President-elect Donald Trump’s inauguration will restore sweeping power to anti-abortion activists’ staunchest ally, who many in the movement once deemed “the most pro-life president” in the nation’s history.

Four years after Trump left office the first time, the state of access looks radically different. Since the 2022 fall of Roe v. Wade, voters across the political spectrum have repeatedly shown they favor reproductive rights, even while voting for GOP lawmakers. It’s deterred some Republicans, Trump among them, from at least publicly endorsing restrictions that could be politically toxic.

Still, once in office, Trump and his administration would have substantial power to further restrict abortion. And with Roe overturned, the avenues to do so are larger than they were last time.

“There’s so many levers he could press,” said Greer Donley, a law professor at the University of Pittsburgh who tracks abortion policy. Despite his recent wavering, she added, “There’s no world in which I think he’s not going to do anything.”

Trump’s previous actions offer some clues as to what he could do this term, even without help from Congress. 

Medication abortion 

Abortion opponents have urged Trump to impose new restrictions on mifepristone, one of the medications used in most abortions. The Food and Drug Administration, a subsidiary of HHS, has approved mifepristone for use in abortion and has said it can be prescribed over telemedicine and taken from home, decisions grounded in a large body of medical research.

The FDA has historically acted with political independence. But that could change. Abortion opponents argue that the agency should be leveraged to limit when and how mifepristone can be used — rescinding its telemedicine approval, or even moving to take the drug off the market. Such decisions would go against scientific evidence. Though medical abortion is still possible without mifepristone, using larger doses of a drug called misoprostol, that one-medication regimen is slightly less safe and effective. 

Some health care providers have said they are unsure if they would continue offering medication abortion without mifepristone. Telehealth abortions using medication now make up about 1 in 5 abortions in the country — including many prescribed and provided across state lines, with health care providers in abortion-friendly states sending medication to those in states with bans.

When asked about whether he would direct the FDA to revoke mifepristone’s approval, Trump has been unclear.

The Comstock Act

Some of the most extreme anti-abortion activists also want the new administration to revive an 1873 anti-vice law known as the Comstock Act, which prohibits the mailing of materials that can be “used or applied for producing abortion, or for any indecent or immoral purpose.” 

The law was never repealed, but has not been enforced for decades. Some abortion opponents believe it could be leveraged now to ban the distribution of all abortion medications, or even all abortions entirely. The Biden administration’s DOJ has rejected this interpretation.

In August, Trump said he would not enforce Comstock. But others in his orbit, including contributors to the conservative policy blueprint known as Project 2025, have endorsed that approach. 

Planned Parenthood and Title X

During his last presidency, Trump worked to boot clinics, including Planned Parenthood — the nation’s largest provider of reproductive health care — from a federal program that supports family planning clinics for low-income people.

The program, Title X, does not directly fund abortion; the money supports health care services such as contraception, cancer screenings and testing for sexually transmitted infections. But the reproductive health clinics supported through the program sometimes may refer patients for abortion. Planned Parenthood, a frequent target of abortion opponents, operates the bulk of clinics that qualify for Title X funds.

Trump’s previous administration forbade Title X clinics from telling patients about abortion options, even if they did not provide the service themselves. The rule resulted in more than 400 Planned Parenthood clinics losing federal funding, along with more than 600 clinics outside of the organization. The Guttmacher Institute, which tracks reproductive health policy, estimates that the change cut the Title X program’s capacity in half, affecting about 1.6 million patients. The Biden administration reversed that policy. 

Trump’s first administration also moved to let anti-abortion centers — mostly non-medical facilities that focus on discouraging people from getting abortions — apply for and receive Title X funds, another policy the Biden administration undid.

On the 2024 campaign trail, Vice President-elect JD Vance said that once in office, Trump would support “defunding Planned Parenthood” — suggesting he might bring back the rule upon returning to the White House. 

Medicaid 

By law, Medicaid, the public insurance program for low-income Americans, is not allowed to discriminate against qualified family planning providers, meaning beneficiaries should be allowed to use that coverage at Planned Parenthood clinics. Medicaid is jointly funded and run by the federal government and individual states, so it can only cover abortion when the state government has specifically put money toward doing so. 

During Trump’s previous presidency, HHS authorized states to have “greater flexibility” in determining which providers could participate in the program, a move that some interpreted as easing the way for states to bar Planned Parenthood from Medicaid. In 2024, the Biden administration issued guidance remaining states that they were required to let Medicaid-covered patients choose their family planning provider, and that they could not prohibit a qualified clinic from participating in the program.

Currently, two states — Arkansas and Missouri — have actively enforced laws that prevent local Planned Parenthood clinics from participating in Medicaid. Similar laws in other states have been blocked by courts. 

The Supreme Court has agreed to hear a case weighing whether states can in fact kick Planned Parenthood out of their Medicaid programs, even when the insurance plan is not being used to cover abortion. The case concerns a 2018 executive order issued by South Carolina Gov. Henry McMaster, who sought to stop Medicaid funds from going to Planned Parenthood.

The Justice Department

The Biden administration has actively defended abortion rights in multiple cases.

One, concerning whether the Emergency Medical Treatment and Labor Act protects abortion access in particular medical emergencies, is pending at the U.S. Court of Appeals for the Ninth Circuit. Another, concerning the legality of medication abortion, is making its way through the federal courts as well.

After the transition, Trump’s Justice Department could drop those cases, or similarly decline to defend abortion rights in court. The new DOJ could also eliminate abortion rights initiatives, such as its Reproductive Rights Task Force, which was established after Roe’s overturn and monitored state anti-abortion policies that could violate federal law . 

The incoming administration could take an opposite approach to the DOJ under Biden — filing lawsuits that challenge state laws protecting abortion rights, rather than suing states with particular restrictions. 

Abortion for immigrants

The Trump administration sought to deny abortions to pregnant immigrant minors in U.S. custody. That effort was led by the Office of Refugee Resettlement, a subsidiary of Health and Human Services (HHS). E. Scott Lloyd, who headed the office under Trump, personally worked to discourage detained teenagers from getting abortions.

In one such case, a 17-year-old woman sought an abortion while detained in Texas. The Trump administration attempted to deny her access, prompting a lawsuit from the ACLU. The young woman received her abortion after a federal appeals court ruling almost two months later.

The global gag rule

Trump’s previous administration said recipients of American foreign aid could not “perform or actively promote abortion as a method of family planning,” a rule that weakened reproductive health providers well beyond the nation’s borders. The global gag rule applied to organizations that received money from government agencies — such as the U.S. Agency for International Development — to work in other countries.

A version of that policy, which was swiftly reversed by President Joe Biden, had been enforced under previous Republican presidents; Democratic administrations have consistently undone it. The Trump administration took a more sweeping approach in preventing global aid providers from talking about abortion. Under previous GOP administrations, the gag rule, also known as the Mexico City Policy, had applied to organizations receiving funding related to family planning. During the Trump presidency, it affected all global health funding disbursed by the United States.

The rule’s broad reach meant it affected about $12 billion and that covered work in contraception, HIV treatment, child nutrition, water sanitation, malaria and tuberculosis. The State Department under Trump’s first term also expanded the policy to include subcontractors who worked with organizations that got American funding, even if they had not received any aid dollars individually. 

Research shows that implementing the global gag rule typically results in family planning clinics shutting down, a decrease in contraceptive use and an increase in abortion. It is not clear whether the broader-reaching Trump rule increased the policy’s impact.