Is the Last Abortion Haven in the Caribbean Closing?

How U.S. influence has been quietly reshaping access in Puerto Rico

By Susanne Ramirez de Arellano

Dr. Yari Vale's petite frame is no longer weighed down by the nine-pound bulletproof vest she wore when anti-abortion threats increased after the end of Roe v. Wade, but she hasn't gotten rid of it. The security guard at Dr. Vale's Darlington Medical Associates clinic in Río Piedras is no longer at the door; still, she has him on standby. With the return of Donald Trump to the White House and Jenniffer González, a Trump devotee, in the governor’s seat, Dr. Vale is bracing for an escalation in the fight to safeguard reproductive rights in Puerto Rico.

The predominantly Catholic island is “on paper one of the most accessible places in the Western Hemisphere” to obtain an abortion, NPR reported just after Roe was overturned. But with the U.S.'s shift toward right-wing Christian nationalism, that could be changing.   

Dr. Vale, an OB/GYN at the Darlington clinic—the only one of the island's four that does late-term abortions—is on the frontline of the fight to keep what’s happening in the United States from happening in Puerto Rico, euphemistically called an unincorporated territory (it's a colony, really). It's a battle that, she says, feels like “throwing a firecracker up in the air, and it's just smoke and no one hears you.” But she persists, knowing that the first line of defense is the clinics.

Dr. Vale at her clinic in Río Piedras (Photo courtesy of Dr. Vale)

The Legacy of Pueblo v. Duarte

For years, Puerto Rico has been known for its liberal abortion laws: The right is enshrined in the island’s constitution (which exists separately from the U.S. Constitution) and is protected by the right to intimacy under Puerto Rico’s penal code. Abortion is legal on request if it is performed (or prescribed) by a physician to protect the pregnant woman’s life or health—and health includes mental health. There are no limits (abortion may not be banned before viability; post-viability abortions are permitted for the preservation of the pregnant person), and the procedure doesn't require the consent of partners, ex-partners, or, in the case of minors, parents. 

However, these laws have their roots in a dark colonial history. In 1902, four years after invading the island, the U.S. enacted policies to control the population, although abortion was still prohibited without exception. Then, in 1937, colonialists who wanted to further limit the Puerto Rican population passed legislation based on racist neo-Malthusian and eugenic theories, virtually legalizing abortion on the island if it was to protect the life and health of the patient. These changes later facilitated clinical trials of the contraceptive pill and mass coerced sterilizations—a procedure that became so common that it was known among Puerto Rican women as “la operacion.” 

In 1980, a case involving a minor and her doctor went even further, and set up modern abortion law in Puerto Rico. In the landmark Pueblo v. Duarte, Dr. Pablo Duarte Mendoza, who had performed an abortion on a 16-year-old girl in her first trimester, was sentenced to four years in prison. He appealed, and the Puerto Rican Supreme Court agreed with him, stating that through the island’s penal code, abortion is legal if it is performed to save the woman's life or health, including mental well-being.

Like many things on an island impacted by colonialism, abortion access is still limited for everyday Puerto Ricans. A surgical abortion costs $250, and a medication abortion between $300 and $350; meanwhile, about 43% of Puerto Ricans live below the poverty line, and insurance plans on the island do not cover abortion. And in addition to cost, religion and social stigma—the “what-will-my-family-say” factor—serve as deterrents for many women.

The Dobbs Effect 

When 2022’s Dobbs v. Jackson Women’s Health Organization decision removed the constitutional right to an abortion in the U.S., it didn’t automatically affect rights in Puerto Rico (unlike on the mainland, where “trigger bans” were in place). In fact, some U.S. women began to travel to Puerto Rico from states with restrictive abortion laws, such as Florida. It was the return of the “San Juan holiday.”

The national campaign for Free, Safe and Accessible Abortion in Puerto Rico called a demonstration on Saturday July 9th to demand that the Legislature protect reproductive and sexual rights in Puerto Rico. (Photo by Alejandro Granadillo/NurPhoto via Getty Images)

But Dobbs did embolden conservative Puerto Rican politicians and pro-life groups, who saw a window of opportunity and seized it. Shortly after the decision, the right-wing religious party Proyecto Dignidad (PD) adopted the U.S. anti-abortion lobby's blueprint and tried to push through several bills to curtail access to abortion, and even criminalize it. They argued that the end of Roe implicitly negated Pueblo v. Duarte. The Senate ultimately defeated the bills; according to many Puerto Rican legal experts, Pueblo v. Duarte rests on the Puerto Rican penal code, which has no analogy in the U.S. Constitution—and should, therefore, not be affected by Dobbs.

An Ascendant Right-Wing Movement

Abortion-rights advocates warn that efforts to criminalize abortion in Puerto Rico are not over. Traditionally, “the issue of abortion in Puerto Rico has not been the overriding controversy that the anti-abortion and ultra-religious politicians want to make it out to be now,” says Senator Maria de Lourdes Santiago, a lawyer and Senator for the Puerto Rican Independence Party (PIP). But, she says, the anti-abortion campaign orchestrated by Proyecto Dignidad now "magnifies the issue to demonize it." 

Founded in 2019, PD has capitalized on its nexus of Catholic and Evangelical churches; the erosion of the traditional duopoly of the pro-statehood New Progressive Party (PNP) and the Popular Democratic Party (PPD); and an increasingly ultra-conservative sector of the population urging a return to traditional values. Even though the party got only seven percent of the vote in the 2024 elections, its influence is strong island-wide, with a campaign that now hinges on the abortion issue. 

Proyecto Dignidad Senator Joan Rodriguez Veve, a canon lawyer and face of the populist religious right, has vowed to continue fighting to restrict access to abortion. She recently introduced legislation, PS 297, restricting access to abortion for adolescents under the age of 15. The bill is a carbon copy of one that the Puerto Rican House rejected a year ago. It calls for jail time for any doctor or person who assists a minor in getting an abortion, and a slew of other measures, including forensic interviews of minors seeking an abortion. 

The Senate approved the bill in February, and almost everyone I spoke to—politicians, legal experts, and abortion doctors—told me they believe it will pass, even though both pro-abortion and some anti-abortion groups have, for different reasons, voiced their opposition to the measure.  

A New Generation Stands Up

Young Puerto Ricans have become a more visible part of activist movements over the last few years. In 2020, thousands took to the streets to demand the resignations of corrupt government officials. (Photo by Jose Jimenez/Getty Images)

At the same time that PD is gaining influence, attitudes about abortion are shifting with the younger generation. Rising numbers of people support abortion rights, and young people have galvanized around the issue, taking to the streets in protest and amplifying groups like Aborto Libre Puerto Rico, Profamilias, and Proyecto Matria, among others. It’s a generation that, unlike its mainland counterpart, grew up without a sense of abortion as a wedge issue.

Most recently, health professionals and activists have spoken out against PS 297, warning that the bill puts women and girls in danger. “What's going to happen here is that young women and those most vulnerable will seek out illegal abortions and go to the places where illegal drugs are sold to purchase abortion pills, many cut with fentanyl, in doses that are not recommended,” says Puerto Rican feminist activist Alondra Hernández Quiñones. 

As religious and conservative groups gain traction in Puerto Rico, Dr. Vale worries that a girl of 15, whose parents are ultra-conservative and refuse to consent to her abortion (as the new legislation would require), would be forced into motherhood. Clinics like Darlington have stopped seeing patients younger than 15 at all, and Dr. Vale fears a future where abortion, currently a safe and regulated procedure, “will once again be a public health problem…where we don't know how many women end up in emergency rooms due to an [unregulated] abortion gone wrong.”

“This worries me a lot,” says Isharedmie Vazquez, a 17-year-old Puerto Rican student. “It seems incredibly wild to me that instead of guaranteeing secure options [for an abortion], what they are looking for is to criminalize it and force women to assume a responsibility for which they are not prepared. It's unfair that they want to take away the right to decide about our lives.” 

 

 

Susanne Ramírez de Arellano is an author on race and diversity, opinion writer, and cultural critic. The former news director of Univision, she writes for NBC News Think, Latino Rebels, and Nuestros Stories, among other outlets.


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Pissed Off About Insurance? So Are These Doctors

Physicians are publicly calling out red tape and immoral practices. Vivian Manning-Schaffel gets the story.

Dr. Elisabeth Potter was still wearing a scrub cap when she fired off a now-viral Instagram post that took direct aim at the biggest health insurance company in the country. In her post, she talked about having to scrub out of surgery to hop on an urgent authorization call with United Healthcare, which was asking for details about her patient’s diagnosis and whether her overnight hospital stay was justified.

“Do you understand that she's asleep right now? And that she has breast cancer?” Potter, a Texas-based board-certified plastic surgeon and breast cancer reconstruction specialist, says she told the rep on the phone. “Actually, I don’t. That’s a different department,” she says the rep replied. “When I get a call from an insurance company for a woman with breast cancer, I always think they're going to try to deny her surgery,” she told The Meteor. After her post went viral, she shared another post on Instagram, a strongly worded letter from the attorneys of United Healthcare demanding that she take her post down, issue a public apology, and inform Newsweek that her “claims were false."  

Then, she went on CNN.

It’s rare to see a doctor putting an insurance company on blast—partly because threats of legal action can be daunting for already overworked providers. Potter has long been the exception, taking to the morning-show circuit five years ago to advocate for safer breast implants despite what she called “bullying and pressure” from insurance companies. But since Potter’s post went viral, the floodgates have opened. Doctors like Washington, D.C. critical care physician Dr. Anita Patel, who recently took on Anthem Blue Cross Blue Shield for attempting to impose time limits on anesthesia, and Florida breast cancer surgeon Dr. Alicia Billington, who took Cigna to task for what she saw as failing to adequately cover reconstructive surgeries, have gotten more vocal about healthcare industry practices that they say sacrifice the well-being of their patients.

 

THE NIGHTMARE OF “PEER-TO-PEER” CALLS 

Dr. Shikha Jain, a hematologist and oncologist at the University of Illinois Cancer Center, has often used social media to amplify unjust insurance practices, tweeting about how insurance companies have delayed her patients’ urgent scans, denied coverage of a cancer combo therapy, and kept her on hour-long peer-to-peer calls. These delays and denials—which Dr. Jain calls “insurance scams”—are “all because insurance companies are just trying to save a buck and don't care about the patients’ lives,” she said. Her online advocacy has led to op-eds, TV interviews, and an appearance in a New York Times Opinion video piece.

“When I get a call from an insurance company for a woman with breast cancer, I always think they're going to try to deny her surgery”—Dr. Elisabeth Potter

One of Dr. Jain’s pet peeves? Those so-called “peer-to-peer” calls, like the one Dr. Potter had to make during surgery, when an insurance company doctor will speak with a patient’s doctor to verify the need for coverage. She’s missed peer-to-peer calls during busy clinic hours, when she sees patients back-to-back, and because she’s missed them, the insurance company denied the claim, she says. This requires the patient to appeal the decision, which can take several months.

Dr. Shikha Jain during a health segment on a Fox affiliate. (via Instagram)

What’s worse, the doctors interviewed say, the calls that can make or break a patient’s coverage aren’t always with doctors who share their specialty or expertise, sometimes resulting in significant care delays and perilous health risks for their patients. “You are the person, sitting in the room with the patient...crying with them because their chemotherapy has been denied,” Dr. Jain says, while “somebody who has never seen a patient with this disease is sitting at a computer a thousand miles away, making decisions based on an algorithm that is set up to deny care.” 

Dr. Anita K. Patel, a pediatric critical care physician at a large children’s hospital in Washington, D.C. says she recently called out Anthem BCBS “100% in response” to Dr. Potter’s own post about the company’s announcement that it would put time limits on anesthesia (a decision it has since reversed due to widespread backlash). “I work in an ICU for kids,” says Patel. “We would get notifications they were denying coverage.” She often finds herself on peer-to-peer calls fighting for life-or-death necessities like ventilators and wheelchairs. She once spent what she describes as a “demoralizing” hour in circles with an attending physician on the insurance side who was intent on denying an ICU stay to a vulnerable child with a life-threatening neurologic injury. “Any delay of care could cost the kid their life, and there was no way the parents could afford the bill,” she said.

“NOBODY WANTS TO BE IN THE HOT SEAT” 

So what can patients do when they’re at wits’ and wallets’ end with the insurance system? Besides keeping meticulous records of each contact with an insurance company and urging one’s workplace to pick plans that prioritize women’s health, Dr. Potter hopes patients will use social media for accountability, too. “I want to see open conversations about the nitty-gritty details of healthcare and the dark stories in courtrooms being had by providers and patients,” she says. But Dr. Jain says that while patients calling out insurance companies on social media can be effective, she understands why it could be the last thing they want to do. “How horrible is it if you're being treated for cancer,” she says, “then on top of that having to go to social media and fight for your ability just to get treated? That's not right.” 

It may not be right, but the discomfort of publicly pressuring insurance companies could lead to more meaningful reform. Though, it may be a long road. While editing this piece, Dr. Potter fired off another IG post saying another patient came to her with a denial from United. “Nobody wants to be in the hot seat,” Dr. Potter says, “but I want to make it more comfortable for doctors and patients to say insurance and hospitals are doing things that are not good for patients, and not good for providers.” 

 

Vivian Manning-Schaffel is a journalist and essayist who covers entertainment, culture, psychology, and women’s health. Her Substack, MUTHR, FCKD, covers pop culture through a feminist Gen X lens.


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