Don’t mess with Mass.: How the state became a center of post-Dobbs resistance – The Boston Globe

Foster has made little effort to hide her efforts to circumvent restrictive laws passed in other states since the US Supreme Court overturned Roe v Wade. She doesn’t need to: She is operating with the full support of Massachusetts government officials, and even has a former attorney general on call in case anyone challenges her. Which may explain why she has not received a single death threat, summons, or cease and desist letter.

“We are part of the formal Massachusetts health care system,” says Foster, whose affable and unpretentious manner offers little hint of a resume that includes a Rhodes Scholarship and degrees from Stanford University and Harvard Medical School. “There is an incredible kind of legitimacy that comes with that.”

The MAP, one of only four domestic services of its kind openly operating in the United States, is currently shipping abortion medications to all 50 states. And it is the only one designed to operate as a fully integrated part of a state health care system. It is just one example of the way Massachusetts is taking its defense of abortion rights national.

In the two years since the Dobbs v. Jackson decision Women’s Health decision, the national news has been dominated by stories documenting the transformation of states like Mississippi, Texas, and Missouri, which have pushed through a raft of new laws to ban or severely limit abortion. But Massachusetts has quietly undergone an equal and opposite metamorphosis, emerging as the legal, spiritual, and intellectual center of the post-Dobbs resistance, with Harvard legal scholars and state agencies filing amicus Supreme Court briefs, new think tanks documenting the changing situation on the ground, a state Legislature instructing college health centers to hand out abortion pills, a department of public health spending millions to support abortion access and security, and a governor and attorney general who have vowed to use their offices to fight back.

The state is currently sitting on a stockpile of more than 15,000 doses of the abortion drug mifepristone, ordered up by the governor in case the Supreme Court bans it, and is home to a new “Reproductive Justice Unit,” tasked by the attorney general with monitoring new legislation and antiabortion tactics bubbling up from red states and helping to coordinate policies to counter them.

“I will do everything I can to protect access to care here in Massachusetts, and help nationally to ensure that women have access to medicated abortions,” Governor Maura Healey told the Globe. “People should not underestimate the very serious threat that is posed to women’s health by this extremist agenda.”

The state’s current burst of activism began in 2020, even before the Dobbs decision, catalyzed by the death of Supreme Court Justice Ruth Bader Ginsberg and a growing awareness of what was coming. In December of that year, the Legislature passed laws strengthening state constitutional protections for abortion, lowering the age of required parental consent from 18 to 16, and allowing abortions after 24 weeks of pregnancy in cases of fatal fetal abnormalities.

After Dobbs came legislation requiring state universities to offer medicated abortions on campus. The state also passed a first of its kind “Shield Law,” engineered to protect local telehealth abortion providers like The MAP from out-of-state prosecution by categorizing all virtual encounters with patients in states that restrict abortion, or gender-affirming care, as local. These policies, along with the rise of telehealth as ready option for patients, have had a potent impact.

Since the 2022 Dobbs decision, the number of abortions in the state has risen 20 percent, from about 1,600 a month to an average of roughly 2,000 a month, according to Dr. Ushma Upadhyay, who co-chairs the Society for Family Planning’s WeCount project. Last year about 6 percent of those abortions were for people who came from out of state, double the percentage prior to Dobbs. The numbers are not nearly as high as those seen in “surge” states like New Mexico and Illinois, which border states where abortions have been severely restricted or banned. And they don’t include medicated abortions provided by those operating here under the Shield Law. The MAP’s numbers alone, which until recently weren’t officially categorized by DPH statisticians as occurring in state, would add another 500 abortions a month, or 25 percent, to the state totals.

Sitting behind a desk in her cramped office on the second floor of a co-working space, a tower of cardboard boxes containing abortion pills worth about $100,000 teetering atop a supply cabinet nearby, The MAP’s Foster predicts the numbers of abortion pills shipped from Massachusetts to other states would explode in the months ahead, as word spreads that safe, medical abortions are easily accessible through the internet.

Since 2022, six other states have followed the lead of Massachusetts and passed Shield Laws with similar language, including Washington, Colorado, Vermont, New York, California, and Maine. There are now four services operating in Shield Law states that ship abortion pills to states with abortion restrictions, according to Elisa Wells, co-director and cofounder of Plan C, a think tank and advocacy group established in 2015.

Supporting the efforts of Shield Law providers like The MAP, Governor Healey says, is in the state’s interest because it helps prevent local abortion providers from being overwhelmed by women from out of state. But it’s also, she believes, a question of doing what’s right. Leaving abortion policies up to states, she said, is dangerous.

“Forcing women who are the victims of rape or incest to carry a fetus to term is outrageous,” she said. “Forcing women who are dealing with complications from pregnancy that put themselves at risk and in danger of dying is outrageous. That’s where leaving it up to states has gotten us.”

Foster considers it a small miracle that she has not received a legal challenge of any kind, or even a single threatening letter, from one of those star-cluttered states on her map. She attributes that to a focus by abortion opponents on the US Supreme Court, which dealt the effort to limit access to medical abortion a significant setback on June 13, when it ruled the coalition of antiabortion groups who filed suit lacked standing to challenge the way the FDA is regulating the drug mifepristone.

The morning of the decision, Foster was ebullient, expressing her relief and making plans to pop a bottle of bubbly after work. Also apprehensive.

“We’re really, really proud of the care and of the service, but worried about what’s going to happen when we get cease and desist letters, when there are subpoenas, when there are lawsuits,” she said. “They’re coming, I’m sure.”

Abortion opponents say Foster is right to worry. Kyleen Wright, president of Texans for Life, called the actions of Shield Law providers like Foster “reckless” “dangerous,” and “so terribly wrong.” She accused supporters of medicated abortions of downplaying the risks and placing the lives of young women in jeopardy.

“If your doctors are in Massachusetts, and they’re surprised that we haven’t come after them, you might just tell them to hold onto their hats,” Wright told the Globe. “We are working on some more innovative and creative ways of putting a stop to this.”

Foster knows that if abortion opponents come after her, she’ll have plenty of powerful allies to defend her. Her first call will go to former state attorney general Martha Coakley, The MAP’s pro-bono legal counsel. She can also expect help from the AG’s Reproductive Justice Unit‚ which Attorney General Andrea Joy Campbell established last fall. The unit, led by Sapna Khatri, a reproductive rights attorney, is helping coordinate the efforts of the attorney general’s more than 300 attorneys on a wide array of initiatives, and cases.

While she waits for the challenges to arrive, Foster and her colleagues are continuing to grow. Recently, a donor agreed to pony up $500,000 to build a free-standing pharmacy to fill more orders.

Foster came to her passion for safeguarding abortion rights early. A native of Portland, Ore.,, she grew up attending Planned Parenthood rallies with her mother and hearing horror stories from the pre-Roe v. Wade era. One of them involved her mother, who was impregnated by an abusive boyfriend at age 19 and had to travel to Mexico to obtain an abortion.

She has grown used to legally precarious circumstances.

In 2008, she cofounded a Cambridge-based nongovernmental organization to provide abortion access to women in the developing world; she cut her teeth flying to Bangladesh to make bulk purchases of misoprostol, a second drug often used to induce an abortion, and then carrying as many as 30,000 pills at a time into camps on the Thai border for distribution to refugees from Myanmar. She was prepared for the possibility of arrest and deportation. But she long ago decided that, in her line of work, the high stakes justify the risks. Most women who feel they need an abortion, she has learned, will do whatever is necessary to get one, even if that means taking extreme measures that put their health, even their own lives, in jeopardy.

“Somewhere between 8 and 15 percent of maternal mortality globally is directly attributable to unsafe abortions,” said Foster. “It is the cause of maternal mortality that is truly preventable.”

She and her collaborators launched The MAP on Sept. 28, 2023, International Safe Abortion Day, with four clinicians, a community outreach director, and a growing network of donors.

The prescribing process begins when a patient fills out a form online. They are then emailed a link to a questionnaire and consent forms and referred to a licensed clinician in Massachusetts, who determines if the patient is eligible. Then The MAP ships them the pills. Patients are asked to pay a minimum of $5. Though the providers and patients exchange phone numbers, texts, and emails in case there are questions, live interactions are not a requirement.

“It’s really profoundly unsettling to me to think that a girl that’s born today has less rights than her mother and grandmother,” Foster said. “That shouldn’t be allowed to take place just because a state has decided to restrict what was for almost 50 years considered a constitutional and fundamental right.”

Adam Piore can be reached at adam.piore@globe.com.