Many patients have used abortion pills as an alternative to abortion because of the strict abortion laws enacted by conservatives.
With the Supreme Court poised to overturn or significantly or reduce the number of abortions, the pills are increasingly in conservative lawmakers.
According to data released earlier this year by the Guttmacher Institute, medication abortions accounted for the majority of abortions in the United States in 2020. This was the first time since 2000 that abortion pills were the most popular choice.
Abortion rights advocates see medication abortion as a way to get around state laws that put strict limits on procedural abortions and aim to close brick-and-mortar clinics. Telehealth companies are trying to expand access by mailing abortion pills directly to people. The pills are seen as a threat by abortion opponents to their goal of ending abortion in America.
Poverty and lack of internet access are some of the structural barriers that are complicating the reach of medication abortion.
There will be more age limits on abortion across the country, says Elizabeth Nash, who tracks state abortion legislation for the Guttmacher Institute. Some people will travel to states with abortion access. For other people, they may use the internet to seek abortion. Ensuring that there is at least some availability of care is important.
Someone looking for a procedural abortion needs to make an appointment at an abortion clinic, take time off work, travel to the clinic, and potentially face protesters or at least other people in the waiting room. Many barriers are eliminated by medication abortion. The two-drug regimen can be taken at a patient's home, or any other location they choose, and they don't need to wait for an appointment time or interact with other people when taking the drugs.
The FDA loosened its rules last spring as the coronaviruses increased demand for telemedicine, allowing the first of the two pills to be prescribed in person. In December, the agency made this change permanent, meaning patients could get the pills via telemedicine appointments or mail-order pharmacies.
The shift, which was cheered by abortion rights supporters, also caught the attention of anti-abortion advocates. Sending abortion pills through the mail made them more complicated for states to police, according to a law professor at the University of California, Irvine.
There aren't obvious targets for some legislators who want to go after medication abortion.
Most mainstream abortion opponents don't want to punish women who have abortions, instead they want to make it harder for providers. When patients use out-of-state providers or order medications from other countries, that strategy becomes more difficult. 19 states prohibit abortion pills from being sent in the mail. The Americans United for Life and Susan B. Anthony List are both anti-abortion groups. In the first three months of 2022, conservative lawmakers introduced more than 100 restrictions on abortion.
Some states are passing total abortion bans that apply to both medication abortions and surgical abortions because they think the Supreme Court will weaken the case. Many of the new bills take novel approaches, such as Texas, which encourages private citizens to enforce a ban on abortion after about six weeks by offering at least $10,000 to individuals who sue anyone that helps someone get an abortion.
Texas passed a law that made it a felony to provide abortion pills through the mail and imposed a $10,000 fine and prison time for violators. Oklahoma recently passed a total abortion ban that makes it a crime to violate it, and it is moving a separate Texas-style bill of its own. Sending abortion pills to another state would be treated as drug trafficking if a bill is passed. The bill in Tennessee would make mailing the pills a felony and impose additional requirements that could result in a $50,000 fine. In Kentucky, legislators passed a law creating a new certification program for abortion pill providers that would list their names publicly and add a portal for people to report potential violations.
Some of the bills that are being advanced raise concerns about the speed with which patients can obtain abortion pills and about the potential for problems. Abortion providers note that the pills are safer than Viagra and other drugs, and that research has shown that using telemedicine doesn't change that.
The greatest risk is the legal risks or the risk of being prosecuted if you order these pills, says Ushma Upadhyay, an associate professor at Advancing New Standards in Reproductive Health.
That legal risk was on display this past week when a young woman in Texas was arrested and charged with murder after the local sheriff's office said she caused the death of an individual by self-induced abortion.
People of color, poor people, people in rural areas and those without other support systems will be the most affected by additional barriers as restrictions increase.
The incident in Texas, which showed that different conduct is permissible for different groups of people, was reminiscent of Jim Crow laws after the Civil War.
New bills are making things more complicated for services that send pills by mail. Aid Access saw a spike in demand after Texas went into effect, but requests leveled off after that.
After the FDA loosened regulations during the Pandemic, telehealth services such as Hey Jane and Carafem started mailing pills to people in states that are legal to do so. Providers are thinking about ways to shorten travel times for people who want to access their services, even though they can't legally mail pills to a state like Texas.
Elizabeth Raymond, senior medical associate at Gynuity Health Projects, which ran the TelAbortion program, said that patients crossed state lines to access the program before the swine flu hit. A patient living in Tennessee could drive to Georgia to have her abortion pills sent to her, and then return home.
It may be possible for patients who can't physically go a long distance to receive the service, but they can just go somewhere where it's legal and receive the service by telemedicine. We want to figure out how to make that more feasible in the future.
The startup that provides abortion pills is looking at ways to do this. The company chose to serve patients in New York, California, Washington, Illinois, Colorado and New Mexico because they are friendly to abortion access and likely to see more out of state patients as restrictions increase elsewhere. According to Guttmacher, if the Supreme Court allows conservative states to ban abortion, California would see a 3,000% increase in out of state women, while Illinois would see a 9,000% increase.
The main role that we see ourselves playing is helping support access. There needs to be more availability of care providers in that area, and I think Telemedicine is a good way to make that happen.
Hey Jane is considering a plan for a more restrictive future now that the FDA loosened regulations around the abortion pills one year ago. According to data the company released Tuesday, patients reported that comfort, privacy, convenience and cost were important factors when choosing Hey Jane. Abortions in clinics can cost between $500 and $1,000, whereas Hey Jane's services cost $249 and other providers are often cheaper than in-person options.
The typical patient of Hey Jane is 29 years old and six weeks pregnant when they complete their intake forms on the company's website; they typically complete the forms within two days of getting a positive pregnancy test. If the average patient in Texas is already at the edge of the law, the speed with which patients are getting prescribed pills could help people who are already seeing long wait times at clinics in surrounding states. Hey Jane's patients have been getting prescriptions confirmed in 24 hours.
These companies don't work for everyone. Upadhyay is working on a study of more than 3000 patients who have tried a telehealth abortion visit, and says that patients from underserved communities are often not aware of these options. She expects to see abortion pills playing an even bigger role with more states adding new restrictions.
The medicine is safe, people can use it on their own, but patients really do have the right to the care and comfort that comes from having a local provider support them.
Write to the author at abigail.abrams@time.com.
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