A nascent but rapidly growing industry of abortion providers performs abortions only via telemedicine, with no physical clinics. A federal court decision Wednesday to ban abortion pills by mail could make it significantly more difficult for them to operate.
But for now, several of the more than a dozen virtual clinics — including Hey Jane, Juniper Midwifery, Pills by Post and Carafem — say they will continue to offer medical abortions that include mifepristone, the disputed pill, as they await clarification from Food and Drug Administration. Honeybee, which fills prescriptions for most of them and is the largest mail-order pharmacy for abortion pills in the United States, said it will continue to ship the pills to the 24 states where it is allowed.
“As a licensed pharmacy, we follow FDA policies and regulations,” said Jessica Nouhavandi, co-founder and president of Honeybee. “And until the FDA says anything, which they haven’t yet, we’ll continue business as usual.”
On Friday evening the Supreme Court issued a temporary residence permit, which expires at midnight Wednesday, which keeps mifepristone, the first of two drugs commonly prescribed to induce abortions, widely available. The lower courts’ rulings, if enacted, could significantly limit the drug’s availability, including allowing it to be administered only to patients in a doctor’s office.
Virtual clinics use specially licensed clinicians and serve women who are physically located in states where abortion is legal and have a mailing address there. They offer online consultations via video or messaging and write prescriptions that are usually filled by a mail order pharmacy. A visit usually costs $200 to $300, although some clinics provide discounts or free services to low-income patients.
Some of these providers offer same-day appointments and overnight delivery and have doctors available if patients have questions during the process. Some also prescribe the pill for women who are not pregnant but may need it in the future. These include Choix, Pills by Post and Juniper Midwifery.
Launched in 2020, virtual clinics are responsible for a growing share of legal abortions. In December, they provided 11 percent of all abortions, or 8,540, up from 4 percent, or 3,610, in April, before Roe v. Wade was overturned. according to the data released this week by WeCount, a research group collecting nationwide numbers of abortion procedures and pill prescriptions.
The WeCount numbers do not include patients who receive medical abortions via telehealth from clinics that also offer in-person abortions. They also do not include women who illegally order abortion pills from providers outside the United States. New data shows that enough abortion pills have been ordered from overseas more than cover the decline in legal abortion in the United States.
Demand for virtual clinics continues to accelerate. The honey bee will fill more than 10,000 prescriptions for abortion drugs a month this year, an increase of several thousand over the end of last year. Since a federal judge in Texas issued a preliminary ruling last week invalidating the FDA’s approval of mifepristone, the pharmacy has seen the highest number of orders for the abortion drug.
Several providers said they are not concerned about the legal risks of continuing to operate because of recent court rulings.
“We will continue to provide prescriptions for both mifepristone and misoprostol,” said Dr. Razel Remen, owner of Pills by Post, which offers telemedical abortions in four states. “We feel we are bound by what the FDA says and not what the courts say.”
Abortion on Demand, the virtual clinic with the largest footprint, which operates in 22 states and Washington, D.C., said it would stop prescribing mifepristone by Monday, when the court order was set to take effect. After staying at the Supreme Court, Dr. Jamie Phifer, medical director of Abortion on Demand, said she believes the clinic can still prescribe both pills in most states after Wednesday, but that the situation is changing quickly.
“We may decide to go miso-only in other states until more information is available next week,” said Dr. Phifer referring to misoprostol, the second pill in a two-pill regimen for abortion medication. He can safely be used separatelyalbeit with lower efficacy rates and more side effects.
Most virtual clinics said they would still prescribe misoprostol if they could not prescribe both pills. Some, such as Twentyeight Health and Wisp, said there could be a break in service if they had to switch to a single-pill regimen. Several other virtual clinics, including Choix and Forward Midwifery, said they did not yet know how they would proceed next week due to legal uncertainty.
In states where abortion remains legal, there are no risks for women who obtain and take the pills from these providers, said Farah Diaz-Tello, legal director of the advocacy group If/When/How. The legal risks of potential FDA enforcement for providers and pharmacies are less clear, and they said they hope next week will be clearer.
The virtual abortion clinic industry is young: they were made possible during the pandemic when the FDA began allowing abortion providers to send pills without the need to visit a clinic in an emergency. FDA in December 2021 this policy permanently.
Since the Supreme Court’s Dobbs decision last June, which ended statewide abortion rights, California and New York have had the most virtual clinic abortions, WeCount data shows. Regulations in half a dozen states more than tripled between last April and the end of the year.
One virtual clinic, Hey Jane, which started in 2021 and prescribes in eight states, has seen more than double the number of monthly patients since Dobbs. To meet demand, it has grown its clinical staff fivefold in the past year and introduced a sliding scale pay scale. It’s also expanding to other states, starting with Maryland this month and targeting states that border states with restrictions.
There are several reasons for the rapid increase in orders from virtual clinics, say people who run them. In some states where abortion is legal, it can be difficult to get an in-person appointment, as clinics have seen an increase in patients traveling from states with bans. Increased publicity for various abortion options since Dobbs’ time has also made more women aware of virtual clinics, they say. Some patients also find virtual clinics more convenient and private.
“We are able to offer this care from the comfort of our own home in a very confidential way,” said Jillian Barovick, midwife and co-founder of Juniper Midwifery.
There are now competing abortion judgments and lawsuits for the Supreme Court to resolve.
“We don’t know what the U.S. Supreme Court will do, we don’t know what the FDA will do,” said Mary Ziegler, a professor at the University of California Davis School of Law. “And I think we’re seeing a larger group of prescribers and other actors using that uncertainty to take a stand.”
Graphics contributed by Alicia Parlapiano.