Project 2025, the 900-page conservative playbook for the next Republican president, issues an ultimatum for California: track and report abortion data to the federal government or risk losing billions in Medicaid funding for reproductive health.
California is one of only three states that do not report abortion data to the Centers for Disease Control and Prevention.
Project 2025鈥檚 proposed federal mandate directly conflicts with the state鈥檚 strong protections for patient privacy and could dismantle the legal and ethical foundations that have made California a refuge for those seeking reproductive care.
The blueprint, crafted by Donald Trump allies and leaders in his first administration, clearly targets states with abortion protections like California, seeking the kind of data that could be used to target abortion-seekers or even criminally punish out-of-staters who come to the state for reproductive health services.
鈥淏ecause liberal states have now become sanctuaries for abortion tourism, [the Department of Health and Human Services] should use every available tool, including the cutting of funds, to ensure that every state reports exactly how many abortions take place within its borders, at what gestational age of the child, for what reason, the mother鈥檚 state of residence, and by what method,鈥� reads on abortion reporting.
Roger Severino, who served as the Department of Health and Human Services鈥� director of the Office for Civil Rights under Trump, authored Project 2025鈥檚 abortion surveillance plan. He is now the vice president of domestic policy at the Heritage Foundation, the conservative think tank behind Project 2025. He declined an interview with CalMatters.
As Project 2025 and reproductive health have become major campaign themes, Trump continues to distance himself from the right-wing plan. He鈥檚 repeatedly called some of the project鈥檚 proposals 鈥渁bysmal鈥� and has said 鈥淚 have no idea who is behind it.鈥� Paul Dans, the Project 2025 director and a former top adviser in Trump鈥檚 administration, resigned from the Heritage Foundation in July after Trump began to disengage from the plan.
In yesterday鈥檚 presidential debate, Vice President Kamala Harris explicitly warned about Project 2025鈥檚 plans to monitor 鈥測our pregnancies, your miscarriages.鈥�
On the stage, Trump denied supporting a national abortion ban, in part because the fall of Roe led to his desire for each state to implement its own policy. 鈥淭his is an issue that鈥檚 torn our country apart for 52 years,鈥� Trump said on the debate stage. 鈥淓very legal scholar, every Democrat, every Republican, liberal, conservative, they all wanted this issue to be brought back to the states where the people could vote. And that鈥檚 what happened.鈥�
Harris鈥� home state has a long history of protecting reproductive rights. The state legalized abortion in 1967, six years before the landmark decision, and has since enacted numerous laws to ensure access to abortion care.
The California Constitution includes an explicit right to privacy, which has been interpreted by state courts to guarantee the right to choose an abortion.
California, along with Maryland and New Hampshire, does not require abortion providers to report patient data to the federal government, as Severino points out. The California Department of Public Health said just days after Roe v. Wade was overturned that it does not report abortion data to the federal government The states that do collect data generally use it for public health analysis that can help improve abortion access by identifying gaps and needs.
Under Project 2025, all 50 states would be required to submit to the federal government data such as the reason for the abortion, fetus鈥� gestational age, the birthing parent鈥檚 state of residence, whether the procedure was surgical or pill-induced, and more.
Cat Duffy, a policy analyst at the National Health Law Program, said the intention of collecting this data 鈥渋s not one of scientific exploration.鈥�
鈥淚t鈥檚 to create a culture of fear, which will spread, not just to abortion seekers, but pregnant people as well, who will be afraid of going to the doctor and what they tell the doctor,鈥� she said.
Medi-Cal and access to critical care
Medicaid 鈥� known as Medi-Cal in California 鈥� is the of maternity care in the country. So, if California fought the proposed abortion reporting requirements, billions of dollars in Medicaid funding that provides critical reproductive healthcare services would be at risk.
The state didn鈥檛 immediately release figures showing how many Californians rely on Medi-Cal for family planning or how much money would be at stake. But Medi-Cal鈥檚 family planning funds pays for about 39 percent of all births in the state. In total, Medi-Cal covers about 14.2 million Californians, according to a . Medi-Cal in federal funds in fiscal year 2021鈥�2022.
Medicaid operates as a state-federal partnership, with the federal government paying a percentage of the costs. And in exchange, states have to comply with minimum requirements set forth by the federal government.
Some examples of minimum requirements include providing such as transportation to medical appointments; maintaining programs for preventing and detecting Medicaid fraud; and reporting immunization figures and annual pediatrician visits. Project 2025 seeks to establish abortion surveillance as another minimum requirement.
Duffy estimates Medi-Cal spends multiple billions annually on reproductive health, considering the costs of comprehensive services like contraceptives, counseling, reproductive health education, prenatal care, labor and delivery, postpartum care, STI and cancer testing, and infertility treatments.
鈥淚f a state like California decided to not comply with those abortion reporting requirements, it could lose billions of dollars and would likely hamstring the ability of the state to provide sexual and reproductive healthcare services,鈥� Duffy said. 鈥淏ecause while I think that there are states that would try to compensate with state funds, it鈥檚 just a lot of money to make up and that it could potentially be really devastating.鈥�
Duffy noted that the proposal could increase surveillance of individuals seeking abortions, particularly targeting vulnerable populations. The fear of being monitored or reported could deter these groups from seeking necessary healthcare, increasing health risks, she said, adding that it can also heighten the risk of legal repercussions for both patients and providers, further marginalizing those already facing systemic inequalities.
鈥淭hose disproportionately impacted by the provisions in Project 2025 are the same folks that are disproportionately impacted by abortion bans: It鈥檚 communities of color, it鈥檚 young people, it is LGBTQ+ individuals.鈥�
Fear of being monitored鈥攊n the clinic and beyond
Josie Urbina, an OB-GYN at San Francisco General Hospital and a research fellow at the University of California, San Francisco, said some individuals are more prone to pregnancy complications due to social determinants like low socioeconomic status, living in urban areas, or exposure to toxins. These factors, along with pre-existing conditions such as diabetes, heart disease, high blood pressure, and chronic stress, contribute to poor outcomes.
Research from the also found that while receiving an abortion does not negatively affect women鈥檚 health, being denied one leads to worsened financial, health, and family outcomes.
鈥淎nd what we鈥檝e seen sometimes for some of our patients who have these comorbidities is that they鈥檙e more susceptible to stillbirth, hemorrhage, preeclampsia and eclampsia,鈥� Urbina said. 鈥淎nd that can lead to complications that are life threatening, where a patient loses their life because of the severity of the medical condition that worsens with the progression of a pregnancy.鈥�
In recent years, abortion has increasingly in the United States, with a wave of restrictive laws and policies sweeping across state lines. Following the overturning of Roe v. Wade, many states enacted strict abortion bans, with some imposing severe penalties, including lengthy prison sentences, for healthcare providers who perform abortions.
These bans also create a chilling effect on those seeking care, as well as on the medical professionals who may fear prosecution. This trend has resulted in a patchwork of abortion access across the country, as the legality of the procedure and the risk of criminalization vary dramatically depending on geographic location.
Haley Tsukayama, associate director of legislative activism at the Electronic Frontier Foundation, said that the language used in Project 2025鈥檚 abortion surveillance proposal is framed to 鈥渙verhaul鈥� the medical system in a way where there will be more integrated data sharing, including intimate information ending up in the hands of data brokers where there鈥檚 room for possible data misuse.
鈥淭here isn鈥檛 a lot of talk about consent or patient knowledge in this document. So it certainly opens up doors to the possibility of more data sharing and possibly more scrutiny on the way that data flows,鈥� she said. 鈥淭he data that will be collected can get sent to data brokers who can re-identify information pretty quickly and paint a picture of your life.鈥�
This has already happened with that share data with Facebook and Google without users鈥� consent. If abortion data were similarly exposed, it could lead to serious privacy violations and unintended consequences, including harassment, discrimination, or even legal action against patients, Tsukayama said.
鈥淲e鈥檙e already in a supercharged, data-driven ecosystem,鈥� she said. 鈥淎nd we鈥檙e going to see that increase.鈥�
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