A Planned Parenthood clinic in Colorado reopened last week, months after a gunman killed three people and wounded nine at the clinic, angry at the abortion services provided there.
That the clinic in Colorado Springs, Colo., reopened at all makes it something of an oddity. Abortion providers across the United States are closing at a record pace, according to data analysis from Bloomberg Businessweek, and the closures are not limited to the conservative states that have been passing regulations – the US Supreme Court will hear oral arguments on Texas's controversial House Bill 2 next week – over when and how abortions can be carried out.
Twenty one abortion providers have opened since 2011, while at least 162 have closed down or stopped offering the procedure, Bloomberg reported. Both supporters and critics of abortion attribute the decline to a range of factors, from high operating costs and reduced demand, to the rise of strict state regulations. And both sides say the abortion debate in America is reaching a seminal moment.
The vast majority – 94 percent – of pregnancy terminations are conducted in stand-alone clinics, as opposed to hospitals or doctor's offices. The number of these facilities that perform 400 or more abortions a year has dropped from a peak of 705 in the late 1980s to 553 in 2011, according to the Guttmacher Institute, a think-tank that supports reproductive rights.
The closures have been felt in all corners of the country. While many of the clinics have shuttered in states that have adopted new regulations on abortion clinics, a broader array of pressures are taking their toll on clinics in states that are friendlier to them.
Texas lawmakers have passed 13 such regulations between 2011 and 2015 – the constitutionality of aspects of one bill are now being challenged in the Supreme Court – during which time 30 abortion providers in the state have shut down. Yet in California, which Guttmacher says "doesn't have any major types of abortion restrictions," a dozen providers have closed since 2011, according to Bloomberg.
"It is difficult to be an abortion provider in the United States regardless of what state you live in," says Vicki Saporta, president and CEO of the National Abortion Federation, a trade association with 400 members in North America.
Even if clinics in states like California don’t have to contend with strict regulations on how they operate, there are still basic economic challenges that come with being an abortion provider. Many clinics in blue states lose money performing abortions for poor women on Medicaid, with states often reimbursing only a portion of the cost of each procedure. Clinics also have costs other medical practices don’t have to worry about, Ms. Saporta says, from extra security to securing a bank loan.
"You can have the same economic challenges even if you don't live in a state where you have the onerous regulatory challenges," she adds. "Security costs alone are astronomical, and you have those costs whether you're providing care in Colorado Springs or in California, because you don't know who's going to target who [and] when."
Of the more than 50 abortion clinics that closed in 2014, "a little more than half were located in blue states," the Guardian's Molly Redden reported last November.
Paradoxically, wrote Ms. Redden, abortion clinics in red states have fewer cash flow problems because, with access limited, more women are discouraged from having an abortion. Those who aren't tend to be those who can pay for the procedure.
"By the time a woman arrives for her abortion [in a red state], she is able to pay full freight," wrote Redden.
In blue states, clinics serve more, often poorer women, and take a loss of hundreds of dollars on each procedure, while still dealing with the same political scrutiny as abortion providers anywhere, according to Redden.
"In blue states, cash-strapped abortion clinics must look for ways to cut costs internally," she wrote. "And every cut comes under a microscope."
Another factor behind the sharp decline in abortion providers has been a decline in demand for abortions, a fact abortion opponents have pointed out.
A survey from The Associated Press found that abortions declined 12 percent from 2010 to 2015, with five of the six states with the biggest declines passing no recent regulations. The teen birth rate has declined almost continuously over the past 20 years, according to the US Department of Health and Human Services. The teen birth rate declined from 31.3 births for every 1,000 adolescent females ages 15 to 19 in 2011 to 24.2 in 2014, according to the DHHS and the US Centers for Disease Control and Prevention. That's a drop of 22 percent.
Karen Swallow Prior, a professor of English at Liberty University in Lynchburg, Va., and a research fellow with the Ethics and Religious Liberty Commission of the Southern Baptist Convention, says the decrease in demand for abortions indicates that "abortions are becoming more unacceptable and more undesirable.
"There are a number of factors contributing to these closures, and the [new] regulations are just one," she adds. "I think we're reaching a turning point in our country in terms of abortion's acceptability and desirability."
Both sides of the debate agree that the impending Supreme Court case is a pivotal moment for the future of abortion services in America. The case, Whole Woman's Health v. Hellerstedt, will examine two aspects of a Texas law passed in 2013 and the extent to which states can regulate abortion clinics without imposing an "undue burden" on access to abortion. Those require abortion clinics to conform to building code, staffing, and other standards of surgical centers and that doctors who perform abortions must have admitting privileges at a hospital within 30 miles of the clinic.
States have adopted 288 new abortion regulations since the 2010 midterm elections, according to Guttmacher, with abortion opponents saying the measures are needed to protect women’s health. A ruling upholding the laws could see similar versions spread across the country; if the court strikes them down it could "create a bulwark for abortion clinics," The New York Times reported.
"Everyone's holding their collective breaths," Mike Gonidakis, president of Ohio Right to Life, told the paper. "We believe this case is either going to expand the ability of states to regulate abortion, or limit it."