How California created the nation’s easiest abortion access — and then went further

California guarantees the right to abortion in statute and the state constitution. It covers the cost of abortion for lower-income Californians on Medi-Cal, and also requires private insurance to cover it. And the state has rejected waiting periods or parental consent for abortion.

Here’s how its abortion policies compare to the rest of the country, based on a scale developed by The Guttmacher Institute.

Note: The Guttmacher Institute was established as part of Planned Parenthood in 1968 but sought independent status roughly 10 years later and stopped taking financial contributions from Planned Parenthood more than a decade ago.

Their methodology considers abortion restrictions such as gestational duration bans, waiting periods, insurance coverage bans and medication abortion restrictions. They also look at protective policies including state constitutional protections, abortion funding, insurance coverage for abortion, and protections for patients and clinic staff.

Despite lawmakers’ best efforts, California is not impervious to all abortion challenges. The U.S. Supreme Court is considering a challenge to the Food and Drug Administration’s approval of the abortion pill mifepristone, which would severely limit access to the pill by prohibiting mail-order prescriptions and requiring in-person doctors’ visits for people considering abortion.

“The reality is we’re not immune,” Planned Parenthood Affiliates of California President Jodi Hicks said ahead of the Supreme Court’s actions.

Mifepristone is the first of a two-drug regimen used for medication abortions. It blocks the pregnancy hormone progesterone and is also used to manage miscarriages. Most abortions in the U.S. and California are medication abortions, according to the Guttmacher Institute, a reproductive health research and policy center.  Although California does not collect abortion data, Guttmacher conducts a survey of all abortion providers in the U.S. every three years. 

If mifepristone were ever to be pulled from the market, medication abortion would still be legal in California, but doctors and patients would have to rely solely on the second pill in the regimen, misoprostol. Misoprostol causes contractions to empty the uterus and is safe to use alone, but it takes longer and there can be more complications, like prolonged bleeding.

Last year, Newsom announced the state purchased 250,000 misoprostol pills and could increase the order to 2 million. By March, the supply was depleted. Reordering was an option, but it wasn’t clear if that would be necessary, given that the court seemed skeptical of the plaintiff’s case for more restrictions.

In the decades before California decriminalized abortion and began loosening restrictions, public opinion on the issue had begun to sway. Driven largely by the worldwide thalidomide tragedy and U.S. rubella epidemic, California women were seeking illegal abortions in droves. 

Thalidomide was a sedative widely used in the 1950s to mitigate morning sickness in pregnant women, but unbeknownst to prescribing doctors it caused severe birth defects in the developing fetus, including limb malformations, kidney dysfunction and cognitive disabilities. Before most countries banned the drug, 10,000 “thalidomide babies” were born worldwide.

Many in California delved south of the border where a black market abortion industry boomed in Mexico, spurred by the 1953 Buffum decision. But the illegal procedures came at a high cost: Post-procedure infections, complications and death were common.

In a 1962 hearing before the Legislature, State Department of Public Health Officer Dr. Theodore Montgomery testified that illegal abortion was the leading cause of maternal mortality and attributed one-third of all maternal deaths to the procedure.

Then — in a time before vaccines — a rubella epidemic swept the U.S. in 1964, infecting 12.5 million people. Infection during pregnancy came with serious consequences, and 20,000 children were born with Congenital Rubella Syndrome, which included deafness, blindness and intellectual disabilities.

The risks associated with rubella didn’t meet California’s criteria for a legal abortion, however,  and more and more women sought illegal procedures in Mexico. By the time Dr. Leon Belous challenged the constitutionality of California’s ban in the state Supreme Court, hospitals on the California side of the border were reporting treating hundreds of women per month with complications from botched procedures.

In the years immediately following Roe v. Wade, the abortion rate skyrocketed across the country, reaching a high of 25 per 1,000 women of childbearing age, according to the Centers for Disease Control and Prevention. Since that time, the rate nationwide has fallen by half. 

Declines in abortion are driven primarily by lower pregnancy and birth rates overall, which in turn are impacted by increased contraceptive access and use.

California, however, stopped providing abortion data to the CDC in 1998 and does not currently track abortion numbers. Why? The California Department of Public Health told CalMatters it did not have information on why it’s failing to collect this basic data.

More recent data points to a reversing trend after the overturn of Roe. The Guttmacher Institute estimates a 10% increase in the national abortion rate from 2020 to 2023, and a 16% increase in the number of abortions provided in California over the same timeframe. The institute’s Monthly Abortion Provision Study estimates abortions obtained within the formal U.S. health care system. Possible factors include increased availability of telehealth for medication abortion, increased financial support from abortion funds and more access in some states.

First Trimester: 0-13 weeks

Medication Abortion

• Also known as the “abortion pill”
• Within the first 10 weeks, advanced practice clinicians can prescribe two drugs — mifepristone and misoprostol — to terminate the pregnancy
• Used in conjunction, these FDA-approved drugs cause cramping and bleeding to empty the uterus

Vacuum Aspiration

• Also known as surgical abortion
• Until around 13 weeks, the uterus can be emptied using manual or machine suction
• The procedure takes place in a doctor’s office, typically with local anesthesia, and can be conducted by certified nurse midwives, nurse practitioners or physician assistants

Second Trimester: 14-26 weeks

Dilation and Evacuation

• Until 24 weeks, pregnancy can be terminated by dilating the cervix and emptying the uterus with surgical instruments
• The procedure commonly takes place under general anesthesia, meaning the patient is asleep, and must be conducted by a physician

Third Trimester: 27-40 weeks

Late-term Abortion

• A fetus is generally considered viable once it reaches 24 weeks or weighs 500 grams
• California law allows abortion after viability only if the life or health of the pregnant person is threatened

Starting in 2023 in California, all abortion-related related services, including consultations and follow-up care, will be free. A new law prohibits insurance companies from imposing deductibles, copayments or other cost-sharing upon an individual seeking an abortion. 

The California Health Benefits Review program estimated that the average out-of-pocket cost is $306 for a medication abortion and $887 for a procedural abortion.

Medi-Cal, the state’s insurance program for low-income residents, funds the cost of abortion services with state money because the federal government, via the Hyde Amendment, prohibits most federal spending on abortion. California is one of 16 states to pay for abortions, and does so under court order. 

Under state law, abortion and related services are considered basic health care and must be covered by all insurance providers, with the exception of self-funded insurance. California and New York are the only two states to require private insurance to cover abortion.

Private insurance may require prior authorization, meaning the patient must seek approval from the insurer prior to getting the abortion, but insurers are not allowed to refuse.

According to a UC San Francisco study on out-of-pocket abortion costs, 7% of those seeking abortion had private insurance coverage, compared to 34% with Medicaid (in California, Medi-Cal) and 29% who received funding from other organizations.

Most Medi-Cal abortions occurred among Californians in their 20s during the past seven years; they account for 57% of abortions. 

However, this same age group also saw the steepest declines in the abortion rate between 2014-2020, decreasing by 32%.

In 2021, California contained 165 abortion facilities, according to UC San Francisco’s Advancing New Standards of Reproductive Health Facilities Database. The number of facilities appears to have increased — up from 151 facilities in 2017 — but large swaths of the state still lack a nearby abortion clinic.

Approximately 78% of Californians live in a census tract without a clinic — not necessarily an obstacle in dense cities where several census tracts are only a short drive or bus ride away, but potentially insurmountable for those living in remote rural areas where census tracts can span several counties.

And not all clinics are created equal, according to UCSF researcher Ushma Upadhyay, who leads the database team. More than half of the clinics provide only the abortion pill, and can’t conduct procedures beyond 10 weeks of pregnancy.

Anecdotally, and in other states, Upadhyay said there is some evidence that more primary care providers are prescribing abortion pills — but that’s impossible to verify in California given its refusal to collect state abortion data.

Over the past two decades, the share of California adults who support legal abortion has generally increased even as the issue has grown more partisan, according to the Public Policy Institute of California, which conducts non-partisan statewide surveys.

The vast majority of Californians support Roe v. Wade’s guarantee of abortion access, with 77% of adults responding that it should not be overturned.

That majority holds regardless of political party, gender or race. Even among Republicans — the group with the highest proportion of voters opposed to abortion — 59% said they supported Roe.

Past polls have shown that public support declines to various degrees when people are asked whether they support using taxpayer dollars to pay for abortions, or allowing minors to obtain them without notifying their parents.