 Good afternoon. My name is Victoria Yu, Chair of the LBJ Library Future Forum Board. On behalf of the Future Forum, thank you all for joining us today. On June 24th, the Supreme Court voted to strike down the landmark Roe v. Wade decision, determining that the constitutional right to abortion does not exist. The decision was met with a variety of responses, celebration and excitement among pro-life advocates, and shock and deep disappointment among those who believe in a woman's right to choose. Today's conversation is intended to discuss the implications for Texans, not only health, but also social and economic consequences. The Future Forum brings together individuals with different backgrounds, experiences and points of view to discuss local, statewide, national and global topics that affect us today. Our goal is to create simple, informed and bipartisan discussions. Today we're honored to be joined by three experts, Dr. Abigail Aiken of the LBJ School of Public Affairs, Dr. Myra Panetta Torres of the Georgia Institute of Technology, and Dr. Carrie White of the Steve Hicks School of Social Work at the University of Texas at Austin. There will be an opportunity to answer your questions at the end of the conversation. You are able to type questions into the Q&A box throughout today's event, and we will address as many as we can at the end. And now, I'll turn it over to our fantastic moderator, Karina Klein, host of Capital Tonight on Spectrum News to lead our discussion. Thank you. Thank you, Victoria, and thank you for having me. I'm very interested in hearing what all of these panelists have to say as well, an issue that we've been covering a lot on the show and diving into in all aspects, and Texans are really having to navigate a new reality since the overturning of Roe v. Wade. And so all of these panelists are here to kind of help us understand who's most affected, what's next for women, and how doctors are having to navigate this new reality and how they're responding. And I'm just going to run through how qualified all of these people are to be talking about this. Joining us today, they mentioned Abigail Aiken. She's an associate professor at the LBJ School of Public Affairs. Her research focuses on unintended pregnancy, evidence-based obstetric practice, and the impacts of laws and policies restricting access to abortion. She frequently testifies on reproductive health issues and provided expert testimony to the Irish parliament on the 2018 abortion referendum. She has consulted for the CDC, the World Health Organization, and the UN. Myra Panetta Torres is an assistant professor in the School of Economics at the Georgia Institute of Technology. Her research interests lie at the intersection of health and economics, or health economics, excuse me, labor economics and gender economics. Her current work studies the health and economic impacts of access to reproductive health care. And Carrie White is an associate professor in the Steve Picks School of Social Work and a faculty research associate at the Population Research Center at the University of Texas at Austin. Her research focuses on evaluating the inner relationship between people's reproductive health behaviors and outcomes and the health services and policies that shape their access to care. So again, welcome to all of you. Thank you for joining us. And Carrie, I'll start with you. I mean, the overturning of Roe, of course, comes after Texas had already put in place a near ban on abortion with the so-called Heartbeat Act, which restricts abortions at about six weeks of pregnancy, which is before many women even know that they're pregnant. What lessons have we learned after a posture of Texas over the last 10 months that SB8 has already been in effect? Well, one of the things that we've learned from our research that my colleagues and I have done at the Texas Policy Evaluation Project is that these kinds of restrictions certainly do nothing to end people's need for abortion care or people's desire to seek abortion care. It does not change people's experiences of having unintended pregnancies. But what we have seen is that over the last 10 and a half months that the numbers of abortions provided in Texas have decreased significantly, but we have also seen that more than a thousand Texans are traveling out of state every month to obtain abortions at facilities in other states. Many were going to Oklahoma before that state banned most abortions in April of 2022. Many were also traveling to New Mexico, Louisiana, Kansas, Colorado, even Mississippi in order to be able to obtain an abortion. And this was coming at an incredible sacrifice. People were delaying, paying their bills, not buying groceries for their families, driving through the middle of the night long distances so they could try to minimize the amount of time that they took off from work or needing to have someone take care of their children, bringing their entire families with them because they didn't have anybody to help with those caregiving responsibilities. So this has really made it very difficult, even though we've seen large numbers of people traveling to get care in other places, it is coming at great sacrifice. I'll let you weigh in on what Carrie was saying, but also just even furthering that. I mean, how will the new laws or will the new laws in Texas post-RO have, I mean, kind of what will the impact be expected on those who really supported them? And what can we learn from what we've seen in other countries that I know an expertise of yours and what you've looked at? Thank you, Karina. I think to add to what Carrie is saying, certainly because there has been no change in people's need to access abortion services in addition to traveling out of state, we will see more people self-managing their abortions. And what I mean by that is performing an abortion or conducting an abortion outside of the formal healthcare setting. And that can mean a lot of different things. It can mean self-sourcing abortion medications or abortion pills and using those at home. There's a variety of ways people can do that online or by crossing the border if they're able to do that to pharmacies in Mexico. It could mean herbal abortion. It could mean ingesting substances that might be unsafe. It could mean physical harm. It can mean a whole spectrum of things. Increasingly, we're seeing it mean abortion pills and we do have evidence for the safety and effectiveness of doing a medication abortion yourself at home. But one thing that we found in our research, I lead the Project Sana team here at UT Austin. We're looking at self-managed abortion in Texas and the U.S. We saw with Senate Bill 8 that a policy shock like that when you really restrict care by a gestational limit, for example, you see increases in people looking online to self-manage abortions with pills. And we expect fully to see that increase even further now in a very sustained way following the new laws in Texas, which right now I think are pretty murky in terms of what is exactly in effect and who it applies to, but certainly Triggerban is coming very soon. And I think we will be looking at those numbers to see what we see. But certainly expecting looking to other settings, we can talk about Ireland as a really recent example of somewhere where there was a complete outlawing of abortion since the 1980s that only changed in 2018. And our work there tells us that even in the face of laws that explicitly criminalized self-management for the person who is self-managing, at least five Irish women a day would go online and source medication abortion pills and do their medication abortions at home. So we actually don't have to look too far to see that, you know, again the need for abortion hasn't changed and people will very often find ways of taking care of their needs, whether that be traveling out of state if it's possible for them or doing their own abortion at home. And you mentioned just kind of what we're seeing in terms of people traveling and I know Kerry spoke to this as well, but Myra, I'll bring you in here too with so many women already seeking abortions in states where it's legal. I mean, what is happening with Texans? What are you seeing in terms of them trying to obtain abortions outside of the state? Well, I would say what I know is mainly based on some of the research, including Kerry's research out there, which is documenting what women are doing right now as a response to these policies, particularly because we don't know the end of the story in terms of what are going to be all the unintended consequences of such policies, but we know some of the immediate effects, right? And these are some of these effects that Kerry mentioned, which includes people, as you said, they are traveling out of the state. But who are the people that are traveling out of the state? In some way, are those that can afford it? And I am not saying these are high income women are those women that are not in the lower tail of income, for which all these additional costs are so big that prevent them from getting access to abortions. So here we are talking about one specific population that can travel to other states. But what happened to those that cannot travel to other states? And these are the women in which we are going to see lots of the unintended consequences that we have learned from research that come from facing an unintended pregnancy, carrying that pregnancy to term, and then seeing all these snowball of effects, which reflect on a household that may live in poverty, a household that may rely on public assistance, women, these women, or these people who couldn't access to abortion services and interrupt the unwanted pregnancy, they may face in general a change in their life trajectory in terms of abandoning their education, altering their investments in labor force, affecting also the next generation, which I would say this is something that we cannot see yet because this is very recent. But these are facts that we have learned from research that has focused from other moments in the history of abortion access in the US, and that has been already documented. Yeah, I want to get into that a little bit more with all of you. But first, Carrie, I know that we're even seeing some of the fight in the pre-row laws here in Texas and kind of what's legal and the legal fight that we're seeing with who can still access and what kind of penalties are in place, given those pre-row laws. I don't know if you can speak to that, but also just under what circumstances can abortions be provided in Texas once the state's trigger law does go into effect. Yeah, so the law that was originally challenged in Roe v. Wade was a Texas law that criminalized physicians for providing abortion, and it also included penalties for people who help someone procure an abortion or the means for an abortion. In current times, that could be someone who provides and pills to someone who ultimately has an abortion or self-manages their abortion. What the courts have at least currently decided is that some elements of that pre-row ban are in effect and people could be charged under those criminal provisions. But once Texas's trigger ban goes into effect, which, as Dr. Aiken mentioned, should happen in the next couple of weeks, this would impose far steeper criminal penalties on people who violate the law. So this can be fines of at least $100,000, and people will face two to five years in jail or even in prison or even longer, depending on their involvement in the abortion procedure and what specific laws are being used to charge them in that case. To your question about what medical care can be provided right now, both the laws that Texas currently has in place, for example, Senate Bill 8, which has been in effect for the last 10 months or so, as well as the trigger ban, once that goes into effect, do allow exemptions for medical emergencies. The law does not allow for abortions to be provided in cases of rape or incest, does not allow abortions to be provided in cases in which there is a severe or life-limiting fetal anomaly, and what we have heard in some of our research interviewing physicians and patients who have experienced complications during their pregnancy is that this medical emergency exemption is far too narrow and really doesn't allow physicians to provide the standard of care for people who are experiencing complications in their pregnancy. They are really having to wait until someone is, in the words of someone that we spoke to, on desk door admitted to the intensive care unit who has developed a life-threatening infection, who is hemorrhaging and is at risk of dying before they are able to provide care. This is not how we treat medical problems in other areas of medicine and really providers are being prevented from intervening early on before very serious complications can develop. I'll bring you in here because I know you've been looking at this as well. Not only just how this will affect other aspects of medical care and the doctor-patient relationship between pregnant women, but kind of what we're already seeing and what you're seeing. Yes, it's an incredibly complicated situation right now as Dr. White has, I think, very clearly explained. It's also very chilling. There are uncertainties here for people who would self-manage their abortions, for people who would provide care, for people who want to help others. Even with Senate Bill 8 still on the books, we are not entirely sure how effective that law might be in terms of civil action against people. Remember, Senate Bill 8 is a civil action, not a criminal action law, but there have been cases, but we have not seen resolutions yet. So I think we're in a very unclear place when it comes to how much people can help, what the penalties might look like. Of course, for the people who are self-managing their abortions, that is something where, like I said before, we have really good evidence from our own research within our project team that if you're doing that with pills from an online service like the aid access service people out there might have heard about, there are very good rates of effectiveness and safety for that kind of a service, but that does not completely negate legal risks. Now, Texas does not at present have any state law that would explicitly criminalize a person that self-manages their own abortion, i.e. does their own abortion at home outside the formal healthcare setting. There are very few states, even in our new post-ro situation, that do have a law on the books that would explicitly criminalize a person who self-manages, but that doesn't mean there has not been surveillance and there hasn't been legal harassment and there hasn't been what I would call unjust prosecution of people when prosecutors decide to throw legal spaghetti at the wall and try to figure out under what statute can I take criminal action against you. And we have seen if Wenhao, lawyering for reproductive justice, a legal team based out of Berkeley, California have been tracking these kinds of cases and there have been at least 24 cases over the past two decades of people being brought into legal jeopardy or be prosecuted for alleged self-managed abortion. A lot of the times those cases don't end up going ahead, but the person is still subject to a very stressful and very difficult process. We had a case in Star County, Texas a couple of months ago where somebody was unjustly illegally harassed and fortunately the district attorney said there's no crime committed here, we are not going to take this forward, but that is very zip code dependent. Depending on where you are in a state, depending on where you are in the country, what that legal picture looks like is going to look different. So I think we can expect to see more of this as we see more people self-managing their abortions at home. It's not clear whether states will have an appetite for passing future legislation that would explicitly criminalize self-managed abortion, but I think it's very clear, again I'll go back to Ireland and say even in the face of a very clear criminal law against self-managing people still did it and the consequences were generally that they were very isolated from the formal healthcare setting. If someone does a self-managed abortion at home and feels that they want to have follow-up to check everything went okay or they really want someone to talk to or they want some information about the process or they are in the rare situation of experiencing a complication where they do need medical attention, we cannot underestimate the chilling effect of not feeling secure, not feeling able to access that care when it's needed for fear of being interrogated by a medical provider. There is, to be clear, no duty of a medical provider in Texas right now to ask someone, did you self-manage an abortion? There's no duty to report that to anybody, but a provider might think that there is, they might be worried about that, they may be unclear about the law or they may personally have feelings about that that make them feel I'm going to report this. That's often unfortunately how people get into legal jeopardy. So I think clarity around that is really important and I think that unfortunately even when laws don't have those specific provisions for criminalizing self-managed abortion you do have this chilling effect where people feel very isolated from the formal healthcare setting and the doctor-patient relationship really can't function because it's a relationship that is based on trust and if you can't talk freely with a doctor about what's happening it makes that providing the best standard of care really very difficult. And could I just jump in here and say that I think that this complication in the doctor-patient relationship is something that we are also seeing here in Texas where providers are afraid because of these civil and potential criminal penalties they are afraid to refer patients to other states to get medically necessary care and patients feel really isolated they feel abandoned and they feel completely overwhelmed trying to figure out where they can go to get care so that you know the pregnancy that they wanted that that baby no longer suffers so that their health is no longer at risk and they are just feeling left to their own devices to figure that out and it is a real disservice to people needing medical care. Mary given that and I know a lot of what you're looking into is access and the economic effects of this I mean explain to us kind of what the costs are for a woman trying to travel out of state to get an abortion and give us some context behind that. There are two costs and Dr. White she actually already mentioned some of them. We have theoretically documented but there are actually sorbet papers that show this so when a woman is looking for an abortion or a person who needs an abortion looks for this service it is not the case that she or they are only paying for the service there are so many arrangements or so many things happening around that decision that she or they have to take into account so for example if she has to take time out of job then she has and she's a this is a salaried work or she's paid by the outward this is money that she's going to lose no matter what then if on top of that she requires she already has a family she requires to take care and she doesn't count with a network of people that can support her to take care of the existing children then this is an additional cost so these are things that she has to consider besides the cost of the procedure on top of that we know that right now and even before a rowy being overturned there was a scarcity of abortion facilities so any person looking for an abortion it was very likely that she or they would have to to drive very far away to find the provider so that means that it is lots of time used traveling to the provider which involves paying for gas so these are the direct costs at the moment the person is looking for the abortion so they are here to pass either the person can get the abortion or not if the person gets the abortion we usually document okay then the unintended pregnancy was interrupted so therefore potentially there was not a change in the economic pathway of this person's life in terms of educational attainment in terms of labor force participation in terms of the future generation etc but what happens for these people that are unable to interrupt the unwanted pregnancy and this is where we have been documenting these health and economic impacts of being unable to interrupt a pregnancy or being unable to access abortion services so we have some evidence as I initially mentioned before which comes we have most of our evidence in terms of economic impacts coming from the abortion legalization from the 70s in which we had some states that were the repealed states that legalized abortion before other states and comparing outcomes for women that were living in states in which abortion was still illegal versus those states in which abortion was legal there we learned that when women gain access to abortion in those repealed states there were benefits in terms of educational attainment for women exposed to that policy there were improvements in access to the labor force being participating in the labor force there were improvements for the next generation those children born to women that were exposed to the legalization of abortion were less likely to live in poverty less likely to grow up in a household that relied on public assistance and interestingly once in a different study once these people are trapped later in life or they these generations that were exposed whose mothers were exposed to abortion legalization also as adults the next generation they were less likely to rely on public public assistance and a living poverty so that's from what we know from the 70s but going back to once people are unable to access abortion services we also have very compelling evidence on what has happened to those people Dr. Diana Green Foster she has a big being conducting a study or while she conducted a study the name of this study is the turn away study and what they did is that they tracked women who were denied an abortion because they were right above the gestational limit in the state and there have been different studies based on this one of them studies the economic consequences of being denied an abortion and what they do is that they compare different economic outcomes which I will explain which outcomes are those next of those women who were denied an abortion because they were right above the gestational limit with those of women who were right below the gestational limit which means they could access abortion services and what they observe is that women who were denied the abortion were more likely to live in poverty to face unemployment to face the link when depth to face bankruptcy up to four years after being denied the abortion relative to women who were not denied the abortion we also know for example that when women a during adolescence have a were exposed to parental involvement loss which is another type of abortion restrictions their educational attainment was lower relative to women living in states that didn't implement parental involvement loss we also know that for example regulations on abortion providers which is what HP2 in Texas was these policies that require abortion providers to comply with very specific requirements we know that those policies their impacts not only are reflected on increases in unintended births also for women who were exposed to these policies during their adolescence it translates on lower probability of initiating college or completing college and this is something like I will just briefly mention in it because I think we will talk about that later there are disparities across demographic groups all these findings I am mentioning here they are not homogeneous across all people there are disparities across demographic groups and this has been well documented in the literature yeah and I do want to get into kind of the people this is most effect who are most affected by this but Abigail I'll ask you this because I know that the abortion funds were mentioned too but seeing a lot of what were how those have helped people who are traveling across state lines to try and get an abortion where it is legal kind of what could be affected as republicans in certain states like Texas try to now pass laws so that you can't go across state lines in order to obtain an abortion but also just the effect that some of these abortion funds have had for people getting them and what we could see if those are restricted yeah I think probably Dr. White will have a comment on this too but what I can say is that of course for sure abortion funds have for decades been playing a really critical role in helping people in Texas to access abortion care because even before we got to our current situation as Dr. Veneto pointed out these laws that we've had on the books now for a decade really don't affect people equally when you do things like force clinics to close because they can't comply with requirements that are not necessary and so you reduce the number of clinics in the state you increase travel distances you increase the cost of abortion care by stopping health insurance plans from covering it by stopping state Medicaid funds from being used to cover it by requiring people to attend multiple appointments when it's absolutely medically unnecessary to do that or to have an ultrasound and pay for that and pay for the provider time when that is not all medically necessary you increase the cost of care and so people living in poverty people who are on the margins of poverty people who are you know actually not in poverty but also not super well off are going to have real problems trying to afford this care and as you make all those things worse so you then require people to travel out of state you know the costs keep increasing the time off work keeps increasing the need to find childcare keeps increasing and so we've seen abortion funds play this critical role in helping people to meet those costs for at least the last decade if not longer at this point and that is now intensifying right the role of these organizations is in some ways even more important than ever but the work that they do has been hampered by state laws that seek to either civilly or criminally punish people who would quote unquote aid in the vet someone seeking abortion care those laws are incredibly chilling because there's so much uncertainty around how they will play out legally we don't actually know yet and I think it's a big risk to people who work in abortion funds to take that on you know it's unacceptable to say you need to figure out whether you're going to face criminal prosecution or not and I think that in the absence of that kind of support whether it's transport or funding or something else for people you know we're going to see more people unable to make those journeys unable to meet those costs and that will play in again to how people access care whether they remain pregnant when they don't want to be or whether they self-manage those options are getting the sort of range of options is getting smaller for people as abortion funds are hampered in their really critical work um Dr. White I'll invite you in also because you may also have things to say yeah thank you Dr. Aitken I think I would just add to that that um while abortion funds have been around for um decades in Texas and and other states you know during the the 10 months or so that Senate Bill 8 has been in effect they have really provided a financial lifeline to people who are needing care those who were eligible for abortions in Texas still under the very narrow gestational age limit the S&A allowed but especially for people who were traveling out of state they were helping to cover the cost of gas food people who got stuck in a snowstorm traveling to another state and needed to stay in a hotel unexpectedly and had no clothes um that you know they could wear the next day they were really essential in in providing that kind of practical support um as well as um you know helping people get to a facility and paying for the cost of the abortion um and multiple visits if needed and this for the many people who were living on low incomes um was just an incredible lifeline to help offset the other economic challenges maybe they only had to delay you know one of their bills versus multiple in order to be able to get to care and with the kind of legal crackdown or threats for legal action that are being placed on abortion funds and and those who um partner with them it really may cut off the ability for people to get services in other states and I think the final point that I would just add here something to keep in mind these are really grassroots organizations they're smally staff and rely a lot on volunteers and so this is really the threat of criminal and civil action against you know people who are volunteering for an organization is just something that we really need to keep in mind about you know how these laws are impacting people who are supporting those who are trying to get services in another place. Dr. Wright I'll just add to and ask you this question I mean have you seen fewer dollars going to these abortion funds because of the potential chance of litigation and what we're seeing of the risks just in terms of people actually donating while they're trying to take care of say Colorado trying to take care of their patients but also dealing with all the Texans now coming into is there even enough money there? Yeah I can't speak to anything about the flow of donations but I think something that has been on a lot of people's minds is that when Senate Bill 8 went into effect in September of 2021 there was such a huge influx of philanthropic support small donors large donors who were supporting both Texas and national abortion funds who were helping people get to abortion facilities in other states. The big concern that we have now is with so many other states prohibiting abortion, Mississippi, Alabama, soon Tennessee, Oklahoma that that funding that level of funding that really helps you know Bowie Texans and get them the care that they needed would be spread far more thinly and that may really impact people's ability to get care in this particular moment. May I add something to to this part something we haven't mentioned is that it is not just about the funding or that's not the only part that determines if you can get an abortion. Something we have to consider is that many abortion facilities that used to provide services won't be able to provide anymore so those that remain open will face an excess or are facing an excess demand for their services so even if someone can reach the facility maybe she won't be able to get the appointment whenever she wants it or even she may not be able to get an appointment at all. So we also have these constraints from the supply side of the market from the the providers there are not enough providers maybe to to take care of all these demands that could have gone to other clinics in the absence of probably being overturned. And Myra I'll stay with you I mean you mentioned the disparities and kind of wanting to get into more of that and what we're seeing kind of across the board can you speak to that and also just want to have a reminder I don't know if everyone can see this but you can submit your questions using the Q&A icon and we'll get to some of those in just about five minutes. Yes so this is I would say like a very persistent finding in the literature and is that in terms of access to reproductive health care not just access to abortion there are different impacts across demographic groups something that has been very well documented is that specifically in terms of abortion access both the impacts of expanding access when abortion became legal but also the impacts of restrictions have been stronger among low income women and particularly other demographic groups which are black women. So we know that for example when abortion became legal the impacts in terms of improvements in educational attainment and labor force participation were stronger for black women relative to white women. Similarly we know that the impacts of some abortion restrictions are concentrated among black women and among the potential explanation why this is the case is because this population in general has higher rates of unmet needs for contraception they have higher rates of unintended pregnancy they also report higher use of abortion services in general they are more likely to live in poverty which even increases these barriers they face in order to access reproductive health care and also this combined with the fact that there is a this structural racism that has created some mistrust towards the health care system even creates some in some cases a hesitation to look for health care when they need it. So a combination of all these factors makes some population groups particularly black women which are the ones that have been documented so far more likely to be most affected by restrictions to access abortion. But since we're talking about Texas and Texas has also a big population that is Hispanic this is total I mean I don't have the data yet to prove it but I would say this is a population in which we could also expect some these differences in impacts relative to other demographic groups. And I just like to pick up on that and say that you know again we do not yet have the information to support this but you know what we have heard through some of our conversations with colleagues is that you know people who are who have concerns around crossing interior border checkpoints those who are living in the lower Rio Grande Valley along US Mexico border in El Paso who are concerned about you know whether or not they or their companions are going to be stopped and interrogated by customs and border officials are those who are going to be reluctant or hesitant to try to cross into another state in order to get care and may look to other means to try to end their pregnancies. Kind of looking ahead if we can look ahead yet because there's still so many unknowns right now in terms of what could be next not only the legal fight but also the the medical care and what we're seeing but doctor I can I'll let you weigh in and obviously we're already hearing and we've mentioned some of these some of the fights that we could see even this next legislative session and speaking to Texas specifically but even kind of what we're seeing in other states what do you think is potentially next when it comes if that you know indeed continues to be a republican led state and the push that they've had for restricting access to abortion care is there more that we should be looking at in terms of how people could be affected or do you think this is kind of the end? I think we're unfortunately quite far from the end and I would say that trigger bands certainly as my colleagues have mentioned will be taking effect are taking effect and have taken effect in large spots of the country and so that in many ways for those who would support and pass those policies in some ways takes care of a lot of the idea of accessing abortion in clinics I think that you mentioned something earlier Karina that is concerning it may well not dive with federal law but the idea of preventing people from traveling outside of states I think federal interstate commerce laws are in direct opposition to that but that doesn't mean that people may not try to pass bills and have subject those to legal challenge to see how far they can get with those I think that another thing that I've been hearing about and reading about a lot from folks who are supportive of these kinds of laws is that there's a big concern about self-managed abortion about the idea that these trigger bands will to some extent take care of abortions in clinic settings but what about what people are doing at home and that is a difficult practice to regulate because of course the private nature of someone's self-managed abortion means it may not be something that's ever known about it's not something that's public knowledge and I think we enter some very difficult territory when it comes to the idea of you know I would argue that a lot of these laws are already subjecting people to completely unacceptable oppression but at the same time how far into people's private lives are legislators going to go how much surveillance can we expect how much crackdown I guess I'll say on the idea of medication abortion pills and how to do that I think it's something folks are actively thinking about I also think that there has been talk of fetal personhood laws and the idea of going further than simply taking away the constitutional right to choose abortion but go further than that and grant full legal personhood rights to fetuses which comes with a huge set of difficult legal jeopardies that have not yet been tested and that will affect people I mean I think these laws already do affect people farther than just abortion care maternal mortality is something we haven't really talked about much yet but that is something that we need to keep in mind you know more on wanted pregnancies more on wanted pregnancies for people who are in bad medical situations who's cannot physically cope with pregnancies who are discriminated against who face all kinds of structural oppressions and racism as Dr. Pineda Torres called out I think we can expect to see increases in maternal morbidity on mortality when you get into personhood you start to look at IVF and fertility treatments it gets very very complicated very quickly so I don't know that I have a prognosis for what is coming down the policy pipeline but certainly there are a lot of things swirling and it remains to be seen how far those will go and to what extent they will run into opposition from federal law or from the courts yeah I think we could do a whole section on the maternal mortality the IVF situation that people have been discussing so much right now too I'm going to get to some of these questions and speaking of the maternal mortality Dr. Wright I'll come to you first on this but Catherine asks if we could speak to the impact of the Dove's decision on maternal mortality and morbidity in Texas and I'm just going to let you weigh in on that as well yeah that's a really great question I think just a nice I guess if you can say that transition from what we were just talking about I mean Texas already has a very high rate of maternal mortality and severe maternal morbidity that particularly affects women of color and black women specifically for the reasons that we've already discussed I think what we we are likely to see the statistics around maternal mortality and morbidity worsen in the coming years if abortion remains illegal and if providers are afraid to offer standard medical care to people who are experiencing complications during their pregnancy it is really going to push people into dangerous medical situations if someone is forced to wait until they develop a life-threatening infection like sepsis or starts hemorrhaging before a provider can intervene we have great medical technologies but sometimes that isn't going to be enough in order to prevent someone from dying from those particular conditions and so I think we are likely to see a worsening of our already abysmal maternal mortality and morbidity rates in Texas and this is going to fall hardest on people of color Mary you may want to weigh in on that as well but I'll also just pose this question another one is well any of the federal interventions that President Biden is proposing be helpful or declaring abortion a public health emergency I would say I don't want to comment on that because I am not very well informed more than not well informed I don't know what we can expect about that I could tell you from what we already know I could tell you I want to speak I would say like very upfront I cannot answer that question because I am not very informed so if anyone can't wait on that I would prefer but I would say that something that is concerning for me in the specific case of Texas is that unfortunately we already know a lot about Texas why because so many previous policies were implemented before that inform us on the status of reproductive health care access in Texas which were the fundings on family planning policy hv2 and unfortunately the behavioral responses of people were not necessarily mitigating the impacts of the policy with this I mean we didn't see changes in contraception use we didn't change this in other situations that could compensate the potential issues with these policies so my point with this I am not really trying to deviate from the conversation is that we already know what how Texas population respond to some of these policies and even if one of a assuming one of these state policies federal policies is implemented in Texas I don't know how responsive the Texas population would be to that I don't know if it would totally compensate the current impacts that banning abortion has in the state so that's all I want to say and Dr. Angan you kind of spoke to to this earlier but I'll just another question is there is there any information on how women access abortion who do not have the ability to order online I'm guessing to do with the medication abortion and yeah for sure and I think that that is something that yeah we have some information on it it's very difficult for example to count so one of the questions I get asked a lot is how many people are self managing and what proportion of them are going to an online service like aid access that's going to provide you with pills and instructions and a help desk where you can ask questions and all that kind of support versus people who are doing things without any of that kind of support or information and the answer is of course it's really tough to tell because of the private nature of these things we can't count them all we never will we kind of have to realize that but there are other ways we know from qualitative research studies talking to people that people will oftentimes get pills through various networks that they might know about they may cross the border if they're able to do that to pharmacies in Mexico where you can get mysoprostyl and you can do a medication abortion at home using mysoprostyl alone even if you don't have a pristone which is the first medication in the medication abortion sequence that pristone followed by mysoprostyl but you can use mysoprostyl alone and then there are people who will be using herbal methods other kinds of methods these are methods we haven't got a whole lot of research on but we do know that self-managed abortion even though we think about it and I think we talk about it a lot more now that we're in this new policy situation it's been going on since there were people in North America right and people have successfully self-managed abortions throughout history so even though we haven't got robust evidence on the effectiveness of things like herbal and botanical methods it doesn't mean that people don't use them or can't use them and that's something I think that we also need to pay more attention to from a research perspective as well so yeah it's not a panacea right not everybody will be able to self-manage it's not going to be everyone's preference some people would absolutely prefer to be in the clinic setting that's what they want or they want what I would call it procedural you may have heard it called surgical abortion I say procedural because there's no surgery involved they may prefer that so having an abortion at home with pills is not acceptable for them or they have someone in their house that they can't disclose this to or they could suffer harm if someone in their household found out about the abortion so it's not of course there's gestational age right we know that with advancing gestational age doing an abortion with pills at home is less likely to work and could subject someone to a higher risk of complication so while self-managed abortion is becoming a lot more of the story I think for abortion access certainly we need to be careful about talking about it as the solution or the sort of silver bullet here and I know that we've spoken to this too a little bit but speaking to the doctors and the providing medical care and Dr. White if you want to weigh in on this Michelle writes women are suffering and will die where the consequences really carefully considered before Roe was ended or SBA passed in Texas well I I think people who crafted these bills you know will say that there are exemptions for medical emergencies to save the pregnant person's life that care can still be provided in cases of miscarriage or ectopic pregnancy but I think what we have seen how these policies play out in practice is that the potential of civil and now criminal liability for someone who is seen as violating these laws is really having a chilling effect as Dr. Inkin said and providers are afraid to intervene they are afraid to provide the standard of care and there becomes this question a very tricky question of you know how at risk of death does someone need to be is is 50 percent a good time to intervene or does it really need to be like 95 percent before a provider can come and offer care for someone to try to save their life so I think you know again in many other instances of medical care providers are trying to intervene to prevent more serious harm from taking place but we are in a situation with these types of very narrow narrow exemptions and the chilling effect from legal penalties that providers are just afraid to intervene until people become very very sick. Dr. Pena Torres here's an actually somebody just put another one the the topic of maternal mortality and I think you can speak to this while they're talking about Texas and the state health department having a maternal mortality task force and saying that maternal mortality has been a priority so what happens now if that goes up we've been speaking to that a little bit but how do you see that affecting all of this in terms of the disparities that you've been talking to the economics that you've been talking to and what happens now if we see that really jump even more than it already is. So I was not familiar with the maternal mortality task force I actually don't know how they operate like what are their strategies but if maternal mortality the point of this task force is to improve a maternal mortality reduce it and it is a priority it is like what they want to do as Dr. A can say like maternal mortality we don't have the data yet but we can expect a change there if people are unable to interrupt a pregnancy when they need it and if we end up in a situation in which the health care providers cannot intervene definitely it's expected that there would be those changes in terms of maternal mortality if maternal mortality goes up then if this is a priority then the maternal mortality task force has to come up with ideas or ways of dealing with this issue if abortion access is out of question like people cannot get access to abortion then maybe I mean this is just total ideas but maybe there should be ways in which a health care providers could intervene to deal with this situation that has nothing to do with abortion access I really don't know what I think like if the priority is dealing with maternal mortality then there should be another way to compensate these losing access to abortion services that's all I could say I don't know if Dr. White can elaborate given her knowledge on what else can be done in that sense I'll just make one brief comment and that is that you know I think one thing that we haven't really talked about here that is very policy relevant is the insurance safety net that is available and the gaps that are in that safety net. Texas is one of just a handful of states now that has not expanded Medicaid the extension for postpartum Medicaid was only authorized for six months following delivery but we know from an analysis of when maternal deaths occur that they can occur up to 12 months following the end of a pregnancy and so there are clear gaps in the benefits or opportunities for people to be able to get health care to help them have healthy pregnancies to help them manage chronic conditions that can put their health or the health of the future pregnancy at risk and those are not policy levers that the state of Texas has currently chosen to use. I'll end with this I think we're about out of time but Dr. Aiken I'll send this to you some of these are kind of what is your opinion and you don't have to say that but it's another issue that we haven't really talked about but that has been brought up what do you think and maybe more so just kind of how feasible do you think it is the idea of making abortion legal and establishing facilities on federal land? Yeah that's such an interesting one and there has been you know a lot of sort of public talking about that recently and I believe just to clarify that I'm not a qualified lawyer but I do believe there are some legal risks to that because although you're correct in that you know federal land is there and it spans many states I think there are some legal question marks around when federal land could be considered an entirely federal enclave versus a area of land that has joint federal and state control a little bit like the Medicaid program where there's a little bit of dollars coming from here and a little bit coming from there to make an analogy and so I think states would still have potential legal recourse over the idea that all federal so-called federal lands are entirely federally controlled. I think there's also an historical issue around the laws applying to that federal land at the time the states gave that land over or the time it became under federal control or became under state control so you may find some legal difficulties in terms of what abortion laws looked like back at that point in history and those might apply but I see the rationale for the idea right that the federal government can say hey we're okay with abortion on lands that belong to us and we'll start putting these clinics in place it still might not get us over even if it is legally feasible and unchallenged or it's unsuccessfully challenged in courts of getting people to those places right in terms of travel in terms of costs in terms of how it will work out because I don't think it would negate the Hyde Amendment the idea that you can't use federal funds to help pay for abortions for people but I've also heard recently too about the idea of a boat in the Gulf of Mexico and that's something you know that was done by international activist groups in Ireland way back in the day in 1999 a boat came and started providing abortions of pills off the coast of Ireland in waters international waters where the jurisdiction of the boat and not the country would apply so there are all kinds of I think creative things that people are thinking of I would say that we are in such a legally swirling time right now that you know because so many of these things will be challenged at different levels of the legal system it is so unclear I think even to the experts how all this is going to turn out and may I add something to that I feel like there is in that statement I mean sounds like a good idea but we're losing track of the other side of the market which are the providers are providers going to be able to let's assume like the situation comes into a way in which state the abortion facilities can be there are abortion providers going to come there to work and provide their services there because they also have like their own life going on they also have things going on so making it's not like they are movable and they can go anywhere and something very important that Dr Aiken mentioned is this also involves traveling we go back to the same issue as before in which people have to go there so there are all these costs associated with getting an abortion that will remain there so this is not a solution that will compensate it I feel it's like a patch on a bigger issue that requires more thinking to the actual root of the problem which is people are losing access to reproductive health care service clearly we've only scratched the surface and we could do probably 20 more of these and get into all of these other topics but we are out of time and I just want to thank all of our panelists for all they've been that they've contributed to this and for helping us kind of understand all of this and and what is happening moving forward Dr Aiken Dr Pineda Torres and Dr White thank you so much for your time and I will hand it back to Victoria thank you all and thank you to our panel and moderator for sharing your time and expertise with us today and thank you again to today's audience for engaging with us the future forums events are made possible by our incredible partners and sponsors including the downtown Austin Alliance if you are not yet a member of the future forum I encourage you to sign up on our website lbjfutureforum.org members enjoy first access to events and happy hours networking opportunities and benefits at the lbj library thanks so much again and I hope to see you all again soon