The rise of medication abortion means life post-Roe v. Wade will be different from life pre-Roe — but it has its limits.
Abortion advocates hope that the pills — which are safe, reliable and approved by the Food and Drug Administration — could allow people in states that ban abortion to get easier access to reproductive care after clinics close. The FDA late last year relaxed restrictions on how the drugs can be prescribed and delivered, meaning that, in theory, medication abortion can be accomplished with just a telehealth visit and a trip to the mailbox.
Yet in practice, the pills are unlikely to be a panacea in a post-Roe United States. They will undoubtedly help some people in states where abortion is banned. But anti-abortion lawmakers are pushing hard to limit access to the drugs, enacting laws in 19 states that range from requiring mandatory ultrasounds and waiting periods to outright bans on telehealth. These already effectively bar the use of telemedicine to prescribe the drugs in a significant chunk of the country.
“It may be a mitigation strategy … and will make self-managed abortions much safer in this environment where people are living under bans,” said Daniel Grossman, director of Advancing New Standards in Reproductive Health at the University of California, San Francisco. “But it’s not a solution.”
The existing patchwork of laws has created a legal gray area for the practitioners, patients and anyone else involved in providing access to abortion pills — especially with states now attempting to criminalize such care.
“A lot of people, when they think about a pre-Roe world, they think about safety. They think about people hemorrhaging in back alleys and unscrupulous doctors. That’s not what the post-Roe world is going to be,” said Kristin Ford, vice president of communications and research at the advocacy group NARAL. “What we do have to worry about is not hemorrhaging, but handcuffs.”
The advent of “21st-century abortion”
When the Supreme Court legalized abortion in 1973, the only medically approved option was a surgical procedure. Decades later, in 2000, the Food and Drug Administration approved the first abortion medication, mifepristone, for use early in pregnancy. The medication blocks progesterone, a hormone necessary for the pregnancy to continue. A second drug, misoprostol, taken up to 48 hours after mifepristone, triggers cramping and bleeding, causing the uterus to empty. If taken within nine weeks of gestation, these two drugs are 99.6 percent effective at ending a pregnancy, with an extremely low risk of serious complications — just 0.4 percent.
Though the drugs have been available for more than two decades, it wasn’t until 2020 that medical abortions became more common than surgical ones — driven in part by the pandemic — according to the Guttmacher Institute.
Years before the world knew of covid-19, in 2011, the FDA prohibited abortion drugs from being administered without an in-person appointment with a provider. Access was further limited by laws in 32 states that stipulate that a medical doctor, rather than a nurse practitioner or other professional, administer the drugs.
But as the virus began spreading, the FDA relaxed the in-person requirement to allow telehealth appointments, and in December 2021, it made the change permanent. Since then, the door has been open for people seeking abortion in 23 states and Washington, D.C., to obtain and use the drugs for a medical abortion without an in-person visit to a provider.
The restrictions applied to abortion drugs over the years are unusual for most FDA-approved medications, and further efforts to regulate medication at the state level are likewise outside the norm, given that drug oversight rests with the federal government, said Alina Salganicoff, director of women’s health policy for the Kaiser Family Foundation.
“We see this in many cases where there is kind of an ‘abortion exceptionalism,’” Salganicoff said. “We don’t regulate other procedures in the way that we regulate abortion.”
These regulatory hurdles have created a lack of awareness and uptake in use of medication abortion in the 22 years it has been available in the United States. By comparison, in some European countries, medication abortions make up more than 90 percent of all abortions, said Elisa Wells, the co-founder and director of Plan C, an information resource on medication abortion.
“A lot of people don’t even know abortion pills exist. They think it’s going to a clinic and getting an abortion procedure,” Wells said, adding that her organization hopes to bring awareness to the option of a “21st-century abortion,” with pills and telemedicine.
States take aim at abortion drugs
A slew of telehealth companies that focus on medication abortions have popped up in recent years, egged on by the FDA’s changing rules. One is Abortion on Demand, where people schedule a 15- to 20-minute virtual appointment with a clinician. If appropriate, the company will overnight abortion pills to a person’s address for $239 — as long as they live in one of the 21 states in which the company currently operates.
“Patients really like doing an abortion this way,” said Leah Coplon, the organization’s director of clinical operations. “It’s very private. They don’t have to travel to a clinic or take time off work or find child care.”
That convenience has sparked a backlash. “The opposition can see the handwriting on the wall,” said Kirsten Moore, director of the Expanding Medication Abortion Access Project. “They’re already moving to restrict access.”
Six states, including Texas and Indiana, have outright banned the use of telehealth for medication abortion, and many other states require ultrasounds, in-person counseling or other restrictions that effectively ban the practice. As a result, organizations like Abortion on Demand don’t provide services in these states for fear of litigation. If Roe is overturned, the situation will get even worse. “It will make an FDA-approved drug unavailable in states likely to make abortion illegal,” said Moore. “That’s never happened before.”
There are options outside the healthcare system, from organizations that operate “extralegally,” Coplon said. Aid Access, an Austria-based group, will send pills anywhere in the U.S. to people who are less than 10 weeks pregnant. After a Texas law barring abortions as early as six weeks into pregnancy took effect last September, daily requests from state residents shot up 1,180 percent.
“People are taking on a legal risk to get an FDA-approved drug,” Moore said. Texas forbids mailing the pills within the state, but policing people’s mailboxes will be difficult. “It’s not a thing you can shut down,” she said.
But restrictive states can use other means. Moore imagines a scenario where someone who self-managed their abortion is bleeding, which happens with medication abortion, and decides to go to the emergency room just to make sure everything’s OK. “Some actor in the ER can say, ‘I’m gonna refer you for having had an illegal abortion,’” she said. Last month, Lizelle Herrera was charged with murder and jailed in Texas for what prosecutors called a “self-induced abortion.”
Although prosecutors later dropped the charges, such incidents create “an aura of illegality,” around self-managed abortions, said Sara Ainsworth, senior legal and policy director at If/When/How, a group of national advocates whose Repro Legal Defense Fund posted bond for Herrera. “That kind of criminalization undermines public health; it discourages people from seeking care when they need it,” she said, and often falls hardest on poor people and people of color.
Not convenient for all
Legal restrictions on medication abortion have created financial barriers as well. Wells, the co-founder of Plan C, estimated that one course of the pills costs less than $75. But a recent Health Affairs analysis found that the median price of a medication abortion in 2020 was $560, just $15 less than a first trimester procedural abortion.
According to Salganicoff, there’s not much comprehensive research on how many insurance plans exclude coverage of medical abortions. As a result, many people are in the dark about what a medical abortion may cost them, just as is the case with much healthcare.
“You don’t know you don’t have the coverage until the plan tells you you’re not covered,” Salganicoff said.
The situation is clearer for recipients of Medicaid, the only coverage accessible to many low-income Americans. Medicaid is governed by the Hyde Amendment, which prohibits the use of federal dollars for abortions except in the case of rape, incest or the endangerment of a life. Further, a 2019 Government Accountability Office survey found that 13 states and Washington, D.C., wouldn’t fund medication abortions in those circumstances, and South Dakota wouldn’t fund medical or surgical abortions, except in cases where a mother’s life is in danger. People living in poverty may also lack reliable access to the internet, further limiting any attempts to secure abortion pills by telemedicine or other online sources.
“We don’t have equitable broadband access around the country,” said Kimi Chernoby, an emergency medicine physician and reproductive health lawyer in Alexandria, Virginia. About 19 million Americans still lack access to broadband internet — including 1 in 4 in rural areas, many of which fall within states likely to make abortion illegal. For such people, brick-and-mortar clinics remain their only way to access care, and post-Roe, many will have to travel far to reach them.
“The reality is the barriers to access right now are the fact that most people are seeking abortion care on low income,” Moore said. “They are parents who are already struggling to make ends meet. So making them jump through extra hoops and spend more time trying to raise the funds to cover the cost of a very time-sensitive medical emergency like an abortion is just unnecessarily cruel.”
By early July, the Supreme Court is likely to end the national right to abortion after nearly a half-century.
Medication abortion will become more important, but “medication abortion is not the answer to Roe being overturned,” Coplon said. “We 100 percent still need our brick-and-mortar clinics. There will always be people who need care later in pregnancy or have medical reasons for not wanting medication abortions.”
Thanks to Lillian Barkley for copy editing this article.
An earlier version of this article misstated If/When/How's involvement in Lizelle Herrera's case. This version has been updated.