Dobbs didn’t – Four years after Roe v. Wade was overturned in Dobbs, abortion access hasn’t disappeared. It has changed shape—telemedicine, shield laws, and pharmacy-style access to pills have widened care for many patients, even as courts and state politicians keep pressing
When the U.S. Supreme Court overturned Roe v. Wade in 2022. Carole Joffe already knew the abortion system wouldn’t simply “go away.” After more than four decades studying abortion in American social. medical. and political culture. she says she was prepared for the legal outcome—what she didn’t expect was how quickly the new fight would reshape daily access.
“Dobbs itself wasn’t that scary to me,” Joffe said. “It was upsetting and politically outrageous, but because of our work, we knew abortion wasn’t going to go away.”
The new fear arrived anyway, last month, in Louisiana. A lawsuit there challenged Food and Drug Administration rules that allow abortion pills—mifepristone—to be prescribed via telemedicine and sent through the mail. The Supreme Court ultimately kicked the case back to lower courts. but abortion advocates were left with a hard reminder: even when the system bends rather than breaks. patients still have something to lose.
Joffe. a sociologist and professor at the University of California. San Francisco. said the case felt scary—then she returned to the work of documenting what’s actually happening. “Things since Dobbs have gone better than many of us thought. but so much of that access has been dependent on telehealth. ” she said. “So yes, the case felt scary, but then I got back to business as usual. ‘Abortion is still happening. Who do I want to interview?’”.
Her latest book. After Dobbs: How the Supreme Court Ended Roe But Not Abortion. co-written with Drexel University legal scholar David S. Cohen, tracks how abortion’s ecosystem adapted after Roe was removed from the national landscape. She describes a surge in abortion protections in blue states. a mobilization of activists to help patients in red states. and the “rage donations” that fueled the early scramble.
Four years later, the legal and legislative pressure from the right has not eased. Still, Joffe says the access movement has shown a stubborn resilience—one that is now visible in numbers.
New data from the #WeCount project shows clinician-managed abortions approached 1.13 million in 2025, with the monthly average up 14 percent from April 2022. By the end of last year, almost 9,000 women a month were accessing care in states where abortion is banned.
“We didn’t anticipate the [nationwide] numbers going up to the degree they have,” Joffe said. “That has been astonishing.”
That shift is not just about courts or politics. Joffe points to legal and medical innovations that have made abortion pills easier to obtain than ever. including telemedicine and blue-state “shield laws.” Cohen helped develop those shield laws. which protect providers in states where Democratic-run legislatures have adopted them.
When Joffe and Cohen were working on their book, she said the laws “had barely taken hold.” Now, she argues, their impact can’t be understated. She says shield laws and telemedicine don’t just reduce travel and costs—they also allow patients more privacy.
But some of these improvements carry a specific kind of benefit, too. Joffe’s concern is that many of the gains center on “everyday abortions”—procedures for non-medical reasons, usually in the first trimester.
For other people, the Dobbs era has remained precarious, sometimes deadly: women facing life-threatening pregnancy emergencies, those seeking abortions later in pregnancy, and immigrants.
She also worries about a different and dangerous pathway: self-managed abortions without enough medical or legal support, which she says increases the risk that women could be criminalized.
Joffe’s attention keeps returning to the same central question—how access can rise while some people still fall through the cracks.
She pointed out that, according to the Guttmacher Institute, the last time the number of U.S. abortions surpassed 1 million was in 2012.
And those figures, she added, are not capturing everything. #WeCount counts clinician-managed abortions within the formal healthcare system. There are also self-managed abortions that aren’t counted. she said. including those coordinated through underground community networks and overseas pill providers.
“If someone goes to their computer and orders from a website in India, that’s not counted,” she said. “If someone gets their pills from one of those grannie expats living in Mexico who are bringing in [medication] over the border, that’s not counted.”
Even without those numbers, Joffe believes much of the WeCount increase is tied to shield laws.
She said telemedicine and shield laws mean women don’t have to travel, and that lowers the price tag. She also described how shield laws can reduce pill costs even further. One provider in Massachusetts—The MAP—offers pills for $150 and accepts as little as $5.
“I didn’t see that coming,” Joffe said.
For a long time, she says, she feared the criminal justice system in red states would go after providers. What she has seen instead is narrower than she expected.
“I’m aware of only three criminal cases: two against shield law doctors in California and New York, and one against a midwife in Texas,” Joffe said. “There have also been some civil cases.”
She said she hopes those targeted providers’ situations work out. Still, she framed the scale of prosecutions as less than the sweeping wave she feared.
When she turns to who is benefiting most, the picture becomes more specific.
“From what I hear from other advocates, the patients who have benefited most from these post-Dobbs improvements in access are women in their first trimester,” she said. Joffe pointed to how many telemedicine providers only prescribe abortion pills through the 11th or 12th week of pregnancy.
That means patients who are further along may lie to obtain pills or search for other sources, including underground networks.
“What do we do with everyone else?” is the question she kept pressing.
“The people I most worry about are those with pregnancy emergencies—serious complications,” Joffe said. “These are not people who could get on a plane and travel from Texas to Illinois or Colorado for emergency abortion care. These are really sick women.”
She offered a vivid picture: “Can you imagine living in Louisiana, going to your boss and saying, ‘I’m going to be gone for several days because I need to get an abortion?’ No.”
Joffe also emphasized people whose social circumstances make telemedicine or travel impossible. She said. “Maybe you’re a single mother with several kids. and you can’t take time off work.” And again. she asked readers to imagine the moment: “Can you imagine living in Louisiana. going to your boss and saying. ‘I’m going to be gone for several days because I need to get an abortion?’ No.”.
She recalled a story from when Dobbs first happened—about a doctor in Texas who told a patient to go to New Mexico, and the patient responding that if a limo were sent, she still couldn’t leave.
“Think of a woman living in her car, or someplace in the Mississippi Delta—if she doesn’t have a computer, how does she even know?” Joffe said.
The question of pregnancy emergencies leads her back to the uncertainties doctors face.
In 2024, she and UCSF colleagues published a report describing how doctors in Texas and other abortion-ban states were forced to delay abortion care for pregnancy emergencies that could endanger the life of the mother.
Joffe said she and a colleague are studying how common those situations are now, because she had assumed that four years after Dobbs, those questions would be resolved.
Doctors still worry, she said, about whether they’ll be arrested if they perform an abortion while fetal cardiac activity is still present, and about how sick a patient has to be for care to be allowed.
Some state legislatures have taken action to clarify medical exceptions—she said the logic often follows grim publicity concerns: when women die, it’s bad press.
In aggregate, she said, the situation has “seemingly improved somewhat” for women with ectopic pregnancies and PPROM—when the amniotic sac ruptures before the fetus is viable.
But Joffe said there are still “too many unforgivable instances of care withheld and delayed.” She said the full impact won’t be known for some time, but she pointed to a fact she considers concrete: “rates of maternal and infant mortality in Texas have significantly risen since Dobbs.”
Her broader point is that abortion access isn’t only an issue of where people live or whether they can travel. It’s also about whether the medical model that is scaling up can safely meet the needs of those arriving with the most severe complications.
Joffe said telemedicine accounts for 30 percent of all abortions in the U.S. That means more than two-thirds of patients are still getting care in person. She said abortion pills from a clinic can cost hundreds of dollars, and she contrasted that with how a shield-law provider can charge much less.
She also said this price gap doesn’t even include federal funding cuts for Title X and Planned Parenthood.
That makes her worry about clinics themselves.
She said many brick-and-mortar clinics in red states have closed after Dobbs. Some have relocated to blue states, but not all. Joffe said many operate on a tight budget.
She warned that a shift toward pills and away from in-person care could put later-abortion patients in a dire position. especially because one of the functions some clinics provide is abortions in the second trimester or later. “As more and more patients order pills and avoid clinics. ” she said. “the clinics may eventually have to close. leaving the minority of patients who require later abortions in a very dire spot.”.
Joffe said she mourns the possible loss of a clinic-based model because abortion is not one-size-fits-all. Some women, she said, do fine managing at home: they order pills online, take them at home, and move forward with their lives.
But other women need something more grounded in human reassurance and in-person care.
She gave an example rooted in her long study of the emotional and cultural dimensions of abortion: “A very religious woman who believes. ‘God will punish me for getting an abortion—I am a murderer. ’ can really benefit from talking to someone who will reassure her that she’s not going to hell.” She cited Dr. George Tiller. the Kansas abortion provider who was murdered in 2009. and the fact that he had a chaplain on his staff.
Joffe also said some people aren’t suitable candidates for pills, including people with bleeding disorders, people with ectopic pregnancies, and people past the gestational age at which the pill is offered. She added that many of the most serious fetal anomalies are only discovered around 18 weeks.
There’s fear too, she said—fear of the remote experience itself. “Some women are afraid— ‘I’m talking to a disembodied voice on the phone, she sounds nice, but I don’t know. My friend had a really bad reaction when she took a pill that somebody sent her.’”
Shield laws and telemedicine have been successful, she said, but “there are still people going to be left out.”
She then turned to the question of whether public engagement has cooled. A narrative has emerged that people don’t care about abortion as much as they did four years ago, including during the 2024 elections.
Joffe linked that concern to a drop in donations to abortion-related organizations over the past couple of years.
“I always expected the so-called rage spending would drop off,” she said. After Roe was overturned, people were furious, and money flowed in for airplanes, hotels, procedures, or pills. Joffe said she knew it couldn’t be sustained, and that other major issues would demand attention.
She said she did not fully predict “the savagery we’ve seen under the Trump administration.”
Still, she said she thinks about the volunteer networks that helped women in red states access care. She recalled an account she described as almost like the Underground Railroad: one person drives a patient to the next location, then another driver takes her further.
“This is part of the larger resistance we’ve been seeing in the Trump era,” she said.
The question Joffe returned to, again and again, was what comes next—because the politics are not the only threat. The courts are.
“We don’t know what’s going to happen politically,” she said. “The midterms will be really important, but even if the Democrats win the House and Senate, the courts will be the ones calling the shots.”
What keeps her up at night is the possibility of an effort to enforce the Comstock Act—a 19th-century obscenity law that would amount to a national abortion ban. She also fears a move that would target mifepristone itself: she raised the possibility of the FDA withdrawing its approval of mifepristone or getting rid of the rule allowing abortion pills via telemedicine.
She said her biggest worry is the possibility that shield laws face a Supreme Court crackdown.
And if there’s a broader crackdown—on providers. on the delivery of pills. on people trying to access care—she worries in multiple directions at once. “I always worry about clinic violence,” she said. “But I worry more now because the anti-abortion movement is furious: ‘We got Dobbs. so how in the hell have abortions gone up?’”.
She added that she worries Republicans and the Department of Justice could figure out how to surveil people who receive abortion pills—tracking what arrives in places far from the states where access is protected.
“I am a Class A worrier,” Joffe said. “So I am worried about everything that one can possibly worry about.”
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