In 2020, a federal judge ruled that the Food and Drug Administration (FDA) must suspend its requirement that patients pick up mifepristone, one of the pills used in medication abortion, in person. After some back-and-forth under the Trump administration, the FDA permanently repealed the rule, which had long been decried by medical experts as unnecessary, in 2021.
This opened the door for providers to send abortion pills by mail in all but the 19 states that outlaw provision of abortion via telemedicine. (Many of those same states now ban abortion entirely.) This regulation change, along with increased popular interest in abortion access following Roe’s overturn, has led to a proliferation of telemedicine companies offering abortion pills. Some of these companies are run by people with prior experience in abortion care and connections in the reproductive health, rights and justice movements; others are not. Regardless, some abortion access advocates are raising concerns about whether the rise of for-profit telemedicine companies is the best way to serve abortion seekers.
Ordering abortion pills online isn’t new. Prior to the pandemic, patients in the United States were only able to receive abortion pills through the mail legally in a handful of states as part of a study by Gynuity Health Projects.
Though many clinics across the country allowed patients to connect with abortion providers remotely, they still had to pick up their pills, and in some cases undergo tests, in person. However, even when there was a constitutional right to abortion, dwindling numbers of clinics meant that nearly one-fifth of abortion patients had to travel more than 50 miles each way to reach their nearest clinic. Abortion seekers in the U.S. are disproportionately likely to be poor or low income, to be people of color, and to already have at least one child. For many such people, a 100-mile round-trip journey simply isn’t possible for financial or logistical reasons. So for decades, people living along the U.S.-Mexico border have purchased misoprostol — a pill that can be used on its own or in combination with mifepristone to induce an abortion — in Mexico, where it is more readily available. And in recent years, they have increasingly purchased pills online.
In 2018, Dutch doctor Rebecca Gomperts, who made a name for herself providing abortions on a ship in international waters, launched Aid Access, a telemedicine service for U.S. users. Originally, abortion seekers would submit information to be reviewed by a doctor, and then pills were mailed to them from a pharmacy in India. That’s still how it works for people in states where abortion, or telemedicine abortion, is banned, but now that telemedicine abortion is legal in many U.S. states, Aid Access patients in those states are served by U.S.-based providers and pharmacies. Even before Aid Access, there were online pharmacies where people could order pills. But now, these mostly foreign pharmacies have largely been eclipsed by the rise of domestic telemedicine companies.
“The techbro-ification of abortion is coming. While I support more access, what this aspect will do is chase VC [venture capital] and profits in states where abortion is legally protected leaving hard, legally challenging work to indie clinics and activists of color serving people without capital,” tweeted Renee Bracey Sherman, longtime activist and founder of We Testify, an organization that aims to shift the way abortion is represented in the media by increasing representation of abortion storytellers, on October 26.
“My concern about anything related to abortion access is: who is it actually centering, and who is it for? Who is the end user and who is the one who is supposed to gain something from this?” Bracey Sherman told Truthout, elaborating on her tweet. “In a capitalist society, people invest in companies because they want to make money. And abortion is health care that people need to be able to participate in [within] society and survive and move forward with their lives. It’s so critical. But capitalism and health care can never coexist because in capitalism, there are always losers,” she said. Abortion care really isn’t profitable; many people seeking abortions are doing so because they can’t afford to have a child, or couldn’t afford contraception in the first place. Most abortion clinics barely scrape by, and though the overhead is much lower for telemedicine providers, it’s impossible not to wonder how, exactly, telemedicine companies think they can turn a big enough profit to satisfy investors.
There are two abortion-focused start-ups currently raising venture capital funds: Hey Jane, which has raised $9.7 million to date, and Choix, which has raised $1 million and is currently crowdfunding up to $2.5 million in additional investment. Both companies are founded by clinicians with experience in abortion care, and both offer sliding scale rates. Hey Jane also accepts Aetna insurance in most states that it serves — a rarity among its competitors, because most telemedicine abortion companies are either too new to be accredited with insurance plans or haven’t opted to accept insurance. Choix, whose founder has said the company considered operating as a nonprofit but chose the start-up model in order to scale up operations more quickly, was a leader in advance provision of medication abortion, meaning that people can order pills to have on hand in case they become pregnant. Its current funding push is centered on Choix Travel, a business-to-business arm that will help companies arrange abortion care for employees in states where abortion is banned.
There’s no question that these companies are improving access to abortion — but only in a handful of states, where abortion is still legal. That is undoubtedly useful: If more people can get abortions via telemedicine in legal states (should that option appeal to them), there will be more appointments available at clinics for people traveling in from ban states. However, that creates a “two-tiered system,” said Bracey Sherman, where people in legal states have better access to abortion and people in ban states are left farther and farther behind, even at risk of being criminalized for obtaining abortion pills.
There are parallels, Bracey Sherman said, between the legal status of medication abortion and the legal status of marijuana. “People have been smoking weed forever. But in some states, it’s legal, and certain people get to profit off of that, all while Black and Brown people are still subject to criminalization,” she said. Referring back to the idea that there are “winners” and “losers” in capitalism, Bracey Sherman said, “The losers in this situation, it’s not just that they don’t get their abortions. It’s that they’re criminalized for doing so. And that’s what’s really, really scary.”
In addition to Hey Jane and Choix, there are numerous other telehealth-only abortion providers, including some nonprofits. Many brick-and-mortar clinics have also introduced telehealth options. Independent abortion clinics — meaning those not affiliated with Planned Parenthood — were among the first to embrace mailing pills to their patients once FDA rules allowed it. However, many in the field are wary of the way telemedicine is being marketed as the end-all solution to abortion access.
“When we champion telemedicine as the ultimate abortion solution, what are we saying to people in the 19 states where telemedicine is banned? Or the folks whose personal choice and preference is surgical or in-person care?” Kenyetta Whitfield, digital communications manager at Abortion Care Network, the national organization for independent abortion providers, told Truthout. Whitfield added that there can never be such a thing as too much access to abortion, but urged people not to see telemedicine as a replacement for closing clinics.
“Once a community loses its clinic, it’s nearly impossible to reopen it — leaving permanent gaps in care. These gaps will fall hardest on people who already face disproportionate issues with access to health care,” said Whitfield. “People need community-based abortion clinics. We need telemedicine, as well as expanded access, which means protecting existing clinics and ensuring that in-person abortion care remains a possibility for all people.” Hey Jane and Choix are members of Abortion Care Network, as are several other telemedicine providers.
The telehealth boom also has some observers worried that new companies may be scaling up too quickly, at the cost of quality care. Though none would speak on the record, multiple sources with knowledge of patient experiences raised concerns about the services provided by one company in particular: Abortion Telemedicine. Founded in 2022 by Jayaram Brindala, a preventive and addiction medicine specialist who has held leadership roles within several health-tech companies, Abortion Telemedicine operates in 17 states — more than most other telemedicine providers — and prices its services at $145, $5 less than the standard Aid Access price of $150.
Abortion Telemedicine is an outlier in that it offers medication abortion through 13 weeks of pregnancy. While medication abortion is only FDA-approved up until 10 weeks, many providers use their own discretion to prescribe it up to 11 or 12 weeks. Medication abortion at 13 weeks can still be safe and effective, but is not common in the U.S.
Initially, Abortion Telemedicine was listed on Plan C, a site that connects users with telemedicine abortion services and vetted online pharmacies. However, the listing was removed in late September, reposted in early October, and removed again in mid-October. Plan C co-director and co-founder Elisa Wells confirmed that Abortion Telemedicine was previously listed on the site but declined to give further specifics. “In general, in our ‘telehealth’ section, we list licensed U.S. telehealth providers and companies who request to be listed and who provide reliable, quality services in compliance with U.S. regulations,” she told Truthout.
Brindala, Abortion Telemedicine’s founder, said that his company opted out of Plan C’s listings until further notice after being added and removed twice, and claimed that Plan C’s concerns stemmed from a single error made by one provider. “We might have had one case with insufficient patient instructions, but we have gone to great lengths to add systems and processes to account for a one-time human error from one provider,” he told Truthout. Brindala also provided Truthout with a list of Abortion Telemedicine’s clinicians and their National Provider Identifier numbers to verify that they do all have active licenses. Brindala added that he started Abortion Telemedicine using his own money. The company is “close to break-even,” he said, and has not sought outside funding.
I Need an A, another directory site, lists Abortion Telemedicine with a disclaimer: “This provider is very new to the abortion space and began building their business in May 2022. We’ve gotten reports that their medical advice isn’t always in line with standard U.S. abortion care. As such, we recommend reaching out to the M+A Hotline if you choose this provider and have medical questions.”
A representative for I Need an A told Truthout that it lists all members of the National Abortion Federation (NAF), a professional organization for abortion providers, and includes additional context such as this where necessary. Sources said that concerns about Abortion Telemedicine have been reported to NAF.
“The fall of Roe has created an unprecedented abortion access landscape with new sets of challenges, some of which telemedicine is uniquely positioned to address. We have been expanding our membership to include telehealth providers and Abortion Telemedicine is one of NAF’s newer members. As the abortion access landscape continues to shift and telemedicine becomes more central to people’s ability to access critical abortion care, we want to ensure providers like Abortion Telemedicine have access to the training, resources, and community of practice the NAF network can offer them so they can provide the highest quality care,” Melissa Fowler, NAF’s chief program officer, said in a statement to Truthout.
Abortion Telemedicine also links to a site called Abortion Compare, which ranks several abortion telemedicine services, placing Abortion Telemedicine first. Abortioncompare.com was registered on September 30, 2022, a few days after Plan C initially removed Abortion Telemedicine’s listing on its site. An email to Abortion Compare went unanswered, and Brindala did not respond to questions about whether Abortion Telemedicine owns or operates the other site.
It’s not just telehealth services: dozens of businesses, nonprofits and other initiatives run by newcomers have sprung up since the leak of the Supreme Court’s draft opinion in Dobbs, leaving those who have been deeply invested in abortion access and reproductive justice work for many years feeling frustrated.
“It’s really difficult, to be honest. It’s really difficult to see that organizations that started in 2022 can already hire staff for salaries that are higher than what my organizational budget has been for the last several years,” said Bracey Sherman. “I’m glad to see that people are interested in investing in abortion access. But what is really challenging is that Black and Brown leaders and organizers on the ground, and abortion providers of color on the ground, are not getting that funding. It’s recreating the same problems that we’ve always dealt with.”
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