Lee had just been dumped when she found out she was pregnant.

With no car, no job and no support, the 23-year-old, who asked for medical privacy to keep her last name secret, ended up at the Hey Jane virtual clinic, where she was quickly examined and prescribed abortion drugs.

Four months later,

she was among them

thousands of Californians

have been in a similar situation

They held their breath as the U.S. Supreme Court deliberated a case that could rewrite health care rules for more than two-thirds of U.S. abortions, limiting access to a popular drug even in states where it remains legal.

The justices expressed clear doubts about a lower court’s decision to overrule the Food and Drug Administration and restrict mifepristone, the first in a two-drug protocol that now accounts for 63% of all legal abortions in the United States. indicating that Byzantine rules are unlikely to be restored. for prescribing the medication.

“Should we also take into account your argument that no one else… in America should have this drug to protect your clients?” Justice Ketanji Brown Jackson said in a sharp exchange, later echoed by her frequent rival Justice Neil M. Gorsuch.

But advocates in California say that will remain true even if current rules remain in place

represents

a growing threat to reproductive rights, especially in “sanctuary” states

as a target for legal challenges

telehealth, which has increased to

bill for

16% of US abortions as of 2021.

These figures do not include the approximately 6,000 abortions estimated to occur each month outside the formal medical system, the vast majority of which are also caused by a combination of mifepristone and misoprostol obtained through the mail, according to a study this week in

the medical journal

JAMA.

“I worry that people don’t realize how important telehealth is: it’s an important pillar in the abortion care landscape,” said UC San Francisco professor Ushma Upadhyay, an expert on reproductive health care. “People don’t understand how important it could become in the future.”

‘Baffling, surprising and unexpected’

The court’s decision on mifepristone is only expected

June

. The reason the stakes are high is because this is different from the decision in Dobbs

vs. Jackson Women’s Health Organization,

that Roe vs. brought down Wade

in 2022

A Supreme Court ruling to restrict the drug would reverse a series of major changes in the way it is prescribed and dispensed nationwide.

Care that can currently be delivered by a nurse-midwife via a brief video call or an online questionnaire would revert to a time-consuming and costly series of clinic visits with a physician. Medical abortion could be offered just 49 days from the start of a patient’s last menstrual period, instead of up to 10 weeks as is currently the case. These changes would also make prescribing mifepristone via telehealth impossible, leaving some dependent on a less effective regimen with more unpleasant side effects.

Telehealth is the only viable option for patients who cannot take a sick day, find a sitter details

from the Centers for Disease Control and Prevention

show that the lion’s share of abortion patients are already mothers, or can take public transportation to a clinic, experts say.

“I’ve had patients say to me, ‘I have a job that doesn’t allow me to take time off. I have kids and no childcare,'” said

Dr. Gomez, the Bay Area provider, Dr. Michele Gomez of the MYA Network, a consortium of virtual providers,

who has helped many patients with Medi-Cal. “A lot of people talk to me while they’re working. I’ve had so many people [take appointments] with their children crawling over them.”

Women who relied on the medication say that it was the most convenient and safest option.

“I knew the locations of the clinics, but it was difficult to get there,” Lee said of her abortion. “It all felt so scary, on top of being in the situation.”

Gomez said that in the past, doctors had to watch patients take the pill for years. The elimination of these and other rules over the past decade has helped push medication abortion from the margins of care to the heart of reproductive rights, the Bay Area provider and others say.

“I can steer [pills] mail it when it suits me,” she said.

The changes also cleared the way for doctors in California and five other states to prescribe and send abortion drugs to patients in jurisdictions where it is banned under so-called shield laws.

“Mail abortion care is now the most viable form of access for most of the country,” said Kiki Freedman, co-founder and CEO of Hey Jane, an abortion telehealth startup. “Any change in the way mifepristone is prescribed is an attack on accessibility, period.”

A growing number of experts believe that the rise of telehealth could explain why the number of abortions has jumped in the wake of the Dobbs decision, even as 21 states have banned the procedure in whole or in part.

“This is mind-boggling, surprising and unexpected. We expected the numbers to come down,” Upadhyay said. “There are many unmet needs that need to be addressed through telehealth.”

‘Half of the patients I see are in the car’

The rapid rise of medication abortion is one reason why anti-abortion activists have fought so hard to get rid of it, many say.

“Telehealth abortion is even worse on that side because they know it’s safe and effective and people can end a pregnancy on their own,” said Michele Goodwin, a law professor at UC Irvine and an expert on reproductive justice. “That’s threatening to them.”

Medication abortion using mifepriestone was already cheaper, faster and more easily accessible than vacuum aspiration and other clinical procedures when telehealth became available in 2020 under emergency pandemic rules.

But it became radically more accessible and less expensive in 2021, as virtual providers, including Hey Jane, Abortion on Demand and 145 Abortion Telemedicine, set up shop alongside brick-and-mortar clinics under the FDA’s new leadership.

And more doctors felt called to offer it in 2022

state bans

forced abortion seekers to do so

neighboring countries,

stretching wait times at in-person clinics in Colorado, Illinois and Kansas, where it can take weeks to get a clinic appointment.

“Even before the Dobbs decision, I asked myself, what can I do?” said Dr. Stephanie Colantonio, a Los Angeles pediatrician who began providing care in 2021. “It was very meaningful to me that I could offer this to people.”

California has also taken steps to make healthcare more accessible, although barriers still exist. Medi-Cal covers about half of all abortions in the state, almost as much as the percentage of births it pays for, but billing for telehealth is still new and few providers can do it.

“California only recently updated its law last year to address telehealth for abortion,” Upadhyay said. “For most [Medi-Cal] “Patients have to decide: Do I want a free abortion or do I want to pay and get telehealth?”

That decision is often fraught.

“We see a lot of patients during the lunch hour,” says Leah Coplon, nurse-midwife and director of clinical operations at Abortion on Demand. “I feel like half the patients I see are in their cars.”

‘In the comfort of my own home’

Seeking pills through the mail may also be the only physically accessible option for disabled abortion seekers.

“The disability community is very concerned about this because it could lead to a complete denial of care,” said Jillian MacLeod, reproductive justice legal officer at the Disability Rights Education & Defense Fund, which filed a brief in support of telehealth abortion .

Still others say telehealth simply feels safer to them.

“I wanted to be able to do it in the comfort of my own home,” says Charlie Ann Max, a Los Angeles model who took the pills earlier this year. “It felt the safest.”

With mifepristone under threat, some providers are looking for alternatives that keep telehealth available to those who need it most. Many say this would mean prescribing only the second drug in the protocol, misoprostol, which is used both to induce labor and to terminate the pregnancy.

“That would be the backup,” said Dr. Jayaram Brindala of 145 Telehealth. “It’s not clinically ideal, but still a good option for those in the first 13 weeks.”

Gomez agreed. “It’s very effective, but it’s not what I would recommend to my sister, my best friend or my daughter,” the doctor said.

Last year, Governor Gavin Newsom announced that California would stockpile the drug to maintain an emergency supply.

“Those who oppose access to abortion have made it clear that they will not stop seeking new ways to reduce abortion access and rights across the country,” said Atty. Gen. Rob Bonta said.

His department

Justice Department will use “every tool” at its disposal to keep California a haven for reproductive health care, he said.

“Whatever happens in the mifepristone case at the Supreme Court, it will not be the end of our fight,” Bonta said.