With federal abortion protections eliminated in a watershed U.S. Supreme Court decision, California is preparing for a flood of out-of-state women seeking abortions as it positions itself as a stronghold for reproductive rights. Most lawmakers are even willing to foot the multi-million-dollar bill.
But amid all the politicking one crucial question remains unanswered: How does California plan for a significant increase when it doesn't know how many abortions are currently performed in the state?
Although almost every other state tracks abortion information — including how many people arrive from out of state — California is one of three that does not. The California Department of Public Health has not kept track of any abortion data since 1997. When CalMatters asked why, the agency did not provide an answer.
"Having a lack of information and data is sometimes an issue," said Jessica Pinckney, executive director of ACCESS Reproductive Justice, which provides funding for those who can't afford abortions.
"Every journalist and every legislator I've talked to in the past six months wants to know how many people are coming to California," Pinckney said.
A recent brief from UCLA's Center on Law, Reproductive Health, and Policy estimated that post-Roe, 26 states would ban all or nearly all abortions — prompting between 8,000 and 16,100 more people to travel to California seeking abortions each year.
Yet as of today, there's no centralized system collecting information on how many Californians are obtaining abortions here. Individual clinics and hospitals in California know how many procedures they perform, but it's hard to get the full picture on abortions and how much they cost, Pinckney said. State officials said the new Health Care Payments Database, which tracks insurance claims, should capture abortion procedures and medication, but the information likely won't be available until the end of next year.
In the meantime, estimating future demand for abortion services remains difficult — but that hasn't stopped legislators from pushing forward with big-ticket budget proposals.
In a budget deal announced Sunday night, Gov. Gavin Newsom and Legislators pledged more than $200 million to improve reproductive health care in the state, including $40 million to directly subsidize the cost of providing abortions for low-income or uninsured patients.
Next year, most insurance plans in the state will be required to eliminate out-of-pocket fees for abortion services, meaning the money will go primarily to uninsured Californians and out-of-state residents.
"With today's Supreme Court decision to endanger the health and safety of millions of women across the country, California must do everything it can to protect the fundamental rights of all women – in California and beyond," Newsom said in a statement following the Supreme Court decision.
Much of the funding is part of a 15-bill package pushed forward by the California Future of Abortion Council to improve clinical infrastructure, strengthen privacy protections and remove barriers to access. The abortion council was convened by Newsom in 2021 to assess the reproductive health landscape in California and draft policy recommendations for lawmakers.
Given the perilous state of abortion rights in most of the country, the legislation and funding is necessary for California to "truly be a reproductive freedom state," said Lisa Matsubara, general counsel for Planned Parenthood Affiliates of California, one of the council's leading organizations.
The budet deal also commits $20 million over three years to establish the California Abortion Support Fund to help offset travel, child care and other costs that might prohibit a woman from getting to a clinic. However, much like the question of how many non-residents will seek abortions here, the number of Californians who need additional support is at best a guesstimate.
"It is my dream to set up some sort of surveillance system for California," said Ushma Upadhyay, a leading abortion researcher and associate professor-in-residence at UC San Francisco's Bixby Center for Global Reproductive Health. Among researchers and public health professionals, surveillance is a term used to describe routine data collection and analysis to assess trends.
"For a researcher (surveillance) is incredible. It's really helpful to understand access," Upadhyay said.
Although the state doesn't track abortions, that doesn't mean that there's no information out there, advocates say. The Guttmacher Institute, a national reproductive health think tank, is widely cited for its survey of abortion providers. The organization sends a survey to all known abortion providers in the country every three years to calculate its estimates.
"It's not like we're running blind," said Fabiola Carrión, director of reproductive and sexual health at the National Health Law Program, a member of the abortion council. "Guttmacher has numbers on abortions in California."
Guttmacher published its latest abortion survey with 2020 estimates this month, showing the first significant increase in abortions nationwide since 1980. The new survey is the first update to include California since 2017. It estimates roughly 154,000 abortions were performed in California in 2020, a 16% increase from 2017.
Some of those abortions were likely for non-residents, but the number isn't specified.
The U.S. Centers for Disease Control and Prevention, which conducts an annual abortion survey, does ask what state women reside in as well as where the procedure was performed. But California does not participate in the CDC survey.
The best guess on abortion numbers comes from another Guttmacher data point. Its projections indicate the number of women of reproductive age whose nearest abortion clinic would be in California would increase 30-fold as other states ban abortions, which they are expected to do now that federal protections are gone.
That means 1.3 million more women, primarily from Arizona, would find themselves closest to a California clinic. Arizona, along with two dozen other states, has a "trigger ban" on abortions, making the procedure illegal the moment Roe was overturned, according to the Guttmacher Institute.
Using women of reproductive age as a proxy for abortion need, however, is an imprecise metric, especially considering how abortion rates have declined nationally over the past three decades.
Those estimates are also based on driving distance and don't take into account the fact that California's major transportation hubs make flying a convenient option, Planned Parenthood's Matsubara said. Evidence from ACCESS already shows women from states farther away than Arizona are seeking abortions in California, with 18 states represented among its clients.
But without detailed yearly state data, crafting precise policy is difficult.
"We want to know these numbers because we want policy to reflect what people need," Carrión said.
Some questions are fairly basic: How many abortions are performed each year in California? How many people seek out medication abortions versus procedural ones?
Others are important to assess the impact of current health policy: Are there ethnic or age groups that are disproportionately impacted? Is telehealth a help or a hindrance for people seeking abortions?
Still others seek to identify how accessible abortion care is and what the unmet needs are: How many people come from out of state for abortions? How far do people in the state have to travel to reach a clinic? In which trimester do most abortions occur and how many Californians have to leave the state to seek late-term options?
The CDC's survey includes answers to many of these questions, but California was no longer included when it stopped reporting data in 1997.
There is no policy preventing the department from collecting abortion data, according to an emailed statement from Matt Conens, a spokesperson for the California Department of Public Health. When asked specifically why the health department doesn't track abortions, Conens said it is not required.
In a separate email sent without attribution, a statement reads "the California Department of Public Health does not have information about the history of abortion-data reporting in California."
That means the information on statewide trends is piecemeal at best.
The only window into abortions is through Medi-Cal, the state's health insurance program for low-income people, which covers roughly a third of all Californians. Medi-Cal data suggest that the abortion rate has been dropping among enrollees since 2014. There are no numbers on procedures among those with private insurance, those who may have paid out of pocket or those from out of state.
Hospitals, surgery centers and insurers may collect the information voluntarily but aren't required to report it. Abortion clinics also are not required to report any of their data.
Likewise, there is no way to track the number of medication abortions in the state, although nationwide trends suggest they may comprise up to half of all abortions. Medication abortions, also known as the "abortion pill," use prescription drugs to terminate a pregnancy within the first 10 weeks, similar to an early miscarriage.
The California Department of Health Care Access and Information collects annual data from hospitals and surgery centers, which captures surgical abortions regardless of insurance status, but the department does not receive any data from abortion clinics, spokesperson Andrew DiLuccia said in an email.
Pinckney said some of the proposals put forth in the bill package, like creating a statewide website where providers can contribute information on services and funding, would be helpful. It would also make it easier for providers to refer patients to one another if they can't accommodate them. The key is making sure the data is secure.
"That takes additional resources but it's absolutely necessary to protect the privacy of patients and providers becasue people have politicized abortion so seriously," Pinckney said.
The budget passed by the Legislature in June includes $20 million to improve physical and digital security at reproductive health facilities. It also includes $1 million for the state health department to research unmet abortion needs.
UCSF abortion researcher Upadhyay said while $1 million isn't a lot compared to how much research typically costs, it is an important signal of California's committment to abortion rights.
"Traditionally the National Institutes of Health and CDC do not fund research on abortion, and that's why this funding is so critical," Upadhyay said. Lack of federal support tends to create a "chilling effect" when it comes to investing in abortion research, she said.
Based on the work of the abortion council — which released a report in 2021 outlining 45 policy recommendations — the Newsom administration is confident proposed spending on reproductive health is adequate, said Richard Figueroa, deputy cabinet secretary for the California Health and Human Services Agency.
A bulk of the spending focuses on offsetting the cost of abortions provided for free or at reduced rates, helping abortion clinics improve security and encouraging more providers to offer abortions with loan repayment. There is also funding for improving sexual and reproductive health education that meets the social, cultural and linguistic needs of commnities throughout the state.
"These are unmet needs that we know already exist. These are not ephemeral things," Figueroa said.
Recommendations made by the abortion council and incorporated in the 15-bill package are based on members' experience. The 40-member group forecasted future costs based on how much money they've collectively spent on improving access.
Matsubara said Planned Parenthood of California provided close to $20 million for abortion care last year that was not reimbursed by insurance. ACCESS Reproductive Justice spent around $63,000 to help people pay for procedures or medication and $28,000 in travel grants or other practical support.
But it's hard to say what the outstanding needs are. Between January and April of this year, ACCESS fielded twice as many calls from people seeking assistance compared to the same period last year. Around 30% of the calls were from out of state.
"We've been really clear that there are a lot of unknowns and we may have to come back to the state Legislature at some point and request additional funds just depending on how it pans out," ACCESS executive director Pinckney said.
The money earmarked for abortion research in the budget can be used to answer some of these questions and assess the effectiveness of the bill package once implemented, Deputy Secretary Figueroa said.
"You need good data to help you make good decisions," Figueroa said. "It was very clear to us that there were still some things that we needed to learn about the provision of abortion care in California."