Abortion rights could be in jeopardy following the death of Supreme Court Justice Ruth Bader Ginsburg last week.

The liberal stalwart was a critical vote against bids to gut access to the procedure, and now President Trump and Senate Republicans are considering replacing her on the bench with a judicial opposite.

If they follow through, the resulting 6-3 conservative majority could feasibly overturn Roe v. Wade, the 1973 decision that first established a constitutional right to abortion.

And if that happens, Missourians would see two things follow: a big change on paper and more of the same on the ground.

Pulling the trigger

The big change on paper would happen in Jefferson City.

House Bill 126, which the legislature passed and Gov. Mike Parson signed into law last year, got a lot of attention for its provision banning most abortions at eight weeks of pregnancy.

But it also contains a provision known as a “trigger law" banning all abortions except in cases of medical emergency, which could take effect after a favorable court ruling.

Sam Lee, the director of Campaign Life Missouri, said there are three ways to activate that trigger.

The governor could issue a proclamation, the attorney general could issue an opinion, or the legislature could pass a resolution.

That could be complicated in the event the current governor and attorney general, both anti-abortion Republicans, are defeated and replaced by Democrats this fall.

But it’s virtually certain Republicans will return their majorities in the legislature, and they’ll include many of the same representatives who voted to pass the trigger ban in the first place.

The legislature might have to wait a while if they end up out of session when a ruling comes down and a Democratic governor refuses to call them back for a special session. But the January-May regular session would come eventually.

Once the trigger is activated, anyone performing an abortion from then on could be charged with a high-grade felony and stripped of any professional licenses they hold.

They could successfully defend themselves by proving they performed an abortion on a woman having a medical emergency, defined as “a condition (that) necessitate(s) the immediate abortion of her pregnancy to avert the death of the pregnant woman or for which a delay will create a serious risk of substantial and irreversible physical impairment of a major bodily function of the pregnant woman.”

(The law bars prosecution of a woman who has the abortion performed on her for conspiring to break the law, however.)

That may not necessarily be the end of the fight.

Abortion-rights supporters would still be free to sue over the move and challenge Republicans’ procedure in Missouri or their interpretation of a hypothetical Supreme Court decision. A judge could put a halt on all those changes and maintain the status quo while considering the challenge; if abortion rights supporters won, they could potentially prompt yet around round of legislation that could also be litigated.

But if not, Jesse Lawder, a spokesperson at Planned Parenthood of St. Louis and Southwest Missouri, said abortion services at the state’s lone provider in St. Louis would cease.

Women seeking abortion in emergency situations would likely get one in a hospital rather than Planned Parenthood’s outpatient center, he said.

On the ground

But here’s the other thing: many Missouri patients seeking an abortion won’t notice much of a difference.

They might see the headlines as politicians here and in other states use a favorable ruling to formally abolish the procedure.

But people on both sides of the issue have said that's almost the case already here. Missouri officials have spent years enacting and enforcing some of the strictest regulations on abortion providers in the country, pushing the number of clinics down from five in 2004 to the one in St. Louis in 2018.

It also knocked out “pill abortion” services at the remaining clinic by requiring pelvic exams before the medication can be administered, which Planned Parenthood says is medically unnecessary and impossible to perform ethically.

That means that for virtually anyone outside St. Louis, getting an abortion in a Missouri clinic already requires reliable transportation in addition to free time for an appointment and the procedure, which must take place at least 72 hours apart.

At the same time, abortion rights have been strengthened in Kansas and Illinois, allowing thousands of Missourians to continue receiving abortions at clinics across the borders each year.

The overall number of Missourians seeking abortions has declined in recent years by some measures, with each side of the issue citing its own reasons for the reduction.

Lee, the anti-abortion lobbyist, credits Republican leaders for building up a “culture of life” in the state and offering more resources to "alternatives to abortion" facilities in addition to the restrictions that reduced the number of abortion providers.

Lawder, the Planned Parenthood spokesman, said easier access to birth control under the Affordable Care Act is playing a role.

But a look at patient numbers at clinics in Illinois makes clear that thousands of Missourians are still seeking abortions by crossing the river.

Planned Parenthood data show that as the number of patients coming to the St. Louis clinic has plunged in the past four years, the number going to its clinic across the Mississippi River in Illinois has increased substantially.

When Missouri Gov. Mike Parson, a Republican, boasted in February that the St. Louis clinic performed fewer than 1,400 abortions in 2019 and had “seven” two months into 2020, he wasn’t far off — it was 12 at the end of February.

But more than 630 Missourians had been treated in Fairview Heights, Illinois, 20 minutes away, in the same time period.

Alison Dreith, the deputy director at Hope Clinic for Women in nearby Granite City, Illinois, said her center has also seen a rising number of Missouri patients in recent years. 

And that’s not expected to change.

Illinois passed a landmark abortion rights bill last year that Gov. J.B. Pritzker said "ensures that women's rights in Illinois do not hinge on the fate of Roe v. Wade, or the whims of an increasingly conservative Supreme Court in Washington."

And to the west, the Kansas Supreme Court ruled that its state constitution provided a right to abortionseparate from Roe v. Wade, and a legislative bid to change that fizzled in February.

Given those options, a Middlebury College analysis projected that the number of abortions in Missouri would decline by just 2.8 percent in a post-Roe world. That compared to an expected  29.8 percent decrease in abortions among people in Arkansas, which like Missouri has a trigger law but is also surrounded by other states likely to enact bans.

Similarly, researchers estimated the drive from a place like Greene County to the nearest clinic in the Kansas City suburbs would increase by 20 miles to 160 miles, a 14 percent increase. That pales in comparison to the expected shift for patients in states like Louisiana, Arkansas and Texas.

The lines might be longer in Kansas and Illinois once they arrive, though.

If other states considered likely to ban abortion do so, patients living in a large swath of the South and Appalachia could soon be joining Missourians there.

And Dreith, the deputy director of Hope Clinic, said she's already seen it this year as states considered shutdowns amid the pandemic.

“We were seeing an increase in patients traveling to us from Texas, Louisiana and Arkansas,” she said. “People are just having to face additional barriers.”

Austin Huguelet is the News-Leader's politics reporter. Got something he should know? Have a question? Call him at 417-403-8096 or email him at ahuguelet@news-leader.com. You can also support local journalism atNews-Leader.com/subscribe.