Manu Raju
@mkraju

The House overwhelmingly voted tonight to back the entry of Finland and Sweden into NATO, with 18 Republicans voting no. The final vote was 394-18. The NO votes:

POLITICO
@politico

10 states where abortion is now illegal have sent Google more than 5,700 demands for location tracking data since 2018.

There's growing alarm about how police or prosecutors could use that data to target abortion providers or people seeking the procedure.

‘A uniquely dangerous tool’: How Google's data can help states track abortions

Last year, a 35-year-old woman named Amanda, who lives in the Dallas-Fort Worth area, had a miscarriage in the first trimester of her pregnancy. At a large hospital, a doctor performed a surgical procedure often used as a safe and quick method to remove tissue from a failed pregnancy.

She awoke from anesthesia to find a card signed by the nurses and a little pink and blue bracelet with a butterfly charm, a gift from the hospital to express compassion for her loss. “It was so sweet because it’s such a hard thing to go through,” Amanda said.

Eight months later, in January, Amanda, who asked to be identified by her first name to protect her privacy, experienced another first-trimester miscarriage. She said she went to the same hospital, Baylor Scott & White Medical Center, doubled over in pain and screaming as she passed a large blood clot.

But when she requested the same surgical evacuation procedure, called dilation and curettage, or D&C, she said the hospital told her no.

A D&C is the same procedure used for some abortions. In September 2021, in between Amanda’s two miscarriages, Texas implemented a law banning almost all abortions after six weeks into pregnancy.

Once home, Amanda said, she sat on the toilet digging “fingernail marks in my wall” from the pain. She then moved to the bathtub, where her husband held her hand as they both cried. “The bathtub water is just dark red,” Amanda recalled. “For 48 hours, it was like a constant heavy bleed and big clots.”

She added, “It was so different from my first experience where they were so nice and so comforting, to now just feeling alone and terrified.”

Cassie, a Houston woman who asked to be identified by her first name, said she learned she had miscarried the day Roe v. Wade was overturned, when her doctor detected blood in her uterus and no cardiac activity.

She was prescribed misoprostol, but said a Walgreens made her wait a day for “extra approval” from its corporate office.

“When I went to pick it up, I then had to chat with the pharmacist and had to state again, even though they were aware my doctor prescribed it, that it wasn’t for an abortion,” Cassie said.

A Walgreens spokesman said some abortion laws “require additional steps for dispensing certain prescriptions and apply to all pharmacies, including Walgreens. In these states, our pharmacists work closely with prescribers as needed, to fill lawful, clinically appropriate prescriptions.”

While laying waste to 50 years of abortion jurisprudence, the Supreme Court — or at least four of the five members of the new hard-right majority — took pains to reassure the country that it had executed an isolated hit on an “egregiously wrong” precedent that would not reverberate in other areas of constitutional law.

But the court will not fully control whether and when it will have to confront demands for similarly breathtaking changes. In fact, the justices’ agenda will be driven primarily by the political ferment in red states that are racing to capitalize on one of the most conservative blocs of five justices in at least 100 years.

And that in turn means that overturning Roe v. Wade will not take the issue of abortion out of the courts but rather intensify the battle there. Dobbs v. Jackson Women’s Health Organization will let loose a whirlwind of red-state lawmaking that will blow to the court’s door in the coming years, as will other constitutional cases of the sort the court tried to bracket off in Dobbs.

These attempts to punish out-of-state abortions inevitably will provoke lawsuits, one or more of which will make their way to the Supreme Court. The justices may duck the issue once or even twice, but eventually they will have to re-enter the fray to address whether the Constitution forbids a state from regulating across state lines in this fashion. The court’s established jurisprudence, combined with the core holding in Dobbs that women lack a constitutionally protected abortion right, leaves it doubtful, notwithstanding Justice Kavanaugh’s concurrence, that the court would find that the Constitution enshrines a right to travel for reproductive health reasons.

Dobbs similarly provokes a range of other questions that Republican state legislators likely will force the Supreme Court to confront: Can states validly declare that life begins at conception? Can they criminally prosecute women who seek an abortion procedure? Can women be denied access to abortion in cases of rape or incest?

It’s clear, in other words, that Justice Samuel Alito’s claim in the main Dobbs opinion that overturning Roe would remove the court from the abortion arena is a vain hope.

A sexual assault survivor chooses sterilization so that if she is ever attacked again, she won’t be forced to give birth to a rapist’s baby. An obstetrician delays inducing a miscarriage until a woman with severe pregnancy complications seems “sick enough.” A lupus patient must stop taking medication that controls her illness because it can also cause miscarriages.

Abortion restrictions in a number of states and the Supreme Court’s decision to overturn Roe v. Wade are having profound repercussions in reproductive medicine as well as in other areas of medical care.

“For physicians and patients alike, this is a frightening and fraught time, with new, unprecedented concerns about data privacy, access to contraception, and even when to begin lifesaving care,” said Dr. Jack Resneck, president of the American Medical Association.

Even in medical emergencies, doctors are sometimes declining immediate treatment. In the past week, an Ohio abortion clinic received calls from two women with ectopic pregnancies — when an embryo grows outside the uterus and can’t be saved — who said their doctors wouldn’t treat them. Ectopic pregnancies often become life-threatening emergencies and abortion clinics aren’t set up to treat them.

A woman with a life-threatening ectopic pregnancy sought emergency care at the University of Michigan Hospital after a doctor in her home state worried that the presence of a fetal heartbeat meant treating her might run afoul of new restrictions on abortion.

At one Kansas City, Mo., hospital, administrators temporarily required "pharmacist approval" before dispensing medications used to stop postpartum hemorrhages, because they can also be also used for abortions.

And in Wisconsin, a woman bled for more than 10 days from an incomplete miscarriage after emergency room staff would not remove the fetal tissue amid a confusing legal landscape that has roiled obstetric care.

In the three weeks of turmoil since the Supreme Court overturned the constitutional right to abortion, many physicians and patients have been navigating a new reality in which the standard of care for incomplete miscarriages, ectopic pregnancies and other common complications is being scrutinized, delayed - even denied - jeopardizing maternal health, according to the accounts of doctors in multiple states where new laws have gone into effect.

While state abortion bans typically carve out exceptions when a woman's life is endangered, the laws can be murky, prompting some obstetricians to consult lawyers and hospital ethics committees on decisions around routine care.

When the Supreme Court overturned the constitutional right to abortion last month, Justice Clarence Thomas made clear that he wasn’t planning to stop there. In a concurring opinion, Thomas called on the high court to revoke the rights to marriage equality, intimate sexual relationships, and contraception, as well. The landmark rulings establishing these rights, Thomas wrote, are “demonstrably erroneous.”

Thomas’ argument, which none of his colleagues joined, set off alarm bells among legal scholars and advocates for LGBTQ and reproductive rights. But then—in a separate opinion three days later that received far less attention—he laid out an alternate route to gut same-sex marriage and other personal freedoms: allowing government officials to simply refuse to recognize Americans’ constitutional rights if they claim those rights conflict with their own religious values.

As the court has moved swiftly to enact its conservative agenda on everything from abortion to religion to guns to climate change, Thomas’ own reputation has shifted with it. Once considered the court’s outlier, he is now viewed as its right-wing trailblazer. Now firmly in the majority, he’s turning his arch-conservative worldview into the nation’s reality. If there’s anything this past term has taught us, it’s to take seriously the possibility that Thomas and his conservative colleagues will not hesitate to make radical changes to American life.

Thomas has laid out two paths to achieve his social agenda. One, as the public quickly took note of, is to boldly overturn the cases that recognized the constitutional right to same-sex marriage and struck down bans on sodomy and contraception. This would allow state legislatures to prohibit these things outright. Thomas’ other strategy is more subtle, but it, too, would erode some of the rights we take for granted today, particularly marriage equality. Importantly, Thomas is not making an either/or proposition here; it’s clear that he wants to pursue both paths.

On June 27, the court’s conservative 6-3 majority ruled in favor of a public school football coach who had been fired for leading prayers at the 50-yard-line—one of multiple religion cases this term in which the conservatives whittled away at the separation of church and state. In this case, Kennedy v. Bremerton School District, the court privileged the coach’s free exercise and free speech rights under the First Amendment over the Establishment Clause’s protection against the government favoring or instituting a religion. Thomas joined this ruling and, in a concurring opinion, called for the court to expand religious free exercise rights for public employees.

“The Court refrains from deciding whether or how public employees’ rights under the Free Exercise Clause may or may not be different from those enjoyed by the general public,” Thomas wrote.

Methotrexate is a fairly common drug that treats a wide range of medical conditions. I take it to help control an autoimmune disorder. So do about 60 percent of rheumatoid arthritis patients. It is used to treat some cancers, such as non-Hodgkin lymphoma. It also has at least one other important medical use.

The drug is the most common pharmaceutical treatment for ectopic pregnancies, a life-threatening medical condition where a fertilized egg implants somewhere other than the uterus — typically a fallopian tube. If allowed to develop, this egg can eventually cause a rupture and massive internal bleeding. Methotrexate prevents embryonic cell growth, eventually terminating an ectopic pregnancy.

And so many patients who take methotrexate say they have become the latest victims of the Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization — the decision overruling Roe v. Wade.



It’s unclear how widespread this phenomenon is, though the problem is serious enough that the Arthritis Foundation put out a statement warning that “arthritis patients who rely on methotrexate are reporting difficulty accessing it,” and that “at least one state — Texas — allows pharmacists to refuse to fill prescriptions for misoprostol and methotrexate, which together can be used for medical abortions.”

In some cases, pharmacists are reportedly reluctant to fill methotrexate prescriptions in states where abortion is illegal, and doctors are similarly reluctant to prescribe it. In other cases, pharmacists may refuse to fill valid methotrexate prescriptions because they personally object to abortion, even in states where the procedure remains legal.

The phenomenon of patients struggling to obtain therapeutic drugs that can be used in abortion care appears to be severe enough that, on Wednesday, President Joe Biden’s administration released a four-page “Guidance to Nation’s Retail Pharmacies.” It informed them that federal laws prohibiting discrimination on the basis of disability or pregnancy may require pharmacists to fill prescriptions for drugs like methotrexate. (The question of whether a particular denial by a particular pharmacist violates federal law will depend on the specific cases of the case.)

Ultimately, however, laws are only as good as the courts that interpret them. And disputes over whether states can ban mifepristone, or whether pharmacists can simply refuse to dispense certain drugs, are likely to be resolved by the same justices who gave us Dobbs.

At best, that means a lot of confusion for patients until the courts sort these issues out. And, given this Court’s hostility toward abortions and sympathy for religious conservatives, it is likely that many patients will be denied prescription drugs.