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Walgreens is pulling back on the abortion pill; these startups and nonprofits aren’t backing down

With a Texas judge weighing a ban on mifepristone, these telehealth startups and nonprofits vow to maintain access to medication abortion.

Walgreens is pulling back on the abortion pill; these startups and nonprofits aren’t backing down

[Source Photo: Erin Hooley/Chicago Tribune/Tribune News Service/Getty Images]

BY Adam Bluestein6 minute read

Hearings are scheduled to start today in a closely watched case in the U.S. District Court for the Northern District of Texas, Amarillo Division, which will determine whether women across the United States will continue to have access to the medication-abortion drug mifepristone. 

The U.S. Food and Drug Administration approved mifepristone in 2000, and currently deems it safe and effective for terminating a pregnancy within 10 weeks from the first day of one’s last menstrual period. In 2016, the agency approved the drug for use in combination with another widely used drug, misoprostol, which has become the standard “Plan C” protocol. The drug regimen terminates pregnancies successfully 99.6% of the time, with a 0.4% risk of major complications, and an associated mortality rate of less than 0.001%.

In 2020, medication abortion accounted for 54% of all reported abortions in the U.S., according to the Guttmacher Institute, which supports abortion access. That number has been increasing since the Supreme Court overturned Roe v. Wade this past summer. 

But the plaintiffs in Alliance for Hippocratic Medicine v. FDA are now challenging the FDA’s approval of mifepristone on a long list of grounds. Their lawyers seek a preliminary injunction that would compel the FDA to withdraw or suspend its original approval of mifepristone, its 2016 ruling extending the gestation period in which the drug can be used from 7 to 10 weeks, and its 2021 ruling that allowed the medication to be prescribed without an in-person doctor’s visit. Basically, a decision in their favor would set abortion rights back 23 years.

As medication abortion has become a hotly contested front in the abortion wars, regulations around where and how mifepristone can be dispensed have been changing dynamically. Before COVID-19, mifepristone could be dispensed only in a clinical setting such as a doctor’s office. A temporary FDA ruling in April 2021, made permanent in December 2021, permitted online pharmacies to dispense mifepristone prescriptions by mail. In January 2023, when the FDA announced that retail pharmacies with a special certification could also dispense mifepristone in person, the two largest chains—CVS and Walgreens—announced they would do so in accordance with relevant state laws. 

But in early March, Walgreens backpedaled. In response to a threatening letter from Republican attorneys general in 20 states, it promised it would not dispense mifepristone in those states. (It earlier made the same commitment to the AG of Kansas.) However, in four of these states—Alaska, Iowa, Kansas, and Montana—abortion, including medical abortion, remains legal.

The Walgreens response triggered a swift, angry backlash. California Governor Gavin Newsom announced that his state would not renew a $54 million deal with the company. Walgreens shares are down about 10% since it announced its decision. Meanwhile, Albertsons, Costco, Kroger, and Walmart—which also received the letter threatening legal action from Republican attorneys general—have not confirmed their plans around mifepristone. CVS has said that it plans to seek certification to sell mifepristone where it is legal to do so. And Walgreens’ responses to the 21 state AGs notwithstanding, a spokesperson for the company declined via email to say whether it would distribute the abortion pill in Alaska, Iowa, Kansas, and Montana, and reiterated part of its March 6 statement: “Walgreens plans to dispense Mifepristone in any jurisdiction where it is legally permissible to do so.” (Square these facts as you will.)

“Attorneys general do not have authority over drug regulation,” says Kiki Freedman, CEO and cofounder of Hey Jane, a telemedicine provider whose doctors help patients obtain prescriptions virtually for mifepristone, which are dispensed by mail through pharmacy partner Honeybee Health. “Walgreens appears to be caving under pressure from anti-abortion extremists and denying people the ability to get healthcare in a way that is beyond what we think is legally required.” 

Freedman points out that Kansas had a notable referendum after the Supreme Court’s Dobbs ruling, in which voters clearly indicated that they wanted to keep abortion available, safe, and legal. “In pushing against that, the AG is really going against the will of the people in an extremist fashion,” she says.

Hey Jane does not currently serve patients located in the 21 states affected by the Walgreens decision. Today, the site provides consultations only for patients who log in from California, Colorado, Connecticut, Illinois, New Jersey, New Mexico, New York, and Washington. (Similar telemedicine services, including Choix, offer care in fewer states.) However, says Freedman: “We definitely want to continue expanding to everywhere that we possibly can.” 

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Given the ever-shifting legal landscape, that may prove challenging. For example, a “fetal personhood” bill pending in Iowa, which would make having an abortion the legal equivalent of murder, means expanding in that state “may not be viable in the coming months,” Freedman says, noting, however, that there are workarounds. “We are able to treat patients who need to travel for care. Patients can cross the border into a state in which we’re live, consult with one of our providers, hear back typically within 24 hours, and get the medication shipped to a post office [in a legal state] for pickup. In the post-Dobbs world, we see that quite frequently.”

One of the big implications of the Walgreens case, Freedman says, is that it makes it harder for cross-state patients to pick up medications in person.

Alternatively, nonprofit Plan C offers an online directory of medication-abortion-by-mail resources—including the European nonprofit AidAccess and overseas mail-order pharmacies—for people in states where abortion is outlawed. “People who live in the United States get medications from pharmacies in other countries all the time,” says Elisa Wells, cofounder and codirector of Plan C. “The consumer-facing information on the FDA website doesn’t say it’s illegal to buy medications online. It just says, here’s what you need to know. We don’t prevent people from importing a 90-day supply of medications for personal use. People might assume these sites are scams, but our research has found that they do ship the pills, and the pills are real.”

Should the judge in Amarillo side with the plaintiffs, mifepristone would be taken off the market during a formal review process. But possession of pills one already has would not be illegal. And the Biden administration would almost certainly appeal any decision against the FDA to the conservative U.S. Court of Appeals for the 5th Circuit, and possibly to the Supreme Court.

“It would be unprecedented for a federal judge to overrule the FDA on the ability for people to access the medication that they’ve previously approved,” Freedman says. “If we set a precedent that judges can start determining what medications people have access to, you can imagine what that might imply for other things, like birth control, gender-affirming care, vaccines. We hope that logic prevails and that the case does not lead to a suspension of access to mifepristone.”

If access to mifepristone does become limited, Hey Jane and other providers say they will continue to offer medication abortion using a misoprostol-only protocol, which is still safe and effective. Misoprostol, a common medication used to treat other conditions, including stomach ulcers, is regulated entirely differently than mifepristone.

Even as the case in Amarillo threatens to block access to medication abortions, Texas lawmakers are seeking to limit access to information about the procedure. A new bill, HB 2690, introduced in the Texas legislature in late February, would require internet service providers inside the state to block sites that provide abortion information, as well as making it illegal to host or even provide domain registration for sites that help people in Texas obtain or pay for abortions. It specifically would require ISPs to block the websites of Hey Jane, Choix, Just the Pill, Carafem, Plan C, and AidAccess—all of which help direct visitors to places where they can access abortion pills. It would also require blocking any site or app “operated by or on behalf of an abortion provider or abortion fund,” including organizations such as Planned Parenthood.

“Texas, which is a state that prides itself on its free speech protections, is now trying to censor information,” says Wells at Plan C. “It’s becoming a totalitarian state with respect to abortion. People need to pay attention, because a minority is really making decisions and manipulating systems to prevent access to basic healthcare in the United States. In a modern democracy, this is unacceptable.”

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ABOUT THE AUTHOR

Adam Bluestein writes for Fast Company about people and companies at the forefront of innovation in business and technology, life sciences and medicine, food, and culture. His work has also appeared in Fortune, Bloomberg Businessweek, Men's Journal, and Proto More