by Dana Northcraft and Natalie Birnbaum
Since Roe v. Wade was overturned in June 2022, fourteen states and two territories have banned the provision of abortion care altogether.[i] Still, abortion rates in the United States are on the rise. This is in part due to the expansion of care delivery through telehealth for medication abortion (TMAB), which now accounts for 19% of abortion care delivery.
Although TMAB improves accessibility to patient populations nationwide, access is not spread evenly. TMAB is prohibited in ten states and one territory in addition to the states/territories with abortion bans.[ii] While some bans are explicit, others result from aggregate regulatory roadblocks that make care impracticable. These barriers to care most commonly impact Medicaid populations, populations living in rural or low-income urban areas, non-English speaking, and BlPOC communities. Research suggests that telehealth utilization more broadly has been lower amongst people in racial and ethnic minority groups than in groups of non-Hispanic White people.
The U.S. Food and Drug Administration (FDA) approved mifepristone to terminate a pregnancy over 20 years ago. Mifepristone is safe and effective for up to 10-12 weeks gestational age and has a success rate of 99% when used correctly. Medication abortion, which typically includes a combination of mifepristone and misoprostol, is the most common, cost-effective, and least invasive type of abortion care available in the United States.
Individuals could first access direct-to-patient TMAB care during the COVID-19 pandemic when the FDA lifted an in-person distribution requirement for mifepristone. Prior to this change, providers could only dispense Mifepristone at a medical facility. This change opened the virtual-only marketplace for clinics and providers, and expanded existing brick-and-mortar providers’ capabilities. As of 2023, over 63% of abortions occurred using medication abortion.
Generally, legislators must defer to clinical indication when regulating matters of medical care. However, for abortion care, many states impose unnecessary clinical standards, such as mandatory ultrasounds, blood testing, and physical exams (e.g., AZ, NC, FL). Other states mandate medically unnecessary in-person visits with a clinician which effectively bans telehealth (e.g., IN, NE, NC, SC). These barriers make it impossible for patients to have an all-virtual telehealth visit to receive abortion care, even when their health care provider recommends it and the patient prefers it. Prohibiting abortion services via telehealth leads to reduced access to health care services for individuals who live in rural areas or have limited access to transportation.
Overall, when it comes to delivering care via telehealth, state policies often create roadblocks to accessing care by prohibiting asynchronous care or limiting reimbursement to video-only visits. Unfortunately, legislators and medical boards similarly fail to consider patient preference and clinical indication when it comes to allowing access to telehealth services.
Limitations on modalities often exclude or limit audio-only or asynchronous care, thereby excluding patients facing pre-existing barriers. For example, requiring virtual video or synchronous visits disproportionately impacts the estimated 42 million Americans without high-speed internet access. Research shows that when audio-only or asynchronous visits are restricted, people living in areas with low broadband access are less likely and able to see a health care provider via telehealth, log in to patient portals, and ultimately, access care. Recent data show that audio-only telehealth care is as effective for patient outcomes as video for medication prescribing.
Another barrier toward telehealth use is limitations on the types of health care that providers are eligible, under state laws and regulations, to offer as telehealth services. Even in cases where a provider is appropriately credentialed to offer certain services, state telehealth regulations may limit eligibility for non-physicians and require medically unnecessary supervision requirements, such as collaborative practice agreements for nurse practitioners. Expanding telehealth eligibility to allow providers to practice at the top of their license and within their full scope of practice helps meet the growing demand for health care, particularly for patients living in remote areas. An estimated 83 million people in the U.S. live in areas without sufficient access to a primary care physician, and the American Association of Medical Colleges projects a national physician shortfall of at least 37,000 over the next decade.
The circumstances are even more emergent for women and people who can become pregnant. Thirty-six percent of all U.S. counties qualify as “maternity care deserts,” meaning they lack a hospital, birthing center, or clinicians with experience delivering babies. Rural areas are at a higher risk of becoming health care and maternity deserts. While telehealth cannot eliminate health care deserts or provider shortages, it can be leveraged to preserve basic human rights and reach patient populations with few other options.
Federal and state Medicaid restrictions create additional barriers for Medicaid beneficiaries who often experience the most persistent access challenges and inequities. A federal budget amendment, the Hyde Amendment, prevents federal Medicaid funds from being used toward abortion care, except in limited circumstances. While states can elect to use state Medicaid funds to cover residents for abortion care, only 18 states do so.[iii] Significantly, in these states, Medicaid pays for over 50% of all abortions.
However, far fewer state Medicaid programs offer support for abortion care via telehealth. Medicaid restrictions on telehealth services, even in states with abortion-friendly policies, create additional barriers, particularly for rural populations. For example, California requires providers to maintain a physical location or a formal affiliation with a brick-and-mortar provider to enroll in Medicaid. Colorado limits providers who may enroll as telehealth-only providers. Providers may be less likely to offer patients telehealth services without adequate reimbursement, perpetuating inequities in care accessibility and stifling innovation. For example, some providers in states with TMAB coverage only accept cash-pay patients because of unsustainable reimbursement rates for TMAB services or a dense bureaucracy to enroll as a Medicaid provider. Payment parity is critical so patients can receive affordable care and providers receive appropriate reimbursement. While TMAB expands abortion accessibility in the post-Roe era, addressing issues that impact the equitable provision of care for both abortion and telehealth, including Medicaid reimbursement, provider eligibility, digital health literacy, and broadband access, are critical to ensuring that traditionally underserved communities are not, once again, left out of health care innovation.
[i] Alabama, Arkansas, Idaho, Indiana, Kentucky, Louisiana, Mississippi, Missouri, North Dakota, Oklahoma, South Dakota, Tennessee, Texas, West Virginia, American Samoa, Northern Marianas.
[ii] Arizona, Florida, Georgia, Iowa, Nebraska, North Carolina, Ohio, South Carolina, Utah, Wisconsin, Virgin Islands.
[iii] This count includes Nevada, which is in the process of implementing Medicaid coverage for abortion following a ruling in Silver State Hope Fund v. Nevada Department of Health and Human Services (8th Dist. of Nevada, 2024).The ruling will likely be appealed, impacting coverage. More information available at: https://www.aclu.org/press-releases/nevada-court-will-block-state-ban-on-medicaid-coverage-for-abortion.
Dana Northcraft is the Founding Director of Reproductive Health Initiative for Telehealth Equity and Solutions
Natalie Birnbaum is the State Legal & Policy Director for Reproductive Health Initiative for Telehealth Equity and Solutions
