In Republican-controlled state legislatures across the country, more than 100 anti-choice bills have been introduced this year. But no state has seen as many of these bills as Missouri, where Republican lawmakers are simultaneously resisting an expansion of Medicaid expansion that could improve health outcomes for hundreds of thousands of residents.

Republican lawmakers in the state have introduced at least 32 bills this year that would restrict access to reproductive health care, often justifying the regulations as protecting women’s health. The bills appear to be part of a coordinated strategy between GOP legislators and anti-choice organizations. “We’re looking to pass at least a couple [bills], if not more,” Susan Klein, the top lobbyist for Missouri Right to Life, told the Washington Post earlier this month. According to Klein, the lawmakers’ plan is to introduce individual bills with specific regulations, as opposed to omnibus bills, like the one passed last summer in Texas.

Angie Postal, director of public policy at Planned Parenthood of the St. Louis Region and Southwest Missouri, told Rewire that the amount of anti-choice legislation in the state is troubling. “What’s concerning is that they have already done so much this session, and the session is only really now half over,” she said. “They’ve spent so much time already debating abortion on the floor of both chambers that it’s hard to say which ones are going to pass, because there are so many options for [the lawmakers].”

The anti-choice legislation that’s progressed the furthest this session would require women to wait 72 hours before receiving an abortion, up from the 24 hours they are already required to wait. HB 1307 and HB 1313, sponsored by Reps. Kevin Elmer (R-Nixa) and Keith Frederick (R-Rolla), were both passed by committee, but HB 1307 has been passed by the house and introduced into the senate. SB 519, sponsored by Sen. David Sater (R-Cassville), has already passed committee and awaits a floor vote.

“This bills are going to make it harder for women to access safe abortion,” said Postal, who noted that the extended waiting period would create a barrier to abortion access for many women, not just in Missouri, but in surrounding states. “Many of our patients come, not just from all over Missouri, but from states surrounding Missouri. Some women are traveling hundreds of miles to get here,” she said. “Essentially we’re seeing women who are facing challenges accessing abortion care due to travel considerations, scheduling child care, and taking time off work. Doing that over a three-day period is just going to force the procedure later in pregnancy, and that poses a senseless risk to women’s health.”

Increasing the waiting period for abortions is a priority for Republicans in the state, who appear ready to use unconventional tactics to pass the legislation. The Republican leader in the senate, Ron Richard, reportedly said members of his party would attempt to use procedural legislative tactics to force a vote on extending the waiting period. 

Another bill that has reproductive rights advocates concerned would force women to view an ultrasound before having an abortion. It is already required that women receive an ultrasound at least 24 hours prior to terminating a pregnancy. HB 1148 and HB 1379, sponsored by Reps. Ron Hicks (R-St. Charles County) and Chuck Gatschenberger (R-Lake St. Louis), require the abortion provider to “review the ultrasound with the woman.” If the woman views the ultrasound in another facility, she must provide the abortion provider with written verification that it was conducted and viewed. The legislation does include exceptions for victims of rape or incest. Both bills are currently pending in the house Health Care Policy Committee. 

“We believe a woman should be informed of all her options, and given accurate medical and science based information about all those options,” said Postal. “That information should be given to a woman to help her make the best decision for herself, and not to coerce her into having an abortion or not having an abortion.”

There are a litany of other bills making their way through the legislature that would regulate reproductive health care in the state, which already has a highly restrictive regulatory regime on abortion care. For instance, lawmakers are considering a ban on the use of telemedicine to prescribe medication abortion, and restricting both private and public health insurance plans from covering abortions except in cases of medical emergencies. 

There are two bills, one that has passed committee and one awaiting a committee hearing, that would change the definition of medical emergency, removing “psychological or emotional conditions.” A ban on sex-selective abortions, much like the bill that was recently passed by the South Dakota legislature, is awaiting a committee hearing. Another bill awaiting a committee hearing would ban abortions performed for the purpose of providing fetal organs or tissue for medical transplantation. In addition, there are two bills, one of which passed committee and another that has passed the house and been introduced in the senate, that would change the parental notification requirement for minors seeking an abortion requiring that both parents be notified (with an exception for parents who have been convicted of abuse or who currently are restrained by a protective order).

Postal says Republicans have spent so much time attempting to restrict abortion in the state that measures that could expand access to health care for all state residents have been neglected. “We think they should spend time trying to pass a Medicaid expansion, something that would actually improve the health of people in Missouri,” she said.

Missouri Republicans have blocked the expansion of Medicaid under the Affordable Care Act. In February, the state senate voted 23 to 9 against expanding Medicaid, which would have reportedly extended health care coverage to 300,000 residents. This week, Republicans in the senate reaffirmed their opposition to expanding Medicaid, even as the Missouri Hospital Association and business leaders called for the expansion.

A study release by the Commonwealth Fund this week finds that many of the states that have refused to expand Medicaid coverage, mostly with Republican-controlled legislatures, would stand to benefit the most from expanded access.

And a report from the Missouri Health Advocacy Alliance predicts that Medicaid expansion would “improve access to health care and health outcomes for nearly 260,000 low-income Missourians who are currently left out of Missouri Medicaid.”

Postal says that some of the same lawmakers who are pushing anti-choice legislation are also blocking the expansion of Medicaid in the state. “These are the same people that really really don’t want to talk about Medicaid expansion, which the people now really want in Missouri,” she said. “They think that maybe if they talk about abortion, some more people won’t notice that we’re leaving behind more than 260,000 Missourians who need health care.”