Kathaleen Pittman first heard legislators say that abortion providers should be legally required to have “hospital admitting privileges” in 2013. In her work as an administrator for Hope Medical Group in Shreveport, La., one of the last three abortion clinics in the state, the term had never come up much before: Since abortion complications are extremely uncommon, the clinic rarely, if ever, sends patients to the hospital.

Right away, Pittman knew this could become a major issue: For years, Louisiana’s legislature had been passing restrictions making it more difficult for abortion clinics to operate. And since so few abortion providers had admitting privileges already — at the time, there was only one in the state — she worried this could be the effort that ultimately succeeded in shutting Hope down.

Pittman immediately got to work, calling every hospital within striking distance of the clinic.

“Just tell me what we need to do,” she’d say.

What came next was different at every hospital, Pittman says. Sometimes, staff would turn her down right there on the phone. Usually, they’d ask for paperwork, eventually finding some issue with the doctor’s responses. At some point, Pittman’s contact at the hospital always seemed to go dark, avoiding follow-up calls. The one time a hospital agreed to extend privileges to a Hope Clinic doctor, green-lighting him to see patients at their facility, Pittman says, it didn’t last: A few longtime hospital physicians didn’t agree with the decision to support abortion providers, a hospital staff member eventually told the clinic, according to Pittman. The offer was rescinded.

“The hospital staff doesn’t want that political battle on their hands,” Pittman says.

Two of the three hospital systems in Shreveport declined requests to comment for this story. The third, Christus Shreveport-Bossier, a Catholic hospital, said, “We’re committed to protecting the value of life. We operate within the Catholic tradition, in terms of the ethical and religious directive for our health care services.”

Hope Medical Group is one of the plaintiffs in Wednesday’s high-profile Supreme Court case, June Medical Services v. Russo, when the justices will hear arguments on the constitutionality of requiring abortion providers in Louisiana to obtain hospital admitting privileges. It’s been called “the case that could end Roe v. Wade,” largely because of barriers like those described by Pittman: It’s not easy for abortion providers to get hospital admitting privileges. Hospitals have little incentive to hand them out, especially in conservative states like Louisiana, where they are particularly wary of coming across as supporting abortion rights.

Hospital admitting privileges have been part of the national abortion debate since 2013, when Texas passed a law requiring abortion providers to obtain privileges, forcing clinics across the state to close. (That law was eventually struck down by the Supreme Court in Whole Woman’s Health v. Hellerstedt, the 2016 case virtually identical to June Medical Services, prompting many critics to question why the court is re-litigating the issue four years later.)

Rather than pushing for Roe v. Wade to be overturned altogether, many anti-abortion groups are advocating for an incrementalist approach, arguing for clinic restrictions they say make abortion safer for women, says Mary Ziegler, a law professor at Florida State University and author of the forthcoming book, “Abortion and the Law in America.”

These restrictions may seem like something advocates on both sides can agree on, designed to help women seeking safe access to the procedure, says Ziegler. Admitting privileges, in particular, can appear “pretty innocuous” and “politically neutral,” she says, which is part of why anti-abortion groups have had so much success pushing them through state legislatures. (Louisiana abortion clinics have been granted a stay while the case makes its way through the courts, allowing abortion providers to practice without admitting privileges until the high court issues its decision.)

“People don’t really understand why people do or don’t get admitting privileges,” says Ziegler. “If you don’t dig into the evidence or the data, then it just sounds like better care for patients. At the minimum, it sounds like you’re providing an extra layer of insurance or safety.”

Anti-abortion advocates will often argue that their first priority is the safety and well-being of women. Abortion providers need hospital admitting privileges, they say, because complications do occur, and the clinic doctor should be able to go with the patient to the hospital, instead of sending her to whatever doctor she might see at the emergency room.

“It is simply not acceptable for us to allow women to be abandoned at the hospital door,” says Catherine Glenn Foster, president and CEO of Americans United for Life, the anti-abortion legal group that first introduced the model law that shaped the admitting privileges legislation in both Texas and Louisiana. “Even if it’s just one in 1,000 women who has a complication, one in 10,000 women. However many women it is, let’s save their lives.”

It’s hard to see a downside, says Foster: Why not just require all providers to have admitting privileges?

“Think of all the doctors out there who already have them,” she says. “It’s not that difficult. It’s really not.”

Foster does not believe that abortion providers have a harder time obtaining privileges than any other kind of doctor. Physicians in Louisiana have been denied because of specific issues with their individual applications, she says: failing to properly circle an answer, or bristling at the suggestion that they shadow a hospital doctor for a day.

“These people should absolutely be able to get admitting privileges, they just haven’t. And once they do, great. That’s the goal here,” Foster says.

But before the Supreme Court struck down the law in Texas, abortion providers struggled to get admitting privileges there, too. Multiple Texas-based OB/GYNs, all with 20 to 30 years experience, applied for privileges to continue providing abortion care at Whole Woman’s Health (WWH), the provider at the center of the Texas Supreme Court case, says Amy Hagstrom Miller, the organization’s president and CEO. They were all denied. The only doctor who successfully obtained privileges at WWH during that time period was Timothy Spurrell, an OB/GYN based in Rhode Island, who flies to Texas to perform abortions a few weekends each month.

Even for Spurrell, the process wasn’t entirely smooth. While he was initially granted privileges by a local hospital, they were withdrawn one year later because he had not admitted any patients. For months, he was unable to perform abortions in Texas, eventually obtaining privileges from a different hospital nearby.

This is a major hurdle to obtaining, and keeping, hospital admitting privileges, multiple people said: Because abortion providers hardly ever send people to the hospital, it doesn’t make financial sense for hospitals to have them on staff. While doctors with privileges are not paid by the hospital — they make money from seeing patients — hospitals will often include all doctors with privileges on their medical malpractice insurance, says Hagstrom Miller. Hospitals also have to consider the cost of going through the admitting privileges application process.

“Physicians are granted privileges because they are going to bring the hospital business,” says Hagstrom Miller. “And in our clinics, we might send a patient to the hospital once every 10 years.”

Hospitals might turn down abortion providers for other reasons, too, says Pittman: Especially in conservative areas, they may be afraid of attracting anti-abortion protesters.

There is currently one doctor at Hope Medical with hospital admitting privileges. He acquired them, long before privileges became relevant to the abortion debate because he frequently sees patients out of an office on the grounds of a local hospital, in addition to his work at the abortion clinic. His clinic job has complicated daily operations at the hospital: Anti-abortion protesters will sometimes gather outside of his office, says Pittman. (He is identified anonymously in the Supreme Court case.)

“There were a few occasions when the hospital had to call security,” she says. “And you have hospital patients there, who are concerned for their safety when something like that happens.”

In Texas, some hospitals require physicians who are already employed at the hospital to “cosign” a new doctor’s application for admitting privileges, says Hagstrom Miller. At Whole Woman’s Health, she says, the staff reached out to over 40 local doctors, asking them to support the applications of clinic OB/GYNs. Almost all of the doctors refused, she says, even those who support abortion rights.

“When push comes to shove, because of abortion violence, they are afraid for their own practice,” says Hagstrom Miller.

If the Supreme Court rules to uphold the Louisiana law, Pittman says, Hope Medical will likely face closure. Their one doctor with admitting privileges has already said publicly that he does not intend to continue practicing if the law takes effect, explains Pittman.

“He cannot be the last man standing.”