SIOUX FALLS, S.D. — A backlog of five patients is waiting for Dr. Sarah Traxler when she arrives with her security detail at the Planned Parenthood Clinic on the west side of town.

She's already six hours into her day when she slips into scrubs and grabs the first manila envelope on the top of the stack. The routine has become almost second nature to Traxler, who has spent the past seven years flying between home in the Twin Cities and South Dakota once a month. For that one week, she's the lone physician who can perform abortions in the state.

"We've been able to justify this because we're willing to go to extreme lengths for our patients, because they should have access to this care," said Traxler, 46. "It's safe, it's legal, it should be everywhere."

These trips could end suddenly if the U.S. Supreme Court this spring overturns Roe v. Wade, the 1973 landmark case that made abortion legal in every state. Such a ruling could quickly make abortion illegal in more than two dozen states, including South Dakota. States such as Minnesota, New York, California, Colorado and Illinois could become islands where tens of thousands of women travel to legally terminate their pregnancies.

Providers in Minnesota and across the nation are bracing for a new — and old — reality in which the opportunity to obtain a safe abortion is determined by geography, wealth and time.

"Someone recently asked me if it would get this bad, and I said yes," Traxler said, adding that she's watched opponents try to chip away at access while growing up in the South and now living in the Midwest. "I think I was sort of anticipating this day."

Requirements for patients

One of Traxler's first patients of the day lives just outside Sioux Falls, is younger than 21 and not ready to have a baby. Under state law, Traxler is required to ask her a series of questions before she gets an ultrasound.

Have you ever had a C-section before? Do you want to know whether there are twins? Do you want to see an image of that ultrasound? Do you want a detailed description of that image? Do you want to hear a heartbeat if possible? Would you like a copy of the image to take home with you?

"I tell everybody, 'Answer these however you want,' " Traxler tells the patient, who didn't want her name used in this report because of safety and privacy concerns. " 'You are not tied to however you answer these. You do whatever you want today — we are here to support you.' "

The patient says yes to every question but the first and last ones. In the ultrasound room, it's confirmed that she is nearly 12 weeks along in her pregnancy. The ultrasound can make out a head, abdomen and an arm, and then the sound of a heartbeat starts pulsing through the machine. This is the moment, abortion opponents say, that shows patients they're choosing to end a life — and gives them an opportunity to change their mind.

The clinic can provide two types of abortions: a medication abortion, where the patient takes a combination of medications over several days to end the pregnancy, or a surgical abortion, in which the physician removes the fetus from the uterus.

After the ultrasound, Traxler hands her patient a five-page, double-sided informed consent packet to sign as required by the state's department of health. That's the moment the patient gets her timestamp for either surgery or when she can receive medication after South Dakota's mandatory 72-hour waiting period between consulting a physician and obtaining an abortion has passed. The abortion cannot happen a minute before.

Later in the morning, another patient hears the same questions from Traxler and says no to them all. She's not interested in seeing the images, having them described to her or hearing the heartbeat.

South Dakotans have voted down two attempts to ban abortion, but lawmakers have passed many requirements related to the procedure. Some women travel hours across the state to get to the Sioux Falls clinic, the only South Dakota provider of abortions.

Patients need to arrange work, school or child care schedules to be at both appointments. If a woman misses her Thursday appointment, the process starts over the next week with a new physician, who must be present at almost every step of the process.

"They already sort of live in a post-Roe world, because it's pretty inaccessible already," Traxler said.

A 'momentous' ruling

The Supreme Court is expected to rule by the end of June on a Mississippi law that bans abortions after 15 weeks of pregnancy, with few exceptions.

The state of Mississippi asked the Court to not only uphold its abortion ban but to rule there is no constitutional right to abortion before fetal viability. That goes to the heart of Roe, which established a right to abortion before the fetus can survive outside the womb, considered by many medical standards to be between 23 and 24 weeks of pregnancy.

The justices could uphold Roe, but most legal experts predict the conservative-majority court will uphold Mississippi's ban, undo the Roe precedent or both. That scenario would immediately ban abortions in some states; in others, it's expected that legislators would quickly move to restrict access.

The landscape is shifting already. When Texas' law prohibiting abortions as early as six weeks into pregnancy took effect in September, some women in the state started traveling to Oklahoma for the procedure. But last month, the governor of Oklahoma signed a near-total abortion ban, with an exception only for medical emergency.

Abortion clinics in states where the procedure is banned or severely restricted are already prepared to shift to helping patients navigate different laws and find money to travel to get an abortion, but lawmakers in conservative states are trying to clamp down on that too. Missouri and Oklahoma legislators have introduced proposals — similar to the Texas law — to allow private citizens to sue anyone who helps a resident get an abortion. In Oklahoma, the Legislature sent a bill to Gov. Kevin Stitt's desk on Thursday, and he is expected to sign it.

"I always tell my staff, it's the same procedure in Texas as it is in Maryland," said Amy Hagstrom Miller, president and CEO of Whole Woman's Health, which operates clinics in five states, including Minnesota, and offers fully virtual services in a sixth. "But what people have to go through to obtain it is night-and-day different."

Whole Woman's Health opened a clinic in Bloomington in February that sees patients a few days a week, and it has already seen higher-than-expected numbers of traveling patients — about a quarter of the 15 to 20 daily appointments, said Sean Mehl, associate director of clinical services. The demand from out-of-state patients can make it more difficult for Minnesota patients to get care.

"That's one of the first things that we noticed, that even patients in the state are being pushed further and further along, because the availability in the state is so limited," Mehl said. "It is like a cascading effect that's affecting, really, most of the country."

Even as women flock to states such as Minnesota, there's fear about not being able to meet the demand. Minnesota has eight abortion providers, and they are not immune to the workforce shortages that have hit health care during the pandemic.

Dr. Julie Amaon, who trained under Traxler and other physicians, is now medical director with the Minnesota-based telehealth clinic Just the Pill. Amaon is licensed in multiple states so that she can see patients in places with limited access. Some states are taking aim at medication abortions, which can be prescribed via telehealth and mailed to patients who then self-manage at home, with physician support if needed.

Amaon said she believes Roe will be overturned. But because medication abortions are now widely accessible, she doesn't expect a return to the dangerous, botched procedures of half a century ago.

"I am just more hopeful that it won't be as disastrous as it was before Roe. But I still think that this Supreme Court decision is going to be momentous," Amaon said. "It's already affecting the most marginalized, and it's just going to get worse for people."

Though the right to obtain an abortion is constitutionally protected in Minnesota under the 1995 state Supreme Court decision in Doe v. Gomez, the state also has laws that restrict abortions, including a 24-hour waiting period, mandated counseling and a requirement that minors notify both parents.

Legislators who oppose abortion regularly introduce further restrictions, including five measures this year that would establish Constitutional and legal rights beginning at conception, prohibit the procedure once a heartbeat is detected and require patients seeking a medication abortion to see a provider in person or read a disclosure statement. A couple of the proposals would allow private citizens to bring civil actions against providers.

All are unlikely to gain traction in the divided Legislature, and Gov. Tim Walz has said he would veto bills that restrict abortion.

Patients who go to Whole Woman's Health in Bloomington are read a script over the phone at least 24 hours before their appointment. Once there, they navigate protesters to pass through a locked door into the lobby, then head to a counseling room, procedure room and recovery space decorated with images and inspirational quotes from famous women.

Lighting is low, paint colors are soft, and chairs are comfortable. As they recover, they can sip tea, have a snack and write a message for those who follow them. Most come down to the same thing: It'll be OK.

Anxiety for the future

By the end of the workday, Traxler had seen almost all of the patients she expected to see. She hopes they'll all make it back on Thursday, if that's what they want to do, but it doesn't always happen.

Traxler's security escort picks her up at the clinic and drives her back to the Sioux Falls airport, which he does each time she visits. They greet each other like old friends, catching up on the latest news in their lives.

Raised Southern Baptist in Louisiana, Traxler never imagined herself doing this work. She was adamantly opposed to abortion until a friend told her about her own. That opened Traxler's eyes and set her on a path to medical school. Now, she's advocating for codifying abortion access in state law, anxious about the future if Roe is overturned.

All she can do is make her monthly treks across the border as long as possible. Traxler, a mother of two, said they've become known as "Sioux Falls week" in her home. She lands back in Minnesota in the evening after a 14-hour day, a trip she'll repeat in three days. It's meant missing countless school games, pickups and drop-offs for her kids over the years.

"Everybody's really aware that it's a busy week, I'm going to be tired because travel is hard," said Traxler. "But we're all in it."

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