The waiting room in the Delta Clinic in Baton Rouge, Louisiana, is crowded as usual with women who are scheduled to have an abortion. But in a radical shift from just one week before, the women, many of whom already traveled from hours outside the city, may only get a consultation at Delta. For the abortion itself, they now must drive another 80 miles to New Orleans – the only location in the southern half of the state which is still providing abortions.

Delta has been sending its patients on this trek for a week – ever since the fifth circuit court of appeals put on hold a lower court ruling that would have allowed the clinic to remain open.

The federal appeals court’s ruling allowed a law to take effect that imposes a requirement on physicians that only two out of six abortion providers in the state can meet.

The law in Louisiana is among hundreds of new abortion restrictions that abortion opponents have enacted since 2010. In the past five years, the measures have helped shutter about a quarter of all US abortion providers.

On Wednesday, the US supreme court heard oral arguments in a challenge to the most devastating of those laws, in abortion providers’ eyes: a law in Texas that has closed more than half of the state’s 41 abortion clinics since it passed, and that threatens to close all but nine or 10 if fully enacted.

The outcome of that case, although it is separate from the lawsuit in Louisiana, could have a heavy influence on how the fifth circuit will rule on Louisiana’s law if it chooses to hear an appeal. If the court hands a decisive win to the abortion providers challenging Texas’s law, it could stop Louisiana’s measure in its tracks. Anything less could give the fifth circuit leeway to uphold Louisiana’s law.

Abortion providers in Louisiana see Texas as a cautionary tale.

Two clinics, 940,000 women

In January, US district judge John deGravelles ruled the law unconstitutional. But the fifth circuit decision puts deGravelles’ ruling on hold while the state of Louisiana appeals.

In the meantime, Louisiana is seeing what the reality would be with only two abortion providers for some 940,000 women of reproductive age.

“It has been a tremendous hardship for our patients,” said Sylvia Cochran, the administrator at the Women’s Health Care Center in New Orleans, one of the two clinics that is still providing abortions. “We’re already getting an influx of women and it has already increased our wait times.”

In the last week, the clinic has seen dozens of women from deep within the state now that a provider in Baton Rouge is out of commission, she said. Almost all of them belong to the working poor. To reach New Orleans, some are traveling four hours each way.

The only other abortion clinic that is performing procedures is in Shreveport, in the far north-western corner of the state. That clinic, Hope Medical Group, is now faced with taking on dozens of patients from a clinic that closed in nearby Bossier City. “It is impossible for one to two physicians to provide services for all the women in Louisiana in need of abortion care,” said Kathaleen Pittman, the administrator there.

The two clinics are struggling with not only the volume of new patients but also a drop in capacity. Before the ruling, both clinics had two providers who performed abortion. But only one doctor at each clinic has admitting privileges.

The two doctors performed less than half of all abortions in Louisiana in 2013. To keep up, the provider in New Orleans has started performing surgeries every day, up from twice a week. The provider in Shreveport, who has an active OB-GYN practice delivering infants, was previously responsible for less than a third of abortions taking place at Hope Medical Group. He is now the only provider left in the northern half of the state.

“Just numbers-wise, it does not seem feasible that there would be enough capacity to provide abortions for Louisiana women,” said Ellie Schilling, a New Orleans attorney who has represented several of the state’s abortion providers.

For the two clinics the law has forced to suspend their operations, there is a creeping fear that they will struggle to reopen. “They’re paying rent but they’re not getting any revenue,” said Schilling. “You can pay your employees a little bit, but you can’t keep doing that forever. It’s true of any business: the longer there’s an interruption, the greater the chance that it will never reopen.”

Supporters of the law have argued that admitting privileges are necessary to make abortion safer. Opponents counter that the procedure is already exceedingly safe. They see the law as a gambit to shut clinics down, and in the course of this lawsuit, they have mustered some proof. In an email sent to the law’s main sponsor, state representative Katrina Jackson, an executive at an anti-abortion advocacy group, noted that a similar measure passed in Texas had “tremendous success in closing abortion clinics and restricting abortion access”.

“Evidence received demonstrates the coordination among advocacy groups, Jackson, and DHH employees regarding efforts to restrict abortion,” deGravelles wrote in his January opinion.

That same law in Texas has already strained Louisiana’s abortion providers, some of whom have seen a wave of abortion patients crossing state lines. From 2011 to 2014, when Texas’s law went into effect, the number of patients traveling to Hope Medical Group from Texas leapt from 15% to 23%. Add Mississippi, which has only one abortion clinic, and Arkansas, and only 69% of Hope’s abortion patients actually live in Louisiana.

The distances are made trickier by the fact Louisiana also has a mandatory counseling law. It requires patients to make an extra trip to the clinic, 24 hours before their procedure, to receive information designed to dissuade them. Combined with the admitting privileges law, women are looking at extra travel expenses and lost wages of up to several hundred, according to Sheila Katz, a Houston public policy professor.

“That’s what you have to understand, is that this is a regional problem,” said Schilling. “There’s a swath of states now, where clinics have been forced to close or they’re only allowed to remain open now because of court orders. Texas, Louisiana, Mississippi, Alabama. Everybody’s struggling to stay open as the tidal wave of these laws spread. But at some point, you’re just going to have a situation where there are very few clinics over just thousands and thousands miles.”

Admitting privileges

Before Louisiana’s law took effect requiring any physician performing abortions to have admitting privileges at a hospital no more than 30 miles from the clinic, five out of the state’s six abortion providers made 13 different attempts to secure admitting privileges at nearby hospitals. Just two of those attempts proved successful – and in one case, Judge DeGravelles found that the privileges the doctor received, from Tulane Medical Center, don’t meet the standards of the new law.

The other 11 attempts are a case study in what makes admitting privileges so difficult for abortion providers to obtain.

Admitting privileges – the ability to admit and treat patients – are generally meant for doctors who treat patients in a hospital setting. Because abortion is an outpatient procedure with a low complication rate – the American Medical Association places the risk of a major incident between 0.05% and 0.2% – abortion providers rarely meet a hospitals’ particular requirements.

One hospital in Louisiana asked the abortion providers to submit 12 months’ worth of data on the patients that they had admitted and treated in a hospital setting. “I’m in a catch-22 basically,” one of the doctors testified. “I can’t provide information I don’t have.” In two cases, doctors lived too far away from the hospital to qualify.

The doctor at Shreveport has admitting privileges requiring him to admit at least 50 patients to the hospital every year. He meets the requirement through his OB-GYN delivery practice, but deGravelles acknowledged that none of the other providers would be able to clear that hurdle.

The politics of abortion have also prevented doctors from receiving admitting privileges. Several doctors struggled to get the necessary references from hospital staff, they testified, because of fears about being associated with abortion. The Family Medicine Department at University Health Hospital in Shreveport told two doctors that it would not grant them admitting privileges because of objections from its staff. Emails submitted to the court showed that Tulane Medical Center planned to consult with its lobbyists before granting admitting privileges.

One doctor previously worked at a hospital, DeGravelles noted, until threatening letters and “protests outside the hospital caused the hospital administration to give him an ultimatum: quit performing abortions or resign from the hospital staff”.

Louisiana does not require hospitals to respond to these requests within a set amount of time. The abortion providers still have ten pending applications for admitting privileges, most of which are more than a year old.

DeGravelles held that by sitting on the applications, the hospitals were essentially denying them.

“It is therefore impossible for these doctors, notwithstanding their best efforts, to comply with the law,” he wrote.

The ruling was a sharp rebuke of prevailing notions about the law in the legislature. In their testimony before lawmakers, supporters claimed that admitting privileges would function as a check on unscrupulous doctors, with one witness saying hospitals denied or approved admitting privileges “based entirely on [a doctor’s] medical training and experience”.

During the trial, a witness for the state denied that politics could influence hospitals’ decisionmaking. Robert Marier, who chairs the department of hospital medicine at Ochsner Medical Center in New Orleans, testified that he didn’t know of any hospital that would refuse to extend admitting privileges just because an applicant performed abortions.

“The Court finds his testimony on this point to be not credible and contradicted by an abundance of evidence,” deGravelles wrote. He added that Louisiana law explicitly protects hospitals that discriminate against abortion providers.

Marier, the judge noted, was one of the physicians who helped draft the law.

‘Fewer doctors to target’

Patients are not the only ones traveling distances to reach the only abortion provider left in New Orleans.

Since the fifth circuit shut down all but two clinics in the state, the Women’s Health Care Center has noticed a bump in the number of protesters outside its doors.

“The protesters are upping their game,” said Amy Irvin, who runs the New Orleans Abortion Fund, a nonprofit that helps women pay for their procedures. “They sense a victory.” In response to the uptick, the fund, which before provided clinic escorts on an as-needed basis, is now providing regular volunteers to shuttle women through the small but fierce battery of protesters. She said that the clinic itself is planning to increase security measures.

Because of the hostile atmosphere toward abortion in the state, all six doctors who provide abortions were allowed to testify anonymously in the admitting privileges lawsuit. Even one of the hospitals that has given an abortion provider admitting privileges was allowed to go unnamed.

The abortion provider at Hope Medical Group, the only one there with admitting privileges, testified that if the law were allowed to take effect, the personal risks posed by being the only abortion provider in all of northern Louisiana would be too great, and he would quit.

“The threat of physical violence and protest does dramatically increase when there are fewer doctors to target,” Schilling said.

Hope Medical Group has been attacked by a protester who hurled a Molotov cocktail, a man wielding a sledgehammer, and by a person who drilled a hole through the wall of the clinic in order to pour foul-smelling butyric acid into the building. The doctor himself has has faced protests at his private practice. Police patrol his neighborhood, and on a few occasions, he has felt the need to ask police to enter his house and make sure it was safe.

“All [they] have to do is eliminate me as they have Dr. Tiller,” the doctor testified at trial, referring to George Tiller, a Kansas abortion provider who was shot and killed by an anti-abortion extremist in 2009.

Because of his vow to quit, Louisiana’s admitting privileges law could ultimately shut down all but one provider in the state, in New Orleans.

Irvin says it would be a public health disaster.

“We’re already seeing women from across the Gulf Coast struggle to get here,” she said. “The women we hear from on the phone are arranging childcare, tapping into meager savings, pawning things, talking to friends, family, putting off paying bills and buying groceries.”

“It’s these experiences that often get lost,” Irvin continued. “If there’s only one provider in the state, it’s hard to say what all those women will do.”