A nascent but rapidly growing industry of abortion providers administers abortions only through telemedicine, with no physical clinics. A federal court ruling Wednesday that aims to ban the mailing of abortion pills could make it much harder 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 offering medication abortions that include mifepristone, the pill under dispute, as they await clarity from the Food and Drug Administration. Honeybee, which fills the prescriptions for most of them and is the largest mail-order pharmacy for abortion pills in the United States, said it would continue to mail the pills to the 24 states where it’s allowed.
“As a licensed pharmacy, we abide by the FDA’s policies and regulations,” said Jessica Nouhavandi, co-founder and president of Honeybee. “And so until the FDA says anything, which they haven’t yet, then we will continue business as usual.”
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On Friday evening, the Supreme Court issued a temporary stay, which expires Wednesday at midnight, that keeps mifepristone, the first of two drugs typically prescribed to induce abortions, widely available. Rulings in the lower courts, if they go into effect, could severely limit the availability of the drug, including allowing it to be administered only to patients in a doctor’s office.
Virtual clinics use clinicians with special licenses, and serve women who are physically in states where abortion remains legal and have a mailing address there. They offer online consults, by video or messaging, and write prescriptions that are usually filled by a mail-order pharmacy. A visit generally costs $200 to $300, though some clinics provide discounts or free services for patients with low incomes.
Some of these providers offer same-day appointments and overnight delivery, and have clinicians on call if patients have questions during the process. Some also prescribe pills for women who are not pregnant but may need them in the future. They include Choix, Pills by Post and Juniper Midwifery.
Virtual clinics started in 2020 and account for a growing share of legal abortions. They provided 11% of all abortions in December, or 8,540, up from 4%, or 3,610, in April, before Roe v. Wade was overturned, according to data released this week by WeCount, a research group collecting nationwide counts of abortion procedures and pill prescriptions.
The WeCount numbers do not include patients who get medication abortions via telehealth from clinics that also offer in-person abortions. They also do not include women who order abortion pills illicitly from providers outside the United States. New data shows that enough abortion pills have been ordered from overseas to more than cover the decline in legal abortions in the United States.
Demand at virtual clinics has continued to accelerate. Honeybee is filling more than 10,000 abortion medication prescriptions a month this year, an increase of several thousand from the end of last year. Since a federal judge in Texas issued a preliminary ruling invalidating the FDA approval of mifepristone last week, the pharmacy has had its largest number of abortion medication orders.
Several of the providers said they were not concerned about legal risks of continuing to operate in the face of the recent court rulings.
“We’re going to continue to provide prescriptions for both mifepristone and misoprostol,” said Dr. Razel Remen, the owner of Pills by Post, which offers telemedicine 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, operating in 22 states and Washington, D.C., had said it would stop prescribing mifepristone by Monday, when the court decision had been set to go into effect. After the Supreme Court stay, Dr. Jamie Phifer, the medical director of Abortion on Demand, said that she was confident the clinic could continue to prescribe both pills in most states past Wednesday, but that the situation was rapidly changing.
“We may opt to switch to miso-only in other states pending more information next week,” Phifer said, referring to misoprostol, the second pill in the two-pill regimen for medication abortion. It can safely be used alone, though with a somewhat lower rate of effectiveness and more side effects.
Most virtual clinics said they would still prescribe misoprostol if they could not prescribe both pills. Some, like Twentyeight Health and Wisp, indicated there could be a pause in service if they had to switch to the one-pill regimen. Several more virtual clinics, including Choix and Forward Midwifery, said they did not yet know how they would proceed next week because of the legal uncertainty.
In states where abortion remains legal, there are no risks to women who obtain and take the pills from these providers, said Farah Diaz-Tello, the legal director of the advocacy group If/When/How. The legal risks from possible FDA enforcement for the providers and the pharmacies are less clear, and they said they hoped for more clarity next week.
The industry for virtual abortion clinics is young: They were made possible during the pandemic when the FDA began allowing abortion providers to mail pills without an in-clinic visit on an emergency basis. The FDA made the policy permanent in December 2021.
Since the Supreme Court’s Dobbs decision last June, which ended the nationwide right to abortion, California and New York have had the most abortions from virtual clinics, the WeCount data shows. Prescriptions in half a dozen states more than tripled from last April through the end of the year.
One virtual clinic, Hey Jane, which started in 2021 and prescribes in eight states, has seen its number of monthly patients more than double since Dobbs. To meet demand, it has grown its clinical staff fivefold in the last year and introduced a sliding pay scale. It is also expanding to more states, starting with Maryland this month and focusing on states that border those with restrictions.
There are several reasons for the rapid rise in orders from virtual clinics, say the people who run them. In some states where abortion remains legal, it can be hard to get an appointment in person, because clinics have seen surges of patients traveling from states with bans. The increased publicity for various options of obtaining abortions since Dobbs has also made more women aware of virtual clinics, they say. Some patients also find virtual clinics more convenient and private.
“We’re able to offer that care from the comfort of home in a very confidential way,” said Jillian Barovick, a midwife and co-founder of Juniper Midwifery.
There are now competing rulings and lawsuits over medication abortion, which the Supreme Court is expected to resolve.
“We don’t know what the U.S. Supreme Court is going to do, we don’t know what the FDA is going to 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.”
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