The Next Stage of the Roe v. Wade Debate: Abortion Pills by Mail
WHY YOU SHOULD CARE
Because it’s not hard to imagine the ways telemedicine could confound abortion restrictions.
From inside the U.S. Capitol, Deb Fischer defends her party’s push for abortion restrictions in states like Georgia and Alabama as protesters outside shout that the Supreme Court’s 1973 Roe v. Wade decision is in danger of being overturned. “I don’t know that I see a case the court would take. It’s a what-if,” the Republican senator from Nebraska says. Meanwhile, hundreds of abortion rights advocates — and harried-looking presidential hopeful Bernie Sanders — are storming the nearby Supreme Court steps. “It’s a human right, and we need to understand that,” says high school senior and ballerina Julie Gundzik, whose company performs while carrying signs supporting abortion access.
The debate in Washington is playing out with ferocity nationwide after six states passed laws to curtail abortion in recent months. Democrats fret that those laws are aimed at challenging past court precedents and could reach the conservative-majority Supreme Court. But a reversal of Roe would merely toss the matter to individual states rather than ban the practice outright. And in the state-by-state legal framework that would emerge, a key question might be one that’s garnered little national attention: What about the intensifying war over abortion facilitated by telemedicine?
If abortion becomes less accessible in some states, providers may respond with abortion-inducing pills sent by mail or picked up at a pharmacy across state lines. Telemedicine abortions began prominently in 2008, when Planned Parenthood branches in Iowa began allowing pregnant women in rural areas to visit one of their centers and meet a doctor through video call before receiving prescription abortifacients. Legally necessary blood tests and ultrasounds are conducted in local labs. That model has now been adopted by Planned Parenthood in 14 states, and some private providers are exploring it as well.
Separately, New York-based research organization Gynuity Health Projects is testing a direct-to-patient model in eight states, with approval from federal regulators, to see if it’s as safe for patients to teleconference from a location of their choosing — such as their home — instead of having to visit centers such as those of Planned Parenthood. Based on the doctor’s conclusions, patients could then receive the abortion-inducing pills by mail. In both approaches, a physical meeting with a doctor would be eliminated.
A state law shouldn’t prohibit something that a doctor can do safely.
Julie Gundzik, abortion rights activist
This push for telemedical abortions hasn’t gone uncontested. Since Planned Parenthood launched the practice in Iowa, 17 states have brought in laws that require a physician to be physically present during a chemical abortion. Many of those laws have been challenged. Iowa’s Supreme Court in 2015 overturned a ban on telemedical abortions that was introduced in 2013. Idaho has repealed two such laws as part of a settlement with Planned Parenthood.
But now, in the shadow of the Roe v. Wade debate, the battle lines over telemedical abortions are sharpening again. In March, Arkansas lawmakers voted down a proposal for doctor visits by telephone. That same month, the Nebraska Legislature debated a bill proposed by Democrat state Sen. Megan Hunt to allow the practice (which it previously banned in 2011). And Planned Parenthood launched lawsuits against Arizona and Wisconsin this spring over their bans on telemedical abortions. Yet the issue has not been making national headlines.
“Seriously, I have never heard of that before,” Fischer, the Republican U.S. senator from Nebraska, says, adding that any consideration of it should be through a “state-by-state discussion.”
Even before the liberal fear of Roe being revisited becomes reality, the growing restrictions on abortions by location are making telemedical abortions more relevant than ever before, experts say. Pregnant women in Alabama, a state that will soon ban abortions after six weeks, could cross the border to neighboring Georgia — which has no laws restricting telemedicine abortions — and pick up pills prescribed by a physician from a legal abortion state like California. Once they have the pills, they could either induce the chemical abortion out of state or risk taking them back at home.
Those opposing abortion point to a study published in the Obstetrics & Gynecology journal in 2009, which found that about a fifth of women using the abortion pill in Finland experienced some sort of complication. Such adverse effects were “fourfold higher” than surgical abortion, with the most common side effects being hemorrhaging (nearly 16 percent) and incomplete abortion (about 7 percent), although the researchers determined the process was still “generally safe.” Arizona courts have previously upheld its telemedicine abortion ban, saying the state had demonstrated enough proof that remote care was less safe.
More recent research directly tied to telemedicine abortion, though, has shown different outcomes. Gynuity’s results from the first four of their pilot states (Hawaii, New York, Oregon and Washington) determined the method was just as safe for the woman as other abortion options, a conclusion similar to that of a similar study in Ireland. A University of California San Francisco study, released in 2017, of 20,000 patients from Iowa also concluded that telemedicine abortions were as safe as those carried out in the presence of a physician.
If Roe is overturned, individual states could pursue legislation on abortion, either banning it or allowing it, each with their own caveats. In that scenario, the demand for telemedical abortions could rise further — getting a surgical abortion might not just be inconvenient but impossible in several states. Most states require physicians to be licensed in the state the abortion is being performed in, regardless of the doctor’s actual location, which complicates telemedicine’s potential as a workaround. Still, “Planned Parenthood will do whatever it takes to stop dangerous abortion restrictions so that all people can access safe, legal abortion — no matter where they live,” says Dana Northcraft, senior director of innovation and policy at Planned Parenthood, in a statement.
Gynuity’s direct-to-patient model would get around the practical aspects of that complication. And while it’s unclear if states would consider that legal, monitoring who’s using abortion pills after talking to a doctor from home won’t be easy.
The situation would bear similarities to the testy framework around another controversial treatment: medical marijuana. When Georgia first legalized medical cannabis oil, parents of seizure-ridden children had to travel to Colorado and other marijuana-legal states to obtain it, then illegally transport it across state lines to treat their kids. “The hodgepodge of different state laws really was a significant barrier of access,” says Allen Peake, a major architect of Georgia’s cannabis oil laws.
The Republican and former state senator believes there is a major difference between the two causes: The medical marijuana cause was to protect a child’s life, while abortion is about ending it, in his view. But to abortion rights activists like Gundzik, it’s wrong for states to ban something that’s been shown to work. “A state law shouldn’t prohibit something that a doctor can do safely,” she says.
And even Peake thinks a patchwork of regulations is good for nobody. “The questions come down to needing some leadership at the federal level,” Peake says. The answers to those questions could shape the future of abortion rights in America — with or without Roe.