THE CULTURE WARS ARE A ROUT:

In the 1970s anti-abortion attorneys formed a decadeslong plan to craft and lobby for state regulations that would gradually strip away physicians' ability to provide the procedure. Much of the legislation makes it more expensive for clinics to operate, and the strategy has proved effective. Since 2011 at least 162 abortion providers have closed or stopped performing abortions, and 21 clinics have opened. That represents the swiftest annual decline in the number of abortion providers ever, according to Bloomberg News. Burkhart is working to start another clinic, in Oklahoma City, which she estimates will cost $1 million. No one has opened an abortion clinic in Oklahoma since 1974.

In 1976, Congress passed the Hyde Amendment restricting the use of federal funds for abortion, which Americans United for Life helped defend before the Supreme Court in 1980. In 33 states, Medicaid can't be used to cover the procedure in most circumstances. Recent polling finds that almost half of women who obtain abortions live below the federal poverty line. Meanwhile, 10 states, including Kansas and Oklahoma, ban all insurance plans--and 25 states restrict government marketplace plans--from covering abortion except in rare circumstances. With a large share of women, including the poorest patients, paying out of pocket, many abortion providers keep their prices low. "What you're doing is--as much as you can--not pricing people out of getting this service," says David Burkons, a physician who opened a clinic in Ohio last year.

Clinic directors say the political climate has made it almost impossible to open clinics. "You'd think, This is crazy," says Amy Hagstrom Miller, founder and chief executive officer of Whole Woman's Health, which has acquired or opened clinics in five states since 2003. She's the plaintiff in the coming Supreme Court case over abortion laws that have shuttered two of her five Texas locations. Arguments begin on March 2. The extra costs she and other providers face are at the heart of the case: The decision will largely come down to whether the justices think the laws have made it too expensive for clinics to operate--and to what extent that burdens patients. Says Hagstrom Miller: "This is probably the most difficult business you could ever run."

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