Grassroots activists believe that high-altitude advocacy is taking precedence over helping patients access care.

Even in a post-Citizens United world, it is difficult to comprehend just how much money Democrats spent on their losses in the 2024 elections. In the Ohio Senate race, Sherrod Brown’s campaign committee burned through eighty-eight million dollars, outspending the winner by four to one. Jon Tester, of Montana, put up similarly lopsided numbers in surrendering his Senate seat. Kamala Harris’s attempt at the Presidency cost around one and a half billion dollars, including at least a half billion on media buys and production and tens of millions to outfits such as the digital-media firm Gambit Strategies (from its Web site: “No one has overseen more spending on digital persuasion, mobilization, and issue advocacy programs than us in the Democratic Party since 2016”). And the political-action committee Floridians Protecting Freedom spent at least a hundred and nine million dollars on its failed campaign for Amendment 4, which marked the first time an abortion-rights ballot measure has failed at the polls since the Supreme Court overturned Roe v. Wade, two years ago.

The amendment, which would have enshrined the right to abortion in Florida’s state constitution, had strong backing from advocacy heavyweights such as Planned Parenthood and the American Civil Liberties Union. But the Republican governor of Florida, Ron DeSantis, used millions of taxpayer dollars and state G.O.P. funds to run public-service announcements and ads against Amendment 4, which needed sixty per cent of the vote to pass. The final count was fifty-seven per cent in favor to forty-three per cent against, which means that, despite majority support for reproductive rights, Florida will continue under a six-week ban.

Anna Hochkammer is the executive director of the Florida Women’s Freedom Coalition, which gave more than half a million dollars to Floridians Protecting Freedom. “Forty-three per cent is getting your ass handed to you,” she said of the amendment’s opponents. But, she went on, “there are no moral victories in politics—you win or you lose, it doesn’t matter by how much or how little. We lost, and there are consequences to losing. My great concern is that millions of women and girls in the state will be seriously harmed under this abortion ban, and we didn’t fix it, and it’s a heavy load to bear.”

Until recently, Hochkammer was a board member of the Miami-based Women’s Emergency Network, one of Florida’s biggest abortion funds, which provides assistance to people seeking abortion care. Daniela Martins, who is the vice-chair of the fund, told me that, after Florida’s six-week ban came into effect, in May, the amount that the Women’s Emergency Network spent per patient roughly tripled. “But our donors came through, and we did not have to close our doors this year,” Martins said. “That was not at all a given after the ban kicked in, when the need just went crazy.” She also observed that, among the fund’s clients, “the level of despair of people calling was unique in the days following the election, with most if not all callers talking about Amendment 4.”

Abortion funds are mainly cash-in-cash-out operations that rely heavily on volunteers and have few, if any, paid employees. They play a crucial role in reproductive care across the U.S., often working in partnership with Planned Parenthood, which runs its own network of providers, and the National Abortion Federation, which supports patients who receive care at independent clinics. As my colleague Eyal Press detailed in The New Yorker last year, independent clinics frequently operate in the country’s most hostile political climates and offer the most complex and expensive care, even to patients who cannot pay.

Many abortion funds were showered with donations in 2022, after the Supreme Court abolished the constitutional right to abortion in Dobbs v. Jackson Women’s Health Organization. As the shock of Dobbs has worn off, that largesse has withered, and the strains on abortion funds have intensified. Bree Wallace, who is the director of case management and the sole paid employee of the Tampa Bay Abortion Fund, said that this year her fund has pledged to spend about six hundred and ninety thousand dollars directly on abortion care and has spent about eighty thousand helping patients pay for airfare, rideshares, hotels, child care, and other costs related to travelling out of state for treatment. Put another way, the Tampa Bay fund’s total annual disbursements will come out to a fraction of one per cent of the cost of the Amendment 4 campaign.

In his prescient book “Left Adrift,” Timothy Shenk, who is a history professor at George Washington University, describes the Democratic Party of recent years as “an alliance between professionals and the poor, with the balance of power weighted toward the top.” The 2024 elections seems to have marked the moment when the bottom fell out—when Democrats lost a critical mass of voters from a racially diverse cross-section of the working class. One of the few strong constituencies the Party has left is the college-educated professional class, which favored Harris over Trump by fifty-five per cent. (The strongest by far, though, is Black voters, eighty-six per cent of whom voted for Harris.)

What remains of the Democrats’ traditional coalition is dominated by what the Princeton history professor Matt Karp has called the “shadow party”—a “constellation of NGOs, media organizations, and foundation-funded activists who now constitute the Democrats’ institutional rank and file.” The fingerprints of the donor and corporate-consultant classes were all over the latter stages of Harris’s truncated campaign, which did little to energize the younger, progressive wing of the Party—at times, it seemed eager to squander its support—and instead tried to woo chimerical swing voters using the fabled suasive powers of the Cheney family. The Democratic Party, as embodied in its Presidential candidate, appeared to stand for little except itself.

Shenk’s and Karp’s readings of the Democrats are remarkably applicable to the contemporary reproductive-rights movement. The balance of power is likewise weighted toward the top: the huge and stunningly well-endowed national organizations, such as Planned Parenthood and the A.C.L.U., and their formidable apparatus of donors, PACs, attorneys, consultants, and communications strategists, whose gravitational pull is toward New York City and Washington, D.C. The working class, in this analogy, is made up of the independent clinics and the abortion funds. They perform much of the labor that enables the top tier of the movement to acquire so much financial and social capital. They put in long hours, worry about making ends meet, and often live in rural and underserved areas. And they are increasingly alienated from an élite that takes their buy-in for granted.

In August, an alliance of thirty-four abortion funds published an open letter in The Nation that flagged “an alarming disconnect between abortion funds, grassroots organizations that are actually providing access to abortion, and large national organizations that are advocating for access.” The letter criticized a new project called Abortion Access Now, a ten-year campaign by a coalition including Planned Parenthood and the A.C.L.U., which, according to Politico, will prepare reproductive-rights policy “for the next time Democrats control the House, Senate, and White House.” “It’s a great idea (and one that abortion funds also dream of),” the signatories of the Nation letter wrote, “but this campaign is a gross abuse of funding and publicity that deprioritizes actual access to abortion care right now.”

Abortion Access Now launched in June; the following month, Planned Parenthood and the National Abortion Federation reduced the subsidies they offer to low-income patients to thirty per cent, down from fifty per cent in most states. Abortion funds were expected to make up the balance by default. In the wake of Dobbs, more people have been travelling longer distances to find abortion care, often to clinics that are booked out for weeks because of the influx of out-of-state patients. More people are in need of expensive second-trimester abortions because of the time they lose getting an appointment, figuring out flights and child care and time off work, and coming up with the cash to cover it all. Making matters worse, Dobbs also coincided with the worst period of inflation in the U.S. for some forty years.

This year, ten states mounted ballot initiatives to protect abortion rights, and, although seven of them succeeded, several advocates told me that the enormous expenditures of the amendment campaigns underscored a fundamental asymmetry of resources in their movement. “Advocacy is what sells, it’s politics, it’s sexy, and you can see it happening in front of your eyes,” Wallace, of Tampa Bay, said. “We are small grassroots teams and our work is not as visible, nor do we have the capacity to go out and find rich people to help us.”

The question of inequity between the high-altitude advocacy and direct-services wings of the reproductive-rights movement is one “that the larger repro orgs and the smallest grassroots orgs are all asking and trying to figure out together,” Olivia Cappello, Planned Parenthood’s associate director for state advocacy communications, told me. “It is really tough to know that electoral campaigns cost so much money, and that we have to pour so much money to win back rights, little by little, when we also see such a tremendous direct patient need.” Cappello also served for many years as a case manager for the D.C. Abortion Fund. From that perspective, she said, “it is really frustrating to see the resources that the Federation has.”

Planned Parenthood is the largest provider of reproductive health care in the country, with about six hundred clinics in all fifty states. Each clinic is run by one of the Planned Parenthood Federation of America’s forty-nine local affiliates, and each affiliate is its own discrete nonprofit. In its 2022-23 annual report, P.P.F.A. and its affiliates—as distinguished from its advocacy arm, Planned Parenthood Action Fund, and its super PAC, Planned Parenthood Votes—logged an annual revenue of more than two billion dollars, of which nearly one billion came from private donations. The organization’s Justice Fund covers procedures for very low-income patients; its Emergency Access Fund provides practical support—flights, hotels, Lyft gift cards—for patients who have to travel more than sixty miles one way for an appointment, and usually caps out at five hundred dollars.

When Planned Parenthood and its affiliates make adjustments to their subsidies and prices, advocates who provide direct services can be caught off guard. Kim Floren is the director and co-founder of the abortion fund Justice Through Empowerment Network, based in South Dakota, a state where voters rejected an abortion-rights ballot initiative on Election Day. She also worked for Planned Parenthood North Central States until October, and she told me that, for about a year following the fall of Roe, the affiliate was using tens of thousands of dollars per month from the Emergency Access Fund. But then, Floren said, “The Dobbs money ran out, and they told us that our budget was going to be around six thousand dollars for the next three months.” Destini Spaeth, who heads the Prairie Abortion Fund, which serves Minnesota, North Dakota, and South Dakota, told me that, recently, one of the Planned Parenthood clinics she works with roughly doubled its list prices for medication-abortion services. “Why are they charging fifteen hundred dollars when somebody can get that for five or seven hundred dollars at an indie clinic, or for a hundred and fifty dollars online?” Spaeth asked. “I was gobsmacked.”

Ruth Richardson, the president and C.E.O. of the Planned Parenthood North Central States affiliate, said that the higher prices Spaeth quoted do not necessarily reflect what patients ultimately pay, but Richardson did not offer alternate numbers. She also said, in an e-mail, “Pitting the finances of abortion funds and Planned Parenthood against each other is not going to help us secure access in the upcoming administration. It’s going to take sexual and reproductive health care supporters stepping up to support every aspect of the abortion care ecosystem to see us through this moment.”

Wallace, in Tampa Bay, values the close relationships she has with patient navigators at Planned Parenthood and case managers at the National Abortion Federation, who work with her to help patients locate abortion providers and patch together funding for their procedures and wraparound care. But she also thinks that the big organizations too often get the credit—and the donations—for the efforts of the lower-profile abortion funds. “We’re doing the on-the-ground work that they’re not, but they’ll try to show themselves as if they’re in that direct-services role,” she said. “They raise millions for the things we’re struggling to pay for.”

Abortion funds have trouble engaging big donors, in Wallace’s reckoning, partly because of a lingering queasiness about abortion as a practical matter, as distinguished from reproductive freedom as a lofty concept. “When people want to donate to reproductive health, that doesn’t necessarily mean they want to donate to abortions,” she told me. “There still is that stigma.” Floren described another hurdle as “that nonprofit-industrial-complex thing where the bigger donors and foundations feel more comfortable with the bigger organizations.”

Donors to abortion funds are often attracted to the idea that their contribution stays close to the ground—it will go straight toward a patient’s procedure or hotel bill, instead of getting folded into a giant organization’s administrative outlay or fund-raising budget. But these direct donors may not realize that they might be indirectly donating to Planned Parenthood. Spaeth, of the Prairie Abortion Fund, explained how a typical exchange between her fund and Planned Parenthood might unfold: “They will reach out to us and say, ‘We have a patient coming in from your service region. Are you able to contribute towards the cost of their appointment?’ Then I say yes, and then, sometimes, they’ll follow up and say, ‘This patient screened further along than we previously thought—are you able to increase your pledge?’ ”

Occasionally, Planned Parenthood will ask Spaeth to pay for travel costs that ideally would be covered by the Emergency Access Fund. A particularly jarring moment for Spaeth came about two years ago, when, not long after the philanthropist MacKenzie Scott gave two hundred and seventy-five million dollars to Planned Parenthood, a call came in from a Planned Parenthood employee asking for money to cover a patient’s Uber.

Richardson, of Planned Parenthood North Central States, told me that about fifty-five hundred people in the region have accessed abortion care through their patient-navigation program, which was launched shortly after the Dobbs decision. Eighty per cent of those patients qualified for financial assistance. Richardson demurred on whether the organization had post-election plans to increase its support for direct services, but said that the current political climate in the U.S. “has put us into a place where we have to make decisions about where we are going to really focus our efforts and resources, because our resources are not infinite.”

Hochkammer, of the Florida Women’s Freedom Coalition, said that there’s little strategic or material incentive for a name-brand national organization to partner in a more equitable way with community-based advocates. “Planned Parenthood has the bullhorn and the relationships with the big donors,” she said, “and Planned Parenthood wants to keep itself in business and fund its priorities, and its priorities are not to fund an underground railroad to get women out of Florida so they can get abortion care elsewhere.”

I asked Laura Goodhue, the executive director of the Florida Alliance of Planned Parenthood Affiliates, about her organization’s immediate priorities following the Republican electoral sweep and the defeat of Amendment 4. She and her colleagues are looking ahead to the spring, Goodhue said, when the Florida legislature reconvenes and Democrats plan to introduce a bill to repeal Florida’s six-week abortion ban. “We are going to call on the legislature to end this egregious ban,” Goodhue said. She pointed out that Donald Trump, who is a resident of Palm Beach County, has said in the past that six-week limits are too restrictive. “I think there’s a lot of momentum there,” Goodhue added.

Republicans maintained their super-majorities in both chambers of the Florida legislature in the 2024 elections, and the new president of the Florida Senate, Ben Albritton, has already stated that he has no intention of revisiting the abortion ban. “What credible path would there be in any scenario for a legislative initiative to repeal that law?” Hochkammer asked. When I followed up with Planned Parenthood to ask for more details on the strategy behind the long-shot bill, a representative said, in an e-mail, “The advocacy fight in the state legislature is consistent with previous years and includes both organizing and lobbying strategies.”

Hochkammer suggested that, for a large-scale advocacy group, a doomed legislative campaign can double as a form of marketing. “What we’re talking about now is not politics,” she said. “What we’re talking about now is development and fund-raising for advocacy organizations. Advocacy depends on donors having a very specific issue with urgency to it. They are presenting their donor base with a next fight.” What’s more, she went on, the significant overlap between these donors and the political donor class incentivizes legislators to join the fight. The latticework joining donors, nonprofits, consultants, and politicians, Hochkammer told me, “does not create high-quality public policy, but it does cost a lot of money and it keeps a lot of people employed.” She added, “I understand why they do it. They’re keeping themselves alive.”

An old corporate maxim holds that, if a business isn’t growing, it’s dying. For some reproductive-rights advocates, it is this institutional logic of self-perpetuation that marks the most irreconcilable difference between the Planned Parenthood universe and the abortion-fund community. As Floren, of Justice Through Empowerment, said, “No one should ever have to call an abortion fund to get an abortion. Planned Parenthood is concerned with development and growing the organization. Our goal is to not have to exist.”