The legal effort to ban mail-order abortion pills came along just as the fledgling telehealth industry became a more accepted and entrenched part of abortion care.
This week, Hey Jane, one of more than a dozen virtual abortion providers that have no physical locations, began contracting with the insurers Anthem Blue Cross Blue Shield of Connecticut, Empire Blue Cross Blue Shield of New York and Sana, which provides health plans for small businesses nationwide. Hey Jane also already accepted Aetna in eight of the nine states in which it operates.
It’s unusual for insurers to cover telehealth abortions, and most virtual clinics are cash only. The clinics are new, and insurance coverage for abortion varies widely. In the year before Roe v. Wade was overturned, just a third of abortion patients used insurance. Some states require private insurers to cover abortions, while others bar it. Federal law prohibits the use of Medicaid for most abortions, though 16 states use state funds to cover them. But even plans that do cover abortion don’t generally include these new telehealth providers in their networks.
Health insurers tend to cover treatments that are widely accepted by clinicians and cost-effective, and Hey Jane’s insurance partnerships are the latest sign that virtual abortion clinics are seen by the health care industry as a safe, in-demand option. They also tend to be less expensive than in-clinic procedures for both patients and insurers.
“In abortion care, as in so many other areas of health care, we believe expanding telehealth’s role is a huge lever” for making care more accessible and affordable, said Will Young, chief executive of Sana.
Not all insurers are ready to cover this new way of providing abortions, said Gaby Santana, head of business at Hey Jane. For example, some require live visits, over video, while Hey Jane sees most of its patients through messaging. Other insurers told Hey Jane they only contracted with clinics with a physical location.
“Our goal is to make this as big and accessible as possible,” Ms. Santana said. “That’s why we want to bring on more states and more payers.”
New data shows telehealth accounts for a rapidly growing share of abortions, and Honeybee, the largest online pharmacy supplying mail-order abortion pills, said it was filling more than 10,000 prescriptions a month.
Yet these clinics could also be hobbled just as they are starting to grow. The Fifth Circuit ruled last week that the Food and Drug Administration should ban telemedicine prescriptions and delivery by mail for mifepristone, the first of two drugs typically prescribed to induce abortions. It’s a temporary order while a Texas court considers whether to overturn the drug’s approval altogether. The Supreme Court ruled Friday that mifepristone would remain available until Wednesday at midnight while it had time to review the case.
Health Care in the United States
The F.D.A. first allowed telemedicine abortion in 2020, following an emergency court decision made early in the pandemic and after extensive data demonstrated that it was a safe and effective way to offer abortion pills to patients. It made the policy permanent in 2021.
Pharmacists must get a special certification to dispense mifepristone, and report data about each prescription, said Jessica Nouhavandi, co-founder of Honeybee. “I had to literally create protocols and train pharmacists,” she said. “Most don’t even learn about this in school.”
Most of the start-up clinics operate in only a few states; they must have a clinician licensed in each state in which they see patients. Some are financed by investors or grant makers as they figure out how to build a profitable business. Few have lawyers on staff to help them navigate the recent legal challenges.
They have formed an unofficial network to help one another, with group chats about electronic medical records or legal questions. A nonprofit called Plan C provides consulting and sometimes small grants, and a database of providers.
They have begun discussing what they will do if the court case prompts the F.D.A. to take mifepristone off the market. Many are preparing to offer just the second medicine, misoprostol, which is effective when used alone to end a pregnancy, but can bring more side effects.
Dr. Rachna Kaul runs Maitri Wellness, a solo primary care practice in New Jersey. But she started offering telemedicine abortions during the pandemic, and now her office mails dozens of pill packs a day into three states where she is licensed. She charges cash prices for patients who can afford the service, and uses grants to cover the costs for patients who cannot.
Dr. Kaul said adding the service was easier for her than many of her peers because she was self-employed. “In the beginning, we didn’t have any funding, so we took it all out of our own pockets,” she said. “I could do any other work and make so much more money. This is such a huge need.”
Juniper Midwifery, which provides 175 medication abortions a month to women in six states, is run by two midwives with day jobs at a New York City hospital and clinic. They operate out of their homes or on the go.
“It’s just the two of us,” said Marisa Poverman, who started Juniper with Jillian Barovick. “We’re still in a grass-roots phase of things. So this week has felt a little bit tenuous. Are we going to be able to keep doing this and providing access to people in this way?”
Juniper saw its first patients in August. Ms. Poverman built the website using WordPress, and their husbands took their headshots. They raised money from friends and family to get it off the ground, and now have a grant from New York State. They accept cash only, and use the grant to subsidize prices or provide free care to patients who need it.
Hey Jane, by contrast, is among the most established of the providers, with $9.6 million in venture capital investment and 40 employees. Abortion on Demand and Aid Access operate in the largest number of states. (A separate branch of Aid Access also operates in states where abortion is illegal by connecting women with doctors and pharmacies abroad.)
Carafem is another larger operation, a provider that offers telehealth abortions in 16 states and also has a few physical clinics. Melissa Grant, the chief operating officer, said one of the hardest parts of her operation had been learning the varying rules in each state.
Questions about insurance coverage reflect these complications — and often amplify them. Ms. Grant said her providers work hard to help patients figure out what their insurance covers, and are trying to persuade more health plans to work with the company.
“Not everyone’s plan covers abortion,” she said. “When you put telehealth on top of it, unfortunately there’s a lot more carriers that deny care.”
Even if they do have coverage, not all patients want to use it, said Dr. Stephanie Colantonio, a primary care physician who offers telemedicine abortion in California through Luna Flow Health. “Some patients are so nervous about privacy and security that they prefer to pay out of pocket,” she said.
