The FDA Opened Abortion Access. Just Not for Everybody.

Lifting a medication abortion restriction means abortion patients can get their medication by mail. But not in states where telemedicine is banned.

[PHOTO: Black female doctor wears a headshot and is shown in a computer screen]
Nineteen states prohibit telemedicine abortion, usually by requiring a doctor to be physically present while the medication is taken, and that number is growing. Shutterstock

The Biden administration recently lifted a restriction on medication abortion that forced patients to pick up the drug mifepristone in person from a doctor. This means patients in some states can reduce their exposure to COVID-19 through a telehealth visit and later receive the medications by mail.

Without additional action from the Food and Drug Administration, however, the policy only applies for the duration of the pandemic. And for patients in conservative states that impose their own telemedicine bans—along with other medically unnecessary restrictions like waiting periods, mandatory ultrasounds, and forced counseling—the FDA’s change doesn’t improve access to abortion care at all.

Abortion care via telehealth improves abortion access for people who live in rural areas, who experience logistical barriers, or who live with limited mobility. Iowa’s Planned Parenthood of Heartland first implemented telemedicine for abortion in 2008, allowing patients to go to a local health center to videoconference with a clinician at a different location. And since then telemedicine has expanded across Planned Parenthood in various states and spurred the development of online projects like TelAbortion, Aid Access, and Abortion on Demand.

But 19 states prohibit telemedicine abortion (usually by requiring a doctor to be physically present while the medication is taken), and that number is growing. Other anti-choice state laws force patients to visit the clinic for a mandatory counseling session or ultrasound, necessitating an additional in-person appointment 24 to 72 hours before they can receive abortion care.

According to Dr. Bhavik Kumar, medical director of primary and trans care at Planned Parenthood Gulf Coast, a “web of restrictions” in Texas is exactly why people seeking abortions still face “significant health equity issues” during the pandemic.

“Despite the FDA’s action, people living in restrictive states—like Texas—are still subject to medically unnecessary barriers to care and will not be able to access some or all of their medication abortion through telehealth,” he said.

The Texas legislature continues to target telemedicine abortion, even though telehealth for a medication abortion is just as safe and effective as in-person care. In fact, it can be safer, because limiting medically unnecessary exposure to health-care clinics during a pandemic is important for pregnant people—especially pregnant people with certain disabilities—who face additional risks when it comes to COVID-19.

“Anyone with any sort of risk factor for the coronavirus during this pandemic [is a person] who can also get pregnant. … Not to mention pregnancy in itself is an immunocompromised condition,” said Dr. Leah Torres, OB-GYN and medical director of West Alabama Women’s Center. “Any requirement for someone who is disabled, who has transport limitations or anything like that—requiring them to be mobile when they don’t have to be—is an undue burden and frankly, cruel. It compromises their safety even further, unnecessarily so.”

These unnecessary laws “don’t have anything to do with actually improving health care, but rather everything to do with imposing more burden on a patient and more risk,” she said.

People seeking abortions in restrictive states like Texas and Alabama are forced to make multiple visits to an abortion clinic because of restrictions like forced counseling and bans on telemedicine. Exposure at health-care clinics and logistical complications like arranging rideshares and child care also increases risk in states where lawmakers failed to ever take the pandemic seriously.

When the pandemic is over, the FDA can go right back to in-person requirements for administering mifepristone—a medication that is safer than over-the-counter pain medication.

Even before the pandemic, it was extremely difficult for patients—“especially people with low incomes and those living in medically underserved areas”—to access the essential care they needed in the first place, Kumar said. In Texas, he’s seen firsthand the consequences of barriers like child care, transportation, time off work, and bans on private health coverage for abortion.

“Systemic barriers to care existed long before the pandemic, and they will continue to exist long after. The web of restrictions around abortion in Texas makes it difficult, if not downright impossible, for so many people to access the care they need—especially people of color, particularly Black people; people with low incomes; people in rural areas; undocumented people; and LGBTQ+ folks,” he said.

The pandemic has only “amplified” these barriers, according to Kumar.

“Anytime health care is restricted, people suffer, and these communities suffer the most,” he said. “We’ve always known this, but the pandemic has really brought it into sharper focus, pouring gasoline on the long-simmering, systemic inequalities that I see every day through my patients’ lived experiences.”

Ashley, 32, had a medication abortion at a clinic in central Texas last year. (Her name was changed to protect her privacy.) Both she and her father, who supports Ashley by providing child care, are considered high risk for the coronavirus.

“I had to secure child care multiple times for each visit, then again overnight for when I took the second medication [misoprostol],” Ashley said. “I have a child with special needs, so finding child care is a monumental task on its own.”

For Ashley, who works in health care, the decision to have an abortion was directly related to her experience as a parent.

“I knew all too well exactly what it means to raise a child, not just be pregnant and give birth. … The reason people like me—[people] who are already mothers—have abortions is because we’ve found our society is not going to be there to help us raise these kids, only to make sure we give birth. My daughter has a lifelong disability [yet] I make $15 an hour part time, don’t own a house … and was denied disability for her because I ‘make too much,’” she said

Ashley also has a uterine polyp, which she said increased her risk of hemorrhaging during pregnancy. She said she was thankful that even with limited clinic availability, the doctor made sure to see her as soon as possible.

“For me, time was essential as I could not wait even one more week for the pregnancy to progress and have that much more fluid pressing on the polyp in my uterus—aggravating it and risking hemorrhaging. … Who knows what could have happened to me? This legal requirement for two appointments does nothing but put lives in danger,” Ashley said.

Being able to have a medication abortion through telehealth would have improved her experience with abortion care, Ashley said; driving 45 minutes each way and waiting alone in the clinic for hours while worrying about her daughter was difficult. A telehealth abortion also would have lowered her risk of pregnancy-related complications, as risks increase as pregnancy continues.

“So you’re increasing risks by not making a safe medication available, you’re increasing risks by imposing telemedicine bans, you’re increasing risks by having imposed waiting periods, [and] all of these things are against evidence-based medicine and only increase risks to the health and lives of real people,” Torres said.

Even when the pandemic is over, many of these barriers will persist—and so might the requirement that patients pick up mifepristone in person.

Torres pointed out that the FDA’s recent decision specifies that it applies during the pandemic, which means when the pandemic is over, the FDA can go right back to in-person requirements for administering mifepristone—a medication that is safer than over-the-counter pain medication.

“When the pandemic is over, it can go right back to how everything was. And it’s not necessary, it’s actually harmful to have that [in-person] requirement,” Torres said.