Medication Abortions by Mail: Orgs Send Pills Across the Country

Earlier this week, Elisa Wells took an old, empty prescription bottle and filled it with a handful of dried beans. She tucked the bottle into an envelope, put it in the mail, and sent it to a friend. It’s a test she’s performed many times over the past several years, but one that’s taken on a new urgency. 

“We’re simulating sending abortion pills,” explains Wells, the co-founder and co-director of Plan C, a team of abortion advocates that researches and shares creative methods for accessing abortion pills. She’s re-testing one of the methods that they recommend on their website: setting up a “virtual mailbox” — a sort of high-tech P.O. box through companies like U.S. Global Mail or iPostal1 — in a state like California, which allow patients to use telehealth to access mail-order abortion pills. When the package gets there, the mail services, commonly used by people who are traveling or who don’t want to use their home address for their business, inform them that a package has arrived. The abortion seeker can then have the package forwarded to wherever they are — including to states that don’t allow mail-order abortion care. “There are always ways to get in between the lines,” Wells says. “To make things happen that aren’t necessarily illegal — just creative.”

Since the Supreme Courts’ draft decision to overturn Roe v. Wade was leaked on Monday, demand for mail-order abortion pills has skyrocketed, and interest in the “virtual mailbox” method — and the other creative workarounds that Plan C recommends in states that have restrictive abortion laws — has understandably spiked. But while newly on the national stage, Wells has been preparing for this moment for years. She and other self-described “renegades” in the abortion access movement have spent the last decade finding ways to put abortion care in the hands of the abortion seeker.

“When we first started working on this in 2013, everybody thought we were a little bit crazy,” she says. Most abortion advocates were focused on improving existing laws, but “we started with the premise that these laws are only going to get worse.” One option was to go international: Dutch abortion doctor Rebecca Gomperts — who in the early 2000s, bought a boat and used it to bring pregnant people in countries that banned abortion into international waters to administer abortion care — established Aid Access, which uses European doctors and Indian pharmacies to provide Americans with abortion pills outside of the U.S. regulatory system. 

Stateside, the Covid-19 pandemic turned out to have an unexpected silver-lining: the expansion of American telehealth, and with it, FDA approval to provide abortion pills by mail. “Awareness of medication abortion and these new ways that it can be used has grown among the medical community drastically in the in the past two years,” Wells says. But despite the fact that medication abortions account for more than half of the abortions in the United States — and the research that has shown that telehealth medication abortions have been overwhelmingly safe and effective — she has found that most clinicians are still reluctant to provide abortion care remotely. “The medical community is usually the last to change on things like this,” she says. But “we got good at figuring out who the forward-looking providers were. Now there’s a group of about nine or 10 of them that are licensed in 20 different states.” For clinic-based care, that ratio would be impossibly restrictive, but “all it takes is one provider in the state to serve that whole state,” she says. “That’s a true telemedicine model.”

This week, in the wake of the leaked SCOTUS decision, Wells is testing for kinks in the process with her bottle of beans: are there unexpected costs that could create a financial barrier? Do certain carriers ask questions that an abortion seeker might not be able to answer honestly? Or notice the rattling beans and stop the mail forwarding because they think it’s a prescription? “We do all that testing so we can report to people, ‘Here’s what we did, here’s what you need to know about,’ so that they can do it successfully when they’re in a time of crisis,” says Wells.

The trick for plan Plan C is to keep these workarounds just within the bounds of legality, but the borders are almost always murky, and the legal landscape is bound to become less predictable if Roe is overturned this summer. “We’re in uncharted territory,” says Farah Diaz-Tello, senior counsel for the reproductive justice group If/When/How. Right now, virtually all abortion restrictions target the abortion provider, not the person ending a pregnancy — and only South Carolina, Oklahoma, and Nevada criminalize self-administered abortion. That means it’s very rare for someone to be charged under criminal abortion laws, says Diaz-Tello. “But you can’t necessarily just say, ‘Oh, well, there’s no criminal ban on self-managed abortion in my state, so I’m safe.’ There’s virtually no correlation between those states and where investigations and prosecutions happen.”

Instead, Diaz-Tello says, in many states, the consequences of self-administering an abortion is up to “the prosecutorial imagination.” People are usually targeted by prosecutors with laws on the periphery of their pregnancy outcomes: for trying to bury or flush fetal remains (where they’re charged with “improper disposal of human remains” or “abuse of a corpse”); or in some states, “we see people charged with things like ‘concealment of a birth’: laws that were passed in the 1800s — called ‘concealment of a bastard child’ — that were intended to punish people who gave birth out of wedlock.”

Without the constitutional protections of Roe, conservative prosecutors’ imaginations are likely to be emboldened. “That poses its own hazards and chilling effects,” says Diaz-Tello. “Whether or not they manage to get a charge to stick, that’s going to have a devastating effect on a person’s life — just being arrested, having their mug shot in the news.” At least twenty states have already proposed bills that would specifically ban at-home abortion pills — like Tennessee’s ban that was signed this week, and goes into effect at the top of next year. And according to the Guttmacher Institute, 22 states will be under an abortion ban the moment Roe is overturned. And losing Roe also opens the door for restrictions that target abortion seekers, rather than just providers. At it’s most extreme, post-Roe restrictions could try to establish “fetal personhood,” like Louisana’s newest bill, which would classify abortion as murder

Legal groups like If/When/How can help inform people of their individual risk when they’re trying to get access to abortion pills, but as the landscape changes, “it has to be up to individuals to decide what level of risk they can tolerate,” says Diaz-Tello, “based on their social location, their family circumstances, whether they are a part of a group that experiences marginalization in our country, because of poverty, because of race, all these other things that make people more susceptible to surveillance and criminalization in US society.” They’re calculations that are somewhat new to reproductive healthcare in the United States, she says, but are “actually very familiar to other groups of people in the U.S. who are used to being under the microscope: people who use drugs, sex workers, LGBTQ communities, people who have already been classified that see it as criminalizable.”

But a decade of groundwork by abortion access advocates has established a support network, both for those navigating abortion restrictions now, and those who will in a post-Roe America. “Even people who are self-managing are not alone, and they can be surrounded by systems of care and support,” says Diaz-Tello. And as restrictions expand, the tools to get around them will keep evolving. “We like a creative challenge,” says Wells. “It’s not perfect, obviously — perfect would be low cost or affordable, safe, effective, legal care in all 50 states. But we know that that’s not a reality. And so we offer up alternate routes of access as a way to help mitigate the damage.”