Abortion rights activists gathered outside the U.S. Supreme Court in Washington, D.C. on May 21, 2019 to protest against the abortion laws passed across the country.
Aurora Samperio—NurPhoto/Getty Images
January 22, 2020

Forty-seven years ago today, the Supreme Court ruled on Roe v. Wade, establishing the legality of abortion nationwide.

But as another case about abortion heads to a significantly more conservative Supreme Court this year, reproductive rights advocates and health care providers say they are preparing for a world in which the landmark 1973 decision is either significantly weakened or overturned.

“We’re at a moment where the threat is imminent for the country,” Alexis McGill Johnson, acting director and CEO of Planned Parenthood, tells TIME. “It’s already real for many women who don’t have access” to safe abortions.

In March, the Supreme Court will hear June Medical Services v. Gee, which challenges a Louisiana law requiring doctors who provide abortions to have admitting privileges at a hospital within 30 miles of where they perform the procedure. The law in question is very similar to a Texas law that the Supreme Court struck down in 2016 in its ruling on Whole Woman’s Health v. Hellerstedt. But the make up of the Supreme Court is markedly more conservative with newcomer Justices Neil Gorsuch and Brett Kavanaugh, both of whom were nominated by President Trump.

The political climate is also different. In early January, more than 200 members of Congress filed an amicus curiae brief in the June case arguing that Roe and Planned Parenthood v. Casey, another case that reaffirmed the legal right to abortion, should be “reconsidered and, if appropriate, overruled.”

Legal scholars have said it’s likely the Supreme Court will rule narrowly on June instead of completely overturning Roe. But even if this is not the landmark decision’s last anniversary, advocates note that access to safe, legal abortions has already become distinctly more difficult in many parts of the country.

In 1976, Congress first introduced the Hyde Amendment, which banned the use of federal funds for abortion services unless the pregnancy resulted from rape or incest, or threatened the life of the mother. (The amendment has been reauthorized every year; it blocks federal funds from covering abortion through Medicaid and any other federal health program.)

Since then, state legislatures have also enacted a patchwork of state laws limiting when, where, how and why people can access abortion. Since 2011, states have passed more than 400 abortion restrictions, according to the Guttmacher Institute, a research group that supports reproductive rights. In 2019, states passed 25 new abortion restrictions into law. Six states passed laws that would limit abortions once fetal cardiac activity is detected, or as early as six weeks, and Alabama passed a near total ban on abortions.

“Roe has not been a reality for people struggling to make ends meet for decades because of Hyde,” says Destiny Lopez, co-director of All Above All, a coalition of reproductive rights advocates that launched in 2013.

Like Hyde, state laws that restrict access to abortion tend to disproportionately affect certain groups, including poor people, people of color, Native Americans, immigrants, queer and trans people, people who live in rural areas, members of the military and federal employees.

“It doesn’t matter if something’s legal if you can’t afford it,” says Quita Tinsley, co-director of Access Reproductive Care-Southeast, a fund that helps organize financial and logistical support for people seeking abortions in Southern states. “It doesn’t matter if it’s legal if you can’t get there.”

ARC-Southeast is one of many abortion funds that have popped up around the country in recent years as states increasingly have clamped down on abortion access. These funds, often started by grassroots activists, guide patients through their state’s laws around abortion and develop a plan for how each person will find the money, transportation and permission they need to get the procedure.

Some states, including West Virginia, have passed so many restrictions on abortion over the years that only provider remains statewide. West Virginia bans abortions after 20 weeks, bans the dilation and evacuation method of abortion, and bans telemedicine abortion. It also requires that minors notify their parents before receiving an abortion, and that providers read a phone counseling script that doctors say is biased and inaccurate 24 hours before a patient’s appointment.

In November 2018, West Virginia voters also approved a ballot measure that changed the state’s constitution to say it does not guarantee the right to abortion, ending the state’s coverage of the procedure through Medicaid. (Because Medicaid is a federal-state partnership, West Virginia had previously been able to cover abortion services for Medicaid recipients with state funds.) Nearly one third of West Virginians are insured through Medicaid, and Katie Quinonez, executive director of the state’s last abortion provider, Women’s Health Center of West Virginia, said Medicaid recipients made up more than half of her center’s patients before the 2018 change. No private insurance carrier in West Virginia covers abortion either.

Quinonez says her state legislature has created a “hostile environment” for abortion access. But, she adds, she and other abortion rights advocates aren’t giving up. “Regardless of the future of Roe, abortion access is something that we have to continuously fight for,” she says.

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With the future of Roe hanging in the balance at the Supreme Court, advocates say they are turning their attention to preventing red states from passing more abortion restrictions, and expanding access to the procedure in blue states and progressive cities. A new California law, for example, will require public colleges to offer medication abortion on campus. Others are hoping to better educate voters about reproductive rights and create “sanctuary cities” for abortion the way local governments have done for immigration.

One advocacy group, URGE: Unite for Reproductive and Gender Equity, has focused on training and mobilizing youth. “Young people are not clinging to Roe to save them,” says Kimberly Inez McGuire, executive director of URGE. “Young folks look at a flawed system, a system that’s not working, a system that’s actually harming them, and they say, you know what, we don’t need that. We deserve better.”

If the Supreme Court strikes down Roe entirely, McGill Johnson of Planned Parenthood says her organization will continue working with its state partners to flip legislative seats and governorships, and help people who need abortions travel to states where they can safely have them. “I also want to make it clear that flying women around the country to access abortion is not a future state,” she says. “We are in it for the long game.”

One silver lining of the current political moment, advocates add, is that they see more people paying attention to — and joining — the abortion fight. “Everyone is now seeing what we’ve been seeing coming down Main Street a long time,” says Tinsley of ARC-Southeast. “We’ve seen some really restrictive anti-abortion laws coming sweeping in the South and Midwest for many years now. And we’ve been saying that this is only a matter of time before this becomes a national issue.”

In 2016, the Democratic Party added getting rid of the Hyde Amendment to its national platform for the first time. This year, most of the Democratic presidential candidates have said they support ending Hyde, and polling continues to show that a majority of Americans support keeping abortion legal. A new poll out from Gallup on Wednesday found that a new high of six in 10 Americans are dissatisfied with the country’s abortion laws.

“I can’t minimize the importance and the significance of Roe when it happened in 1973, and the catalyzing effect that it has had for people’s ability to determine how they want to live their lives,” says Kwajelyn Jackson, executive director of Feminist Women’s Health Center, which provides abortion and gynecological services in Atlanta. “At this anniversary, what I want is for folks to be thinking about what does our future look like?”

Correction, Jan. 22

The original version of this story misstated how West Virginia abortion providers deliver a state-mandated script to patients. A licensed medical provider reads the script; it is not played through a recording.

Write to Abigail Abrams at abigail.abrams@time.com.

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