The confirmation of conservative Brett Kavanaugh to the Supreme Court has raised fears that Roe v. Wade could be undercut or even overturned. In fact, abortion access has been under attack for decades by restrictive state laws and regulations (more than a thousand restrictions have been passed since Roe, almost a third of them between 2010 and 2016).
But Charlottesville’s Amy Hagstrom Miller is fighting back. As the lead plaintiff in Whole Woman’s Health v. Hellerstedt, she helped secure a crucial victory against abortion restrictions in Texas, which has since been used in at least 12 other states. Now, she’s challenging similar restrictions in Virginia. Being a plaintiff, she says, serves her broader mission: to eliminate the stigma and shame surrounding abortion. On that front, she says, “I’m a ninja.”
Hagstrom Miller is founder, president, and CEO of Whole Woman’s Health LLC, which operates seven abortion clinics in Texas, Maryland, Illinois, and Missouri as well as its newest clinic in Charlottesville. Most provide comprehensive gynecological care in addition to abortion services. Whole Woman’s Health is “committed to providing holistic care for women,” says its website, and the design of its clinics and offices make that stance clear: Walls are painted a soft lilac, clinic rooms are named for notable women (including Heather Heyer), and empowering quotes from Rosa Parks, Frida Kahlo, Eleanor Roosevelt, and other influential women are stenciled everywhere.
The Charlottesville clinic is on a quiet, tree-lined street; its waiting room has wood floors, a working fireplace, herbal tea, and purple fleece blankets. But outside, the precautions are evident—the signage is small, the parking lot is hidden behind the building, and entry is controlled by intercom.
Hagstrom Miller, 51, is tall, strongly built, and smartly dressed. She looks like the high school athletic champion she was, and like the national entrepreneur she is. Her square black glasses are stylish, her blond hair is streaked, and her lipstick is bright. Her appearance is part of her work, as she sees it, to take on and take down stereotypes. When she went to hearings in front of Texas legislators, she wore business suits and pearls to counter their preconceived ideas about “abortionists.” Now a nationally known advocate, she continues to spend time in her Charlottesville clinic working with patients and staff, making sure that both feel supported.
Amy Hagstrom grew up in Minnesota in the 1970s, in a culture she describes as “Democratic farm and labor, committed to being citizens of the community—supporting bike trails, libraries, things like that.” Her upbringing was “traditional, progressive Christian/Presbyterian.” She calls herself part of the Title IX generation, because that landmark support for girls’ athletics gave Hagstrom, the youngest of five children, an outlet her two older sisters didn’t have. Participating in sports—Nordic skiing and both competitive and synchronized swimming—enabled her to recognize her personal strength and competitive drive; both her teams were state champions.
At Macalester College in St. Paul, Hagstrom began as a religious studies major. A semester abroad in India “changed my psyche and affected my behavior,” she says. Her Indian host mother faced discrimination and disapproval, even from other women, because she was a widow. “One time she went to get her beautiful long hair trimmed,” Hagstrom recalls, “and the hairdresser cut it off in a short bob, without her consent, because the hairdresser felt my Indian mother should have shaved her head after her husband died.” Her university-educated host sister’s plan to marry for love was still viewed as unusual.
“I thought so much about the things I had taken for granted and the paths many of these Indian women were still having to forge,” Hagstrom says. Back at college, she added a major in international studies and women’s issues, doing her thesis on arranged marriage and bride-burning.
In 1989, Hagstrom went to Washington, D.C., for the nation’s first national march to support reproductive rights and counter an increasingly violent anti-abortion movement. (The New York Times tallied over 100 clinic bombings and incidents of arson; over 300 invasions; and over 400 incidents of vandalism at abortion clinics between 1978 and 1993.) After graduation, committed to taking a stand on women’s rights, Hagstrom took a job at Planned Parenthood in St. Paul.
She started as a receptionist, handling eight phone lines and the front desk; soon she was involved in every task in the clinic, as well as assisting an outside physician who performed abortions. She began to see an unintended pregnancy as a crisis point at which a woman confronts an intimately personal choice affecting not only her life but, often, the life of her family. “Abortion and other reproductive decisions are not simply medical matters,” she later wrote. “When a woman makes a decision about her pregnancy and her body, she undergoes an intense evaluation of her beliefs, identity, goals, and dreams for the future.”
She witnessed anti-abortion protesters accosting women right up to the clinic door and shouting taunts and threats at patients as well as clinic staff. “The Jesus I was taught about would be holding the hands of the women inside the clinic,” she has said. “He wouldn’t be screaming at them.”
Hagstrom’s experience at Planned Parenthood solidified her conviction that the abortion debate isn’t really about abortion. “I call abortion ‘the hole in the donut,’” she says. “What’s driving the issue is what’s around that hole”—how our society views a woman’s biological and social role and her right to make her own decisions. She sees anti-abortion activists restricting access to abortion without any concerted effort to reduce the need for it, by providing women (or men) with effective sex education, reproductive counseling, and affordable birth control. One example she cites: In 2009, a grant from billionaire Warren Buffett’s family underwrote low-cost or free IUDs in Colorado’s public health clinics, and over the next eight years the teen pregnancy rate dropped by half and the teen abortion rate by almost two-thirds.
A different approach
Hagstrom married her college boyfriend, Karl Miller, and in 1994 the couple moved to New York City. Karl started graduate work in history at NYU, and Amy got a job at an abortion clinic in the city. It was an eye-opening change.
As a counselor in St. Paul, she had often started with a non-judgmental, open question like “How did you come to be here today?” to allow the woman to acknowledge her feelings about the decision facing her. With her New York patients, the same question elicited very different answers, more like “I got here on the subway. Why?”
In New York, a place with more opportunities and more cultural and religious diversity, women saw ending an unplanned pregnancy as a serious decision, but not as a moral failure, she recalled. Her conclusion: ending the stigma about abortion—and the deliberate shaming of women facing that decision—was central to empowering women to pursue their own dreams, goals, and lives.
Soon, Hagstrom Miller moved into clinic management, the business side of abortion services (what she calls “my M.B.A. time”). Even in New York, she found, getting an abortion was too often a demeaning, impersonal, and non-supportive experience. In addition, limited public funding or health insurance coverage hit low-income and poor women—the majority of those seeking abortions—the hardest. “It was sad,” she remembers, “to see women pawning their possessions to pay for a procedure they needed.” Hagstrom Miller wanted to build her own, holistic approach to providing abortion services. When she was recruited to turn around a struggling abortion clinic in Austin, Texas, in 2003, the couple picked up stakes.
Her husband, who had finished his Ph.D., got a job at the University of Texas at Austin. And Hagstrom Miller set to work revamping the Austin clinic, drawing on her counseling and managerial experience from St. Paul and New York City. She also had the support of a group of high-powered and committed professional women working in reproductive health and social justice, who called themselves “the November Gang.” Formed in November, 1989, the group has been meeting twice a year ever since. They provided Hagstrom Miller with advice on clinic administration, staff development, and finance.
Her new company, Whole Woman’s Health, concentrated on patient service—“everything from how we answered the phones to what the waiting room looked like,” Hagstrom Miller says—and on employee support and empowerment. In the process, she tripled revenue. “I found that I could expand access, improve the quality of counseling, and justify the counseling end to the business people, while keeping our focus on that seminal moment [for the individual woman].”
Her success made Hagstrom Miller the go-to person for abortion providers looking to sell or retire. By 2004, she owned three clinics in Texas, and was actively involved with every patient, she says. Next, she bought a clinic in Maryland, where her role was more to train the manager and staff in the Whole Woman’s Health approach. In the process, she was building a national company and developing her business and employee development skills.
Building her own firm was Hagstrom Miller’s graduate education in finance. “I’ve used every form of financing there is,” she says, “because you can’t get a bank loan as a female abortion provider.” She has built her business using angel investors, seller-financing, and now foundation funding through the Whole Woman’s Health Alliance, a non-profit that owns several of her clinics while Whole Woman’s Health LLC manages them. All her clinics accept Medicaid and health insurance, and work to find funding sources so that no woman is turned away because she can’t pay.
While Hagstrom Miller has become a successful entrepreneur—on the table in her corporate office waiting room are fact sheets about abortion, a copy of House & Garden, and an issue of the Harvard Business Review—her goal is not making money: “What we are providing is the supportive experience,” she says. “I don’t care whether a woman has an abortion [or not], but whatever she decides should be provided with dignity.”
‘I had to litigate’
By 2010, the Hagstrom Miller family’s life was full: Whole Woman’s Health was running six facilities, Karl was making a name for himself as a professor and scholar of American popular music, and the couple had two sons. But at the same time, the Texas legislature was enacting significant restrictions on abortion providers. Clinics around the state were closing. “It became a matter of survival,” Hagstrom Miller says. “I had to litigate.”
Hagstrom Miller’s first lawsuit challenged a Texas law mandating that a woman seeking an abortion undergo an ultrasound first, a requirement with no medical basis. She won in district court in Austin, but lost in the Fifth District circuit court in New Orleans, and decided not to appeal. The experience did, however, open her eyes to how abortion opponents around the country were using state legislatures to undercut Roe. The mandatory ultrasound law she challenged in Texas, for example, was later passed in Virginia and several other states.
In 2013, Hagstrom Miller and pro-bono lawyers from the Center for Reproductive Rights filed Whole Woman’s Health v. Hellerstedt. It challenged Texas law H.B. 2, which required abortion clinics (the majority of which are outpatient facilities) to meet the same regulatory standards as ambulatory surgery centers. The bill’s supporters claimed this was necessary to protect women’s health, but the immediate impact was to force clinics throughout the state to close, including two owned by Whole Woman’s Health. Women were calling in desperation, trying to find a clinic that was still open. In a 2016 interview, Hagstrom Miller recalled, “One woman told us ‘I can’t travel to San Antonio, I have three children, I’m working two jobs—I’m going to tell you what’s in my medicine cabinet and what’s under my sink, can you tell me how to do my own abortion?’ We have many stories like that.”
Sean Mehl, now clinic director at Whole Woman’s Health in Charlottesville, was working at Hagstrom Miller’s clinic in Fort Worth when H.B. 2 went into effect. “Everything was up in the air,” he recalls. “When the law closed us down, we had to call patients to cancel their appointments [for abortion procedures] and we couldn’t reschedule.” When the district court ruled for Whole Woman’s Health and issued an injunction, the clinic re-opened—but no one knew for how long. “We would see as many patients as we could while we could.” Because their San Antonio clinic was attached to an ambulatory surgical center, it could stay open; “we would refer women there, even bring our Fort Worth patients in,” he says. “But Texas is a big state, we couldn’t help everyone.”
Challenging the law had its costs, however. Whole Woman’s Health had to provide the court with more than 10,000 emails and seven years’ worth of clinic documents demonstrating the law’s impact. “The sad thing was that the load of paperwork involved took the best and brightest of my staff off actually helping patients,” Hagstrom Miller says.
Trying to keep clinics open while handling litigation costs left Hagstrom Miller “hugely in debt.” And it made her a public figure, recognized wherever she went. Looking back, she says, “I didn’t know it then, but my husband believed he had to get me out of Texas.”
As an employee at a state university, Karl was also affected by the state’s increasingly conservative government. When the University of Virginia’s McIntire Department of Music recruited Karl in 2014, the family was ready to go. Hagstrom Miller liked Charlottesville’s greenery and changing seasons—“more like Minnesota”—and its university town atmosphere.
For the next two years, while Hagstrom Miller waited on the litigation process, she was living in Charlottesville. “Nobody knew me here—it was surprisingly nice,” she says. “I hadn’t realized how much [the atmosphere in Texas] had affected me. And it was really good for our family.” One day, another mother on a school field trip recognized Hagstrom Miller from the abortion rights documentary Trapped, which the local Planned Parenthood chapter had screened for a fundraiser–without realizing one of the film’s featured advocates was living nearby.
The Whole Woman’s Health decision finally came down on June 27, 2016. The Supreme Court ruled 5-3 that states cannot place restrictions on the delivery of abortion services that create an undue burden on women seeking an abortion. One factor in the decision: Texas’ lawyers maintained the law’s restrictions were intended to protect women’s health, but when questioned could not produce any medical studies or statistics supporting those claims.
Above Hagstrom Miller’s standing desk in her Charlottesville office is a photograph of her on the steps of the Supreme Court that day, beaming against a summer-blue sky. The first thing she did was hold a conference call with her staff and clinic managers in Texas, to tell them of the victory and let them know the clinics would stay open. “It was a very powerful thing, to see my work bear fruit,” she says.
Overturning the Texas law, however, doesn’t automatically wipe away restrictions in other states; each state’s laws have to be challenged in court. “Before, we challenged a law so we could get an injunction to stop it being implemented,” she says. “Now we have the basis to clear out laws based on a new standard.” Whole Woman’s Health has been used to support lawsuits in at least 12 states, including Virginia. Part of Hagstrom Miller’s national strategy is to open clinics in states like Virginia that are classified as “extremely hostile” to abortion rights, so she has standing to bring legal challenges.
In 2016, Hagstrom Miller bought an existing clinic in Charlottesville. Women’s rights groups here and around Virginia were excited. “Virginia women now have an additional option for quality, compassionate, affordable reproductive health care access, and a fierce advocate for women’s dignity and autonomy,” says Anna Scholl, executive director of Earlysville-based Progress Virginia, an advocacy organization promoting progressive policies. While the purchase was part of Hagstrom Miller’s legal strategy, it also allowed her to return at least part-time to clinic services. “I missed the touchstone of working with women,” she says. “And from here, we are within reach for so many underserved women. There’s only one abortion provider south and west of here, in Roanoke; only one in West Virginia; and clinics in North Carolina are closing.”
In June 2018, Whole Woman’s Health and three other abortion providers in Virginia filed a new lawsuit in federal court in Richmond, challenging a range of laws, regulations, and licensing requirements built up over the last 40 years. Tarina Keene, executive director of NARAL Pro-Choice Virginia (not a party to the lawsuit), says, “Having Amy and Whole Woman’s Health in Virginia is really welcome—they are an advocate as well as a provider, and they bring clout.” The lawsuit, Falls Church Medical Center v. Oliver, is set for trial in April 2019.
There are women’s rights advocates and legal strategists who shy away from bringing challenges now that Justice Kavanaugh has been seated. Does Hagstrom Miller have concerns that the Virginia lawsuit, or the ones in Texas and Indiana that Whole Woman’s Health is part of, might provide the Court an opportunity to limit or even overturn Roe?
“Winning at the Supreme Court [with the Texas H.B. 2 challenge] was a long shot,” she points out. “What if we hadn’t brought up our case because we were worried about how [Justice] Kennedy would vote? It’s not just about winning, it’s about the chance to raise the narrative about abortion in this country. Women deserve to be treated with respect and with dignity.”
She recalls the day of the Whole Woman’s Health ruling: “I knew we had won because [Justice] Breyer was reading the decision. And then he kept on reading… and I realized how many states we could help.” And then you see the inner steel of the champion athlete, the social conscience of the Midwestern progressive Christian, the commitment of the woman who came back changed from India: “It’s always the right time,” she says, “to do the right thing.”
The state of abortion laws in Virginia
In 2006, the Guttmacher Institute, a research and policy organization focused on reproductive rights, classified Virginia as one of 19 states “hostile” to abortion rights. The organization identifies states as “supportive/middle-ground/hostile/extremely hostile” based on an analysis of state laws and regulations. At that time, only Ohio and Alabama were classified as “extremely hostile.” By 2016, Virginia had become one of 22 “extremely hostile” states.
The following abortion restrictions are among those on the books in Virginia as of May 2018:
• Health insurance for the state’s public employees covers abortion only in cases of rape, incest, danger to the woman’s life, or fetal impairment.
• Medicaid funding for abortion is only allowed in cases of rape, incest, danger to the woman’s life, or fetal impairment.
• Health plans in the state’s Affordable Care Act health exchange can cover abortion only in cases of rape, incest, or danger to the woman’s life.
• If the woman is a minor (under age 18), her parent must consent and must be notified before the procedure is performed.
• A woman seeking an abortion must be given state-mandated information, including booklets designed to discourage abortion, at least 24 hours (or two hours if she lives more than 100 miles away) before an abortion procedure.
• The “Two-Trip Mandatory Delay Law:” A woman seeking an abortion must undergo an ultrasound at least 24 hours (two hours if she lives more than 100 miles away) before undergoing the procedure; the abortion provider is required to offer her the option to view the ultrasound image.
• Abortions, even those induced by medication, must be performed by a physician, excluding advanced practice clinicians, licensed nurse practitioners, and physician assistants (who are qualified and allowed to perform abortions in many other states).
• Second-trimester abortions must be performed in a facility that meets all the regulatory requirements of a licensed hospital. This law was enacted in 1975, when most second-trimester abortions were performed by inducing premature labor—a procedure now rarely used.
Falls Church Medical Center v. Oliver, scheduled to be heard in April 2019, challenges the last four restrictions cited above.
In addition to these barriers, as of 2014 roughly 92 percent of Virginia counties did not have a single clinic providing abortion services.