BRISTOL, Tenn. and BRISTOL, Va. — The community of Bristol is proud to straddle the border between two states.

Tennessee flags fly on the south side of State Street, Virginia flags on the north. A series of plaques down the middle of the main downtown thoroughfare mark the twin cities’ divide. A large sign at the end of town reminds everyone they’re right on the state line.

After the U.S. Supreme Court’s June decision in Dobbs v. Jackson Women’s Health Organization, which gave regulation of abortion back to states, such borders make all the difference in what care is available. In Tennessee, most abortions will soon be illegal. In Virginia, they won’t be.

For staff members at Bristol Regional Women’s Center, an OB-GYN practice that offers abortions in Bristol, Tennessee, the proximity to Virginia created an opportunity. They could ensure access by helping open a clinic on the other side of the state line in Bristol, Virginia.

“Why did we choose Virginia?” asked Diane Derzis, who owns the clinic, which opened in July about a mile across town. “It just made sense.”

Clinics across the country are still adjusting to the new legal landscape created by Dobbs. Some have shut down completely. Others have scaled back the services they offer. Still others have relocated hundreds of miles away.

A federal appeals court allowed Tennessee’s six-week abortion ban to take effect, and a near-total ban is set to begin in late August. Meanwhile, Virginia still allows most abortions through the second trimester.

The adjoining towns govern independently and are subject to different state laws, said Anthony Farnum, mayor of Bristol, Virginia. The covid-19 pandemic, he said, provided a good example. “It was interesting,” Farnum said as he sat outside the Burger Bar, a diner just a stone’s throw from the state line. “The bars on the Virginia side closed at 10 p.m., and masks were required. The bars were open to 2 a.m. on the Tennessee side, no masks required.”

Also, each state handles sales and income taxes differently, Farnum said. And his city is home to Virginia’s first casino, something that can’t be found in Tennessee. What’s happening with abortion is just the latest example.

Derzis said a doctor at the Bristol Regional Women’s Center reached out to her with the idea for the Virginia clinic. Derzis owned Jackson Women’s Health Organization, the Mississippi clinic at the heart of the Dobbs case. She said she’s working to offer abortions to people across the Southeast who have lost access as states restrict the procedure. She opened Las Cruces Women’s Health Organization in southern New Mexico in late July after closing her clinic more than 1,000 miles away in Jackson, Mississippi.

“It’s like a game of dominoes. It’s just a huge swath of states not offering the service any longer,” Derzis said. “So those women have to go north or west.”

Derzis opened the clinic in Bristol, Virginia — registered with the state as Bristol Women’s Health — in late July and said she’s already had a few patients. Derzis said the Tennessee and Virginia clinics are separate, distinct operations.

Moving a medical practice across state lines presents several costly logistical challenges.

Deborah Jo Adams, who works at Bristol Regional Women’s Center, has raised more than $100,000 for the new clinic through an online fundraiser. The money will help cover “extra legal fees, new certifications, licenses, and regulations to practice in Virginia, a raise in prices of certain medical equipment, and unexpected building repairs,” she wrote on the fundraiser page.

In the past, Dr. Howard Herrell, an OB-GYN in Greeneville, Tennessee, referred women to clinics in the Tennessee cities of Bristol and Knoxville and in the North Carolina city of Asheville — all about the same distance from his practice.

But even those clinics — at least an hour away by car — are not guaranteed to be there forever, he said. In recent months, both clinics in Knoxville that offered abortion services have closed, one of them after an act of arson, and the future of clinics in nearby states is uncertain.

“All of that is dependent upon what might happen with laws over time in Georgia, North Carolina, and Virginia,” said Herrell, the incoming chair of the Tennessee chapter of the American College of Obstetricians and Gynecologists.

Bristol Regional Women’s Center, the Tennessee clinic, sits along a busy, four-lane highway that rumbles with heavy truck traffic. But that doesn’t stop protesters from gathering outside on the few days a week the clinic provides abortions.

On a recent weekday morning, a handful stood on the sidewalks around the clinic holding large anti-abortion signs. On the clinic property, a group of volunteers who call themselves the Pink Defenders had put up pro-abortion rights signs and hung large sheets in various shades of pink and purple around the clinic parking lot. They’re here regularly, in an effort to keep patients from being bothered by anti-abortion protesters.

“Honk twice for choice,” read one of the signs, which faced oncoming vehicles. Pink Defenders cheered when drivers obliged.

Erika Schanzenbach, who opposes abortion and whose longtime protests outside the Tennessee clinic have led to civil lawsuits, said she heard about the Virginia clinic from the online fundraiser. This summer, she distributed flyers in the neighborhood around the new clinic encouraging locals to call city officials and the property owner to complain.

“As we were informing people about this clinic coming to their neighborhood, there were quite a few people that didn’t know,” Schanzenbach said. “A lot of people don’t want it in their neighborhood.” She said she plans to protest there, too.

Farnum, the Virginia mayor, said he received dozens of calls and emails — “a lot for a city this size” — from residents concerned about the clinic. But he told them he can’t do much to stop it. “It’s really more of a state decision. And currently, right now, the state law is that it is legal to operate that in the state,” Farnum said. “Our hands are sort of tied. We don’t really have anything to vote on.”

For now, there’s not much activity at the Virginia clinic. The low-slung brick building sits at the end of a residential street. On a recent weekday morning, a small pile of empty boxes, formerly full of new office supplies, sat outside. While Pink Defenders and protesters gathered at the Tennessee clinic about a mile away, the Virginia one sat quiet, empty.

To Max Carwile, it’s a symbol of resilience. She’s the director of programs at Abortion Access Front, a national abortion rights group, and a co-founder of Mountain Access Brigade, an abortion fund that works in East Tennessee.

She grew up in the region, which she called a “desert of health care access,” and said the clinic opening in Bristol, Virginia, will mean a “world of difference to patients” — even if the people running it can’t keep the doors open forever.

“For the ones who have the chance to move a short distance, that’s amazing,” said Lori Williams, chair of the National Abortion Federation’s board of directors. “For the ones that are able to move great distances, that’s also amazing. But there’s many of us who won’t be able to make that move.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.