Anniversary of Dobbs v. Jackson – Womens’ Loss of Reproductive Healthcare – From Crisis to Action: Innovative Strategies for Ensuring Access to Healthcare
A Conversation with Cecile Richards
Cecile Richards is a national leader for women’s rights and social and economic justice, and a co-founder of Supermajority – a new organization fighting for gender equity. She is the author of New York Times bestseller Make Trouble. As President of Planned Parenthood Federation of America and Planned Parenthood Action Fund for 12 years, Richards worked to increase affordable access to reproductive healthcare and to build a healthier and safer world for women and young people. After starting her career as a labor organizer, working with women earning the minimum wage, she went on to start her own grassroots organizations, and later served as Deputy Chief of Staff to House Democratic Leader Nancy Pelosi. Richards is a frequent speaker and commentator on politics and progressive issues.
Martin H. Goldstein: Cecile Richards, thank you for agreeing to this interview on the anniversary of the Supreme Court decision, Dobbs v. Jackson Women’s Health Organization. You've spoken and written about your childhood. Your father was a civil rights attorney. Your mother was an activist. She was a Democrat who became Governor of Texas. In the sixth grade you did not recite the Lord's Prayer. In the ninth grade you protested the Vietnam War. You went to Brown University and after college became a labor organizer. You returned to Texas and worked on your mother's campaign for Governor. You campaigned for Sarah Weddington, the attorney who prevailed in Roe v. Wade. You were deputy chief of staff to Nancy Pelosi. Seems you were on a path leading to a career in politics. What led you to focus on women's rights?
Cecile Richards: Well, I was raised in a family that believed in politics. My dad is still alive and has sued the state of Texas more than anyone I could name. I think there are different ways of being involved in politics, small “p.” I was always most comfortable being an organizer and an agitator from my early days in the labor movement. The chance to work for Planned Parenthood was an opportunity that seemed like the right bookend to the work I had done early on in the South, organizing women who primarily earned the minimum wage, worked at jobs with no healthcare, very little opportunity, and they are the same people who relied on Planned Parenthood for all of their healthcare. It was a natural evolution. It’s so important to support and encourage people who run for elective office. They're only as good as the rest of us are at supporting them and holding them to account. It’s really important that some of us devote our time and energy to organizing people. That's the only way to change things in this country. That's the path I've been on.
Goldstein: At the time you joined Planned Parenthood how did you think about women's health? What was your priority list of near-term challenges?
Richards: Well, it's actually a little bit ironic now given what's happened. But when I came to Planned Parenthood, the organization, which was almost 100 years old at that point, had become an excellent healthcare provider for millions of folks. It was then and is still known as the kind of resource for people who either don't have healthcare coverage or need reproductive care in a state where it might be difficult to obtain care.
The first time I interacted with Planned Parenthood was as a college student. I was going to Planned Parenthood in Providence, Rhode Island, when I had no idea where else to go for birth control. Planned Parenthood had become excellent in that vein, and it had a tremendous reputation. The problem was laws were being passed all across the country that prevented folks from being able to come to us for care. Those laws were politically motivated. They weren't healthcare related. When I came to Planned Parenthood, it was at a time that folks believed we needed to build our movement side as well as our healthcare delivery side, because those two things went hand in hand. We did have a lot of opportunities, particularly when President Obama came into office. We contributed to shaping the Affordable Care Act which frankly transformed healthcare access for millions of people in this country. We also had to fight state by state the trench warfare to restrict abortion access, but even to access birth control and basic women's healthcare. We were on the front lines. That was how I spent my twelve plus years at Planned Parenthood, engaging a whole new generation of young people to be fighters for their right to healthcare. It is ironic that, of course, here we are the ultimate travesty has happened, and despite frankly building enormous support for Planned Parenthood, for abortion rights, for birth control access, for women’s healthcare, we are in a situation where a Supreme Court that doesn't represent the majority of people in this country have taken away this fundamental right (See for example: Pew Research Report June 13, 2022 and Gallup Poll June 14, 2023). In some ways, I think the work we did was as important as ever. But obviously it wasn't enough.
Goldstein: Thinking about access to reproductive healthcare and maternal healthcare in light of 2020 data, the U.S. has the highest infant and maternal mortality rate of any other high-income country while simultaneously spending the most on healthcare. You spoke about the impact on poor and marginalized people. How do you reconcile U.S. healthcare underperforming with the passage of restrictions on women accessing healthcare?
Richards: I remember looking at a map when I was with Planned Parenthood, the difference in this country, state by state, on every aspect of access to healthcare, access to reproductive healthcare, maternal mortality rates, child poverty they were all connected. And of course, there's a big red band running through the southern U.S., where I'm from and where I am now. We not only had the most restrictions on access to reproductive care writ large, but also the worst outcomes for children, for women, particularly for people with low incomes, women of color, and black women in particular. There’s a direct correlation. That was one of the reasons we took on a big project to actually build out healthcare centers in the deep South because there weren't the resources, the philanthropic resources coming into this area, and these are folks who needed care and had no other access to healthcare. The infrastructure is missing which is one of the things that is under-reported that the media may be missing. It took decades in many of these areas of the country to build a public healthcare infrastructure largely through Planned Parenthood to provide reproductive healthcare to women. It doesn't take much to tear that down. But the rebuild is going to be difficult and will take a long time. These are not things where you just switch on the lights and start over again.
I think the long-term impact of ending abortion access, at least legal abortion access, is profound. It means ending the access to cancer screenings, ending the access to family planning services, STD testing and treatment, the whole array of sexual health and reproductive health services that often just aren't provided anywhere else. And then, of course, there is the cascading impact of the loss of OB-GYN care, the loss of medical providers being able to stay in the southern U.S. and other states that have banned reproductive care. There are many repercussions that we're only beginning to see. This is just a year out, but we can already begin to understand as we hear stories. I was just in Texas where families are literally leaving the State because their children can't get care anymore now that Texas has banned access to services for transgender people. Doctors are saying they’re leaving the state because they can no longer care for their patients. These are more than anecdotes. This is something that is going to profoundly reshape the disparity of access in half the country. These issues are all directly connected.
I'll actually give you an example. Mississippi passed a law that banned abortions after 15 weeks. The law was challenged by Jackson Women’s Health Organization, the only abortion clinic in the state of Mississippi. The Supreme Court ruled 6-3 in favor of Mississippi overturning Roe v. Wade the landmark Supreme Court decision that legalized abortion nationwide. It was the first case banning abortion. It's a state where they were obviously trying to ban abortion. It also happens to be the poorest state in the country by almost every measure. Mississippi ranks 50th for the rate of child poverty – 30.5% of Mississippi children live in poverty compared to the national average of 16.8%. Mississippi ranks 50th for maternal mortality rates. In 2020, there were 33.6 maternal deaths per 100,000 live births compared to the national average of 19.4. For black women it’s worse. In 2020, there were 67.3 maternal deaths per 100,000 live births for black women in Mississippi, compared to the national average of 55.3. The same legislature that passed the abortion ban in Mississippi, also refused to expand Medicaid access for new moms. So, if you are a pregnant woman in Mississippi who gave birth and relied on Medicaid you got two months of care after you gave birth. Mississippi ranks 47th for Medicaid access. Mississippi has some of the worst health outcomes for children, mothers, and pregnant women. All of these pieces – high rate of poverty, maternal mortality, and lack of access to healthcare are all contributing factors to the poor outcomes. I know there's been a lot written about the hypocrisy of being a pro-life legislator, but then voting against all of the very measures that would help women, families, and children to have a healthy life of opportunity. That is the case in my home State of Texas as well.
Goldstein: I’ve read that for the first time in your life you're wondering whether your daughters will have fewer rights than you've had. After the election Planned Parenthood saw a 900% increase in requests for IUDs from women looking for birth control. One in 5 American women visited a Planned Parenthood clinic. Almost all women have used birth control at some point in their lives. It appears a majority of women value reproductive rights. So how is it that people and organizations opposing reproductive rights have been so successful?
Richards: Well, actually, I would say they haven’t been successful. If you look at the big picture, one of the great ironies is that support for abortion rights is stronger now than it's ever been since Roe. I think, understandably, a lot of people thought the right to abortion was really not at stake. In fact, there’s been a backlash in the last twelve months, beginning in Kansas and running all the way through the Wisconsin Supreme Court race in April. Now average voters actually realize that folks like the previous President weren't kidding when they said, we're going to appoint judges that will overturn the right to abortion. People didn't take it seriously. Now they understand it is real. They are feeling the impact and are addressing it every chance they've had. They voted to elect people who support abortion rights.
It does seem like those opposing abortion were successful. The right wing was successful in that Donald Trump was able to appoint, in an asynchronous partisan way, three judges to the Supreme Court, carried out in a process that was a departure from the past. They have now been able to take away a constitutional right because of their power, but against the will of the American people. It’s true they have succeeded in sort of a tactical victory in the Supreme Court. But what the opponents of legal abortion have not been successful in is convincing the American people that this isn't a right they want. We saw this in the first midterm election. I was stunned at how immediate the understanding of the American people was to what happened and who was responsible. It wasn't just the Supreme Court. It was frankly the Republican party that made it their mission to overturn Roe v. Wade. And so, we saw, in every State, in every close race in competitive states, where abortion was clearly on the ballot, voters, including independent voters and Republican voters voted for abortion rights. But the important point is, women woke up the next morning after the election. We could all say what a tremendous victory this was, but women in Texas still have no access to abortion care. And, as you know, the stories are now coming out about exactly what women, families and doctors are facing and it is horrific. This is not a Supreme Court opinion that is going to age well. Every single day there are more and more stories of what the impact is on people who are not political people. These are average folks trying to live their lives. I think what has happened is devastating. But the understanding among the American people is profound. It may well have a significant impact on the upcoming presidential election, but that remains to be seen. It is very important to distinguish between what the Supreme Court did and where the American people are at.
Goldstein: How will women once again have those reproductive rights? What is the path forward?
Richards: It's all about politics. People stop me thinking there is some kind of magic wand. It's politics that got us here, and unfortunately, I think it's going to be politics that gets us out. But it's not politics in a vacuum, it requires building strong movements, agitating, organizing young people, and bringing in people who have been uninvolved, people who were just living their lives when this happened to them. You can't rely on the political system, or the electoral system, or the party system to do that work for you. That's on all of us. We have to organize the generation of young people that just lost their rights, and no one even asked them. It's like a drive-by shooting. These are folks, some of whom weren't even able to vote and yet the Supreme Court took away their right to make the most fundamental decision of their life – when and whether to have children and raise a family. None of us can stand on the side lines. We need to be investing in young people. They're mad. They're agitated. We need to support their activism if we're going to actually win this back in the political arena.
Goldstein: But there is an immediate problem especially for women of color, low-income women, marginalized women, and those living in underserved communities. You talked about Mississippi and the red band of states. How do we address their immediate need for access to reproductive healthcare?
Richards: I would love to say there's some simple answer. But there isn’t. Now we have to do two things. We have to change the politics and that means movement building, storytelling, lifting up what's the real lived experience of people in America and make sure that's connected to who did that to them. This can't be divorced. The Supreme Court decision didn't just drop out of the sky. This has been an intentional effort by a group of people for many years. We have to make those connections. And the second piece is to do everything we can to get abortion access to people who need it. There are a lot of interesting, creative, disruptive ways in which folks are doing that. It means doing some things that people have never done before or haven't done since the 1950s. From a moral point of view, we have to ensure that we are doing everything possible to make sure that every person in this country can make their decision to have a child or not, to continue a pregnancy or not, and to do it safely with all the support they need. We are in a public healthcare crisis right now and it's going to get much worse as Florida and North Carolina are likely to ban abortions as well. People are already driving from Texas and Louisiana to North Carolina. They're going to Florida. We're about to be in a place where about half the country has no easy or legal access to abortion, and the rest of us are going to have to step up and make sure that we're providing it. There are a lot of creative things happening and we've got to do those things because it's not enough to just leave everybody on their own.
Goldstein: What are some of those creative, disruptive approaches that should be taken?
Richards: Well, as I used to say when I was at Planned Parenthood and it felt like things were just so bad, the two things that gave me hope were the improvement in medical research options and technology. We actually have to leverage both of those. Now, the majority of people in America that have an abortion do it through medication. Obviously, Republicans are trying to do everything they can to make that impossible. Medication is a safe, effective way, as long as we can get people information and access. Coupled with technology, you can go online now and find out pretty much everything needed to self-manage an abortion. That did not exist in the olden days or not very well. It used to be that people had to find a poster with the Jane Collective on it and call an anonymous number. I've been tracking, as part of a project, to understand where people are going online and how to get them more directly connected to services they need. This is something we can do that works. The caveat to that work are the people in these states – the overzealous prosecutors and, in some cases, even statewide elected officials like we have in Texas – their entire MO is to create fear and chaos. In Texas we have the bounty hunter law to make people afraid of even asking their friends or family, or anyone they know for assistance. People assisting anyone with getting access to an abortion can be prosecuted. Doctors can be put in jail for life. It's not a small matter. We have to find ways online to give people access to the information they need, that they may be totally fearful of trying to get even from people they know. That is a robust area where folks are working to reduce the friction online so that people can find out what's available and how to pay for it. That’s work that's going to continue to grow because we just can’t wait until the politics get fixed.
Goldstein: How do we address immediate issues such as, family planning and contraception, use of IUDs, and genetic testing to address disorders such as Tay-Sachs, especially for women who are marginalized and women of color? If we can get it right for those women, then we can get it right for privileged women.
Richards: Centering now on people living in banned states, particularly those with the least access to healthcare, yes, helps us get it right or get it better. The lack of access to all forms of contraception, including IUDs, was profound long before the Dobbs decision. There’s a significant lack of and reduction of OB-GYNs, certainly OB-GYNs and PAs trained in things like IUD insertion. It hasn't taken center stage yet, but the efforts of the right wing and the Republican party to also ban forms of birth control including IUDs, is not insignificant. The other piece of that is IUDs are a very effective form of birth control, they're cost effective. But the upfront cost is really high. A woman living in those same states that restrict access to an IUD or some other longer acting method of birth control is stuck back in time when the pill was discovered. You get the worst form of birth control. Not that the pill is terrible, but it's not as good as a lot of other methods. We have to continue to highlight that access to highly effective contraceptives continues to be a problem. There's so much research by Guttmacher Institute or other groups about the deserts for reproductive care in this country, and they all correlate with the states that have banned abortions.
The other question, though, is so deep. In California women are showing up for an abortion who haven't even had a pregnancy test. They know they're pregnant, but they're terrified to even get a pregnancy test because immediately they don't know who's recording that. They’re afraid to buy pregnancy tests. My daughter is pregnant now with what I hope will be my first grandchild. I'm familiar with all the various medical interventions, issues, and information that pregnant people have now, much more so than when I had my children. But what she has available is rare – she has good medical insurance and excellent doctors. We are facing a world in which a very small group of people have access to all the information and the ability because of where they live or their economic status to make decisions about pregnancy. It's getting even worse for people with low income and people who don't have access to care.
Doctors in Texas have countless examples. Some have already been written about because they are suing the State of Texas. Women who have deeply problematic pregnancies are being forced to either go into sepsis or forced to leave the state to get what should be routine medical care for a termination. I talked to a rabbi the other day who had previously been addressing prenatal screening in Texas and accompanying women to get reproductive care. He said, I'm not worried about the stories that we're hearing, the ones we’re reading about. I'm worried about the thousands of stories that we aren't hearing, the people who literally have no one to talk to and compound that with income, race, and age. Think about young people in Texas, the state that has the highest repeat teen pregnancy rate in the country – 15% of all teen births in the state. Texas does not teach sex education; instead teaches abstinence; provides limited access to contraception, because I guess that would encourage people to have sex. Young people have no one to turn to. We have to find ways through technology, through trusted sources that young people can get information so they can find out if they're pregnant, find out what the laws are in their state, find out how they can get an abortion and how they can pay for it. Those are the basics. Again, it's a stopgap measure. It's not a solution to the long-term problems. We have to do all of that as well as solve the politics.
Goldstein: Family planning and contraception for women who don't know their ancestry, who may have genetic abnormalities in their history is problematic. Does the technology exist and how can it be made accessible so women can understand what they might be facing if they become pregnant?
Richards: A woman’s access to genetic testing in states where abortion is banned may be compromised by a lack of insurance or access to Medicaid. We have many states where there is no legal access to abortion and reproductive counseling. It doesn't matter whether it’s ancestry, genetic complications, or threat to the life and health of a mother. All of the services and the access are going to be non-existent. There are so many stories. Talking to an oncologist in Dallas, she said, I can't care for my pregnant patients because the medicine they need is a risk for the fetus. And in Texas that's not possible. And then, they're in the situation where legally they can't even tell their patient or refer them to go to Colorado or to New Mexico. That's not even legal. Doctors talk to me about literally waiting, making all the nurses, all the clinicians get out of the room, putting nothing on paper, and having a one-on-one conversation, and then only referring them to doctors that they feel like they can trust in another state. This is crazy. This is what it's like living in an authoritarian country where people are literally afraid to speak.
Ultimately, we will win this right back. There's going to be a lot of suffering, unnecessary suffering for people in the meantime. It is unconscionable and immoral what is happening in this country. We have to continue to lift up the stories. Why do people vote for people who would take away their rights? I think we have to do a better job of explaining what the difference is and why it matters who is in office. So many of the people that are being impacted are disenfranchised. We're seeing that in all the southern states. They're also trying to take away voting rights and making it difficult for young people and for working mothers to vote. It's all part of an overarching strategy. It just requires the rest of us to do a lot more work to draw these connections; to get people access to care, and then ensure that at voting time people are aware of the stakes. What a luxury to be able to vote. You're a woman in Mississippi working two jobs just to support your family. Voting is a luxury for that woman. It is not an imperative which the rest of us take for granted.
Goldstein: Lack of jobs, low income, minimizing childcare, loss of reproductive rights, obstacles to voting, lack of access to healthcare has been a problem that’s been around for a long time. How would you characterize Dobbs and its impact on women?
Richards: For those of us who think about Dobbs in political terms, it's literally a loss of freedom and the ability to control your body in a way that's so basic, which is what I think we are seeing now. People don't think of this in political terms. I think that's why Kansas shocked people so much. They thought this was a big Republican Democrat fight. It's a Republican state and people went out and voted because they wanted to make the decision whether to have a child or not. That is not a decision to be made by the governor and the legislature. I do think that for people all the political nomenclature – the pro-life / pro-choice – is really unhelpful. That is not how American people think of these things? Instead, they ask themselves several simple questions: Can I have a child? Can I afford to have a child? Will I be able to support my child? Is my child going to be healthy? These are the fundamental questions. They don’t think about it in theoretical terms. They don’t think about it in constitutional terms. The thread that has been repeated and resonant – is the question of personal freedom. It's too early to tell how all of this plays out, but I think people can also make the connection between: if the Government can tell you when or whether you are having a child, then they can tell you what care you can get for your child, or how you treat someone in your family who is LGBT, or they can tell you what books you can read or tell you if you can vote. There's a thread here and it's kind of interesting. In politics, people have always felt that the Republican party stood for the economy, jobs, low taxes, and the Democrats were obsessed with all the social issues. Well, the whole thing is flipped. People can begin to see there's actually a party that is completely obsessed with controlling individual people, their choices, and telling them what they can read and what they can do with their body. Maybe we're in the middle of this sort of shift, but that will take a long time. Abortion and the Dobbs decision were the first up, but it was not the last up. This is just the beginning of a lot of decisions, both by this Supreme Court and by one of the national parties that has become obsessed with controlling what people do in their personal lives.
Goldstein: Is an underlying thread that ties all of this together how men relate to women in the workplace and in their personal relationships – how women are perceived in society?
Richards: It’s a loss of power. There was an interesting poll after the last election. The pollster said, forget inflation, forget crime, forget all these things. I could ask two questions of any voter, and I could tell you how they voted. The first question is, how do you feel about Black Lives Matter? And the second question would be, do you believe that white men are the most oppressed group in America? She said, that's all I need to ask. It has nothing to do with all the other things that the pundits like to say it’s about. It's not. It's about race. It's about gender. It's about power. People don't like to say that in polite society, but that's the truth. And it's hard to imagine, for some of us – is that really how people think? I do think that's a huge piece of this. Right wing media has certainly fomented that – there's a loss of status and for white men in America loss of place is hugely impactful. I know this is not a political conversation, but I do think that Donald Trump is a perfect icon for that. That appeals to a lot of women, too. It's not just men. Yes, I think that's kind of fundamental.
Goldstein: Your passion and your commitment to your work is obvious. Where does that come from?
Richards: Well, I have led a very privileged life. My parents said early on that if you can choose what you do for a living which 99% of people in this country and in this world cannot do and you find something that actually can change the world then you're so fortunate. People remark, oh, my God, you know those jobs and running Planned Parenthood must be so hard. Instead, I think what a privilege to work with a group of people that every day get up and make the world a little bit better, and sometimes in very specific ways. I remember one of the many times we were going through getting defunded when then, Congressman Mike Pence, now Presidential candidate, Mike Pence, was trying to end all access to Planned Parenthood through Congress. And I thought, this is just so overwhelming because it will affect millions of people. A friend of mine from the environmental room, suggested thinking about it in a different way. Every day that you guys stay open – we did the math – 5,817 people get healthcare that day, and they might not otherwise be able to get it. Sometimes when you're dealing with a world that is very frightening in many ways, you have to break it down, what did I do today that maybe moved the ball a little bit forward. It’s the joy of that work and meeting amazing people along the way every day who have committed their lives to try to change things.
A really quick story. I am down here in New Orleans. I'm moving to Louisiana because I just feel like I need to be where it's all happening right now. I was in a store the other day, and the young woman who was the clerk, asked me, what do you do? And I said, well, I work on abortion. Her eyes just welled up, and she said, well, you know I just had to go out of state. She had to fly out of the state of Louisiana, and she said, I was just really feeling it today. And she went through the process that she'd been through, the shaming here, how hard it was, and lack of support. She listed a lot of the groups that I work with, where she got support to get there and the funding she received, and the medical folks that had talked to her. Damn! I can go on for days just on that one experience. Her life is different now. And she said, I realize I have the education or whatever personal fortitude to go online and find the information and get the support. But I know I'm not the only one. She went on, let me know how I can help, so I can pay it forward. That's why we do this work. There's a lot to do. A lot to do.
About the Author:
Martin Goldstein is a 2020 Harvard ALI Senior Fellow and Senior Editor for the Social Impact Review. Martin has thirty plus years in biopharma, initially at Hoffmann-La Roche; followed by Genentech; subsequently, as founder and CEO of ViroLogic, Inc., a clinical laboratory providing therapy guidance of HIV-infected patients; and more recently working with venture to build biotech companies pursuing cutting edge science to develop therapeutics to treat disease.
This interview has been edited for length and clarity.