This spring, Montana enacted four major abortion restrictions, which might sound unsurprising to outsiders who see Montana as a solid red state, but these were the first successful anti-abortion laws here in nearly a decade.

Republicans in Montana are moving farther to the right, and they appear eager to bring their Mountain West state’s abortion laws more in line with those seen across the Midwest and South. If allowed to go into effect, the new restrictions will force rural Montanans to drive up to nine hours to reach clinics rather than receiving care via telemedicine, and could send some as far away as Washington state for abortions later in pregnancy.

Before Montana Gov. Greg Gianforte signed these laws—including a ban on abortion after 20 weeks, a requirement that providers offer patients the choice to view an ultrasound, a ban on insurance coverage of abortion in marketplace plans, and a slew of new restrictions on medication abortion—Montana had only one major abortion restriction, a post-viability ban, in effect. Three of the four new restrictions are blocked by court order thanks to a legal challenge brought by Planned Parenthood of Montana (PPMT). Only the ban on marketplace insurance coverage is in effect.

If abortion were banned after 20 weeks, for most Montanans, the nearest providers offering care at that point in pregnancy would be in Washington. But many in Montana already live a day’s drive away from their nearest clinic.

“Montana is a huge state. It’s covered with mountains, and mountain passes that can be snowbound in the winter,” Helen Weems, a nurse practitioner and the founder and director of All Families Healthcare in Whitefish, told Rewire News Group. (In addition to All Families, there is another independent abortion provider in Missoula, Blue Mountain Clinic. And PPMT operates five clinics within Montana.)

“All our abortion clinics are concentrated in the more populous western side of the state,” Weems said. “Folks living on the eastern front could be forced to drive seven or eight hours one way to reach the nearest abortion clinic.”

The attack on medication abortion, then, is no surprise. Montana conservatives know that telemedicine is a lifeline for abortion access in their state. The medication abortion restrictions they enacted include an outright telemedicine ban and require an ultrasound at least 24 hours before pills are dispensed, as well as an in-person follow-up. This takes medication abortion, which can safely be done entirely via telemedicine, and turns it into an onerous process involving three in-person visits. The law also includes extensive new reporting requirements for medication abortion, and bans “providing abortion-inducing drugs at elementary, secondary, and postsecondary schools.”

Weems said she began offering medication abortion via telemedicine as soon as the FDA relaxed regulations during the pandemic. PPMT has been offering telemedicine abortions for even longer, by mail as part of the Gynuity TelAbortion study and through a site-to-site telemedicine model. With site-to-site telemedicine, patients still come to a health center in person, where they’re connected remotely with a doctor or nurse practitioner at a different clinic. This allows a single provider to reach patients across multiple locations.

Since the start of the pandemic, “we’ve seen a huge spike in the number of medication abortions by telemedicine. We’ve seen a huge growth in medication abortion generally,” said Martha Stahl, PPMT’s president and CEO. From July 1, 2020, through June 30, 2021, 78 percent of the abortions PPMT provided were medication abortions. Nationally, only about 39 percent of abortions are done by medication. Of these medication abortions provided by PPMT, 76 percent were accessed via telehealth—20 percent of these involved mailing pills to patients, and 80 percent were done between PPMT health centers using site-to-site telemedicine.

“We actually looked at how far our patients would have had to travel if they hadn’t been able to access their abortions via teleheath,” Stahl said. “Currently, our abortion patients are typically traveling about 90 minutes. If this law had been in effect, requiring patients to come in person for three visits, these patients would have had to travel an average of nine hours.” Stahl said the state of Montana notified PPMT that it plans to appeal the court order blocking the restrictions. PPMT hopes the case will be able to move forward in lower courts while the Montana Supreme Court considers this appeal.

So what is driving this rightward turn in Montana? The biggest change was the election of Gianforte, a Republican, in 2020. For the previous 16 years, Montana had Democratic governors.

“They would pass abortion restrictions in the legislature almost every year,” Stahl said. “But the governor would always veto them. We used to talk about the governor as the goalie.”

Rep. Mary Ann Dunwell, a Democratic member of Montana’s House of Representatives, said she has seen significant political changes in the state since she was elected in 2014.

“I think it’s the influence across the country of extreme, regressive right-wing Republicans,” she said. “Republicans in Montana weren’t that extreme. But many have fallen victim to the Trump influence, and this national movement toward restricting freedoms like reproductive rights, voting rights, and public health protections.”

In a recent report, the Guttmacher Institute identified Montana as a state likely to ban abortion should the Supreme Court overturn or significantly weaken Roe v. Wade. If this were to happen, the closest abortion provider for 74 percent of Montanans would be in Washington, and for the other 26 percent, in Colorado. The average one-way driving distance to a clinic would increase by 1,640 percent, from 22 miles to 384 miles.

Dunwell knows how high the stakes are here. “For the first time ever, I recently made public that when I was in my 20s, I had an abortion,” she said. “I was living in Louisiana then, and at the time, you couldn’t get an abortion there. You had to drive to Texas. I had to drive myself four hours each way. It was shaming, and frankly it was dangerous to get in the car and drive back. No one should have to do that.”

While Stahl is certainly concerned about post-Roe possibilities, she said Montana has a few key things working in its favor. First, the state legislature only meets every other year, and won’t be back in session until 2023 barring any special sessions.

“We also have a very strong constitutional right to privacy, and case law has applied that right to privacy to the right to have an abortion,” Stahl said. On this basis, Montana courts have invalidated abortion restrictions including a parental notification requirement for minors, a 24-hour waiting period, biased state-mandated counseling, and a physician-only law.

However, the Montana Supreme Court is elected. “For now we are in a good position,” Stahl said. “But elections matter.”

In the meantime, Montana abortion providers continue to provide care, including via telehealth.

“How do we feel? Beleaguered. What are we going to do about it? Keep on fighting,” Weems said. “These laws do not represent the will of the majority.”