Two years after Roe v. Wade was overturned, an honest assessment of how things could get worse.

Nine months before the 2016 presidential election, I declared in an op-ed that if a Republican were to win in November, Trump would be “the best-case scenario for American women, not the worst.” Having covered politics and abortion rights for years, I’d been wrong in my predictions before—but never quite as spectacularly as I was about that.

It’s not that I thought the plainly misogynistic Trump would be good for women, but rather that Senators Ted Cruz and Marco Rubio—two of the highest-profile GOP alternatives to Trump at the time—would be worse. I wasn’t alone in thinking so: That February, a left-leaning columnist for Glamour had labeled Trump the “Best Republican Presidential Candidate on Women’s Health Issues” because he was noncommittal on abortion and had taken less extreme positions overall than other Republicans in the race. Trump was and remains amoral and unprincipled, but, at the time, he was considered somewhat of a wild card, whereas Cruz and Rubio were running as ideologues with carefully cultivated right-wing brands. Both wanted to force women to carry their rapists’ babies to term, and Cruz vowed to prosecute Planned Parenthood if elected president. I was surprised that Trump—who was pro-choice for years and never cared about abortion, except as a means of shoring up support from the religious Right—turned out to be the most ruthlessly effective of the three at rolling back women’s rights nationwide.

Two election cycles later, I’m relieved that that op-ed was never published. But being so wrong about the former president taught me an important lesson: What Trump believes, says, or avoids saying has little bearing on what he does—and countless people will suffer as a result of his whims. He is a creature of impulse, guided by an outsized ego and often sharp political instincts. Barring some unforeseeable and extraordinary event, he will be his party’s nominee in November. But what matters far more than “who” leads the GOP ticket is how life would change for abortion seekers with a Republican in the White House next year.

We already know the consequences of anti-abortion laws and policies because we’ve been witnessing them for years, more commonly but not exclusively in red states. Thanks to our shockingly inadequate healthcare system, millions of pregnant people are already suffering—and not just those who need abortions. States with the cruelest abortion bans have the highest maternal and infant mortality rates in the country: Give birth in Alabama, for example, and you are more than four times as likely to die during or shortly afterward than you would be in California. In states like Idaho, Missouri, and Texas, abortion is a felony in nearly all circumstances; and with Roe overturned, healthcare providers across the country must now weigh their responsibilities to their patients against the risk of being sued, stripped of their medical licenses, or jailed—a choice with deadly consequences for patients. A 2022 survey of medical students found that a majority, around 58 percent, were unlikely or very unlikely to apply to residencies in states that restrict abortion, meaning we’re on the brink of a serious shortage of qualified OB/GYNs in the states where they’re needed the most. We’ve already seen the consequences of this play out: A January New Yorker story posed the question, “Did an Abortion Ban Cost a Young Texas Woman Her Life?”—and, as the author’s extensive reporting makes clear, the answer is a resounding “Yes.” Yeniifer Alvarez-Estrada Glick, the young woman in question, died while pregnant in 2022. After trying and failing to save Glick’s life, a doctor attempted to deliver her baby prematurely via C-section. The baby died, too.

Glick’s health problems, coupled with the poor care she received as a low-income, uninsured, undocumented Mexican woman in a small rural town in Texas, all contributed to her death. But according to the four outside experts The New Yorker asked to review her medical file, doctors likely could have saved her life by explaining how risky it was to continue her pregnancy and, if she wanted one, performing an abortion. Texas’ cruel abortion law made them afraid to do so.

If a Republican wins the presidency in November, the landscape will be even bleaker. While Congress is unlikely to pass federal legislation banning abortion nationwide, a Republican presidential administration wouldn’t need a law to accomplish that goal. As with the repeal of Roe, anti-abortion activists have been laying the groundwork for a backdoor ban for decades. And while Trump recently claimed that he would not support a federal abortion ban (a stance he’s likely to waffle on), anti-abortion activists don’t need him to. Below are the three main strategies they are pursuing—despite stiffening opposition from a passionate but fragmented pro-choice movement—to make a national ban a reality:

A Republican HHS Secretary could override the FDA’s approval of mifepristone, one of the two drugs most often used to induce abortion. Mifepristone was first approved by the Food and Drug Administration (FDA) in 2000; but in 2022, anti-abortion activists, hoping to curb access to the drug, filed a lawsuit challenging the FDA’s approach to regulating it. The Supreme Court’s June ruling in that case preserved access to mifepristone for now, but left the door open to further challenges down the road. And the next president’s Health and Human Services (HHS) Secretary could still override the FDA’s approval of the drug, effectively ending what has become the most common method of abortion nationwide.
An anti-abortion administration could resurrect the Comstock Act. Comstock is a 150-year-old anti-obscenity law which prohibits using the mail to send or receive “obscene” items, potentially including anything that could be used to perform an abortion. Under the Telecommunications Act of 1996, Comstock applies to the internet, as well, meaning that even discussing abortion online could lead to up to five years in prison, $250,000 in fines, or both. Medical abortions performed via telemedicine, wherein providers consult with patients online and send the necessary pills by mail, are just as safe and effective as those performed in person; but Comstock would prevent doctors from sending the pills at all, severing a lifeline connecting women in red states and remote, rural areas to needed care. (Between April 2022 and August 2022, around 4 percent of total recorded abortions in the U.S. were performed via telemedicine; as of May 2024, that figure had risen to 19 percent.) Because Comstock is a federal law, it would most likely invalidate state laws, which means a Republican Department of Justice could federally prosecute doctors and drug companies nationwide. It could also shut down all U.S. abortion clinics by barring them from receiving any abortion-related materials via mail.

An anti-abortion Republican president could reinstate the global gag rule. The rule bars foreign nongovernmental organizations (NGOs) from using any funds, including non-U.S. government funds, to provide abortion services, information, counseling, referrals, or advocacy, effectively forcing NGOs outside of the U.S. to choose between receiving U.S. global health assistance and providing comprehensive healthcare. It has largely been in place under Republican administrations since 1984, but the Trump administration expanded it to apply to an unprecedented range of agencies and public health programs, many of which serve poor women in rural areas. When women desperate to end a pregnancy are kept in the dark about their options, they have more abortions, not fewer—and many end up dead or seriously injured as a result. The International Women’s Health Coalition wrote in a 2019 report that the rule “contributes to arbitrary deaths by impeding the provision of life-saving care.” Marie Stopes International, one of the largest global family planning organizations, estimated in 2017 that Trump’s expanded gag rule would increase abortions in Nigeria by 660,000 over four years, and that 10,000 women would die as a result. Precise figures are difficult to come by, but it’s clear that women have, as predicted, died as a consequence of this cruel and pointless policy. (Healthcare providers also expect the repeal of Roe to continue harming women worldwide.)

Whether or not the above scenarios come to pass—and there is little doubt that, if a Republican wins the White House in November, the last one will—the harm already caused by state abortion bans shows that a national ban would be an unmitigated disaster. Nor would it stop people from getting abortions. Women end pregnancies for a myriad of reasons, some more common than others. They do so whether it is safe, legal, and accepted, or dangerous, criminal, and condemned. And they do it whether or not their parents, lovers, spouses, friends, neighbors, religious leaders, strangers, or elected officials approve. The only difference is how many will get the quality care they need, and how many will suffer and die.

Forcing a person to carry a pregnancy to term and give birth against their will is a brutal act under any circumstances. But in a country like the U.S., with its threadbare social safety net and policies that vary wildly by state and region, it often means forcing them into poverty, as well. As Bryce Covert explained in 2023, “The states that have banned abortion are the same ones that do the least to help pregnant people and new parents make ends meet.” Most states with abortion bans offer little help to pregnant workers; none guarantee any control over work schedules, paid family leave, or paid sick days. When Lationna Halbert of West Jackson, Mississippi, found herself unexpectedly pregnant in 2022, she told In These Times, she cried and cried. She was earning just $8.50 per hour and already had a four-year-old son. She and her partner were not ready for another baby, nor could they afford to raise one. When Roe was overturned, an abortion ban automatically went into effect in Mississippi, shutting down the state’s last remaining clinic. By the time Halbert realized she was pregnant, it was too late: She couldn’t afford to travel to another state to get an abortion, and it was impossible to get one safely and legally in Mississippi. She delivered her second baby in a hospital with no hot water.

As I have written for The Conversationalist before, the same officials who worked so tirelessly to overturn Roe have also fiercely resisted using public funds to help vulnerable women like Halbert. This is because the same politicians who romanticized her fetus have nothing but contempt for Halbert herself, and for all the other people—who are, not coincidentally, mostly women—being forced to have babies they do not want and cannot provide for. That contempt is matched only by their sociopathic indifference to the children who make it out of the womb—the kind who already exist, only to be routinely denied housing, healthcare, and basic nourishment by their state governments. (Nor do these politicians have any empathy for living, breathing children facing crisis pregnancies of their own.)

If pregnant women are the primary and intended victims of U.S. abortion policy, which is rooted in a desire to control and punish them, their children, partners, and families are collateral damage. It is bad for babies to be unwanted; bad for already existing children to be deprived of needed resources; and bad for the couple experiencing an unexpected pregnancy to be forced to have a baby that one or neither wants. It is delusional and insulting to pretend otherwise. Anti-abortion zealots’ cozy fantasies of domestic fulfillment have nothing to do with the daily lives of women forced into motherhood.

Even under a Democratic administration, women are already being investigated, prosecuted, and punished for various pregnancy outcomes, including miscarriages. In 2023, Brittany Watts, a 33-year-old Black woman in Ohio whose water broke prematurely, leading to a miscarriage, was charged with abuse of a corpse—a felony punishable by up to one year in prison and a $2,500 fine. Doctors told Watts her fetus was nonviable, and she spent a total of 19 hours in a local hospital over the course of two days, begging for supervised medical help. Concerned about the potential legal ramifications, the hospital repeatedly delayed her care. Watts ultimately gave up and miscarried alone in her bathroom. When she returned to the hospital for follow-up care, a nurse rubbed her back and told her everything would be okay—then called the police at the behest of the hospital’s risk management team. As Watts was lying in the hospital recovering, police searched her home, seized her toilet, and broke it apart to retrieve the remains of her fetus as “evidence.” Watts’ charge was dismissed after a grand jury declined to indict her: Her prosecution was meant to shame and punish her, not protect her fetus. But prosecutors have always been more inclined to target women of color, immigrants, and/or poor women in these types of cases—because it’s easier to win against someone who can’t fight back. Watts’ experience also specifically demonstrates how little our healthcare system values the health and well-being of Black women, who are three times more likely than white women to die from a pregnancy-related cause.

One of the bitterest ironies of conservative reasoning on abortion is that, followed to its logical conclusion, it will impede tens of thousands of people who desperately want to become parents or expand their families from doing so. When the Alabama Supreme Court ruled in February that embryos created through in vitro fertilization (IVF) are children, three of the state’s IVF providers suspended their services, fearing legal repercussions. (Alabama voters in a longtime Republican stronghold were so alarmed that they elected a pro-abortion rights Democrat to Congress a few weeks later.) A number of prominent Republicans, including Trump, have since affirmed their support for IVF, but that hasn’t stopped many of them from co-sponsoring the Life at Conception Act, a piece of federal legislation that would ban nearly all abortions nationwide and does not include a carveout for IVF. Nor has it stopped those same Republicans from blocking a recent bill that would have protected the procedure. Leaders of the nation’s largest Protestant denomination, Southern Baptists, have recently voted to condemn the use of IVF, as well.

While Republicans’ support of openly fascist and deeply unpopular abortion policies has become a political liability for the GOP, it’s simultaneously become a human nightmare for the rest of us. Trump’s failed attempt to contain the political fallout from Arizona’s recent revival of an 1864 ban is an object lesson in locking the barn door after the horse has bolted. If abortion is the same as infanticide, as most anti-abortion activists insist that it is, then no person seeking one would be exempt from prosecution, whether you’re 9 years old and a man rapes you, 11 years old and your grandfather rapes you, 12 years old and a man rapes you, 33 and desperate to end your pregnancy, 33 and suicidal, a married mother who doesn’t want another child, or unexpectedly pregnant at 45. Even white, married, heterosexual moms are not exempt. The state of Texas recently forced lifelong Texan Kate Cox to travel out of state for an abortion she needed to protect her life and fertility. Cox, a married mother of two who wants more kids, was told that her third pregnancy was nonviable: The fetus was unlikely to survive, and the best-case scenario was that she might give birth to a baby who would live in anguish for a week or less. Alternatively, she could experience a life-threatening uterine rupture and need a C-section and/or a hysterectomy, potentially losing the ability to have more children in the future. Forced sterilization, which is one outcome Texas’ barbaric denial of care could have imposed on Cox had she lacked the means to travel out of state, is internationally recognized as a human rights crime. No wonder she fled.

It’s a sad truth that things can always get worse, even for relatively privileged Americans. Until it did, many legal experts considered it highly unlikely that the Supreme Court would overturn Roe, upending nearly 50 years of precedent and stripping American women of a right guaranteed to us for half a century. But many U.S. residents, particularly in rural areas and throughout the South and Midwest, have been living under de facto abortion bans for at least the last decade. A right is only guaranteed when it can be freely and easily exercised by all; for many U.S. residents, the cost of abortion—the procedure itself, the travel, the lodging, the childcare costs, the ability to request and take time away from paid work—is too high. One in five U.S. women must travel more than 40 miles one way to access care; in some rural areas, that distance is 300 miles or more. Under a national abortion ban, the situation will only grow more dire. People have taken and will continue to take risks that range from reasonable but frightening (crossing the border to buy pills from a pharmacy in Mexico) to desperate and potentially fatal (shooting themselves in the stomach). Denying care to women who need it permanently alters their lives, most often not for the better.

There is no reason to believe that the proudly anti-democratic GOP will uphold democratic norms or respect the popular will, and little reason to trust the Democratic Party, which has, in recent years, canceled elections, failed to defend abortion rights, and repeatedly defied its own voters. But focusing on how abortion politics are hurting the GOP or improving Biden’s chances misses the point. Like miscarriage, abortion stops an embryo or a fetus from becoming a baby. Restricting it tortures women, children, and families and rips holes in communities. Policies that harm actual, living people must be stopped, and those who promote them held to account. Voting is one fragile, inadequate tool. With so many lives at stake, we’ll need more.