What does the Texas ruling mean for getting abortion pills online?

Access to medication abortion in the U.S. hangs in the balance after a Texas federal judge ruled last week to put the U.S. Food and Drug Administration's approval of mifepristone, one of the two drugs used in medication abortion, on hold.

For now, access to mifepristone remains unchanged, after the Supreme Court on April 14 put on hold the full decision by the Texas federal judge, until midnight E.T. on April 19, giving “the justices time to consider what next steps to take,” NBC News reported.

But a series of legal decisions over the past week calls into question how long mifepristone may remain accessible, as well as if it will be available via telehealth or mail.

On April 7, U.S. District Judge Matthew Kacsmaryk, based in Amarillo, Texas, issued a temporary injunction that suspended the approval for mifepristone, also known by the brand name Mifeprex, which was first approved for use in abortions by the FDA more than 20 years ago.

In 2016, the FDA expanded the approved use of mifepristone in medication abortions through 10 weeks of pregnancy. The FDA also allowed a generic version of mifepristone onto the market in 2019. And, during the COVID-19 pandemic, the FDA rolled back some restrictions on mifepristone that temporarily allowed people to get the medication through the mail and, ultimately, made those changes permanent in 2021.

But on April 12, the U.S. 5th Circuit Court of Appeals partially blocked the Texas injunction and opted to essentially revert the FDA approval of mifepristone to pre-2016 rules. That means that, if the court of appeals' decision goes into effect, people will only be able to use mifepristone through seven weeks of pregnancy — and they’ll need to have multiple in-person medical appointments to get it.

And a conflicting decision in another case that applies to 18 states, filed by a federal judge in Washington, adds even more uncertainty to the evolving landscape of medication abortion access. While this decision only affects certain states, the Texas decision could affect the entire country.

Can you still get mifepristone by mail?

For now, there is no change in access to abortion pills, Jean Bae, visiting associate professor of public health policy and management at NYU School of Global Public Health, tells TODAY.com. Currently, more than half of all abortions in the U.S. are medication abortions, according to the Guttmacher Institute, a research group that supports abortion rights.

While these restrictions were set to go into effect on April 14, the short-term administrative stay granted by Justice Samuel Alito extends that deadline — and preserves current access to mifepristone — at least until midnight E.T. on April 19.

But how much longer that access will last isn't clear yet.

“It’s a little hard to say (what will happen because) we do have these dueling decisions,” Wendy Mariner, professor of health law, bioethics and human rights at Boston University School of Public Health, tells TODAY.com. “The general assumption seems to be that it will go to the U.S. Supreme Court to resolve the conflict between them.”

Whatever happens, it's important to keep in mind that these are all temporary decisions, Bae says. Both the Texas and Washington decisions were primary injunctions, which are granted temporarily while the rest of the case is decided, she explains.

"At least some amount of access to the drug has been preserved as of now," Bae says. "The Washington district court decision still exists and, ultimately, the Supreme Court might also be intervening."

At least three U.S. telemedicine abortion companies, which connect patients with health care providers and deliver abortion medications by mail, are sticking to their normal operations. Representatives for Hey Jane, Choix and Abortion on Demand tell TODAY.com that they will continue to provide the usual combination of mifepristone and misoprostol and are prepared to offer misoprostol alone if necessary.

"The most important thing to know is that right now, patients can still legally access medication abortion care through Hey Jane," Kiki Freedman, the company's co-founder and CEO, tells TODAY.com in a statement. "We are continuing to monitor the lawsuits as they progress, and our focus remains on our patients and delivering the best possible evidence-based, compassionate care."

This is a "dynamic situation," Leah Coplon, director of clinical operations at Abortion on Demand, an online telehealth service that provides medication abortion, tells TODAY.com. The company will "continue to offer abortion via telehealth to folks who need and want this care," she says. "Whether this means moving to a misoprostol-only model in some or all the states we serve —depending on upcoming legal decisions — or continuing with mifepristone if able, we will be here for patients who are entitled to the abortion care they want and deserve. "

Cindy Adam, nurse practitioner and CEO for Choix, tells TODAY.com the company will continue to provide abortion care and advance provision of abortion pills and calls on the FDA and the Biden administration to "not only protect but expand access to mifepristone — politics should not stand between people and the health care they deserve."

Medication abortions by mail are a safe and private option for many

When Amy* (name changed to protect her privacy) learned she was pregnant, she was about seven weeks along. And she knew, almost immediately, that she didn't want to endure another pregnancy.

Amy, 27, has multiple chronic health conditions. And, if she became pregnant again, she would have had to temporarily go off many of the medications that help her, she tells TODAY.com. Plus, her previous pregnancies ended in miscarriages.

"Physically, (miscarriage is) not pleasant. But emotionally, it really takes its toll," she says. "So, I was just like, I don't even want to go through it anymore. I just can't."

Looking for abortion services near her, Amy turned to the internet. And she found Choix (French for "choice"), one of several companies that provide medication abortions exclusively via telemedicine. "I just wanted to be in control of the outcome, and I wanted to figure it out sooner than later," Amy explains.

She took an initial online survey and received the pills, along with a care package, in the mail two days later. Throughout the entire process, Amy communicated with her providers entirely through secure text messages, an option that made her more comfortable and made abortion more accessible, she tells TODAY.com.

“I didn’t talk to anyone, I didn’t have to call anyone, I never had to speak it out loud,” Amy says. “It just felt so much more liberating. And I didn’t feel guilt or shame (because) it could be totally confidential.”

What is telemedicine abortion?

Telemedicine abortion, also called telehealth abortion, is essentially a medication abortion in which medical consultations occur over video chat, phone call or text message, and the medications are sent through the mail.

With some telemedicine services, the entire process happens through telehealth, meaning the patient never meets their provider in person; they may be asked about a positive pregnancy test, but aren’t generally required to provide one, and there are no mandatory ultrasounds, multiple experts tell TODAY.com.

In other settings, clinics or hospitals may use telehealth for just a part of the process, like the initial consultation, Dr. Nisha Verma, Darney-Landy Fellow at the American College of Obstetricians and Gynecologists, and OB-GYN with a specialty in complex family planning, tells TODAY.com.

How safe is telemedicine abortion?

"We actually have a lot of data that shows that telehealth abortion is just as safe and effective as medication abortion provided in person and that it increases access to care," Verma says.

Dr. Montida Fleming agrees: "Medication abortion is very, very safe. Using telemedicine for medication abortion is very, very safe," says Fleming, who is a physician in the department of family community medicine at the University of California, San Francisco, and a clinician with telehealth abortion service Hey Jane.

The ACOG guidelines for medication abortion at or before 10 weeks also state that "medication abortion can be provided safely and effectively by telemedicine with a high level of patient satisfaction, and telemedicine improves access to early abortion care, particularly in areas that lack a health care practitioner."

Adds Ushma Upadhyay, Ph.D., associate professor in the University of California, San Francisco’s program Advancing New Standards in Reproductive Health (ANSIRH): "In our research, we've worked with 14 different clinics and found that all of them follow more or less the same protocol."

That process was codified by a variety of experts in the field affiliated with major reproductive health organizations — including ANSIRH, the Society of Family Planning and Planned Parenthood — amid the COVID-19 pandemic, Upadhyay explained. "We recognized there was a need to simplify the screening process and get people their medications," she says.

For instance, based on research showing that "people are extremely good at recognizing their pregnancies and assessing how far along they are," Upadhyay says, the protocols omit the need for a positive pregnancy blood test. And other research shows that neither a pelvic exam nor an ultrasound actually improves outcomes, suggesting that telemedicine abortion — with just a screening survey and virtual conversation about the patient's history — is a safe and effective option.

What is the process actually like?

Although there may be slight differences from practice to practice, all telemedicine abortions follow those same basic evidence-based steps, multiple experts tell TODAY.com.


First, there's an initial survey to assess how far along the patient is in their pregnancy, to make sure they're currently located in a state where telehealth abortion is legal and that they don't have any underlying health issues (or an IUD) that could increase their risk for complications.

Some services ask whether or not you've had a positive pregnancy test, but they typically don't require you to provide proof of the results.

Contact with providers

If everything looks OK, the clinic will reach out to the patient to let them know they can proceed. If a patient has a more complex case — such as if they have an IUD, which can increase the risk for ectopic pregnancy, or an underlying health condition that puts them at greater risk for excess bleeding — more questions about the process or they just want to chat with a provider, they may do so through a video chat with a clinician who is licensed in their state.

"Some folks have had it before and know exactly what to expect," Coplon says. "Some people have done a lot of research. And some people really need everything very carefully explained."

If the patient's case is relatively straightforward, they may be able to follow a path like Amy's and communicate via secure text messages or audio messages (a model called asynchronous care, Coplon says).

Like Amy, Laura* (name changed to protect her privacy) chose to communicate with her providers at Hey Jane entirely through HIPAA-secure texts. Already a mother of three small children and in the middle of buying a new house, Laura, 36, appreciated the simplicity of using telehealth to get an abortion.

And she says the nonjudgmental tone of the texts helped, too. "Every time they messaged me, they asked how I was feeling and they added little smiley faces," she tells TODAY.com. "I felt like I was talking to a friend."

Receiving and taking the medication

Once approved, the patient can choose to receive their medications through different delivery options, including overnight. In the U.S., there are two online pharmacies that send out pretty much all of these medications, Coplon said, which are Honeybee and American Mail Order Pharmacy.

(One major exception is Aid Access, an international telemedicine abortion provider, which, depending on your state, may fill your prescription through a pharmacy in India. The CEO of Aid Access told the New York Times that if the Texas ruling stands, it will most likely ship pills from India regardless of where the patient lives. Aid Access also fills advance prescriptions, so you don't necessarily have to be currently pregnant to order the medications.)

Amy decided to take her pills before going to bed so the process would happen overnight.

“I had a really terrible few weeks being pregnant. I lost like 15 pounds, I was in poor health,” she explains. But the morning after taking the pills, “I had never felt better. I just woke up, and for the first time in like two months, I wasn’t throwing up. I didn’t feel nauseous. I didn’t feel dizzy.” She felt “mentally relieved,” as well.

Before taking the medication, Laura read up on other people's experiences with medication abortion and learned that heavy bleeding is a common side effect. "I was so frightened, but honestly it was not that bad for me," she says. As someone who is used to heavier periods, she says her medication abortion felt like a "mild period" and was "much easier" than what she'd been expecting.

Following up

As with any medication, abortion pills can cause side effects, most commonly cramping, bleeding and nausea, Verma says. Some people might also develop a mild fever and gastrointestinal symptoms, she said.

But recent research estimates that serious complications — those requiring hospital admissions, blood transfusions or surgery — occur in less than 0.5% of medication abortions in the U.S., according to ANSIRH.

And the science-backed process of surveys, initial conversations and follow-ups with telehealth abortion providers was designed to reduce those risks as much as possible, Upadhyay says. "The protocols are really about screening for eligibility and ensuring that the patient is not at high risk for an ectopic pregnancy," she explains.

In fact, telehealth abortion providers follow up with patients throughout the process to determine whether the medication worked and to make sure they aren’t experiencing any serious complications. And then they’ll follow up again about a month later and prompt patients to take a pregnancy test to confirm.

Hey Jane is able to provide real-time support for patients 24 hours a day, Fleming says. With experts available on their chat platform 12 hours a day and a 24-hour call line, the company is able to “answer their questions, evaluate whether their experience is what’s expected, offer reassurance if needed, and to identify any rare complications that may warrant additional care,” she says.

Amy appreciated the care she received from Choix so much that she’s still in contact with her providers there. “I was really impressed with their empathy and how they handled it,” she says. “And it was always the same people, too, which was really nice.”

In the rare event that the medication doesn’t work or there’s a complication that requires in-person care, the telemedicine abortion service will work with patients to get them the help they need, Coplon says. That might mean having the patient take a second round of pills or connecting them to an in-person clinic.

“We know this care. We are exceptionally good at working with patients to figure out what’s going on if there are any concerns,” Coplon says. She noted that Abortion on Demand has deep connections with independent clinics, so the organization is particularly adept at getting patients in-person help when required.

How to find a provider offering legal telemedicine abortion in your state:

To find telehealth abortion services near you, including telehealth abortion providers, the experts recommended you consult online databases they say are reliable, such as Plan C Pills and AbortionFinder.org.

But keep in mind that telemedicine abortion isn’t legal in many U.S. states, and the specific regulations differ by state. Each telehealth abortion company may have its own cutoffs for eligibility — generally no later than 10 weeks of pregnancy — and may only operate in a few states. And it’s the abortion laws of the state where the patient lives that govern their access, not the provider’s. Some telemedicine abortion services require the patient and provider to be located in the same state.

Telemedicine abortion typically costs between $350 and $500, Verma says. But that varies from clinic to clinic. And some online services are able to keep their costs lower, Fleming says. For instance, a telemedicine abortion with Hey Jane costs $249, according to its website. Choix offers its services for $289, and Abortion on Demand may charge between $239 and $289, depending on the state.

Whether or not insurance covers telemedicine abortion is a complicated issue. "It's very state-specific," Verma says. Medicaid may cover medication abortions in some cases, Upadhyay says, but in "some states, like California, people can only use their Medicaid if they go to a brick-and-mortar clinic. So it kind of depends on the patient and their insurance."

Telemedicine abortion can make it easier for some to access care — but not all

There are a variety of reasons someone might choose to have a medication abortion via telehealth rather than going in person.

"I've had patients from really remote areas in the states where the nearest abortion provider might be three or more hours away," Fleming says. "And I've had patients who live in a really big city where their nearest abortion clinic might only be 10 minutes away, but the wait times are weeks long."

Some patients, like Amy, simply don't want to talk about their decision in person and find it more comfortable to do everything at home on their own terms. And for Laura, who "gets anxious going to the grocery store," telehealth helped make the whole process more approachable.

Both Amy and Laura tell TODAY.com that if telehealth wasn't an option, they doubt they would have gotten an abortion.

Now that Roe v. Wade has been overturned, telemedicine can help ease the burden on clinics in those states where abortion is still legal, which are likely to see an influx of new patients, Upadhyay says. And if telemedicine abortion helps more people get their pills earlier, "they will be more likely to be successful and ... they can avoid long waiting times for an in-person clinic," she adds.

But telemedicine abortion isn't available for everyone.

“Patients don’t have this option in (at least) 19 states across the country — and those are the very same states that have the fewest abortion facilities and the greatest need for telehealth abortion,” Upadhyay says.

This article was originally published on TODAY.com