Offices of Planned Parenthood Columbia Willamette, in Portland, Ore., April 14, 2022.
MacGregor Campbell
Medication abortions now comprise up to an estimated two-thirds of all abortions in the U.S., and about a quarter of the mifepristone-misoprostol combination are prescribed via telehealth. Medication abortions are safe and effective when used within the first 12 weeks of pregnancy. Forty percent of all abortions occur at six weeks or less, another 38% between 7 - 9 weeks and 14% between 10 - 13 weeks, according to the Guttmacher Institute.
Not having to visit a doctor in person to get the medication can make all the difference for access, particularly for those who are low-income or live in rural areas. Telehealth access to mifepristone was briefly paused after the state of Louisiana sued the FDA, saying its rules violated its total abortion ban. On May 1, the 5th Circuit Court of Appeals granted Louisiana’s request for a stay, which meant doctors could not prescribe the drugs via telehealth. But the U.S. Supreme Court blocked that stay, restoring the FDA’s rules while the Louisiana lawsuit continues.
Amy Handler is the CEO of Planned Parenthood of Southwestern Oregon. Sara Kennedy is the CEO of Planned Parenthood Columbia Willamette and also an OBGYN. They join us to discuss the implications of this case—and the impact of the law signed this week by Gov. Tina Kotek to restore Planned Parenthood’s medicaid funding.
Note: The following transcript was transcribed digitally and validated for accuracy, readability and formatting by an OPB volunteer.
Dave Miller: This is Think Out Loud on OPB. I’m Dave Miller. Yesterday, the U.S. Supreme Court ruled that Americans should have telehealth access to the abortion drug mifepristone, at least for now. Louisiana has sued the FDA, saying federal rules violate the state’s abortion ban. The high court did not put out a final ruling in this case. It simply said that telehealth access to mifepristone should continue while the legal challenge moves forward.
For more on the situation and what’s at stake, I’m joined now by Dr. Sara Kennedy and Amy Handler. Dr. Kennedy is an OBGYN and the CEO of Planned Parenthood Columbia Willamette. Amy Handler is the CEO of Planned Parenthood of Southwestern Oregon. Welcome back to Think Out Loud to both of you.
Amy Handler: Thanks for having us.
Dr. Sara Kennedy: Thank you, Dave.
Miller: Amy, first – what was the question before the court?
Handler: The question before the court really hinged on if Louisiana’s rights are being violated for mifepristone getting mailed into the state because they have a total abortion ban. So the Fifth Circuit judge ruled that yes, Louisiana’s rights were being violated and mifepristone should no longer be mailed to anyone in the country.
Miller: Sara, what does yesterday’s ruling mean in practice?
Kennedy: So in practice, it means that we go back to before the Fifth Circuit ruled, which means that mifepristone is available to be used for medication abortion, both in person and can be mailed and used for telehealth. We suffered a lot of whiplash over the past couple of weeks when the Fifth Circuit ruled that mifepristone could not be mailed. We had to, that moment in time, immediately stop sending mifepristone to patients seeking medication abortion. And then there was a stay and we were allowed to use mifepristone again. Yesterday at 2 p.m., the stay actually expired, so we had about 30 minutes of time where again we were no longer able to mail mifepristone. And then the Supreme Court had this order or extended the stay until they could hear the case.
Miller: How common is it just in Oregon for mifepristone to be mailed?
Kennedy: So just to frame this nationally, medication abortion via telehealth makes up about 25% of all abortions. That number rose pretty dramatically during COVID and then again when Dobbs overturned Roe v. Wade. In Oregon, it is slightly less common than that. We have more patients seeking medication abortion in person at the two Planned Parenthood affiliates, but it’s still a really important way for people to access medication abortion.
Miller: The court has now addressed mifepristone twice, Amy. The first time the justices unanimously ruled that Texas doctors who brought a suit didn’t have standing. This time, this 7 to 2 majority extended the stay that, as we’ve been talking about, keeps the status quo. But neither ruling has been a substantive one about whether or not mifepristone should be, allowed to be, prescribed via telehealth. Are you anticipating that the court will ultimately side with Louisiana when this inevitably does come back to them?
Handler: You know, I can’t really speculate on this court in particular. I think it will be really telling to see what the FDA does in their review of mifepristone that I believe is coming this year. But we’re prepared for any scenario. And I think that when all of these arms, [like] the FDA, the CDC, the court, are being used as political arms, it really harms all of us and puts us all at risk for adverse health outcomes.
Kennedy: And I would just add to that that over the past decade, based on science and evidence, the FDA has sequentially made mifepristone more accessible and available because it has been proven to be successful, safe and effective over more than 100 excellent clinical studies. So for the court to weigh in on this is inappropriate actually and just a political attack.
Miller: What would the end of telehealth access to mifepristone – let’s say it were to happen nationally – mean for Oregonians where abortion is legal?
Kennedy: Right. So this restricts our rights in Oregon. Oregon has laws that make abortion safe and legal. If the Supreme Court ruled in favor of Louisiana, it would take away Oregonians’ right to access telemedication abortion within Oregon’s walls…
Miller: Using this one medication.
Kennedy: That’s correct. So we would not be able to use mifepristone via telehealth medication abortion. We would be able to continue to use it in person, prescribed by one of our excellent health care providers. But it would ultimately restrict the many people who are traveling 100 or more miles to a bricks and mortar health center.
Miller: So rural Oregonians would be more affected by this than people in cities?
Kennedy: I think that there are many reasons that people choose telehealth. So it’s not just rural folks who enjoy telehealth. And for a variety of medical reasons, we also see people living in more urban areas who might have physical access to a health center, want to access health care, all kinds of health care, from the safety and privacy of their own home. So their access would also be restricted.
Miller: But I mentioned that – this is specifically about mifepristone – it’s important because it’s normally, as I understand it in the U.S. now, prescribed alongside misoprostol. What’s the difference between these two drugs?
Kennedy: Thanks for asking. I can go into my medical knowledge here a bit. So mifepristone is a progesterone antagonist. What that means is that it blocks the progesterone from taking effect within the pregnancy, and it’s important for the growth of a pregnancy. So mifepristone initially halts the growth of the pregnancy, then the patient either immediately or within 48 hours takes misoprostol. Misoprostol is a synthetic prostaglandin. And those receptors are found within the cervix and the uterus, and those cause the cervix to soften and the uterus to start to contract, thus expelling the contents of the uterus.
And those two medications are used, it’s important to note, not just for abortion but also for miscarriage management, and increase the safety and efficacy of miscarriage management when used together.
Miller: What would it mean for women to lose access to some extent of mifepristone and to only have access to misoprostol?
Kennedy: The first message is that abortion will remain safe and legal in Oregon, and that even if we have to only use misoprostol, especially for telehealth medication abortions, it is still safe and effective. However, we know that adding mifepristone to the regimen increases the efficacy of abortion by a couple percent. And that means that patients have less bleeding, less cramping, and are more likely to complete the abortion without needing second or third doses of medication, without needing potentially a surgical procedure, and also less risk of them having to go to the emergency room. That can also then, again, result in a surgical procedure or more medications.
Miller: Less risk of severe complications and less pain.
Kennedy: Mmm hmm.
Miller: Amy, why is it that mifepristone is a subject of these current legal attacks, as opposed to misoprostol?
Handler: Mifepristone is really exclusively used for abortion care and misoprostol has a wide range of medical uses. So, a great use for it is stomach ulcers. There’s just other uses for misoprostol. Taking it off the market or making it inaccessible would hinder lots of other medical procedures.
Miller: I want to turn to some of the bigger pictures here. Amy, how do you explain the fact that abortions in this country are actually slightly up in the years since the Dobbs decision got rid of the constitutional right to abortion?
Handler: We’re seeing a lot of patients or people across our country, I would say especially in red states with bans, they’re having severe limited access to reproductive health care overall. So physicians, clinicians are leaving those states because they don’t believe that they can provide comprehensive, safe, effective medical care to people. In these deserts, people have less access to contraception, they’ve got less access to everything related to reproductive health care. So the rates of unintended pregnancies will continue to rise and folks will have to continue to travel to get the abortion care that they need.
Miller: Sara, you were nodding there. So part of the reason here is that there are more unwanted pregnancies now than five years ago?
Kennedy: We believe so. We don’t know for sure. There’s a couple of theories. That’s certainly one of them. We know that as people have a harder time accessing health care, as Amy said, and are kicked off of insurance, or their local health center closes, that they can’t access all kinds of health care, and that could include contraception or counseling about preventing pregnancy.
I think another reason … When we look historically, over time, regardless of whether abortion is legal or not, unintended and unplanned pregnancies are really common. And people who do not want to be pregnant find ways to end their pregnancy. It’s just a matter of whether they have the ability to end their pregnancies in a safe way, in a supported way with the health care system, or whether they access abortion in other ways that are not safe.
Miller: What legal challenges to existing abortion access, Amy, are you paying the most attention to right now? We’ve been talking about this one avenue of legal challenge: telehealth provisions for medication abortion for this one drug. But there are a lot of other kinds of legal challenges that are making their way through courts right now. What are you paying the most attention to?
Handler: I mean, we’ve been paying attention to this Louisiana for a couple of years now, about two years I think, and this has really been the main case that we’ve been tracking. I think the main thing on the horizon for us is really seeing what the FDA does with mifepristone. Like Sara said before, we’ve had 100 evidence-based studies that show the efficacy of mifepristone in abortion care. And the FDA, over the last 30 years, has continued to expand the provision and reaffirm the safety and efficacy of mifepristone. So having an FDA that has really become, or could become, a political arm of this current administration could be very harmful to abortion care and access across our country.
Miller: Sara, my understanding is that one of the avenues of legal challenge right now are state shield laws that are basically intended to prevent doctors in blue states, like Oregon, California or Massachusetts, from being prosecuted if they provide abortion care to patients from red states. Do Planned Parenthood doctors, just to start with, prescribe medication for abortions for patients in states where abortion is illegal?
Kennedy: No. So that’s really important for our listeners to know, Planned Parenthood, always, is compliant with federal and state laws. So neither Planned Parenthood affiliate within Oregon or Washington prescribes medications or performs abortions for patients who are physically located in any other state – and that includes in banned or restricted states. And there are some providers, we suspect, who are doing that outside of the Planned Parenthood system. That is not what Planned Parenthood does. The risk is just too high to our providers.
Miller: The legal risk.
Kennedy: The legal risk, right. However, we know that patients have to travel a really long way. At PPCW we have a center in Ontario with a wonderful group of staff and we know that…
Miller: For folks who are new to Northwest geography, so right on the Idaho border.
Kennedy: That’s right. So it’s located within Oregon, but on the Idaho border. It serves rural Eastern Oregonians and it also is one of the primary access points, or the primary access point, for Idahoans who are seeking reproductive care.
Miller: And just about an hour or so from Boise, a major population center.
Kennedy: So we do not send medications into other states. We do not provide abortions for patients who are physically located in other states at the time of their abortion. But we will, and do, and welcome any patient from anywhere who needs basic health care within Oregon.
Miller: One of the stats that I remember hearing for years when political conversations about abortion coverage and Planned Parenthood have come up is people from Planned Parenthood saying just so you know, as a reminder, abortions are not the majority of the care we provide. We provide all kinds of care: Pap smears, preventive care, family planning options that are not about abortion. And abortions is just one part of it. But am I right that at the center in Ontario, abortions are the majority of the care that’s provided because of proximity to Idaho?
Kennedy: Yeah that’s right. So, throughout Oregon and Washington, somewhere around 90% of the visits that we see in all of our centers are preventative care. The big buckets would be cancer prevention, STI treatment, infection treatment and testing, and then contraception and other kinds of preventative care, including vasectomy and men’s health. In Ontario, because Idaho has made abortion illegal and there are no options for people who are pregnant in Idaho to get that care, there are so many folks traveling from Idaho into Oregon to be seen at Ontario that that number is roughly reversed. So the majority of the patient visits in Ontario are related to abortion.
Miller: And to be clear, that’s why you opened the center there, right?
Kennedy: That’s one of the reasons. It’s also to serve rural Oregon. It’s a health care desert. We have people traveling for hundreds of miles just to get a Pap smear and who are now able to be seen in Ontario. So we are really excited to be there and to be able to support the rural parts of our state, in addition to folks traveling from really far.
Miller: Amy, I want to turn to some state news. On Wednesday, Gov. Tina Kotek signed a law passed by Democratic lawmakers intended, as I understand it, to replace the federal funding for Planned Parenthood that was targeted by the One Big Beautiful Bill Act. Can you explain what this means?
Handler: Correct, this is very, very exciting. Gov. Kotek and the Oregon Legislature are the first in the country to pass a bill of this nature. And if we go back in time, House Bill 1, the Big Beautiful Bill that was signed on July 4 last year, barred Planned Parenthood from being able to bill Medicaid and receive reimbursement for care that we provide. About 70% of our patients use or access Medicaid to pay for their care. We made the decision, PPCW and PPSO, to not turn a single patient away. So we continued to see patients regardless of their insurance status and partnered with the state.
We have some real legislative champions in Oregon and we walked towards some stopgap funding in November that helped cover this year. We were able to bill for the patients that we’re seeing through OHP. And then, they took a real visionary stance and said this could continue to happen. We think it will probably be some sort of on-again, off-again, which is a total administrative net mess and also confusing for patients – can we bill Medicaid, can’t we bill Medicaid? So the state said, we’re going to do a structural fix, and in the event that Planned Parenthood is barred from receiving Medicaid reimbursements, people in Oregon can still come and Planned Parenthood will bill the state for that care. So it’s truly incredible and a really historic bill.
Miller: Sara, does this leave you whole? I mean, will this be a complete replacement of federal funding that may not come back?
Kennedy: Well, those are two separate questions. So it is a replacement for the lost federal dollars from Medicaid. So we deliver patient care. We used to bill the feds via the Medicaid program. Now we’re billing the state. And that way, it makes us whole. However, Medicaid reimbursement rates are incredibly low and have not been raised in many, many years. So overall, on average, Medicaid reimbursement rates only cover about 50% of the true cost of care.
Miller: So you’re getting as much as you were. You’re saying you were never getting as much as you wish you had gotten.
Kennedy: Correct. And we’re losing money. Essentially, truly, every Medicaid visit we see, we, for the most part, lose money and that’s why we seek out generous donations to be able to help support that care.
Miller: But, if I understand correctly, what you’re saying there, that’s not specifically really about Planned Parenthood. You’re talking about the larger health care world of federal reimbursement.
Kennedy: Absolutely. Except that what is specific to Planned Parenthood is that 70% of our patients are on Medicaid. There’s very few health care providers where the majority of their patients are actually low income and on Medicaid – that’s what makes the difference.
Miller: Sara Kennedy and Amy Handler, thanks very much.
Kennedy: Thank you, Dave.
Handler: Thank you.
Miller: Dr. Sara Kennedy is an OBGYN and president and CEO of Planned Parenthood Columbia Willamette. Amy Handler is president and CEO of Planned Parenthood of Southwestern Oregon.
“Think Out Loud®” broadcasts live at noon every day and rebroadcasts at 8 p.m.
If you’d like to comment on any of the topics in this show or suggest a topic of your own, please get in touch with us on Facebook, send an email to thinkoutloud@opb.org, or you can leave a voicemail for us at 503-293-1983.
