Judges, state lawmakers and voters are deciding the future of abortion in the U.S. two years after the Supreme Court jolted the legal status quo with a ruling that overturned Roe v. Wade.

The June 24, 2022, ruling in Dobbs v. Jackson Women’s Health Organization sparked legislative action, protest and numerous lawsuits—placing the issue at the center of politics across the country.

Abortion is now banned at all stages of pregnancy, with limited exceptions, in 14 Republican-controlled states. In three other states, it’s barred after about the first six weeks, which is before many know they are pregnant. Most Democratic-led states have taken actions to protect abortion rights, and become sanctuaries for out-of-state patients seeking care.

That’s changed the landscape of abortion access, making it more of a logistical and financial ordeal for many in conservative states. But it has not reduced the overall number of procedures done each month across the U.S.

Here’s what to know about the state of abortion rights in the U.S. now.

Limited abortion access prompts more out-of-state travel

Bans in Republican-led states have prompted many people seeking abortions to travel to get care.

That translates into higher costs for gas or plane tickets, hotels, and meals; more logistics to figure out, including childcare; and more days off work.

A new study by the Guttmacher Institute, which advocates for abortion access, found that out of just over a million abortions provided in clinics, hospitals and doctors’ offices, more than 161,000—or 16%—were for people who crossed state lines to get them.

More than two-thirds of abortions done in Kansas and New Mexico were for out-of-staters, particularly Texans.

Since Florida’s six-week abortion ban kicked in in May, many people had to travel farther than before, since throughout the Southeast most states have bans.

Low-income patients and those lacking legal permission to be in the country are more likely to be unable to travel. There can be lasting costs for those who do.

In Alabama, the Yellowhammer Fund, which previously helped residents pay for the procedure, has paused doing so since facing threats of litigation from the state.

Jenice Fountain, Yellowhammer’s executive director, said she met a woman recently who traveled from Alabama to neighboring Georgia for an abortion but found she couldn’t get one there because she was slightly too far into her pregnancy. So she then went to Virginia. The journey wiped out her rent money and she needed help to remain housed.

“We’re having people use every dime that they have to get out of state, or use every dime they have to have another child,” Fountain said.

It’s usually provided with pills rather than procedures

Nearly two-thirds of known abortions last year were provided with pills rather than procedures.

One report found that pills are prescribed via telehealth and mailed to about 6,000 people a month who live in states with abortion bans. They’re sent by medical providers in states with laws intended to protect them from prosecution for those prescriptions. The laws in Colorado, Massachusetts, New York, Vermont, and Washington specifically protect medical providers who prescribe the pills to patients in states with bans.

The growing prominence of pills, which were used in about half of all abortions just before the Dobbs ruling, is a frontier in the latest chapter of the legal fight.

The U.S. Supreme Court this month unanimously rejected an effort by abortion opponents who were seeking to overturn or roll back the U.S. Food and Drug Administration’s approval of mifepristone, one of two drugs usually used together for medication abortions. The issue is likely to return.

Abortion is on the 2024 ballot

In this presidential election year, abortion is a key issue.

Protecting access has emerged as a key theme in the campaigns of Democrats, including President Joe Biden in his reelection bid. Former President Donald Trump, the presumptive Republican nominee, has said states should decide whether to restrict abortions. He also suggested states could limit contraception use but changed his tune on that.

“We recognize this could be the last Dobbs anniversary we celebrate,” Kelsey Pritchard, a spokesperson for Susan B. Anthony Pro-Life America said in an interview, noting that if Democrats win the presidency and regain control of both chambers of Congress, a right to abortion could be enshrined in the law.

The issue will also be put directly before voters in at least four states. Colorado, Florida, Maryland, and South Dakota have ballot measures this year asking voters to approve state constitutional amendments that would protect or expand access to abortion. A New York measure would bar discrimination against someone who has an abortion. There are attempts to put questions about abortion access on the ballots this year in Arkansas, Missouri, Montana, Nebraska, and Nevada.

There’s also a push for a ballot measure in Arizona, where the state Supreme Court this year ruled that an 1864 abortion ban could be enforced. With the help of some Republicans—Democrats in the Legislature were able to repeal that law.

Generally, abortion rights expand when voters are deciding. In the seven statewide abortion policy-related votes since 2022, voters have sided with abortion rights advocates in every case.

It’s still up to the courts—including the Supreme Court. The Dobbs ruling and its aftermath gave rise to a bevy of legal questions and lawsuits challenging nearly every ban and restriction.

Many of those questions deal with how exceptions—which come into play far more often when abortion is barred earlier in pregnancy—should apply. The issue is often raised by those who wanted to be pregnant but who experienced life-threatening complications.

A group of women who had serious pregnancy complications but were denied abortions in Texas sued, claiming the state’s ban is vague about which exceptions are allowed. The all-Republican Texas Supreme Court disagreed in a May ruling.

The Supreme Court also heard arguments in April on the federal government’s lawsuit against Idaho, which says its ban on abortions at all stages of pregnancy can extend to women in medical emergencies. The Biden administration says that violates federal law. A ruling on that case could be issued at any time.

Meanwhile, bans have been put on hold by judges in Iowa, Montana, Utah, and Wyoming.

—By Geoff Mulvihill, Associated Press