As the one-year anniversary of the decision in Dobbs v. Jackson Women’s Health Organization approaches, the public’s attention is likely to focus on how state laws criminalizing abortion have limited access to it. Although it is important to recognize this crisis, state policymakers and the public should not ignore the many ways in which access to abortion care can be expanded in states where it is still legal. One critical step is for state Medicaid programs to adequately reimburse providers for medication abortion via telehealth.
The safety and importance of medication abortion
Medication abortions comprise more than half of all abortions provided by the U.S. health care system. Since the U.S. Food and Drug Administration (FDA) approved the two-drug regimen of mifepristone and misoprostol in 2000, more than 5 million women have safely used it. Clinical and service delivery innovations now allow clinicians to offer that regimen to patients remotely via synchronous (live communication) or asynchronous (communications through messages) telehealth platforms for patient screening and counseling. Patients can then receive the medication abortion pills by mail for use in the privacy of their home. Significant research demonstrates high levels of clinical safety and patient satisfaction with this option.
Legal threats to mifepristone and medication abortion
A variety of lawsuits concerning access to mifepristone are ongoing in federal courts across the country. Perhaps the most notable is Alliance for Hippocratic Medicine v. FDA, which disputes mifepristone’s demonstrated safety record, challenges the FDA’s decadeslong approval of the drug, and seeks to end access to medication abortion nationwide. While the approval of mifepristone, and therefore access to medication abortion, remains unchanged for now, Alliance for Hippocratic Medicine is currently pending before the U.S. 5th Circuit Court of Appeals. This case represents a serious threat to both abortion access and the larger structure for ensuring drug safety in the United States.
Although innovation has occurred in telehealth provision, access to this option remains limited for many people. One barrier is obvious: Hostile state governments either prohibit telehealth medication abortion specifically or all abortion generally. In states that are supportive of abortion rights, the story is more complicated, with access limited for individuals who have Medicaid.
Difficulties in securing care and needed policy changes
In general, the federal Hyde Amendment prohibits Medicaid from paying for abortion. However, 16 states use state dollars—which are not subject to federal restrictions—to cover that cost of care. A 17th state, Rhode Island, made this legal change on May 18, 2023, but the policy has not yet been implemented. Research has previously shown that in states with Medicaid coverage, more than 50 percent of all abortions are covered by Medicaid. In states where such coverage does not exist, gathering the necessary funds remains the most commonly reported barrier to obtaining a desired abortion. Yet while state Medicaid coverage is indeed good news for low-income people, it is a challenge for health care providers, as reimbursement rates—in addition to other restraints described below—are often insufficient to cover the cost of offering abortion services. This can make providing medication abortion through telehealth difficult, or even impossible.
How telehealth reimbursement policies can affect abortion access
A recent report from the National Health Law Program documented the many ways in which telehealth reimbursement policies under state Medicaid programs limit access to abortion. In some states, for example, health care providers must have a preexisting relationship with a patient in order to bill for telehealth service. However, most abortions in the United States are provided by facilities focused only, or mostly, on abortion; thus, patients do not have preexisting relationships with them. Another state requirement is that only physicians can bill Medicaid for telehealth services. However, states that are supportive of abortion and that allow Medicaid funding to cover it have long recognized advanced practice registered nurses and physician assistants as legal providers of medication abortion—and in these states, those clinicians provide a significant amount of this care. But under some state Medicaid programs, they are not allowed to bill for telehealth services. These are only two examples of the unique challenges that abortion providers face, which layer on top of the wider challenges faced by all health care providers when it comes to being paid appropriately for care provided via telehealth.
As a result of existing telehealth policy barriers, Medicaid recipients find themselves without access to a health care service from which they could significantly benefit. While not a panacea for limited abortion access, telehealth medication abortion has some important advantages. People with limited incomes often have less control over their work schedules and more individual caregiving responsibilities. These burdens make taking time off to travel to an abortion clinic challenging. Moreover, because of historical and ongoing structural oppressions, people of color are disproportionately represented among those eligible for Medicaid. Thus, limits on what type of care people with public insurance can access have larger health equity implications.
Since Dobbs, a research project of the Society of Family Planning is tracking where people are obtaining abortions and has found that 8 percent of people are receiving services from abortion providers that only offer medication abortion via telehealth. None of these providers accept Medicaid reimbursement for care despite operating in states where Medicaid pays for abortions. Most abortion providers with brick-and-mortar clinics do not offer telehealth medication abortion, and in June 2023 conversations with the author about why not, providers reported challenges with accepting state Medicaid for this service because of the myriad intersecting barriers that make receiving adequate reimbursement difficult. Three abortion providers in California, Illinois, and Montana reported positive experiences with providing this care, although how it is provided—such as whether Medicaid requires synchronous visits or provision by a physician—has limited services for some Medicaid patients. In New Mexico and California, two physicians in private practice reported being able to offer the service to existing patients.
While reversing Dobbs and passing new laws in abortion-hostile states must continue to be a long-term goal, proactive changes to Medicaid reimbursement policies for telehealth medication abortion in abortion-supportive states can be made now and would be a critical step forward for equitable access.