1 big thing:

1 big thing: The shame of the Atlanta pen

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2. New lawsuit challenges Georgia abortion ban  

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3. County tells churches they can't host homeschooled students

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4. A poll, hot off the presses

On the job hunt?

5. One photo to go: Whatever you do, do it with style

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It's 🐪 day. How do you plan to conquer it?

⛱ Today's weather: Mostly sunny, with a high near 92. 

Situational awareness: The CEO of Bryan County-based Daniel Defense will be on a panel testifying before the House Oversight Committee this morning about gun manufacturers' role in the country's gun violence. 

Daniel Defense produced the weapon used by the Uvalde shooter, and its marketing techniques have come under scrutiny.

Today's newsletter is 948 words — a 3.5-minute read.

🤓 Thomas is nerding out on the Georgia State University library's Planning Atlanta photography archive.

😍 Kristal wants to add this plant to her growing collection. 

🤤 Emma is pretty excited about Poco Loco & Butter and Cream’s "Choco Loco Taco" reboot. 

Plus: 📚 Churches cited for homeschooling

Atlanta

A daily look at the most significant and interesting stories affecting Atlanta. Written by Emma Hurt, Kristal Dixon and Thomas Wheatley.

Axios Atlanta

National

Politicians in red states are placing new limits on gender-affirming care for transgender people, creating a patchwork of sanctions on health providers who offer such services and limits on access.

By the numbers: Over 100 pieces of legislation introduced in state legislatures in 2023 focus on banning aspects of gender-affirming medical care, according to data from the American Civil Liberties Union. 

Proponents of the measures have characterized gender-affirming care as "harmful" and "experimental" medical procedures. But such care has been deemed medically necessary and potentially life-saving for transgender youths by leading medical associations, including the American Medical Association and the American Academy of Pediatrics.

State of play: Utah in January enacted a law banning gender-affirming health care for transgender youth. Since then, Mississippi, South Dakota and Tennessee have followed suit.

Arkansas in 2021 became the first state to make gender-affirming care for patients under 18 illegal, but the ban is being challenged in court. A similar law in Alabama is also on hold.

Arizona in 2022 enacted a law prohibiting gender-affirming care from being offered to trans people under 18. That law is set to take effect in March.

Missouri's attorney general declared in March that gender-affirming care treatments are prohibited under state law because they are "experimental."

Florida last year became the first state to enact a ban through a non-legislative body, using a medical board appointed by Gov. Ron DeSantis. Legal experts fear it could set a precedent for restrictions on other forms of health care.

Florida Republicans turned to executive action from DeSantis — who has openly opposed gender-affirming care for minors — after a legislative attempt failed, per legal experts.

In Texas, Gov. Greg Abbott issued a directive ordering state agencies to investigate parents for child abuse for seeking gender-affirming care for their trans kids.

Reality check: 71% of LGBTQ youth — including 86% of trans and nonbinary youth — say that debate around state restrictions on LGBTQ young people has negatively impacted their mental health, according to a poll by The Trevor Project, which provides crisis intervention and suicide prevention services to LGBTQ youth.

Between the lines: Most anti-trans bills look to prohibit gender-affirming care for people under 18, but some states have introduced measures that extend to adults.

Kansas, South Carolina, Oklahoma and Texas have bills moving through their legislatures to ban care for people under 21. Texas also has a proposed ban for people under 26.

Zoom in: Texas,  Wyoming and New Hampshire have bills that also categorize gender-affirming care as child abuse under state law.

What else is happening: Lawmakers in states like Indiana, Kentucky, Missouri and Oklahoma  have introduced bills prohibiting the use of state funds to pay for gender-affirming medical care, as well as barring insurers from offering coverage.

What they're saying: Opponents say the measures impose restrictions on the doctor-patient relationship. 

"Decisions around transgender medical care should be between trans patients, their families, and their doctors — not made by politicians," said Kasey Suffredini, vice president of advocacy and government affairs at The Trevor Project.

Meanwhile... Lawmakers in at least 21 states are working on "trans refugee laws" that would allow out-of-state patients to seek gender-affirming care within their borders to avoid criminal prosecution, said Elliot Imse, executive director of LGBTQ Victory Institute, an advocacy group working with state lawmakers across the U.S.

Such laws have been enacted in California, Connecticut, Illinois and Massachusetts. They look to protect trans patients and health providers from potential prosecution in other states.

Below are prominent anti-trans health care curbs in the 2023 legislative cycle.

Anti-trans health care bills that have been enacted

Arkansas: SB 199 makes it easier to sue health providers who provide gender-affirming care to a minor, effectively bringing back the state's blocked ban.

Mississippi: HB 1125 states that health providers cannot offer gender-affirming surgeries, puberty blockers or hormone therapy to trans youth under 18. If a provider violates the law, they could lose their license and face civil lawsuits.

South Dakota: Under HB 1080, a health care provider cannot offer gender-affirming care "for the purpose of attempting to alter the appearance of, or to validate a minor's perception of, the minor's sex."

A medical provider risks lose their license, as well as risk civil action, if they provide this type of car to trans youth.

Tennessee: SB 1 says that a health provider cannot "perform or offer to perform" any sort of gender-affirming care to trans minors. Doing so puts a provider at risk of lawsuits from the minor, their guardian or the state attorney general.

Utah: SB 16 specifically prohibits health care providers in the state from performing gender-affirming surgeries on trans youth and places an indefinite moratorium on their access to hormone therapy and puberty blockers.

Go deeper: Axios Explains: Gender-affirming care in the U.S.

Axios Explains: Gender-affirming care in the U.S.

What states are restricting transgender health care

A record-high over 300 anti-LGBTQ state bills have been introduced, including more than 100 gender-affirming care restrictions.

LGBTQ

This is a map showing anti-transgender legislation by state.

Politicians in red states are placing new limits on <a class="gtmContentClick" data-vars-link-text="gender-affirming care" data-vars-click-url="https://www.axios.com/2023/03/03/gender-affirming-care-trans-youth-us" data-vars-item="in_content_link" href="https://www.axios.com/2023/03/03/gender-affirming-care-trans-youth-us" target="_self">gender-affirming care</a> for transgender people, creating a patchwork of sanctions on health providers who offer such services and limits on access.By the numbers: Over 100 pieces of legislation introduced in state legislatures in 2023 focus on banning aspects of gender-affirming medical care, according to <a class="gtmContentClick" data-vars-link-text="data" data-vars-click-url="https://www.aclu.org/legislative-attacks-on-lgbtq-rights?impact=health&amp;state=" data-vars-item="in_content_link" href="https://www.aclu.org/legislative-attacks-on-lgbtq-rights?impact=health&amp;state=" target="_blank">data</a> from the American Civil Liberties Union.

The U.S. faces a range of health care flashpoints — unaffordable drugs, opioids, vaping — as we debate whether to adopt universal care. For now, the Affordable Care Act is the law of the land, but Republicans want to issue it a final death blow.

Health

The fight over abortion pills has been escalating since before Roe v. Wade was overturned, but the pills' availability is in danger now more than ever.

Why it matters: With pills now accounting for the majority of abortions, opponents of the procedure are focusing on legislatures and courts to erect barriers. But that's triggering thorny legal questions, foremost of which is playing out in a federal court in Texas over whether the FDA has the final say on whether the pills are safe.

Abortion pills have been available in the U.S. for decades, and while the FDA says that medical evidence shows they are safe and effective, the drugs have been subject of fights over manufacturing, distribution, insurance coverage and who can provide them.

Confusion around the drugs continues in the U.S., where nearly half of adults say they are not sure whether medication abortion is legal in the state they live in, according to a recent KFF survey.

Over half of abortions in the U.S. occur via abortion pills, according to the Guttmacher Institute, a research organization that supports abortion rights. 

Abortion pills are often accessed online and mailed to patients, effectively working to circumvent state bans and restrictions that took effect after the Supreme Court overturned Roe v. Wade.

Medication abortion normally consists of two pills: mifepristone and misoprostol.    

Mifepristone is approved by the FDA to be used alongside misoprostol to end a pregnancy during the first 10 weeks — this includes elective abortions and miscarriages. 

A patient first takes 200 milligrams of mifepristone orally to stop the pregnancy from growing. This is followed 1-2 days later by 800 milligrams of misoprostol taken buccally — placed between the gums and cheek — which causes cramping and bleeding to empty the uterus.

The mifepristone-misoprostol combination regimen has been found to be at least 95% effective at terminating a pregnancy.

Zoom in: Misoprostol — which is approved for the prevention and treatment of gastric ulcers — can also be taken on its own for medication abortion, a method that is supported by the World Health Organization.

While misoprostol is not specifically FDA-approved for abortions, it can still be used to terminate a pregnancy. A health provider has the authority to prescribe the drug for off-label use if they consider it to be medically appropriate.

The misoprostol-only method is slightly less effective than the combination regimen. A February study with over 1,000 U.S. participants found that using misoprostol alone was 88% effective at ending a pregnancy. 

How are the pills used in miscarriage care?

The mifepristone-misoprostol method is considered the most effective medication regimen for managing early miscarriages, per Planned Parenthood. 

The drugs are used to make sure that pregnancy tissue passes after there has been a miscarriage, which makes the patient experience bleeding.

While pregnancy tissue can pass naturally and take a few weeks to do so, the experience can be incredibly distressing for the pregnant person, so they can take mifepristone and misoprostol to ease and speed up that process.

Details: A 2018 study from the New England Journal of Medicine found that the combination regimen was more effective than the use of misoprostol alone, and reduced the likelihood for additional treatments — which might include additional doses of misoprostol or potentially surgical intervention.

Abortion pills are considered safe and effective by major medical groups, such as the American Medical Association and the American College of Obstetricians and Gynecologists.

"Medication abortion using mifepristone and misoprostol has always been part of my practice. It's incredibly safe and effective for people to end their pregnancies or to treat their pregnancy losses or miscarriages," said Jamila Perritt, president and CEO of Physicians for Reproductive Health and an OB-GYN in Washington, D.C., during a roundtable with abortion providers.

Zoom out: Mifepristone is approved for abortion use in over 80 countries.

Why is mifepristone at risk of becoming unavailable?

A coalition of anti-abortion groups in November filed a lawsuit challenging the FDA's overall approval of mifepristone. The plaintiffs argue that that the FDA did not properly authorize mifepristone for terminating pregnancies.

The lawsuit was filed in the Northern District of Texas, where a Trump-appointed federal judge who has openly opposed Roe v. Wade is considering whether to temporarily block the FDA's approval of mifepristone, which would make the medication unavailable even in states that protect access to abortion.

Meanwhile: Two lawsuits in North Carolina and West Virginia are challenging restrictions in those states to settle the question on whether states can regulate or limit drugs that have been approved by the FDA.

Another lawsuit brought by Democratic attorneys general challenges the FDA's dispensing restrictions on mifepristone, arguing that they are "unnecessary" because they drug is considered to be safe and effective.

The FDA first approved mifepristone for pregnancy termination in 2000 under the agency's Risk Evaluation and Mitigation Strategy, a program that adds dispensing restrictions to certain drugs, including requiring specific certifications for those who prescribe them. 

Since its initial approval, the FDA has loosened mifepristone's REMS restrictions over the years, including getting rid of the original in-person requirement and allowing the drug to be accessible via telehealth, as well as letting pharmacists become dispensing-certified.

State of play: Patients can go on websites like Aid Access, Hey Jane and Choix to get the drugs online and have them mailed.

Yes, but: At least 17 states have laws in place that prohibit the use of telemedicine to access abortion medication, and instead require patients to take the treatments in a health care facility.

So-called trigger laws took effect that can make it impossible for people to access abortion pills. Since then, pill providers have experienced soaring demand online.

Most of these bans and restrictions are specific to the pill provider, not the patient. As a result, a user could travel across state lines to pick up the pills. 

Some telemedicine providers — such as Aid Access — are located overseas and mail the pills to all 50 states. However, people who live in red states face a higher risk of prosecution.

What's happening: The FDA recently made a regulatory change to allow retail pharmacies to offer abortion pills, an update that looks to expand access as more red states move to ban or restrict access to abortion.

Walgreens and CVS, two of the largest U.S. pharmacy chains, have said that they plan to have some of their pharmacies certified to dispense mifepristone, as long as it does not conflict with state and federal law. 

Editor's note: This story has been updated with information about the lawsuit from Democratic attorneys general. 

How abortion pills work and why they're in the spotlight

Demand for abortion pills has soared since the Supreme Court decided to overturn Roe v. Wade.

A combination pack of mifepristone (left) and misoprostol tablets, two medicines used together as the abortion pill. Photo: Elisa Wells/ Plan C/AFP via Getty Images

Abortion

Axios Explains: Abortion

Public health

The <a class="gtmContentClick" data-vars-link-text="fight over abortion pills" data-vars-click-url="https://www.axios.com/2022/06/24/abortion-pills-mifepristone-misoprostol-roe-wade" data-vars-content-id="70893cb7-f24c-4d72-a61d-251fa9c0ff4e" data-vars-headline="How abortion pills work and why they&#x27;re in the spotlight" data-vars-event-category="story" data-vars-sub-category="story" data-vars-item="in_content_link" href="https://www.axios.com/2022/06/24/abortion-pills-mifepristone-misoprostol-roe-wade" target="_self">fight over abortion pills</a> has been escalating since before <a class="gtmContentClick" data-vars-link-text="Roe v. Wade was overturned" data-vars-click-url="https://www.axios.com/2022/06/24/roe-wade-decision-abortion" data-vars-content-id="70893cb7-f24c-4d72-a61d-251fa9c0ff4e" data-vars-headline="How abortion pills work and why they&#x27;re in the spotlight" data-vars-event-category="story" data-vars-sub-category="story" data-vars-item="in_content_link" href="https://www.axios.com/2022/06/24/roe-wade-decision-abortion" target="_self">Roe v. Wade was overturned</a>, but the pills&#x27; availability is in danger now more than ever.Why it matters: With pills now accounting for the majority of abortions, opponents of the procedure are focusing on legislatures and courts to erect barriers. <a class="gtmContentClick" data-vars-link-text="But that&#x27;s triggering thorny legal questions" data-vars-click-url="https://www.axios.com/2023/01/04/lawsuit-fda-abortion-pills-mifepristone-ban" data-vars-content-id="70893cb7-f24c-4d72-a61d-251fa9c0ff4e" data-vars-headline="How abortion pills work and why they&#x27;re in the spotlight" data-vars-event-category="story" data-vars-sub-category="story" data-vars-item="in_content_link" href="https://www.axios.com/2023/01/04/lawsuit-fda-abortion-pills-mifepristone-ban" target="_self">But that&#x27;s triggering thorny legal questions</a>, foremost of which is playing out in a federal court in Texas over whether the FDA has the final say on whether the pills are safe.

President Biden has made the COVID-19 crisis and a post-Trump return to national unity and traditional democratic ideals his top priorities. From vaccinations to stimulus to schools, Biden is seeking bipartisan compromise while showing a willingness to use executive authority and bare Democratic majorities in the U.S. House and Senate to implement his policies. Republican leaders are navigating deep party divisions over if and how to move beyond former President Trump.

Politics & Policy

The Oklahoma Supreme Court ruled 5-4 on Tuesday that the state constitution guarantees a "limited right" to abortion, including in cases where there is a "reasonable" certainty pregnancy threatens a person's life.

Why it matters: Abortion providers filed a lawsuit last year challenging two laws in the state, a pre-Roe ban and another one that the governor signed into law in 2022. The court ultimately ruled that the 2022 ban interfered with the "inherent right to terminate a pregnancy to preserve the woman's life."

Context: Abortion providers had argued that abortion rights are protected by the state constitution, which says: "No person shall be deprived of life, liberty, or property, without due process of law."

The 2022 ban specifically states that a health provider cannot provide an abortion unless a person's life is "endangered by a physical disorder, physical illness or physical injury."

The pre-Roe ban is less strict, allowing abortions when the procedure is "necessary to preserve her life."

Driving the news: In its opinion, the court concluded that the provisions of the 2022 law are "much more invasive to a woman's right to terminate a pregnancy in order to preserve her life." 

The opinion highlights a language discrepancy between "save the life of a pregnant woman" and "preserve her life," both of which are used in different state laws addressing abortion.  

The judges say that the first phrase, "save the life of a pregnant woman,"  limits abortions to a pregnant woman "in a medical emergency" if her life "is endangered."

Details: That portion of the law, the opinion said, requires a woman to be in "actual and present danger" to obtain a "medically necessary abortion." 

"We know of no other law that requires one to wait until there is an actual medical emergency in order to receive treatment when the harmful condition is known or probable to occur in the future," the opinion reads. 

"Requiring one to wait until there is a medical emergency would further endanger the life of the pregnant woman and does not serve a compelling state interest."

What they're saying: "We are disappointed that the Court declined to rule whether the state Constitution also protects the right to abortion outside of these circumstances," said Nancy Northup, president and CEO of the Center for Reproductive Rights, in a statement. 

"The Oklahoma Supreme Court’s own precedent and the plain language of the Oklahoma Constitution guarantee the right to liberty and assure that a broad right to reproductive autonomy exists."

Editor's note: This article has been updated with comment from Nancy Northup, president and CEO of the Center for Reproductive Rights.

Oklahoma Supreme Court: State constitution grants "limited right" to abortion

In its opinion, the court concluded that the provisions of the 2022 law are "much more invasive to a woman's right to terminate a pregnancy in order to preserve her life."

A woman takes part in a nationwide abortion rights protest in New York on March 12, 2023. Photo: Kena Betancur/AFP via Getty Images

Oklahoma

Pharma lowers insulin costs to save money

Illustration of a syringe pulling from a vial with a hundred dollar bill as a label.  

Medicaid

The biggest U.S. insulin manufacturers have each committed to lower the cost of their products — a move that will save them money by lowering the amount they&#x27;d otherwise have to rebate Medicaid.Driving the news: <a class="gtmContentClick" data-vars-link-text="Sanofi" data-vars-click-url="https://www.sanofi.com/en/media-room/press-releases/2023/2023-03-16-20-06-43-2629188" data-vars-content-id="db247039-971a-4e72-8f28-ea9e9dd511e3" data-vars-headline="Pharma lowers insulin costs to save money" data-vars-event-category="story" data-vars-sub-category="story" data-vars-item="in_content_link" href="https://www.sanofi.com/en/media-room/press-releases/2023/2023-03-16-20-06-43-2629188" target="_blank">Sanofi</a> yesterday said it plans to cap out-of-pocket costs for its most prescribed insulin, Lantus, at $35 per month for people with private insurance, following similar steps from <a class="gtmContentClick" data-vars-link-text="Eli Lilly" data-vars-click-url="https://www.axios.com/2023/03/01/eli-lilly-insulin-price-cut" data-vars-content-id="db247039-971a-4e72-8f28-ea9e9dd511e3" data-vars-headline="Pharma lowers insulin costs to save money" data-vars-event-category="story" data-vars-sub-category="story" data-vars-item="in_content_link" href="https://www.axios.com/2023/03/01/eli-lilly-insulin-price-cut" target="_self">Eli Lilly</a> and <a class="gtmContentClick" data-vars-link-text="Novo Nordisk" data-vars-click-url="https://www.novonordisk.com/news-and-media/latest-news/lowering-us-list-prices-of-several-products-.html" data-vars-content-id="db247039-971a-4e72-8f28-ea9e9dd511e3" data-vars-headline="Pharma lowers insulin costs to save money" data-vars-event-category="story" data-vars-sub-category="story" data-vars-item="in_content_link" href="https://www.novonordisk.com/news-and-media/latest-news/lowering-us-list-prices-of-several-products-.html" target="_blank">Novo Nordisk</a>.

Officials in Texas have released a transcript of this week's hearing in a major federal case that could limit access to abortion pills for millions of people across the country. 

Why it matters: The legal challenge was brought by a coalition of anti-abortion groups that argued the FDA did not properly authorize the pill for terminating pregnancies — and a decision in their favor could reverse the agency's authority on drug regulation for the first time.

The groups are asking the judge to grant a preliminary injunction on the FDA's approval of mifepristone, used alongside misoprostol for medication abortion.

The FDA first approved mifepristone in 2000. Now, medication abortion accounts for the majority of abortions in the U.S., according to the Guttmacher Institute.

What happened: District Judge Matthew Kacsmaryk, a Trump appointee who openly opposed Roe v. Wade, asked attorneys in the case a series of questions about legal precedent and the drug approval process during the hearing Wednesday.

Kacsmaryk at one point asked Erik Baptist, one of the anti-abortion groups' attorneys, if he could name any other cases in which a court had intervened when a drug had already been on the market for several years.

Baptist responded that he could not, and proceeded to explain that his clients had been trying for years to challenge the approval through citizen petitions that they say the FDA did not respond to in time.

The judge also asked the defendants, represented by the Department of Justice, about the FDA's use of a specific process known as Subpart H to originally approve mifepristone, noting that it had typically been used for drugs that treat diseases such as cancer and HIV.

The big picture: While Wednesday’s court hearing was open to the public, attendance was limited. Fewer than 19 reporters and 19 members of the public were allowed in the courtroom, according to the Center for Reproductive Rights.

"We represent and advise clinics who provide abortion care to patients across the country, and who could be directly impacted by this lawsuit, yet we were not allowed entry to the hearing despite traveling to Amarillo at a moment’s notice and waiting in line for hours," said Elisabeth Smith, the Center's director of state advocacy.

Worth noting: Kacsmaryk had initially planned to delay telling the public about the hearing due to security concerns, per a previous court transcript.

After The Washington Post reported his plans and several news outlets demanded that the hearing schedule be made public, the judge announced the details on Monday evening.

What we’re watching: A decision to suspend the FDA’s authorization of mifepristone would make it unavailable nationwide, and would impact how health providers across the country offer abortion care.

Some abortion providers have already said they plan to switch to a misoprostol-only regimen for medication abortions, and others say they plan to solely focus clinical abortions.

State of play: Kacsmaryk said after the hearing that he would issue a ruling "as soon as possible."

Editor's note: This story has been updated with additional details from the transcript. 

READ: Transcript from high-stakes hearing on abortion pills

The case could potentially reverse the agency's authority on drug regulation for the first time.

Photo of Mifeprex pills laid out next to the brand's box

Mifepristone tablets. Photo: Stormi Greener/Star Tribune via Getty Images

Officials in Texas have released a transcript of this week&#x27;s hearing in a major federal case that could limit access to <a class="gtmContentClick" data-vars-link-text="abortion pills" data-vars-click-url="https://www.axios.com/2023/02/22/abortion-pills-supreme-court-roe" data-vars-content-id="efa6a83b-eb06-4c0c-8c05-2a5036d0ea0b" data-vars-headline="READ: Transcript from high-stakes hearing on abortion pills" data-vars-event-category="story" data-vars-sub-category="story" data-vars-item="in_content_link" href="https://www.axios.com/2023/02/22/abortion-pills-supreme-court-roe" target="_self">abortion pills</a> for millions of people across the country. Why it matters: The legal challenge was brought by a coalition of anti-abortion groups that argued the FDA did not properly authorize the pill for terminating pregnancies — and a decision in their favor could <a class="gtmContentClick" data-vars-link-text="reverse the agency&#x27;s authority" data-vars-click-url="https://www.axios.com/2023/03/16/abortion-pill-fda-impact-drug-regulation" data-vars-content-id="efa6a83b-eb06-4c0c-8c05-2a5036d0ea0b" data-vars-headline="READ: Transcript from high-stakes hearing on abortion pills" data-vars-event-category="story" data-vars-sub-category="story" data-vars-item="in_content_link" href="https://www.axios.com/2023/03/16/abortion-pill-fda-impact-drug-regulation" target="_self">reverse the agency&#x27;s authority</a> on drug regulation for the first time.

Oriana González

Stories

Oklahoma Supreme Court: State constitution grants "limited right" to abortion

What states are restricting transgender health care

READ: Transcript from high-stakes hearing on abortion pills

How abortion pills work and why they're in the spotlight

Pharma lowers insulin costs to save money

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