States Prepare for Threats to Abortion Access by Stockpiling Mifepristone and Misoprostol

Medication abortion is the most common method of getting an abortion in the United States, accounting for more than 63 percent of all abortions in the country’s formal health care system in 2023. Typically a two-drug combination of mifepristone and misoprostol, medication abortion has now come under attack by far-right activists in the aftermath of the U.S. Supreme Court decision in Dobbs v. Jackson Women’s Health Organization, which struck down constitutional protections for abortion care. A federal ban on abortion pills—a component of Project 2025, the far-right authoritarian playbook—could be a catastrophic blow to access all over the country. In an urgent attempt to prevent shortages, states have begun to stockpile the medication, but this is only a stopgap solution and is legally complicated. The only way to truly protect access is to prevent a federal ban on medication abortion from taking effect by restoring the constitutional right to access abortion.

Abortion medication is under attack

Project 2025 explicitly states that banning abortion medication should be a goal of a conservative administration. It is not unreasonable to assume that doing so could be a goal of the incoming administration given the first Trump administration’s actions to dismantle reproductive rights. Project 2025 seeks to misapply a 150-year-old antivice law called the Comstock Act to prohibit abortion medication from being delivered via mail. Project 2025 also calls for a reversal of the U.S. Food and Drug Administration’s (FDA) previous decisions regarding how mifepristone is labeled and distributed, thereby immediately restricting access and imposing nationwide barriers to abortion—even in states where it is legal.

In June 2024, the Supreme Court ruled that the particular anti-abortion plaintiffs in Alliance for Hippocratic Medicine v. FDA lacked standing to bring the case against the FDA’s decisions on medication abortion. However, the justices left open the possibility of a challenge from different plaintiffs in the future. Moreover, while the FDA has consistently reaffirmed the safety of mifepristone, some fear that under the leadership of Robert F. Kennedy, Jr., President-elect Trump’s nominee to lead the U.S. Department of Health and Human Services, FDA approval could be revoked, and the medication used for abortion could be taken off the market.

Abortion bans make medication abortion less safe

Medication abortion is overwhelmingly safe and effective when used to terminate an early pregnancy. Mifepristone is one of the safest drugs on the market and has an efficacy rate greater than 94 percent. More than 100 studies have affirmed its safety over the past 30 years, and less than 1 percent of patients experience serious side effects when using it. Childbirth and procedural abortion both have a higher risk of serious complications than medication abortion.

One thing that makes any form of abortion less safe is abortion bans. Bans force many people to seek abortion care without the advice or supervision of a doctor and to self-administer the medication. Many women can safely and successfully self-manage an abortion, and choosing to have an abortion at home may provide them with a greater sense of agency and control over their bodies and health care decisions. However, in places with abortion bans, women are less likely to be able to consult a medical professional or seek care if something goes wrong. As a result, abortions can turn fatal in places with bans, as they did in the cases of Josseli Barnica, Nevaeh Crain, and Porsha Ngumezi in Texas, and Amber Nicole Thurman and Candi Miller in Georgia.

State stockpiling attempts to preserve access

Far-right anti-abortion extremists have a clear goal: to make medication abortion illegal everywhere in the country. In an attempt to preempt this, several states have resorted to stockpiling mifepristone and/or misoprostol since the overturn of Roe v. Wade. However, the benefits of stockpiling abortion pills can be limited by the shelf life of the medications. In the United States, mifepristone has a shelf life of approximately five years if stored properly, and misoprostol has a shelf life of approximately two years. Although, many medicines may still be safe and effective past their expiry, and expiration dates can vary depending on the manufacturer.

At least six states have either started stockpiling one or both of the drugs needed for a medication abortion or initiated the process. For example:

• Oregon: Tina Kotek (D) directed the Oregon Health Authority to partner with Oregon Health and Science University (OHSU) to secure a three-year supply of mifepristone. As of November 2024, OHSU has secured a supply that will last until September 2028.
• California: Gavin Newsom (D) purchased a stockpile of 2 million misoprostol pills in 2023.
• New York: Kathy Hochul (D) began stockpiling misoprostol in 2023. Gov. Hochul indicated that 150,000 doses of abortion medication had been stockpiled in the state as of March of 2024.
• Washington: Jay Inslee (D) ordered the state’s Department of Corrections to use its pharmacy license to purchase 30,000 doses of mifepristone in 2023 and has fast-tracked legislation allowing health care providers across the state to distribute it.
• Massachusetts: Maura Healey (D) had the University of Massachusetts Amherst order 15,000 doses of mifepristone in April 2024. Massachusetts health care providers also agreed to buy additional quantities of mifepristone, and the administration is dedicating $1 million to help providers contracted with the state Department of Public Health to pay for the doses.
• Maryland: The Board of Public Works approved the funds to purchase a stockpile of 30,000 doses of mifepristone and 5,000 doses of misoprostol in 2023.

Legal issues with stockpiling

Depending on how any attempts to ban medication abortion nationwide proceed, complicated legal questions may arise about state stockpiling and distribution of medication abortion. Project 2025 calls for misuse of the Comstock Act to prohibit mailing the drugs. In this scenario, the U.S. Department of Justice could decide to prosecute anyone who has shipped or received the pills in the previous five years, the act’s statute of limitations. States could attempt to get around this by distributing the medication without the mail system, such as by using state vehicles at state-run facilities and clinics. However, if state actors have already received the drugs via the U.S. Postal Service or a private shipping company, they could potentially be charged with having already violated the Comstock Act. Therefore, alternative distribution is not a risk-free solution, and stockpiling does not solve the many thorny legal problems that could emerge.

The FDA may also attempt to rescind approval of mifepristone. A drug’s lack of approval does not mean it is banned, but the U.S. manufacturers of the drug—Danco and GenBioPro—will no longer be allowed to market or distribute it. It is unclear what that would mean for states that already have the drug and begin to distribute it at the state level. One analogous situation may be the current legal limbo of marijuana, wherein a state’s laws may allow people to use marijuana for medicinal or even recreational purposes, but federal law does not. This would make questions of manufacture, distribution, transport, and use of the medication incredibly complex. It could also put those who use the medication at legal risk, no matter which state they are in.

Individuals are also stockpiling medication abortion drugs

Many individuals are also stocking up on abortion pills for themselves and their communities. Some organizations working to expand access to all, such as Aid Access, ship abortion pills “advance provision.” This way, women can order the pills whether they are currently pregnant or not, in case they need them in the future. Since early November 2024, groups such as Aid Access reported receiving roughly 17 times the number of requests they typically receive in a day for the medication.

Some of these abortion pills, like many of the pharmaceuticals Americans take, come from abroad. Pharmacies in other countries with fewer or no abortion restrictions are not subject to American legal consequences, and they are able to ship abortion medication to patients in the United States. However, there can be legal consequences for people ordering and receiving abortion pills in states where abortion is not legal or is severely limited. To help combat this, the group If, When, How has a legal hotline to answer questions for concerned abortion seekers, including those who choose to use abortion pills. The Miscarriage + Abortion Hotline provides medical advice and emotional support to those seeking abortion care or going through a miscarriage. However, the legal consequences individuals face if they stockpile and use the pills in states with bans make this option prohibitive for many.

Conclusion

Although they are safe and have been widely available in the United States for decades, access to abortion pills is under unprecedented attack. While some states are attempting to stockpile these drugs in anticipation of potential federal restrictions or bans, expiration dates, federal restrictions, and unclear legal consequences mean that these efforts are insufficient to protect access. The only sure way to protect access to medication abortion and increase its availability is for policymakers to continue to work diligently to prevent additional federal or state abortion bans and repeal the bans and restrictions that exist.

The author would like to thank Kierra Jones for their research help on this piece.