When the Supreme Court intervened to keep mifepristone accessible by mail for pharmaceutical abortion, courts and commentators focused on a procedural question: Could Louisiana show concrete harm from a drug approval? I keep thinking about the women.
I don’t know the specifics of the care those individual patients received. What I do know — as a physician, a former Medicaid medical director and a former Medicaid enrollee — is the way shield-law telehealth providers operate. These providers prescribe drugs for abortion across state lines without holding a license in the state where the patient lives, and their home state “shields” them from prosecution.
Their standard practice depends on patient self-report. The provider prescribes the pills; the patient takes them. The patient is expected to initiate contact if something goes wrong. There’s no scheduled follow-up, and no clinician outreach.
This is not how we practice medicine.
Supporters of this practice point to the California Home Abortion by Telehealth study — the most-cited “proof” for the safety of pharmaceutical abortion by telehealth. The study enrolled patients in 2021. Telehealth providers who were operating legally in states where abortion was permitted prescribed the pills for a pharmaceutical abortion, and then researchers proactively followed up with women twice after they’d taken the medication — first, at three to seven days, and then again at two to four weeks.
This is a categorically different context from the cross-state, unlicensed model under which shield-law providers now operate. What Aid Access, the largest shield-law provider, actually does is “invite” patients to self-report outcomes via an online form four weeks after receiving pills in the mail. Those models of care are not the same, and conflating them is not honest science.
The population this matters for most is women on Medicaid. These women are more likely to have comorbid conditions that elevate their risk, and, for financial reasons, more likely to be further along in their pregnancies when they seek care. Their higher risk was highlighted in a peer-reviewed study conducted among California Medicaid recipients that found that 5.2 percent of pharmaceutical abortions were followed by an emergency department visit within six weeks. That is not a trivial signal. Diagnostic colonoscopy — a procedure no one would manage with self-report — generates even lower rates of unplanned visits, and yet a next-day outreach is routine.
Here is the equity problem in plain terms. A woman with private insurance who obtains a pharmaceutical abortion through her Ob/Gyn, a Planned Parenthood clinic, or a traditional telehealth provider has a clinical relationship. There is a follow-up encounter — a call, a portal message, an office visit.
A woman in a state where abortion access is limited, who obtains a pharmaceutical abortion through an out-of-state shield-law provider, has none of that. If she starts hemorrhaging at home and doesn’t know that the bleeding has crossed the threshold from an expected outcome to a sign of danger, her first clinical contact will be in an emergency department — staffed by physicians who may not know what she took, when she took it, or how far along she was.
The American College of Obstetricians and Gynecologists supported a change in the standard during the COVID-19 pandemic as an emergency measure. That accommodation became a permanent practice, but only for one population. Women with private insurance never lost their continuity of care. The standard of care has only been lowered for poor women.
You don’t get to call that equity. If the goal is to ensure that every woman who needs this care can access it safely, then the conversation has to include what comes after the pills arrive in the mail. All women deserve a standard of care that includes continuity of care. Right now, for the poor women who need follow-up the most, no one is asking.