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WASHINGTON — On the fourth anniversary of the Dobbs v. Jackson decision, which overturned the constitutional right to abortion, Samantha Casiano carried a picture of her daughter, Halo, with her to meetings on Capitol Hill.

The photo showed Halo without a fully formed skull and brain, leading to her death four hours after she was born. Casiano’s OB-GYN had told her 20 weeks into her pregnancy that the defect was “incompatible with life,” but while Casiano said she could see her doctor wanted to help her end the pregnancy, she also saw the physician’s hands were tied by the life imprisonment Texas doctors can face for providing abortions under the state’s laws.

“She had to choose between her life and mine,” Casiano said.

Casiano was one of several women who traveled to Washington last month with Free & Just, a national nonprofit formed after the 2022 Supreme Court ruling that upended abortion access across the country, to speak with federal lawmakers as part of their “Abortion Stories on the Hill” campaign. It was the second June in a row in which women, like Casiano, trekked with Free & Just to the Capitol to relive some of their worst moments in an effort to explain to lawmakers how abortion restrictions delayed their medical care or forced them to carry a nonviable baby to term — an experience Casiano described as watching her daughter “suffocate.”

“I was more prepared this time,” Casiano said, comparing her first visit to Washington, in 2025, to a practice run. “I made sure to look the staffers in their eyes and let them know who I was.”

But not everyone was receptive to the message. After Casiano shared Halo’s story and photo with a staffer for her congressman, U.S. Rep. Morgan Luttrell, R-Magnolia, she was told the office is “pro-life” and escorted out minutes after.

“It was a slap in the face,” she said. “I really wish that [the staffer] would have taken a deep breath with me.”

Despite their annual visits to the Hill and efforts to share their stories with lawmakers, abortion advocates have struggled to break through in a Congress that, since Dobbs, has lacked the numbers to roll back state bans or otherwise loosen restrictions.

Rather, some GOP lawmakers say they want to further clamp down on abortion by targeting pills like mifepristone, which now account for nearly two‑thirds of abortions nationwide. In Texas, telehealth makes up virtually all abortion care that still happens within state law, according to recent estimates.

U.S. Rep. Beth Van Duyne, R-Irving, said advocates’ warnings about the effects of abortion bans were overblown and intended to “scare the shit out of people.” And she criticized federal rules that allow abortion medication to be prescribed virtually and mailed to patients.

“What you saw with Dobbs was the same scare tactics we always hear from Democrats about what Republicans are going to do, and history has proven them wrong once again,” Van Duyne said, adding that she still sees work to be done in scrapping federal policies allowing drugs like mifepristone “that actually kill a baby.”

Abortion and the campaign trail

Advocates like Casiano are also confronting the reality that, at least in Texas, abortion access is not top of mind for voters. In a recent Texas Politics Project poll, just 2% of voters named abortion as the most important problem facing the state, with inflation and the economy and a host of other issues ranking higher.

That disconnect is something Kaitlyn Kash, an Austin mom who joined a 2023 lawsuit challenging Texas’ narrow medical exceptions to its abortion bans, says she thinks about when she talks to Texans about her own experience.

Kash, who has spent the last three Dobbs anniversaries on the Hill, said she tries to be careful when speaking about abortion and reframes it as a broader fight over access to reproductive healthcare — and as an issue that’s interwoven with the economy, people’s families and their freedoms.

“You can have more than one issue. I don’t think people understand that you’re not voting about abortion, you’re voting for reproductive healthcare because they’re all interrelated,” Kash said. “It’s a continuum of care, and doctors need the ability to be able to give you that care.”

Raven E. Freeborn, a former abortion doula and president of Avow, a Texas-based abortion-rights organization, said she doesn’t see abortion as separate from voters’ pocketbook worries.

“Abortion rights and access are vital to affordability,” she said. “Not being able to access abortion when you need it, that’s an economic justice issue. You’ll likely miss work, so you’re going to lose wages. Economic justice, affordability, reproductive justice, and abortion access are all living inside the same constellation.”

While Casiano, Kash and others have failed to move the needle on Capitol Hill, their stories, along with the deaths of Texas women due to delayed treatment, have helped generate changes at the state level. Last year, Texas lawmakers passed Senate Bill 31, dubbed the Life of the Mother Act, a measure that directs doctors to use “reasonable medical judgment” in medical emergencies involving a patient’s life or serious harm. The law says a medical crisis need not be “imminent” before healthcare providers can act, and that a doctor can only be charged if the state can prove “no reasonable doctor” would have made the same call.

But some advocates say that has not helped when it matters. Texas Equal Access Fund, an abortion access advocacy group, has called SB 31 a “fake fix,” arguing it adds legal red tape for physicians without resolving the gray area around the ban’s exceptions, still leaving pregnant patients in medical limbo.

Additionally, two Austin-area emergency rooms were the subject of a recent federal complaint from a woman alleging she was denied miscarriage care, even with the new clarifying language on the books.

John Seago, president of Texas Right to Life, an anti-abortion group that helped craft Texas’ abortion bans and SB 31, said he sees the remaining problems not as flaws in the statutes but as failures in how hospitals and attorneys are applying them. That was the impetus, he explained, behind the new law’s requirement for the Texas Medical Board to create training for doctors who perform obstetrics care.

“We passed Senate Bill 31 last session to require education of physicians on this topic, because we want the message to be very clear that whenever there’s a serious situation like an ectopic pregnancy or miscarriage, there is no hesitation, that doctors are supposed to serve those women and help them immediately,” he said. “[If] the attorney at the hospital misrepresented the law, that’s just malpractice.”

Freeborn pushed back, describing abortion as more than an emergency moment, but also as “healthcare, a political bargaining chip and a moral clause.”

“These doctors are wrestling with everything that’s in the room with them about a healthcare procedure — stigma, shame, disinformation — and that is not true of other medical care,” Freeborn said. “Birthing people are navigating their reproductive realities, and their ability to have bodily autonomy and govern over themselves is often in question by way of their relationship to something else.”

Some research has found that Texas’ abortion restrictions are linked to worsening mental health among reproductive‑age women. A study of more than 15,000 Texas women found that reports of “frequent mental distress” rose significantly after the state in 2021 banned most abortions after about six weeks.

Cracking down on abortion pills

Meanwhile, Seago’s group and other anti-abortion advocates have been moving to restrict the flow of abortion drugs to states like Texas where the procedure is banned. The Texas GOP, for example, listed “protect life” as one of its eight legislative priorities at last month’s convention, a plank that includes a call for “strong criminal penalties and new enforcement tools to fight abortion and abortion pill trafficking.”

In a letter signed last week by more than 80 anti-abortion groups, advocates urged Acting Attorney General Todd Blanche to settle a lawsuit challenging the Food and Drug Administration’s Biden-era policy allowing mail delivery of mifepristone.

“Pro-life states cannot enforce their laws while an FDA regulation gives cover to mail-order abortionists and DOJ defends the profits of abortion drug manufacturers,” the letter said.

Texas Attorney General Ken Paxton has filed two civil suits since 2024 against out‑of‑state providers he says illegally mailed abortion pills to Texans.

In a statement marking the four-year anniversary of Dobbs, Jonathan Saenz, president of the conservative advocacy group Texas Values, celebrated that Texas “has been a beacon of life” since the decision, while calling for action on drugs like mifepristone.

“As the state where Roe v. Wade originated, Texans have a deep and personal stake in never going back to that deadly time period,” said Saenz, one of the signatories on the letter to Blanche. “Sadly, illegal mail order abortion pills are still being sent into Texas and we must continue working hard to protect moms and babies from this type of exploitation.”

Abortion advocates like Kate Cox say lawmakers should focus instead on Texas’ post-Dobbs medical landscape. The Dallas mother, who traveled to New Mexico to terminate her pregnancy in 2023 after her fetus was diagnosed with a genetic condition that’s almost always fatal, said she is concerned that the state’s severe abortion penalties, even with SB 31, will push OB‑GYNs to practice in other states and make Texas a less attractive place for top medical talent.

“I think new OB-GYNs coming out of school look at the situation, and they don’t want to come practice in Texas, where they would have to navigate what would be a very different situation in other states,” said Cox, the first adult woman to seek a court’s permission to have an abortion post-Dobbs. “I was in the emergency room four times, and I asked my doctor, ‘If I choose not to continue the pregnancy, can I make that decision?’ And she said, ‘Not in Texas.’ I think that puts them in a very difficult spot.”

That’s why Cox wants lawmakers to focus less on prescribing what doctors can do and more on recognizing the volatile realities of pregnancy.

“Every pregnancy is different. Some bring joy, some bring heartbreak, and some bring medical emergencies,” Cox said. “The Legislature can write a law that covers every possibility with compassion. And the more we learn about pregnancy, the more we realize how unpredictable it can be. Instead of trying to legislate every scenario, we should trust families and the physicians that are caring for them.”