On a mild afternoon last April, Randy Grau, a Republican representative from Edmond Oklahoma, took to the state House to argue in favor of Senate Bill 1848. The bill, later signed into law, regulates standards for abortion centers and requires abortion providers to obtain nearby hospital admitting privileges. Clad in a crisp white dress shirt and light blue tie, Grau, a co-sponsor of the bill, turned to his peers and began softly: “On an unassuming street in Philadelphia, Pennsylvania, tucked in among houses, churches, little shops, right next to an elementary school, a building went by the name of the women’s medical society. Inside that women’s medical society, run by Dr. Kermit Gosnell, could only be described as a house of horrors.” He paused and cast his eyes to the floor before cataloging the conditions at Gosnell’s now-notorious Philadelphia abortion clinic: dirty equipment, blood-splattered floors, and untrained staff administering anesthetics.
“This bill will ensure that there’s proper standards and training of the staff that are helping perform these procedures,” the clean-cut young representative continued. “Does it prevent more abortions? I dunno. But I’ll tell you what I think it will do. It will ensure that none of these clinics prey upon women that are in a vulnerable and miserable position.”
To the outside observer, Grau’s position — pushing for regulatory standards he claimed were necessary to protect women’s health — might have seemed reasonable. But as the debate ensued, legislators from both sides of the political spectrum voiced their concerns. Some cited the Oklahoma State Medical Association’s opposition of the bill, which in a letter to the state senate insisted that it “may not reflect medical science or the best interest of the patient.” Others, like Republican Doug Cox, firmly rejected Grau’s argument that the proposed legislation would shield its intended constituents from harm. When pressed “How does this make life easier for patients?” by another House member, Cox, a physician who ultimately voted nay on SB 1848, replied, in a rare moment of candor that contradicted the party line: “Well, I’m not sure that it does.”
To the pro-choice advocates closely tracking the rash of anti-abortion bills introduced at the state level, however, Grau’s bill looked eerily familiar. His charges — that SB 1848’s abortion restrictions (also known as Targeted Regulations on Abortion Providers, or TRAP, laws), were being introduced to safeguard women’s health — had all been seen before. The language in the bill was strikingly similar to “The Abortion Providers’ Privileging Act,” a piece of model legislation introduced by Americans United for Life (AUL), a Washington-based anti-abortion organization that pens and propagates model legislation through ties with conservative legislators. In fact, a ThinkProgress examination found that parts of Grau’s bill were essentially written by AUL; the two are so comparable that in the section of SB 1848 outlining admitting privileges for abortion providers, only ten words from the AUL version are not used. (Oklahoma’s bill, for example, replaces “abortion clinic” with “facility providing abortions,” and “accredited hospital” with “general medical surgical hospital.”)
Not unlike the American Legislative Exchange Council (ALEC), AUL functions as de facto legislation mill for like-minded politicians and on-the-ground anti-abortion activist groups — offering model legislation that, according to its website, “enables legislators to easily introduce bills without needing to research and write the bills themselves.” The organization operates in relative obscurity despite its exceptionally far reach. According to an email obtained by ThinkProgress that was sent to AUL supporters, the group is responsible for one third (74) of the 200-plus anti-abortion laws that have passed since 2010. Elizabeth Nash, a Public Policy Associate at the Guttmacher Institute, says that 231 abortion restrictions were enacted between 2011 and 2014, which is nearly 20 percent more than what was seen in the entire decade before.
One such AUL-inspired law is Texas’s notorious House Bill Two (HB2), which has shuttered clinics and pushed women into the black market to buy abortion-inducing drugs. HB2, signed into law by AUL ally Rick Perry in 2013, belongs to a family of anti-abortion legislation called TRAP laws, which place burdensome restrictions on abortion centers and providers. These regulations, which have risen in popularity since 2010, have also found their way into AUL model legislation: A ThinkProgress examination found a handful of state TRAP bills that used AUL language in 2014 alone — Arizona, Illinois, New Hampshire, and West Virginia, for example, copied and pasted nearly every word of AUL’s admitting privileges requirement into their proposed legislation.
Despite medical evidence to the contrary, AUL’s role in shifting the abortion debate to a “death by 1000 cuts” strategy has proven effective. AUL employs a strategic brand of messaging that differentiates it from the openly religious fire-and-brimstone anti-abortion groups of the past. The organization packages its agenda with intentionally soft language about protecting women’s health, which some say has helped the group maintain a relatively low profile in spite of the scope of its influence. “The semantics display a retreat from extremism,” says Carol Joffe, a professor at the Bixby Center for Global Reproductive Health at the University of California, San Francisco. “One could argue they won by defanging the war on women.”
AUL’s Successful Anti-Abortion Campaign By The Numbers
That Grau’s bill so blatantly overlapped with AUL’s was no surprise to Hayley Smith, Associate Advocacy and Policy Counsel of the ACLU who tracks anti-abortion state policy. “If you look at it, word for word, there are small differences but it is nearly the same. You can put them side-by-side, and even where they put the parenthesis is nearly exact. So it’s clear that there was copy and paste into bill form and insert Oklahoma, and it’s coming from someplace outside of Oklahoma, because the language is so similar.” Smith elaborated: “When you see a bill introduced in one state, and then you see a bill introduced across the country, and the language looks nearly exactly the same, you realize: Oh, this is all coming from the same base” — Americans United for Life — “and the intent is the same underlying each.”
In 2014, AUL consulted with legislators on 74 anti-abortion measures in 32 states, and was the driving force behind 11 anti-abortion laws; providing model legislation for states in Alaska, Arizona, Georgia, Mississippi, Oklahoma, and Nebraska. In 2013, it was behind 16 anti-abortion bills and worked in 31 states; in 2011, AUL consulted on and provided model language for 28 state laws. The annual AUL report in 2013 found that 35 states “made progress in defending life” in 2013, and in 2012 AUL was the driving force behind 19 anti-abortion laws.
An analysis by ThinkProgress reveals at least 13 bills that have been introduced on the state level have used language that is similar to AUL’s admitting privileges provisions, which have dealt a blow to abortion clinics across the country. SB 1848, for example, co-sponsored by Grau and signed into law by Oklahoma Governor Mary Fallin (R) last May, was recently put on hold after the Center for Reproductive Rights filed an emergency appeal with the Oklahoma Supreme Court.
CREDIT: ThinkProgress/ Andrew Breiner
Grau has been vocal about his relationship with AUL in the past. In 2011, he co-sponsored HB 1970, a bill drafted with AUL requiring abortion providers to follow the Food and Drug Administration’s outdated guidelines for medication abortions; in 2013, he co-sponsored HB 1361, a parental notification law based on AUL model legislation; and in 2014, he co-sponsored HB 2684, a follow-up to AUL-sponsored HB 1970.
The Oklahoma representative’s rhetorical strategy on the House floor is similar to AUL’s. The organization doesn’t deal in bullets and blood-soaked posters. Instead, it wraps its anti-abortion agenda in language about protecting women’s health — an emphasis on the mother rather than on the fetus — which, though not based on any real medical need or data, has proven to be remarkably effective.
“They’re trying to position themselves as these defenders of women’s health and safety,” says Amanda Allen, State Legislative Counsel at the Center for Reproductive Rights. “But these are measures that are coming from a national anti-abortion advocacy group that are really designed to close clinics in the state, under the bogus claim that they would protect women’s health and safety.”
The success of AUL’s framing can be traced back to its dynamic President and CEO, Charmaine Yoest, formerly of Mike Huckabee’s failed presidential campaign and The Family Research Council (deemed a hate group by the Southern Poverty Law Center). A soft-spoken mother of five with a polished brown bob, Yoest distances AUL from the anti-abortion community’s militant ideologues: She has been profiled across the media for her warm, subtle approach, dubbed “charismatic,” “especially good at sounding reasonable rather than extreme,” and the movement’s “kinder, gentler face.” But it is much more calculated than that. In a 2011 interview with The National Catholic Register, Yoest equated the organization’s approach to a “military strategy. We don’t make frontal attacks. Never attack where the enemy is strongest. We don’t want to re-create Pickett’s Charge at Gettysburg. We pick our battles. What we do is very much under the radar screen and not very sexy.”
The ALEC Of Abortion
AUL, founded in 1971 by a group conservative Catholics including L. Brent Bozell, is often described as the primary legal arm of the anti-abortion movement. Its goal is to make abortion inaccessible through an approach many call “incrementalism” — blanketing the country in laws and court cases that choke abortion access at the state level — which contrasts an all-or-nothing absolutist strategy pushing to ban abortion outright. Regardless of their tactics, though, AUL and other anti-abortion advocates all have the same end goal: to abolish abortion in the United States. (From the organization’s website: “AUL knows that reversing Roe v. Wade can be accomplished through deliberate, legal strategies that accumulate victories, build momentum, and restore a culture of life.”)
The group has gotten a huge monetary boost from right-wing allies. In 2010, AUL’s legal arm, Americans United for Life Action, received $559,000 from the Center to Protect Patient Rights, a secretive non-profit group linked to the Koch Brothers that has injected nearly two hundred million dollars to in undisclosed donations to right-wing advocacy groups since 2009.
AUL’s Koch connection and collaboration with anti-abortion legislators to pass model legislation has prompted comparison to another bill mill that has come under fire from watchdog organizations: “They are the ALEC of the anti-abortion movement,” says Donna Crane, the Policy Director at NARAL Pro-Choice America. “If you think these ideas to restrict abortion are spontaneously coming to the hearts and mind of legislators across the country, think again. It’s all part of a very coordinated effort state-by-state to deny women their rights.”
The two groups have a symbiotic relationship. According to Wisconsin Representative Chris Taylor (D-Madison), AUL has been spotted at a series of ALEC conferences and policy summits, where it hands out copies of model legislation plucked from its crowning glory, a 400-plus-page book of anti-abortion sample bills called “Defending Life.” Rick Perry, who signed Texas’s AUL-inspired HB2 in 2013, penned the book’s introduction: “AUL plays a key role in developing and promoting legislation in all 50 states, legislation crafted to minimize the damage done by the abortion industry and its proponents,” he gushes.
Perry should know about the impacts of abortion restrictions. Last March, a group gathered outside the Whole Woman’s Health Clinic in McAllen, Texas, mourning the closure of the Rio Grande Valley’s last abortion clinic with a candlelight vigil. The clinic (which has since reopened temporarily) was barred from providing abortions after HB2, Texas’s omnibus abortion bill, went into effect.
For Women’s Health?
The Texas law, among other things, requires abortion providers to have hospital admitting privileges at clinics within 30 miles of where they practice and mandates that abortion clinics comply with ambulatory surgical center requirements. It has fallen heavily on the shoulders of low-income and undocumented women, many of whom can’t afford to travel across hundreds of miles and through internal border checkpoints to the nearest abortion clinic. Despite evidence that the restrictions will negatively impact Texas women’s health (forcing them into later term abortions which run a higher risk of complication) AUL has publicly claimed responsibility for the law.
Daniel Grossman, a gynecologist and Vice President of research at Ibis Reproductive Health, analyzed the impact of HB2 with the Texas Policy Evaluation Project. He says that the law will likely lead to an increase in DIY, or do-it-yourself, abortions. “We’re definitely seeing that women are attempting to self-induce abortions. They’re using herbs, medications, injections sometimes they get in Mexico, as well as hitting themselves in the stomach and throwing themselves down the stairs.”
Though unsupervised self-induced abortions carry significant risks, legal abortion is one of the safest medical procedures in the United States: A woman is 14 times more likely to die from giving childbirth than getting an abortion. More than 90 percent of abortions in the United States are performed in an outpatient setting, and less than .3 percent of abortion patients in the U.S. experience complications requiring hospitalization. In fact, surgical abortion has a complication rate comparable to other routine procedures performed in a doctor’s office, like dental extractions, vasectomies, endometrial biopsies and gastrointestinal endoscopies. On the rare occasion that an abortion-related complication does arise prior to 16 weeks of pregnancy, it can almost always be safely managed in an outpatient clinic.
From 2000-2009, the abortion-related mortality rate in the United States was 0.7 per 100,000 abortions — which was lower than the mortality rate for plastic and dental procedures. During the same time period, the mortality risk for abortion was equal to the traffic and marathon fatality rate in the US. The mortality rate for RAGBRAI bike racing is more than four times the abortion mortality rate, and, according to CDC data, the risk of death from a penicillin injection is twice that of abortion.
“But you don’t see any moves to make a penicillin shot only given in an ambulatory surgical center,” says David Grimes, a Clinical Professor in the Department of Obstetrics and Gynecology at the University of North Carolina School of Medicine. In North Carolina, he added, more people die in dentists’ chairs than in abortion clinics, but politicians are mum on TRAP-inspired dentistry regulations. “This clearly shows the state legislatures not being concerned about safety. There are all these public health problems they’re ignoring. They’re attacking one of the safest procedures in medicine because they don’t like it.”
AUL’s Chosen Facts
Like the big tobacco and climate denial industry, a crucial link in the legislation of anti-abortion measures is the establishment of an alternative set of scientific literature — unencumbered by the rules of evidence and standards of truth that define legitimate medical science — and insistence that data published by organizations such as the Centers for Disease Control (CDC) and World Health Organization (WHO), is inaccurate.
AUL has actively participated in this process. Like many anti-abortion organizations pushing TRAP laws, it rejects research from physicians about the impact of clinic and provider restrictions, and instead refers to internal “medical experts.” AUL’s Senior Counsel, Clarke Forsythe, for example, authored a paper called “A Fact Ignored by the WHO” with John Thorp, a North Carolina-based gynecologist whose testimonies have been used to defend admitting privileges laws. AUL’s model legislation cites research by Thorp, who served as a witness in anti-abortion cases in Alabama. Alaska, Arizona, Indiana, Mississippi, North Carolina, North Dakota, Texas, and Wisconsin, and was recently discredited by a federal judge in Alabama’s admitting privilege litigation for having “disturbing apathy toward the accuracy of his testimony.” The organization’s use of Thorp’s research “shows that they’re not grounded in science and medicine and women’s health, says Smith of the ACLU. “They’re grounded in politics and bias.”
AUL’s model legislation also cites anti-abortion advocate David Reardon’s research. Reardon received a degree in biomedical ethics from Pacific Western University in Hawaii, an unaccredited diploma mill that was shut down in 2006 and forced to pay half a million dollars in fines. Reardon’s theory that abortion causes clinical mental problems has been rejected by C. Everett Koop, Ronald Reagan’s Surgeon General and the American Psychological Association, and his research has been widely criticized by the British Journal of Psychology, and critiqued by UC Santa Barbara psychology faculty, to name a few.
Similarly, AUL routinely refers to Charmaine Yoest as a “Dr” — but she does not have any medical expertise. Instead, she holds a Ph.D. in philosophy of government from the University of Virginia. In fact, there appears to be just one M.D. on AUL’s Board of Directors and Board of Advisors combined — Dr. Monique V. Chireau. Her claim, that abortion causes mental health issues, has been refuted by the American Psychological Association; and in a July 2014 testimony against the Women’s Health Protection Act, Chireau cited research that has been challenged by the British Journal of Psychiatry for failing “to state obvious conflicts of interests and follow well-accepted scientific standards for the conduct and reporting of systematic reviews and meta-analyses.”
Because Chireau appears to be the only doctor on AUL’s staff, Board of Advisors, and Board of Directors, ThinkProgress contacted AUL for comment on the number of physicians that work with AUL to draft model legislation. A spokesperson from the organization replied in an email: “I don’t know that numbers of physicians per model bill is a rubric available,” adding that, “AUL talks with a wide network of specialist (sic) to ensure the best possible product.”
An Effective Strategy With Political Backing
However, medical experts find AUL’s abortion provisions troublesome. ThinkProgress reviewed sections seven and eight of AUL’s “Women’s Health Protection Act” with Grimes, who flagged more than 20 of the organization’s suggested administrative rules for abortion clinics. These included: rules requiring private procedure rooms for abortion clinic’s physical facilities; rules related to medical screening of abortion patients; rules requiring standards that conform to obstetric standards; rules outlining the use of appropriate precautions, including the establishment of intravenous access for patients undergoing second or third trimester abortions, and many more.
ThinkProgress also asked AUL for comment on objections from physicians that HB2’s provisions have crippled women’s access to reproductive services and haven’t impacted the safety of abortion in the state. “Abortion advocates routinely oppose health and safety standards for women,” AUL responded. “However, no case more clearly illustrates the need for them as the ‘ House of Horrors’ abortion clinic that was operated by Dr. Kermit Gosnell. It is appalling that women receive one standard of care for a breast biopsy but are left to the tender mercies of whatever an abortionist want to offer when the surgery is abortion.” However, Gosnell’s medical failures were already contrary to existing health care standards. What he did — performing abortions after 24 weeks, snipping babies’ necks, utilizing unlicensed employees — was illegal already and has no connection to the restrictions placed by AUL’s legislation.
The wave of abortion restrictions can be traced back to the results of the 2010 elections, which welcomed a new wave of Tea Party anti-choice Republican legislators. “Part of it is the coming together of conservative legislators and local organizations and model legislation at the right time,” she says. “The legislators wouldn’t be able to adopt these restrictions if the ideas weren’t available and there weren’t organizations on the ground willing to pursue them. You need all three pieces for it to work. It’s crazy.”
AUL’s admitting privileges and clinic standards requirements are both TRAP laws, which have been stunningly effective at shutting down abortion access on the state level. In the past decade, the number of states with TRAP restrictions has more than doubled: 27 states now have some type of TRAP law (up from 11 in 2000), and nearly 60 percent of women in the country of reproductive age now live in states with TRAP laws. As of this November, 22 states require that abortion clinics meet ambulatory surgical center requirements, and 14 require abortion providers to have admitting privileges (or an agreement with another physician who has admitting privileges) at a local hospital.
TRAP laws are designed to make as difficult as possible for women to access legal abortion services even though the procedure is still federally protected. They are dangerous precisely because they’re meant to sound reasonable, says Susan Berke Fogel, the Director of Reproductive Health at the National Health Law Program. “How many people really understand what it means to have hospital admitting privileges? Most people think, ‘that’s a very standard thing,’ and if a doctor has admitting privileges that that is somehow a mark of professionalism. Instead, it’s very common for doctors not to have admitting privileges at any particular hospital.”
Other TRAP restrictions — like hallway width and doorway requirements — are also medically unnecessary, says Grimes. “When I was at the CDC one of my jobs was to study every abortion-related death in the country, and I can say with certainty that there’s never been a woman who died in the US from an inadequate doorway in an abortion clinic. This is really a perversion of public health practice. The way public health works is that you identify a problem, you develop a solution, you implement the solution, and you monitor the effect. What you’re seeing is a brisk legislative response to a non-problem. “