from states where abortion access is under threat. California Gov. Gavin Newsom (D), for example, announced that his state would be an abortion “sanctuary.”
In a post-Roe world, Planned Parenthood estimates that as many as 14,000 people could seek abortion care in southern Illinois. There would almost certainly be an initial influx of cash to abortion funds and providers, said Redd-Greiner of Hope Clinic, as people across the country respond to the decision. After that, she said, she’s not sure what would happen.
“There is not a bottomless pot of gold,” she said.
In this otherwise sleepy region in southern Illinois, the presence of two prominent abortion clinics has become a cultural flash point.
The Planned Parenthood clinic, tucked behind a long line of strip malls, looks more like a hospital than a typical abortion clinic. It has three surgical rooms, four consultation rooms and 12 chairs in its spacious recovery bay.
A wrought-iron fence surrounds the sprawling brick building, separating the clinic from the antiabortion protesters who post up every day with camp chairs and blown-up baby pictures.
“We provide free ultrasounds right here,” they say to every person who drives up to the gate, gesturing to a nearby van operated by a local crisis pregnancy center, an antiabortion organization.
More than 100 people packed into the parking lot for the clinic’s 2019 opening, hoisting hot pink Planned Parenthood signs above their heads.
The clinic would be an “oasis of sexual and reproductive health care, not just for patients in Illinois, but the entire region,” Rodríguez said as she addressed the crowd. “That means that whether you are from … Missouri, Indiana, Louisiana or Kentucky, there will be a place here for you at Planned Parenthood.”
Antiabortion activists were there, too.
Missouri Rep. Mary Elizabeth Coleman (R), one of her state’s most prominent antiabortion legislators, prayed on the other side of the fence that day. As she watched the celebrations, she said, she promised herself she would try to stop Missouri women from coming here.
More than two years later, Coleman believes she has found a way, recently introducing a measure designed to stop Missourians from obtaining abortions out of state. Her plan, inspired by the controversial enforcement provision of the Texas abortion ban, would allow private citizens to sue anyone who helps a Missouri resident cross state lines for abortion care. The measure would target anyone involved in an abortion performed on a Missouri resident, from a hotline staffer like Ball who helps the patient schedule her procedure to the doctor who performs the abortion.
Attached as an amendment to several abortion-related bills that are waiting to be heard on the House and Senate floor, the measure has been embraced by several Missouri Republicans, including Sen. Rick Brattin, who is carrying a version of the Texas law in the Senate, which is favored by Republicans to pass in Missouri.
“We know women are going across the river — and whether the damages occur across the river or not, a Missouri citizen should be made whole,” said Brattin, who said he would like Coleman’s proposal to pass as part of his bill.
“If your neighboring state doesn’t have pro-life protections, it minimizes the ability to protect the unborn in your state,” Coleman said.
Much of the major legislation proposed in Missouri has been moving slowly this year, thanks to heated battles over redistricting. But even if the Missouri measure doesn’t pass, similar legislation could soon emerge elsewhere.
GOP lawmakers in other states have been considering the same approach, said Kristi Hamrick, chief media and policy strategist at the national antiabortion group Students for Life. When the National Association of Christian Lawmakers convenes in June, President Jason Rapert, a Republican state senator from Arkansas, said it will discuss this idea.
If Roe is overturned this summer, restricting out-of-state abortions is likely to become “the next frontier,” said David Cohen, a professor at Drexel Kline School of Law, who anticipated proposals like Coleman’s in a recent paper.
To a certain extent, it doesn’t matter whether this kind of law is unconstitutional, said Elizabeth Myers, an attorney for Texas abortion rights groups in a court challenge to the six-week abortion ban: If abortion providers in Illinois are sufficiently intimidated by the prospect of lawsuits, they might stop performing abortions on Missouri residents, just as Texas abortion providers have been complying with Senate Bill 8, even though the law violates Roe v. Wade.
Sitting in her cubicle in Fairview Heights, Ball said she’s not intimidated by the Missouri lawmakers targeting her and her work.
“You can’t get blood from a turnip,” she said as she scheduled another appointment. “They ain’t getting a dime out of me. I ain’t got nothing for them.”
As the Supreme Court decision approaches, Ball said, she feels more and more like she’s headed for battle. Every day, as she drives into work, the throng of protesters at the gate try to persuade her that she has picked the wrong side.
When they start to swarm her car with antiabortion pamphlets, she accelerates and looks straight ahead.
To win, she has to get to her desk and pick up the phone.