With the November election weeks away, President Donald Trump’s reelection campaign is leaning on his anti-abortion record — emphasizing reproductive health on the campaign trail as well as at August’s Republican National Convention.

Before joining the Republican Party, Trump said publicly he supported the right to have an abortion. Now, limiting abortion has become a signature issue for the president. In the 2016 race, he — along with many other then-candidates for the Republican presidential nomination — called for “defunding” Planned Parenthood. Candidate Trump also pledged to look “very, very carefully” at Roe v. Wade, the Supreme Court case that guarantees the constitutional right to abortion, and appoint judges who might overnturn it.

As president, Trump was the first sitting president to speak in person at the March for Life, an annual anti-abortion rally that draws hundreds of thousands. He has overseen a massive effort to curtail abortion, restrict access to contraception, and create more exemptions for both insurers and health care professionals when it comes to reproductive health services. All those changes have broad ramifications for health and health care. 

“It’s been a very holistic attack,” said Katherine Kraschel, a lecturer at Yale Law School and expert on reproductive health policy.

Experts agreed that reproductive health will likely emerge as a top administrative priority if Trump wins a second term. But it’s harder to tease out what, exactly, that will look like in practice.

Earlier this week, Trump put out a list of potential Supreme Court nominees that included Sens. Ted Cruz, Tom Cotton and Josh Hawley, all of whom have vocally opposed both abortion in general and the Roe v. Wade precedent specifically. That garnered praise from the Susan B. Anthony List, a major anti-abortion advocacy group. 

Federal judge picks have the most potential to reshape access to abortion specifically, and reproducitve health care broadly, Kraschel said. 

In a campaign letter sent September 3, Trump promised to, if re-elected, appoint federal judges who would oppose abortion, as well as to “fully defund” health care providers that perform abortions, including Planned Parenthood. Already, health care clinics do not use federal funds for abortion, a restriction enacted by the Hyde Amendment (with exceptions if continuing a pregnancy will endanger the parent’s life, or if the pregnancy was the result of rape or incest).

That emphasis appears to be part of an effort to court anti-abortion voters. And though its electoral implications are unclear, anti-abortion groups are rallying around Trump.

“During his first term, President Trump has become the most pro-life president our nation has ever seen. But there is more work to be done and that is why the pro-life movement is working vigorously to secure four more years for President Trump and Vice President Pence,” said Marjorie Dannenfelser, SBA List’s president, in a statement.

But gauging just how widespread the president’s impact on anti-abortion efforts has been is tricky. Virtually all of the president’s reproductive health initiatives have faced court challenges, and the record of success is about evenly split. 

A rule to let health care professionals decline to provide medical care if they had moral objections, which included procedures like abortion and gender-affirming care, was blocked last year by a federal judge, who called it “arbitrary and capricious.” 

But others regulations, including efforts to broaden exemptions for employers that might otherwise be required to provide insurance that covers contraception, have survived and had an impact.

And the administration is currently arguing that the Supreme Court undo a lower court order that allowed people in the pandemic to take mifepristone — a drug used as part of medication abortions — from home, without visiting a doctor in person. Appealing such a ruling straight to the Supreme Court and bypassing the appeals process was uncommon prior to Trump’s presidency, but has become a frequent strategy for the administration.

 The American College for Obstetricians and Gynecologists, the defendant in the case, notes that the Food and Drug Administration has relaxed in-person requirements for many other medications for the duration of the pandemic. Currently, the FDA is required to allow people to do medication abortions without an in-person visit. 

The administration has also issued rules barring any health care providers that refer patients to abortion services from getting money through the federal Title X program, which financially supports family planning services including contraception as well as STI screening and treatment. Beneficiaries are predominantly low-income, and mostly women. 

“President Trump has dramatically reshaped federal funding for family planning,” said Larry Levitt, a vice president at the Kaiser Family Foundation, a nonprofit health care research group. 

The move, largely seen as targeting Planned Parenthood, resulted in more than 1,000 health care clinics across the country losing federal funds — including more than 400 Planned Parenthood affiliates. Experts said the impact extended far beyond abortion access. Planned Parenthood, for example, performs half a million cancer screenings per year. And in many areas, Planned Parenthood is the only family planning provider. The Title X regulation is still winding through court challenges. 

Title X represents only a fraction of the government funding at stake. Medicaid, which provides insurance for low-income people and disproportionately covers Black and Latinx people, is a critical source of funding for Planned Parenthood, and is the single biggest source of insurance for people who visit its clinics. 

“These are millions of Americans who, by this one rule change, were directly impacted in a very significant way,” said Dr. Jen Villavicencio, an OB/GYN associated with the American College of Obstetricians and Gynecologists. “That has had a direct and negative, objectively negative impact on health around the country.”

Efforts to “fully” defund the organization could mean instituting changes so that people with that Medicaid wouldn’t be able to use it to pay for health care at Planned Parenthood, or similar clinics. But that’s complicated. Federal law says Medicaid must give patients their choice of family planning providers, assuming they are both willing and qualified. Referring patients for an abortion or providing abortions themselves is not supposed to be disqualifying. 

So Trump alone can’t “defund” Planned Parenthood entirely. Legally, Congress has to act, too, meaning Republicans would need to regain control of the House of Representatives and get a filibuster-proof majority in the Senate — both uphill battles.

But the administration could take other approaches. In 2018, representatives from the federal Centers for Medicare and Medicaid Services (CMS), a subsidiary of the Department of Health and Human Services, walked back an Obama-era guidance that told states they could not independently try to block Planned Parenthood from receiving Medicaid funding. That guidance “limited states’ flexibility,” CMS argued. 

Observers at the time argued that the change could reflect a willingness not to enforce the Medicaid law. And the administration could try to issue regulations changing how states define a “qualified Medicaid provider,” opening the door to blocking Planned Parenthood, noted Sara Rosenbaum, a professor of health law and policy at George Washington University. Again, though, it’s not clear whether that would stand muster in court. 

“If he gets a second term, I put this high on the list,” Rosenbaum said.