Three years after the Supreme Court overturned Roe v. Wade, Republicans in Congress are poised to further erode access to abortion and reproductive care.

President Donald Trump’s “big, beautiful bill” would not only directly threaten reproductive care by defunding Planned Parenthood and other abortion providers, it would also incentivize insurers for Affordable Care Act plans in some states to drop abortion coverage or make it significantly more expensive.

And it would slash Medicaid coverage, impacting Americans’ ability to access medical care of all sorts. Though Medicaid funds cannot fund abortions except under very narrow circumstances, the cuts would threaten access to non-abortion reproductive care. Many abortion providers, including Planned Parenthood, also offer health care in the form of contraceptives, treatment for sexually transmitted diseases, and cervical cancer screenings.

GOP lawmakers are targeting a July 4 deadline to pass the bill. It passed the House in May and cleared a key procedural vote in the Senate on Saturday. Following a rapid-fire vote on a series of amendments, the bill could go up for a final vote in the Senate as soon as Monday night. GOP lawmakers have faced many internal disagreements about the bill, but there’s a strong push to include both attacks on Planned Parenthood and cuts to Medicaid.

If the initiatives go through, they’ll come at a time when abortion rights and access are under attack, but the actual number of abortions has increased.

Monthly abortions in the US are up about 19 percent nationally since the Supreme Court struck down Roe in the 2022 case Dobbs v. Jackson Women’s Health Organization.

That’s driven almost entirely by the increasing prevalence of medication abortion. It also comes despite the fact that accessing in-person abortion care has become significantly harder, with many women having to travel much further to their nearest clinic due to closures.

Republicans in Congress are trying to create additional hurdles to accessing such care and other women’s health services, both in-person and via telehealth — even in states that have sought to protect reproductive rights. A Supreme Court ruling on Thursday allows states to move forward with their attempts to defund Planned Parenthood will make their task easier.

“What we’ve heard from a lot of anti-abortion politicians since Dobbs is that this was just the way to return the issue to the states,” said Katie O’Connor, senior director of federal abortion policy at the National Women’s Law Center. “It indicates that their ultimate goal is what we’ve always known: They want abortion to be out of reach for everybody, everywhere, and under every circumstance.”

There are now 37 fewer brick-and-mortar abortion clinics in the US than there were in March 2022, before the end of Roe. Many of the closures have been in states that have passed laws that ban abortions in all but narrow circumstances.

That has resulted in women across large tracts of the southern US and Midwest now having to travel much further to go to an abortion clinic in person. That has limited the options available to people who can’t just rely on medication abortion prescribed via telehealth or who sought other forms of reproductive care at these facilities.

The GOP spending bill would bring on the closure of additional clinics by defunding Planned Parenthood, the single largest abortion provider in the US, and other abortion clinics for at least 10 years. That would be disastrous not only for abortion access, but also for access to non-abortion reproductive care for low-income people.

The organization estimates that almost 200 of their clinics could close as a result of the legislation, affecting 1.1 million patients, the vast majority of whom live in states where abortion is legal. That includes its two clinics in Alaska, the only remaining abortion providers in the state, said Laurel Sakai, Planned Parenthood’s national director of public policy and government affairs.

Since 1977, the Hyde Amendment has banned the use of federal funds for abortion, with some narrow exceptions for when the life of the pregnant person is endangered or when pregnancy is the result of rape or incest. But Planned Parenthood, as a provider of general reproductive services, receives reimbursements from Medicaid, as well as federal grants through the Title X program, which funds affordable family planning and related preventative care for low-income families.

If Republicans were to cut off those funds, as proposed in the draft Senate bill, “there just simply aren’t enough other providers to be able to take on the care that Planned Parenthood gives,” Sakai said.

The reproductive rights think tank Guttmacher Institute found that federally qualified health centers — often pointed to as an alternative to Planned Parenthood by proponents of measures to defund the organization — would have to increase their capacity to administer contraceptive care by 56 percent to fill the gap.

Planned Parenthood closures could affect not just the availability of in-person abortions, but also medication abortion.

“A lot of the doctors who provide medication abortion care do so through Planned Parenthood and other brick-and-mortar clinics,” O’Connor said. “We certainly have a lot of providers who are doing telehealth now, but there’s still a good number of providers who provide medication abortion at brick-and-mortar clinics.”

The provision to defund Planned Parenthood, which the Congressional Budget Office estimates would raise the deficit by about $300 million, faced procedural hurdles.

Because Republicans are trying to pass their bill via a process known as budget reconciliation, there are certain rules about what kind of provisions can be included. That includes a requirement that a provision included in a reconciliation package must have a “more than incidental” impact on the budget.

Senate parliamentarian Elizabeth MacDonough reportedly determined Monday that the Planned Parenthood provision qualifies.

That clears the way for Congress to defund the organization, along with last week’s Supreme Court ruling allowing states to do the same. On Thursday, the justices ruled that Planned Parenthood and one of its patients could not challenge South Carolina’s efforts to deny Medicaid funds to the organization.

In its current form, the Republican spending bill would not only cause abortion clinics to close. It would also affect insurance coverage for abortion and reproductive care.

For one, 10.3 million fewer Americans are projected to be enrolled in Medicaid by 2034 if the bill passes. That may make it prohibitively expensive for them to access reproductive care other than abortion care, which is not covered under Medicaid.

The bill also excludes Affordable Care Act marketplace plans that offer abortion coverage from cost-sharing reductions, which decrease out-of-pocket costs for lower-income individuals. That won’t affect ACA marketplace plans in the 25 states that currently prohibit those plans from offering abortion coverage. But elsewhere, it will incentivize insurers administering ACA plans to either drop coverage for abortion or, in states where they are legally required to offer such coverage, increase premiums.

It’s not clear exactly how much premiums could increase in those states, which include California and New York, or whether insurers may find ways to make up for the loss of cost-sharing reductions.

But O’Connor said that reproductive rights activists anticipate that the provision is just an “opening salvo in a continuing fight that would ultimately pit those states that require coverage against the federal government and put insurers in an impossible position.”

“What we assume is that this is just the first of many tactics that this Congress and this administration might take to make it more difficult for insurers to cover abortion,” she added.