Earlier this month, Politico broke news that Walgreens, the nation’s second-largest pharmacy chain, assured 21 Republican attorneys general that it would not dispense abortion pills in their states should the company be approved to dispense them. The decision was met with sharp protest by Walgreens customers, abortion rights activists, and Democrats, who accused the pharmacy of caving needlessly to pressure.
But fear of state prosecution is not the only factor shaping Walgreens’ decision-making. Another previously unreported constraint on the company is that its sole supplier of Mifeprex — the brand-name drug for the abortion pill mifepristone first approved by the Food and Drug Administration in 2000 — circulated a list to its corporate clients in January naming 31 states that it would not supply the abortion medication to. Vox spoke with two sources who had reviewed that list recently.
The sole US distributor for Mifeprex is AmerisourceBergen, one of the largest pharmaceutical distribution companies in the world. (The federal government is currently suing AmerisourceBergen for allegedly distributing opioids while knowing they would later end up on the illegal market. The Pennsylvania-based company has denied this.) Back in January, AmerisourceBergen created its list of 31 states using as a source the website of the Guttmacher Institute, a reproductive research organization that tracks state abortion restrictions, according to sources with knowledge of the list’s origin.
The list’s existence underscores the precarious state of abortion rights in the US in the wake of Dobbs v. Jackson — the 2022 Supreme Court ruling that struck down Roe v. Wade, effectively leaving abortion rights to each state. Walgreens drew condemnation for saying it would not dispense abortion pills, even in states where it’s currently legal to do so. AmerisourceBergen’s list indicates another reason influencing Walgreens’ stance: a distributor — it’s the only one for this drug — had signaled that it would not supply pharmacies with abortion pills.
Walgreens and Danco Laboratories, the manufacturer of Mifeprex, declined to comment. A source with knowledge of the contractual agreement between Walgreens and AmerisourceBergen told Vox that the parties are legally barred from talking publicly about the supplier, but that advocates have been trying to persuade AmerisourceBergen to adopt a less risk-averse stance on abortion-pill distribution.
Lauren Esposito, a spokesperson for AmerisourceBergen, told Vox over email that the situation “is dynamic and ever evolving. Any information that you’re referring to from January is certainly out of date by now. Additionally, as I’m sure you can appreciate, for contractual purposes we are not able to discuss specific products.” The company later released an additional statement, emphasizing that AmerisourceBergen does not “independently decide what medications should be available to health care professionals as part of their treatment plans” and does “not make clinical decisions or values-based judgements on which FDA approved products it distributes.”
Vox asked Guttmacher about the supplier’s list and its reported use of the institute’s site as a guide for compiling the list. “We would like to understand what data AmerisourceBergen is basing these claims on, as we are not aware of any policies that would prevent the shipping of mifepristone to such a large number of states,” said Elizabeth Nash, a Guttmacher policy analyst. “Private companies should be extremely careful not to limit access to mifepristone in response to threats from anti-abortion groups or politicians.”
Abortion rights advocates and consumers responded with outrage to the Politico report, calling for a boycott of Walgreens until it reverses its stance. At particular issue is the fact that four states on Walgreens’ list — Montana, Kansas, Iowa, and Alaska — have restrictions on pharmacists that are blocked in court. California Democratic Gov. Gavin Newsom announced he would not renew a multimillion-dollar contract with the pharmacy chain to signal his disapproval.
Walgreens spokesperson Fraser Engerman maintained the company’s position hasn’t changed, and that they still intend to dispense mifepristone “in any jurisdiction where it is legally permissible to do so.”
In January, the Food and Drug Administration announced that brick-and-mortar pharmacies could apply for certification to sell abortion medication at their stores, a move hailed as an important step toward expanding access to the safe and effective drug that has become the most common method for ending pregnancies in the United States.
Representatives from CVS and Rite Aid, which like Walgreens said they would seek certification, have remained conspicuously quiet on the issue for the last two weeks, and did not return requests for comment. (No drugstore has yet been certified, and it is not clear how long the process will take.)
The ongoing debate over what pharmacies like Walgreens can and should do when it comes to dispensing mifepristone reflects the political challenge of navigating the patchwork of conflicting state abortion restrictions in the post-Roe era. With a bevy of new laws and litigation, individuals, abortion providers, and companies are left to make consequential decisions in a highly fraught and confusing legal environment — which, in the case of Walgreens and AmerisourceBergen, means inaction in the face of uncertainty.
Pharmacists are caught in the middle
Caught in the middle of this legal and political tug-of-war are abortion providers. While it’s easy for Democratic governors in states like Illinois and California to tell companies they should dispense medication abortion, it’s harder to insist that they should put their pharmacists at risk.
“Violating the has-to-be-done-by-a-physician requirements in some of these states is punishable by jail,” a Walgreens spokesperson told the New York Times. “In other states, it’s punishable by a civil fine, and in a number of them it’s punishable by licensing sanctions. And so these are restrictions that present real risks to pharmacists.”
The 21 states where Walgreens has said it will not dispense mifepristone fall into a few different categories, explained Nash of Guttmacher. Some have banned abortion entirely, while others have laws requiring physicians to dispense drugs in-person, or require in-person counseling and ultrasounds, making the prospect of dispensing mifepristone through a pharmacy impractical. And still others, like Alaska, should feasibly be able to dispense through a pharmacy, Nash said.
“Overall there’s a lot of confusion in the marketplace as pharmacies and pharmacists try and follow all the laws and regulation and litigation,” said Ilisa Bernstein, the interim CEO of the American Pharmacists Association. “It’s unsettled right now.”
Bernstein told Vox that beyond legal risks, members are grappling with new safety issues: “Pharmacy team staff safety is a concern, whether it’s getting into the pharmacy and going through people who may be demonstrating and picketing outside or in the pharmacy, where team members want to be sure they’re in a safe space when they’re working,” she said. Recently anti-abortion activists protested Walgreens’ annual shareholder meeting, casting drugstores as the new abortion clinic.
Next week the American Pharmacists Association is holding its annual meeting where hundreds of delegates from across the country plan to revisit the group’s policies on mifepristone and reproductive health care.
Regardless of what pharmacists want their group’s policies to be, they will remain bounded by the FDA’s Risk Evaluation and Mitigation Strategies (REMS) list, a restrictive designation the federal government places on mifepristone over the objections of groups like the American Congress of Obstetricians and Gynecologists. Pharmacists will also be circumscribed by the lawyers of their companies, and other actors involved in the medication abortion supply chain, like drug distributors and lawmakers.
Esposito, the spokesperson for AmerisourceBergen, told Vox, “We continue to make FDA-approved medications, including reproductive health medications, available to health care facilities and providers in all 50 states and territories that meet local, state, and federal requirements to distribute and dispense.”
But whether AmerisourceBergen will let Walgreens and other drugstores sell Mifeprex in all the locations pharmacies would be willing to dispense them from is another question.
Update, March 17, 10:10 am ET: This story was originally published on March 15 and has been updated with an additional statement from AmerisourceBergen on access to reproductive health medication that the company issued after publication.