INDIANAPOLIS (AP) — Indiana on Friday became the first state in the nation to approve abortion restrictions since the U.S. Supreme Court overturned Roe v. Wade, as the Republican governor quickly signed a near-total ban on the procedure shortly after lawmakers approved it.
The ban, which takes effect Sept. 15, includes some exceptions. Abortions would be permitted in cases of rape and incest, before 10-weeks post-fertilization; to protect the life and physical health of the mother; and if a fetus is diagnosed with a lethal anomaly. Victims of rape and incest would not be required to sign a notarized affidavit attesting to an attack, as had once been proposed.
Under the bill, abortions can be performed only in hospitals or outpatient centers owned by hospitals, meaning all abortion clinics would lose their licenses. A doctor who performs an illegal abortion or fails to file required reports must also lose their medical license — wording that tightens current Indiana law that says a doctor "may" lose their license.
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"I am personally most proud of each Hoosier who came forward to courageously share their views in a debate that is unlikely to cease any time soon," Gov. Eric Holcomb said in the statement announcing that he had signed the measure. "For my part as your governor, I will continue to keep an open ear."
His approval came after the Senate approved the ban 28-19 and the House advanced it 62-38.
Indiana was among the earliest Republican-run state legislatures to debate tighter abortion laws after the Supreme Court ruling in June that removed constitutional protections for the procedure. But it is the first state to pass a ban through both chambers, after West Virginia lawmakers on July 29 passed up the chance to be that state.
"Happy to be completed with this, one of the more challenging things that we've ever done as a state General Assembly, at least certainly while I've been here," Senate President Pro-Tem Rodric Bray told reporters after the vote. " I think this is a huge opportunity, and we'll build on that as we go forward from here."
Sen. Sue Glick of LaGrange, who sponsored the bill, said that she does not think "all states will come down at the same place" but that most Indiana residents support aspects of the bill.
Some senators in both parties lamented the bill's provisions and the impact it would have on the state, including low-income women and the health care system. Eight Republicans joined all 11 Democrats in voting against the bill, though their reasons to thwart the measure were mixed.
"We are backsliding on democracy," said Democratic Sen. Jean Breaux of Indianapolis, who wore a green ribbon Friday signifying support for abortion rights, on her lapel. "What other freedoms, what other liberties are on the chopping block, waiting to be stripped away?"
Republican Sen. Mike Bohacek of Michiana Shores spoke about his 21-year-old-daughter, who has Down syndrome. Bohacek voted against the bill, saying it does not have adequate protections for women with disabilities who are raped.
"If she lost her favorite stuffed animal, she'd be inconsolable. Imagine making her carry a child to term," he said before he started to choke up, then threw his notes on his seat and exited the chamber.
Republican Sen. Mike Young of Indianapolis, however, said the bill's enforcement provisions against doctors are not stringent enough.
Such debates demonstrated Indiana residents' own divisions on the issue, displayed in hours of testimony lawmakers heard over the past two weeks. Residents rarely, if ever, expressed support for the the legislation in their testimony, as abortion-rights supporters said the bill goes too far while anti-abortion activists expressed it doesn't go far enough.
The debates came amid an evolving landscape of abortion politics across the country as Republicans face some party divisions and Democrats see a possible election-year boost.
Republican Rep. Wendy McNamara of Evansville, who sponsored the House bill, told reporters after the House vote that the legislation "makes Indiana one of the most pro-life states in the nation."
Outside the chambers, abortion-rights activists often chanted over lawmakers' remarks, carrying signs like "Roe roe roe your vote" and "Build this wall" between church and state. Some House Democrats wore blazers over pink "Bans Off Our Bodies" T-shirts.
Indiana's ban followed the political firestorm over a 10-year-old rape victim who traveled to the state from neighboring Ohio to end her pregnancy. The case gained attention when an Indianapolis doctor said the child came to Indiana because of Ohio's "fetal heartbeat" ban.
Religion was a persistent theme during legislative debates, both in residents' testimony and lawmakers' comments.
In advocating against the House bill, Rep. Ann Vermilion condemned fellow Republicans who have called women "murderers" for getting an abortion.
"I think that the Lord's promise is for grace and kindness," she said. "He would not be jumping to condemn these women."
Q&A: Abortion medication explained
Medication abortion explained
How does medication abortion work?
Medication abortions became the preferred method for ending pregnancy in the U.S. even before the Supreme Court overturned Roe v. Wade. These involve taking two prescription medicines days apart — at home or in a clinic.
Abortion procedures are an invasive medical technique that empties the womb. They are sometimes called surgical abortions, although they don’t involve surgery.
Abortion by pills involves the drugs mifepristone and misoprostol. As more states seek abortion limits, demand for the pills is expected to grow.
Two pills work in combination
Mifepristone is taken first, swallowed by mouth. The drug dilates the cervix and blocks the effects of the hormone progesterone, which is needed to sustain a pregnancy.
Misoprostol, a drug also used to treat stomach ulcers, is taken 24 to 48 hours later. The pill is designed to dissolve when placed between the gums and teeth or in the vagina. It causes the uterus to cramp and contract, causing bleeding and expelling pregnancy tissue.
How late in pregnancy can the drugs be used?
Abortion medication is approved for use up to the 10th week of pregnancy.
The pills may be taken in a doctor’s office or clinic, where patients sometimes have an ultrasound or lab tests beforehand. Some providers also offer the pills through telehealth visits and then send patients the medication by mail.
Use of the pills has been increasing in recent years. As of 2020, they accounted for 54% of all U.S. abortions, according to preliminary data from the Guttmacher Institute. The group’s final estimate is due later this year.
Are the drugs safe? What are the risks?
Studies and real-use evidence show that when taken together, the pills are safe and up to 99% effective. Side effects may include nausea, vomiting and diarrhea.
Bleeding is normal. Very heavy bleeding — soaking more than two pads an hour for more than two hours — is uncommon but requires medical attention.
Dr. Stephanie Rand, a New York ob-gyn and abortion specialist with the advocacy group Physicians for Reproductive Health, says pregnancy tests should not be used right away to determine if a medication abortion was successful because the pregnancy hormone may linger in the body for several weeks. Bleeding, with blood clots that include lighter colored tissue, are signs of success, she said.
Serious complications are very rare. The Food and Drug Administration says more than 3.7 million U.S. women have used mifepristone since it was approved more than 20 years ago. The agency has received 26 reports of deaths in women using the medication, including two involving ectopic pregnancies, which grow outside the womb.
The medications are not recommended for certain patients, including those with suspected ectopic pregnancies or with implanted IUD birth control devices.
What are the costs and rules for use?
Costs vary by location but are similar to abortion procedures and may total more than $500. Health insurance coverage varies, with some plans making the pills free or low cost and others not covering them at all.
Mifepristone is sold under the brand name Mifeprex and misoprostol under the brand name Cytotec, but both pills are available as generics.
The FDA approved mifepristone to terminate pregnancy in 2000, when used with misoprostol. At the time, it imposed several limits on how the drug could be prescribed and dispensed.
In December, the agency dropped the biggest restriction: a requirement that patients pick up the medication in person. The FDA said a scientific review of the drug’s use — including during the COVID-19 pandemic — showed that women could safely receive the pills through the mail after an online consultation, without any increase in side effects or complications.
The decision allowed mail delivery of the pills nationwide, a change long-sought by medical professional groups and abortion-rights supporters.
Still, millions of women will have trouble accessing the pills due to a patchwork of state laws targeting abortion broadly and the pills specifically. About half of U.S. states are expected to ban or greatly restrict abortion.
Will the pills be covered by state abortion bans?
Legal experts foresee years of court battles over access to the pills, as abortion-rights proponents bring test cases to challenge state restrictions.
There are strong arguments and precedents on both sides, experts note, though little certainty about which side might prevail.
The Biden administration’s Justice Department has already signaled plans to challenge state restrictions on medication abortion. And federal lawyers are likely to be joined by outside parties, including abortion rights groups like Planned Parenthood and even the companies that make the pills.
The chief argument against pill restrictions is likely to be the longstanding principle that federal laws, including FDA decisions, preempts state laws. Indeed, few states have ever tried to fully ban an FDA-approved drug because of past rulings in the agency’s favor.
Still, states with blanket abortion bans are likely to interpret them as barring abortion pills. Many of the laws don't distinguish between abortion procedures and medication abortion.
“In the short term, those states that ban abortion are going to assume that their bans also include medication abortion and that will be prohibited,” said Greer Donley, a professor specializing in reproductive health care at the University of Pittsburgh Law School.
What is the current situation in the states?
Even if blanket bans are successfully challenged, more than 30 states have laws specifically restricting access to abortion pills. For example, 19 states require that clinicians be physically present when the drug is administered.
Those laws could withstand court challenges. States have long had authority over how physicians, pharmacists and other providers practice medicine.
States also set the rules for telemedicine consultations used to prescribe medications. Generally that means health providers in states with restrictions on abortion pills could face penalties, such as fines or license suspension, for trying to send pills through the mail.
Women have already been traveling across state lines to places where abortion pill access is easier. That trend is expected to increase.
Meanwhile, some women will still get the medication via online pharmacies in Canada and overseas, often with telehealth consultations from foreign doctors. The practice is technically illegal but essentially unenforced, and advocates believe women will increasingly choose this method as more states move to ban abortions.
“Anti-abortion states are going to do everything they can to restrict medication abortion, but practically speaking people have been and will continue to access it through the mail from international pharmacies,” Donley said.
Donley expects lawsuits based on various legal theories to play out for a few years before any clear decisions emerge.
One key question is how the nation’s top court might rule if and when it takes up those court cases. While the Supreme Court has rejected a constitutional right to abortion, conservative justices have also generally deferred to FDA's primacy over drug decisions.