Rachel Castor, a single mom of two and teacher, stands outside her home in Sandpoint, Idaho. Castor’s son could not be admitted to the local hospital during an asthma attack because Bonner General Health lost its pediatrician coverage at the same time it closed the labor and delivery unit in 2023 following the Dobbs decision. (Photo by Erick Doxey for States Newsroom)

Editor’s note: This report examines the impact of the U.S. Supreme Court decision that struck down the federal right to abortion three years ago.

Of all the outcomes Rachel Castor could have predicted from Idaho’s abortion ban, her teenage son being denied hospital admission during an asthma attack wasn’t on the list.

Bonner General Hospital in Sandpoint announced its decision to end obstetric services in March 2023, roughly six months after the near-total ban took effect. Among the stated reasons were the state’s legal and political climates concerning health care, and the loss of pediatrician staffing.

Castor saw the fallout from that decision on a night in early April. Her 17-year-old son spent several hours in the Bonner General emergency room, before the staff informed her if his breathing didn’t improve enough for discharge by the morning, he would need to be transferred an hour south to the hospital in Coeur d’Alene. Bonner General had no pediatricians.

“And I was like, ‘Excuse me?’” Castor said.

Elaine Gloeckle, a 66-year-old Boise resident, said she started having trouble with urinary tract infections and hormonal balances recently and found it hard to get an appointment to see a specialist, even with a referral. It was even more difficult to see a doctor for gynecological care. That wasn’t always the case in the more than 30 years she’s lived in the area — she used to have no trouble seeing doctors.

But now for the gynecology visits, along with care for diabetes management and kidney issues, she has seen physician assistants, who are supervised by the doctors within a practice. While she has had good experiences with the assistants, it’s sometimes difficult to feel confident in their assessments when she isn’t sure how much they are consulting with doctors. And the wait times are still long — at least six weeks, usually, in her experience.

“I have no idea who the doctors are, I’ve never met them,” Gloeckle said. “And I don’t know if that means anything, or if it’s just peace of mind that there is a doctor in the mix.”

It’s been three years since the U.S. Supreme Court issued the Dobbs ruling that ended federal abortion protections and allowed more than a dozen states to implement abortion bans. States that were already struggling with physician shortages say they’re getting worse, especially in rural areas, where many labor and delivery units have also closed their doors. Clinics have closed and resources become more strained with every passing year.

Patients and providers have been left to adjust to barriers accessing abortion care; legal battles that continually redraw access lines; and heartbreak and tragedy as women die from easily treatable conditions like miscarriage and infection.

In places like Florida, Kansas and Louisiana, patients have had to find other providers who will help them with miscarriage complications, often requiring them to travel to a neighboring state with legal access because doctors in states with bans are afraid to see them. Other patients experiencing miscarriage or the threat of miscarriage have reported waiting hours in emergency rooms to be seen while hospital staff consult with attorneys about their legal exposure before taking any action. A Florida Republican lawmaker who opposes abortion said recently that she waited hours to receive treatment for an ectopic pregnancy, which is dangerous and nonviable.

Besides Texas, few states that implemented abortion bans after Dobbs have been as much of a spectacle as Idaho. Between a so-called “abortion trafficking” law that first passed in Idaho, the very public loss of many OB-GYNs and maternal-fetal medicine specialists, and a legal fight with the federal government over whether abortions should be permitted in emergencies — a lawsuit that made its way before the U.S. Supreme Court — the state has been a testing ground of sorts for how a near-total abortion ban can play out for communities.

Many health care providers and advocates warned it wouldn’t just be abortion care, or even pregnancy-related care, that would be affected by the Dobbs decision. Dr. Stacy Seyb, a maternal-fetal medicine specialist in Boise, said in July 2023 that the near-total ban would lead to more consequences as time went on.

“It feels like a step backward in improving the health of women and children in the state,” he told The Guardian. Soon, he warned, the state would “see a collapse in women’s health care.”

‘It makes me wonder what else we’ve lost that we don’t know about’

Bonner General Health’s obstetrics unit was one of many rural hospitals that was already struggling before Dobbs with changing community demographics that meant lower birth rates and difficulty recruiting and retaining physicians. Among its population of about 10,000, the hospital admitted fewer than 10 pediatric patients in 2022 and delivered 265 babies, a decrease from prior years.

It’s a familiar situation nationwide. More than 100 hospitals across 26 states have closed labor and delivery services since 2020. To be sure, the reasons for those closures include many more factors than abortion bans, such as low reimbursement rates from Medicaid programs for obstetrical services and difficulty recruiting and retaining physicians.

In its announcement, Bonner General representatives said they tried to recruit active and retired pediatrics providers in the area, but no long-term sustainable solutions were available.

At that time, it didn’t sink in for Castor that having no pediatrician coverage at the hospital would mean no admission to the hospital for minor children.

Sandy Brower, director of quality and risk management at Bonner General Health, told States Newsroom via email that their staff is well-equipped to see pediatrics patients, who are always seen, treated and stabilized in the emergency department. But she confirmed that the hospital does not admit minors because they have no pediatricians on staff.   

“This approach is not unusual in rural health care,” Brower said. “Around the country, critical access hospitals often rely on stabilization and transfer protocols to ensure that patients …  are seen in the most appropriate setting.”

Faced with the prospect of driving her son to Coeur d’Alene herself or guessing what a 44-mile ambulance ride might cost, Castor — a single mom of two and a teacher — decided to drive to the hospital she’d never been to before. But with little information to go on about the transfer process, she was left wandering around the hospital looking for the right place to go while her son’s condition deteriorated.

“He’d already been away from the hospital for an hour for the drive, and he was starting to not do OK, and it was really stressful because I didn’t know what we were supposed to do,” Castor said. “He had his arms wrapped around himself and he just didn’t look good.”

Once she found her way, Castor said everything went well and they were discharged after one more night. But she was left shaken by the experience and her sense of stability about where she lives. She shares custody with a former partner who lives nearby, so it’s difficult to consider moving.

“I think everyone at the hospital is lovely, but it does seem like we don’t have all the services we need,” Castor said. “It makes me wonder what else we’ve lost that we don’t know about.”

Physician recruitment difficult for pediatrics in populous areas too

Amid the implementation of the abortion ban, Idaho’s population exploded. Between 2020 and 2024, more than 152,000 people moved in and the total number crossed 2 million statewide for the first time in its history. On top of all that, at least three clinics that provided labor and delivery services closed, including two in the Boise area, the most populous portion of the state. The combination created longer wait times and more complicated staffing scenarios.

Christine Myron, spokesperson for Idaho’s largest health care system St. Luke’s, told States Newsroom via email that the time to get an appointment with an OB-GYN has increased over the last two years in all of their service areas, which include every region of the state.

Myron also said in recent weeks, a candidate for a pediatrician position declined their offer because of the restrictive obstetrical care environment in Idaho. She said the difficulties in recruiting extend to every specialty of physicians because young families hesitate to move in.

As of Wednesday, St. Luke’s had 10 pediatric physician vacancies, including specialists for pediatric nephrology, oncology, infectious disease and endocrinology. 

Shifting providers, delays frustrating while trying to conceive

For women like Cynthia Dalsing, who has lived in Sandpoint for more than 30 years, it’s difficult because of her age and location. She is 71, and a recent exam showed a polyp in her uterus that needed to be biopsied and removed. That type of exam and procedure could have been done 3 miles away from her house a few years ago, she said, before Bonner General closed its labor and delivery services.

Instead, she drove back and forth to Coeur d’Alene to complete pre-operative steps, including X-rays, blood work and an EKG, then to have the procedure, then to go back again to talk about the results.

“It’s taken weeks to get care that normally would be pretty routine,” Dalsing said. “It’s a 20-minute procedure.”

The procedure was dilation and curettage, Dalsing said, often referred to as a D&C, which is the same treatment sometimes used for an early abortion or miscarriage where pregnancy tissue needs to be removed from the uterus. When she mentioned the upcoming appointment to a friend, Dalsing said they asked if that was still allowed, given the abortion ban, not knowing it’s a common procedure for many other conditions.

“That’s how clueless and confused people are about all this,” Dalsing said. 

Younger women like 36-year-old Danielle Young, who has lived in Boise since the early 2000s, report issues receiving care as well. Young said since 2016, she has switched providers five times because they kept leaving — three of those were within the past three years.

Young said she had to wait eight months for an annual gynecological wellness appointment with a nurse practitioner, and when the time came, the exam felt rushed and chaotic. After that, she decided to switch practices. Young said it took another six months to be seen by the doctor she chose, but it has been worth the wait.

At the same time, Young said she and her husband are trying to conceive, and he has had difficulties finding a clinic where he can get fertility testing. She said most of the past year has been wasted just trying to reach someone on the phone who can tell them where he should go and when he can get an appointment.

“It’s been frustrating for us, because we would like to have children or a child, and I’m getting older,” Young said.

A decision is imminent in three of the four cases that will determine whether individual health information for legal reproductive care remains protected by a 2024 federal rule.

Dr. Eve Espey has many stories she can tell about patients who travel to her clinic in New Mexico from their homes in Texas, where abortion laws are some of the most restrictive in the country.

In one recent case, Espey said a patient flew from Texas to Albuquerque for an abortion after her doctor advised that an autoimmune disease she has made being pregnant incredibly dangerous. At the same time, she had an IUD placed as future contraception.

Shortly after returning home, the patient had some cramping and discomfort that prompted her to have the placement of the IUD checked and make sure it hadn’t moved. But her doctor turned her away because she’d had an abortion.

“She flew back to New Mexico to get her IUD examined,” Espey told States Newsroom.

In this case, Espey’s patient voluntarily told her doctor that she’d had an abortion. But if a rule exempting reproductive health information from law enforcement investigations is struck down or altered by one of three federal cases brought by Republican attorneys general from more than a dozen states, that information could become mandatory to disclose.

A decision is imminent in three of the four cases that will determine whether individual health information for legal reproductive care remains protected by a 2024 federal rule under the Health Insurance Portability and Accountability Act (HIPAA), including a case in Texas before the same judge who tried to revoke government approval of an abortion drug.

The plaintiffs in the cases, which include 17 states that heavily restrict or outright ban abortion, say the rule undermines their state rights to investigate waste, fraud and abuse. Chad Kubis, spokesperson for Tennessee Attorney General Jonathan Skrmetti, told States Newsroom via email that the office could not comment because of the ongoing litigation. But the complaint in the case led by Tennessee said, “The final rule will hamper states’ ability to gather information critical to policing serious misconduct like Medicaid billing fraud, child and elder abuse, and insurance-related malfeasance.”

HIPAA is a federal law passed nearly 30 years ago to protect the privacy and security of patient health information, especially as that information travels between clinics in an increasingly all-digital world. It includes some exceptions under limited conditions, such as law enforcement investigations. After the 2022 Dobbs decision returned abortion regulation to the states, prompting more than a dozen to pass abortion bans, advocates worried that such records could be used by state officials and law enforcement to investigate and prosecute patients seeking an abortion and those who help them.

Former Democratic President Joe Biden’s administration sought to remedy those concerns by adding a rule to the HIPAA law in 2024 restricting disclosure of the information. Meanwhile, states with legal abortion passed their own shield laws to protect providers and patients from out-of-state investigations.

In New Mexico, doctors like Espey are protected by a shield law that covers patients, providers and those who help someone obtain an abortion. Even with that, Espey worries and makes sure she’s careful with the notes she puts into writing. Lawmakers in New Mexico have considered going further with the shield law to require patient consent for any release of reproductive health records, but that could become an issue in emergencies.

“That is a colossal barrier to a provider,” Espey said. “Somebody could come into the ER and you can’t access the fact that they had an abortion two days ago.”

Lauren Paulk, senior research counsel for If/When/How, a nonprofit that offers legal support to those seeking reproductive health care, said the rule is important to keep intact because it helps patients and providers feel safe. Without it, more people will be turned away from clinics and hospitals, she said.

“Since Dobbs, there have been documented cases of at least seven people who have died in part because they were afraid to seek care or were denied care. We know that patients see these stories too,” Paulk said. “We also run a help line, so we hear people calling in every day who are scared to seek health care.”

For many years, people have considered health privacy to be a basic right, Paulk said, and have taken it for granted that when they see a doctor, the information shared will be confidential. But she said it’s vital that it stays that way.

“Having the state involved in health care poisons the well of the patient-provider relationship,” Paulk said. “When I go to my health care provider and I can’t be frank with them, it means I’m not going to get care to the extent that I need.”

Since Republican President Donald Trump’s administration took office in January and Secretary Robert F. Kennedy Jr. is now at the helm of U.S. Health and Human Services, the agency that administers the rule, the suits have become more complicated, including how the government is responding to each case.

They are:

State of Missouri v. U.S. Department of Health and Human Services: Republican Missouri Attorney General Andrew Bailey filed this lawsuit in January, claiming that the rule infringes on state powers to investigate fraud, abuse and public health violations. U.S. District Judge John A. Ross, who was appointed by former Democratic President Barack Obama, is weighing the Trump administration’s request to dismiss the case for lack of standing. 

State of Tennessee v. HHS: Republican Tennessee Attorney General Jonathan Skrmetti filed this lawsuit in January, also claiming that the rule infringes on state powers of investigation. Republican attorneys general in 14 other states joined as plaintiffs. U.S. District Judge Katherine A. Crytzer, an appointee of Republican President Donald Trump, has been asked by the Trump administration to dismiss the case for lack of standing or grant the states’ request to block the rule. 

Purl, M.D. v. HHS: Dr. Carmen Purl, the sole owner of Dr. Purl’s Fast Care Walk In Clinic in Dumas, Texas, sued in October because she said the rule creates a conflict with the laws requiring her to report child abuse. The case is before U.S. District Judge Matthew Kacsmaryk, an appointee of Republican President Donald Trump. Kacsmaryk granted a preliminary injunction, but is expected to rule soon on a permanent injunction. 

State of Texas v. HHS: Republican Texas Attorney General Ken Paxton sued in September, claiming the 2024 rule violates state investigative authority. Paxton argued the underlying 2000 HIPAA rule should be struck down as well — a move that could open many more avenues for state investigations if it is granted. U.S. District Judge James Wesley Hendrix, a Trump appointee, has given the federal health agency two extensions of time to decide whether they want to rescind and rewrite the rule.

The judges presiding over the cases in Missouri and Tennessee, as well as the Purl case in Texas, could issue decisions at any time Missouri filed its lawsuit alone, while 14 other states with Republican attorneys general joined Tennessee’s lawsuit as plaintiffs: Alabama, Arkansas, Georgia, Idaho, Indiana, Iowa, Louisiana, Montana, Nebraska, North Dakota, Ohio, South Carolina, South Dakota and West Virginia. All but three of those states either heavily restrict or outright ban abortion, and if the lawsuits are successful, records kept by doctors and pharmacists in other states could be subpoenaed.

If the underlying 2000 HIPAA privacy rule is somehow altered by court rulings in Texas, it could have even more effects, Paulk said. If/When/How receives phone calls from therapists living in states with abortion bans who are afraid of facing criminal charges just for talking about abortion with a patient, or for not reporting a person considering an abortion to the police, she said. That’s not true under existing laws, but if privacy rules change, records like therapy notes could also be subject to investigation.

“It’s clear to me that the folks who are pursuing the overturn of these laws and the folks who are in states where they’re trying to get access to health information are seeking to criminalize people and further stigmatize health care like abortion and gender-affirming care,” Paulk said. “They want people to be afraid to access care and providers to be afraid to provide it, and they’re using this specter of punishment to do that.”

DOJ asked two courts to dismiss Republican-led lawsuits

Democracy Forward, a nonprofit legal organization, is representing the cities of Columbus, Ohio, and Madison, Wisconsin, and Doctors for America, and has attempted to intervene in all four cases — Kacsmaryk denied the request, but the other three are still pending. If any of the motions are granted, attorneys for Democracy Forward could defend the rule, because they do not think the DOJ attorneys will adequately defend it, said Carrie Flaxman, the nonprofit’s senior legal adviser.

The cities and Doctors for America filed a friend-of-the-court brief after Kacsmaryk’s denial, arguing that HIPAA is vital to protecting patient confidentiality, including the 2024 rule.

At the end of March, Trump’s Department of Justice attorneys asked the federal courts in Missouri and Tennessee to dismiss the cases for lack of standing, saying the states have not demonstrated any harm.

“Missouri’s complaint vaguely alleges that the rule impedes state investigations and requires the state to expend resources to comply with the rule’s requirements,” the motion to dismiss says. “But absent from the complaint are any concrete facts supporting these conclusory assertions of harm, which one would expect to see if the rule truly posed the risks that the state alleges.”

In Texas, Kacsmaryk ordered the Department of Justice to provide an update about the health services agency’s review of the Biden-era rule in May, and asked if they wished to pause the court proceedings while they conduct that review. Acting Assistant Attorney General Yaakov Roth told the court in a brief that the rule remains “under consideration” but no imminent action on the rule is expected. He added that they were not requesting any pause in the case.

That response differed in Paxton’s suit, which was already on hold. DOJ attorneys asked for more time to “evaluate the agency’s position in this case and determine how best to proceed.” The judge granted the extension, and another update is expected in July.

“Blocking either or both of these rules could pave the way for government investigations by Attorney General Paxton or others and threaten the foundations of medical privacy that we all rely on,” Flaxman said. “Patients nationwide should be concerned about investigations … into the most personal of their medical records.”