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The FDA made mail-order abortion pills legal. Access is still a nightmare.

Restrictive states have already set their sights on a new wave of telehealth companies that were supposed to be a panacea for a post-Roe world.

Part of the Drugs Issue of The Highlight, our home for ambitious stories that explain our world.

When Emma found out she was pregnant in February, it was too late for an in-clinic abortion.

She estimated that she was at six weeks, but Texas, a bastion of retrograde abortion policy, bans the procedure at roughly that mark, so any local options were out of the question. Her local Planned Parenthood told her to prepare to travel out of state and offered to connect her with a clinic. Emma, who takes medication that makes her cycle irregular, wanted an ultrasound to confirm her recollection of the gestation age. But the clinic didn’t have an appointment for the next two weeks.

“If I was below six weeks at the time of booking, I certainly wouldn’t be by the time I would make it to the clinic,” she said.

Emma, who is well-versed in reproductive health care, knew there was an additional option. So she started researching telehealth services that would ship mifepristone and misoprostol, two medications required to induce abortion safely at up to 10 weeks, through the mail. She decided on a cheery-looking telehealth startup that markets the pills. (Emma asked to use only her first name, since Texas law allows abortion providers or anyone who assists in accessing the procedure to be sued.)

Telehealth companies focused on abortion access use a straightforward model. Once a patient decides on a service that’s legally allowed to ship to their state — like Hey Jane, Choix, Just the Pill, or Carafem — they fill out a medical history questionnaire, learn about the treatment, and sign a few consent forms. Then, within hours, they’ll hear back from a physician if they’re eligible to manage the procedure at home; the pills arrive in one to five days. “Abortion is something that is underserved,” said Kiki Freedman, the CEO and co-founder of Hey Jane. “Being able to access something more conveniently, more discreetly, more affordably, and more robustly is beneficial.”

That’s in an ideal scenario in a progressive state like California or New York. Unfortunately, the process was more complicated for Emma and others who live in states where abortion access is legally hindered. Texas and Indiana ban medication abortion starting at about seven and 10 weeks, respectively. Thirty-two states require a physician to administer the medication, while 19 states require the prescribing clinician to be physically present when the pills are taken — legalities that amount to a de facto ban on receiving abortion care via telehealth. These laws don’t affect the safety of the procedure, which is safer than Tylenol, but, instead, construct barriers to accessing abortion.

If the Supreme Court deals a blow to Roe v. Wade this summer, as many expect it to do, these obstacles will get worse. While telehealth startups focused on reproductive health are hoping to play a role in expanding access, state laws and societal structures such as poverty and lack of access to health care prevent these companies from helping those most in need of their services should Roe be overturned. Nineteen states, including Texas and most of the Deep South, require two or more in-person visits to access medication abortion, while eight others require at least one visit; in 2021, six states, including Texas, passed explicit laws against receiving medication abortion through telehealth.

“It’s great that we have so many more options with things like telehealth, but even right now, that’s not available to every single person across this country,” said Renee Bracey Sherman, the executive director of We Testify, an advocacy organization for people who have abortions. “What feels challenging is this idea that people are looking for a panacea to just fix it all. And they’re like, ‘Great! If we just have pills mailed, then everything will be fine. That’s the solution to the crisis around Roe.’ But it is not the solution.”

When the FDA announced in December that it would permanently allow mifepristone and misoprostol to be sent to someone’s mailbox, it was hailed as opening a world of possibilities for abortion access. In some ways, it does.

Two-dose medication abortion has been available in the US since mifepristone was approved as an abortion pill in 2000. The first pill, a single dose of mifepristone, stops the pregnancy from progressing by blocking progesterone and helping the embryo detach from the uterine wall. Within 48 hours, the patient takes a dose of misoprostol to cause heavy cramping and bleeding, which empties the uterus. In 2016, softened FDA regulations allowed the misoprostol portion of the procedure to occur at home. The process is a highly safe and less expensive alternative to surgical abortions, with complications occurring in less than 1 percent of cases. (Misoprostol alone also has a high success rate since it causes the cervix to open and the uterus to cramp, inducing a miscarriage.)

Sending the pills directly to consumers sidesteps several everyday challenges encircling abortion access. Nearly 90 percent of US counties lack an abortion clinic, according to the most recent data from the Guttmacher Institute; clinics, for various reasons, continue to close. Multiple states in the South and Midwest rely on doctors from out of state, limiting the number of abortions a clinic can provide. Five states — including Mississippi, North Dakota, and West Virginia — have one clinic left.

Mifepristone and misoprostol now are used in more than half of the country’s abortions. And interest in medication abortion is rising — by choice and out of necessity. Many birthing people don’t discover they’re pregnant until the five- or six-week mark, about a week or two after a missed period, which only leaves roughly a four-week window to perform a medication abortion.

“Getting abortion medication in the mail, or just expanding access to abortion medication period, could potentially be a game-changer in a United States, where abortion is illegal in some places and inaccessible in lots of places,” said Mary Ziegler, a law professor at Florida State University and the author of Abortion and the Law in America: Roe v. Wade to the Present.

The convenience for people who can’t afford to travel to a clinic, take time off from work, or find child care is unmatched. The more traumatic aspects of visiting an in-person clinic are removed, too: There are no protesters to navigate, no apprehension about being recognized at a small community clinic, and removal from the potential threats of violence clinics often face. Appointment wait times are also shorter, and the cost can be a bit cheaper than in-clinic services, which can cost anywhere between $400 and $1,000, with the price increasing depending on factors such as gestational age of the fetus.

For example, Hey Jane guarantees patients will see a physician within 36 hours, while Choix promises 24 hours, and Just the Pill offers 48 hours. The cost is $249, $289, and $350, respectively.

Abortion medication by mail is also an alternative for people who’ve had bad experiences with clinicians, those who don’t want an ultrasound, or to discuss their decision any further — all of which rang true for Emma.

When she had her first medication abortion, Emma attended college in one of the 13 states requiring multiple visits to a clinic before a patient can be provided an abortion. She was also required to submit to an ultrasound. It was the dead of winter, and she didn’t have a car. So, on three occasions, Emma took a 45-minute bus trip accompanied by a 20-minute walk to the nearest abortion clinic. Each appointment required taking off work and scheduling the visit around classes. To add to the plight, her partner at the time wasn’t supportive.

Emma was in it alone.

“It was a fairly traumatic experience, having to be in touch with medical professionals that much when I was very clear about my choice, very clear about what I wanted to do,” she said. “It was making unnecessary complications.”

“I already knew I didn’t want to continue with this pregnancy, and I had to go through the [transvaginal] ultrasound. So it was another level of intrusive where I’m like, ‘I know I don’t wanna do this,’” she continued. “At least this time I didn’t have to be in contact with medical professionals who may or may not be in support of my choices, but they were under a legal obligation to make me question it.”

The same laws complicate the expansion of telehealth startups. If patients don’t live in a state where the telehealth consult and subsequent treatment are legal, the pills can’t be shipped directly to them. Before any of these companies can expand their services, they must consider a state’s laws covering telehealth, what type of clinician can provide abortion care, and any TRAP laws, which regulate and restrict abortion providers with the intention of hampering access to reproductive choice. So, patients who can travel to a state with looser restrictions are encouraged to do so. (Hey Jane has partnerships with local abortion organizations to facilitate travel for anyone who needs financial support.)

One workaround to improve access would be to make the medications available over the counter, just as emergency contraception is, or allow for an advanced provision of medication abortion — meaning people can have the pills on hand in case they get pregnant. “People who live in a state where it might be restricted and maybe the pills weren’t being sold there, they could travel to another state to get them,” said Daniel Grossman, a physician and the director of Advancing New Standards in Reproductive Health. “Or maybe someone in that state where they’re available could send them to them, or a variety of options that you can think of.”

Another option is international groups like Aid Access, which will continue shipping medication abortion to birthing people in the US despite demands to stop from the FDA. In September 2021, when Texas’s new law went into effect, Aid Access received 1,831 requests from people in the state for medication abortion, according to new data from researchers at the University of Texas at Austin.

Access to abortion-inducing drugs may seem like the future of care in America, but it’s been an option for birthing people elsewhere in the world for quite some time. In spite of the criminalization of abortion, in most Latin American countries, misoprostol is available over the counter for other medical purposes, and many people have used it to induce abortion without serious complications. (It’s worth noting that even as American states work to curtail access, several countries in Latin American countries — including Colombia, Mexico, and Argentina — have made the procedure more accessible.)

According to Grossman, advocates in Latin America have also developed robust models of care, such as telephone hotlines and other digital networks, to support people throughout the process of ending their pregnancies with medication. Aides help people access the medication and explain how they should use it. In some scenarios, a helper can be physically present to determine if the patient needs to get to a health care facility or if the treatment worked.

Before abortion was decriminalized in Uruguay, Iniciativas Sanitarias, a reproductive health advocacy group, developed a harm reduction model to assist people who wanted to terminate their pregnancies. They provided safety information and support to people considering self-managing an abortion, including how to use misoprostol. “For example, for [those] beyond 11 or 12 weeks, if they have a bleeding disorder, or are taking blood thinners, it’s not an appropriate method,” said Grossman. “So if people have accurate information, they have access to good quality medications, and they know about the warning signs that should prompt them to seek medical care, I think that self-managed abortion can be very safe and effective,” he added.

Similar networks may take root in the states as the fight against access intensifies. Despite the existence of these workarounds, however, abortion access ultimately remains elusive to the people who need it most. Traveling across state lines presents the same challenges as visiting a state’s only clinic; there are travel time and costs to consider, along with taking time off work and finding child care. Meanwhile, telehealth and medication-by-mail are much less likely to reach people who are incarcerated, unhoused, live on low incomes, don’t have an HSA/FSA, or internet access — groups disproportionately made up of Black and brown people.

It’s crucial, advocates say, that the current hierarchies to abortion access aren’t replicated as well-intentioned companies search for solutions.

“That FDA decision is not actually making a difference in the people’s lives who need it most because they simply cannot have [the pills] mailed,” said Bracey Sherman, of We Testify.

Emma shipped her pills to an address in California and someone she trusted sent them to her in Texas, where it’s illegal to access medication abortion through a telehealth service. The workaround meant she got her medication in a week and a half — which would have been a problem had she been further along. Anyone who assisted Emma in receiving the prescription needed for her abortion could have faced legal repercussions under Texas law, which allows private citizens to sue those who help someone access abortion. So Emma had to keep the process hushed, only looping in people she could trust to help.

There is some legal risk to forwarding abortion pills through the mail, but it depends on the laws of the states where someone is sending and receiving the pills. And the only way to avoid that risk completely in a state like Texas is to get a prescription in-person from a licensed medical provider and within the state’s legal cutoff.

“It was an experience that was way more isolating than it needed to be, and just an unnecessary barrier to access that I had not experienced before,” Emma said.

Many states maintain that their laws aren’t meant to punish pregnant people. Instead, the focus is on prosecuting in-state abortion providers. This opens the door for national telehealth startups with the gumption to serve patients in states with abortion bans, anyway. (All the companies who spoke with Vox emphasized that they would continue to work within a state’s given laws. Representatives from Just the Pill and Choix said, however, that they’re aware that restrictive state laws compel some pregnant people to take the same route as Emma.) Or companies like Hey Jane could lobby more states to adopt, as some California lawmakers have pledged to do, a sanctuary state model for pregnant people forced to seek out-of-state abortion care.

“States are going continue passing laws to limit access to medication abortion,” said Ziegler, the Florida State law professor. “But they’re also going to have a very hard time identifying when those laws are being broken or enforcing laws, especially against actors who don’t live in the state, and especially if they’re actually serious about not punishing pregnant people.”

But there have been instances of prosecutors reaching deep into their briefcases to figure out legal ways to hold pregnant people accountable for perceived crimes against life. This includes, but isn’t limited to, charging folks with “abuse of a corpse” for a pregnancy loss — whether it be by miscarriage, stillbirth, or an abortion.

“We talk about this aura of criminality that already exists and surrounds abortion,” said Yveka Pierre, the senior litigation counsel at If/When/How Lawyering for Reproductive Justice. “And that’s all based in the stigma about abortion, about people who have abortions, about folks who are partnered with folks who have an abortion, and all of these existing TRAP laws that have been slowly eking away at the protections.”

Fewer legal protections, particularly in states where the right to self-managed abortion isn’t codified at all, could result in more people being criminalized for their pregnancy outcome. There will most likely be a push-pull method at play here, explained Pierre. Some people will be pulled toward a self-managed abortion because it’s an affirming choice for them. Others will be pushed into it even though they would’ve opted for clinical care if they had a choice. That dynamic and any legal crackdowns will be felt most by those who live in overpoliced communities or those who have had prior contact with the criminal justice or family separation systems.

“Who is likely to have the cops be in their community? Who is likely to have never seen a police officer in their suburb driving around? Who’s likely to have their mail checked? Who is already under surveillance in some sort of way?” said Pierre. “Those are the people that are more likely to experience criminalization — folks that are already at the intersection of oppression from various systems.”

An earlier version of this story misstated the name of an online provider of abortion medication. That provider is Choix, not My Choix.

Those in a similar predicament as Emma’s can call the ReproLegal helpline.

Julia Craven is a reporter covering health. She’s the brain behind Make It Make Sense, a weekly health and wellness newsletter, and her work has been featured in HuffPost, Slate, and the 2021 edition of The Best American Science and Nature Writing.


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