The Safer, More Affordable Abortion Only Available in Two States

Medicated abortions provided via telemedicine can help bring down costs and get women care earlier in their pregnancies, but opponents have blocked them throughout the country.

Abortion opponents in Iowa protest along the campaign trail. (Jim Young/Reuters)

Were he graduating medical school today, Dr. Joel Fleischman might not have been needed in rural Alaska. Fleischman, the main character for TV’s Northern Exposure, was stuck in a small Alaskan village in order to pay off some debts and provide the town with medical care. But now, thanks to rapid advances in telemedicine, Alaskans don’t need quite so many doctors throughout the state. Though 65 percent of the state’s doctors are located in Anchorage, a woman in Alaska’s Northwest Arctic Borough can give birth aided just by a nurse guided, over video, by a doctor, some 200 miles away.

Telemedicine has made rapid advances in the past few years, expanding access to healthcare for all sorts of people. It’s not just people in rural areas either: Veterans in Virginia can now talk to therapists through their computers, avoiding the stigma of a doctor’s office, and inmates in Texas can now see specialists through a program that’s brought telemedicine into prisons.

The cost savings and improved health outcomes from telemedicine are very real. Telemedicine reduced life expectancy gaps between American Indians and whites from eight years to five years in one study. Another found that telemedicine saved Medicaid and Medicare 19 percent on costs when it helped offer hospital-level care in patients’ homes. And in Alaska, after telemedicine was first introduced in 2003, the state's Institute of Social and Economic research estimated that the practice saved doctors from taking more than 3,000 trips, worth $3 million, every year.

But there is one procedure that, though it could be easily, safely, and cheaply administered via telemedicine, is widely unavailable: the termination of a pregnancy. Fifteen states have adopted bans on telemedicine abortion since 2010. The practice was only ever available in three states—Iowa, Minnesota, and Texas—though Texas now has banned it. In Iowa telemedicine abortion continues to be available, though is being challenged in courts, and in Minnesota the legislature passed a ban, which the governor vetoed.

Planned Parenthood of the Heartland (as the Iowa affiliate is known) first began offering abortions via telemedicine in June of 2008. Jill June, the affiliate’s longtime president, had seen a TV news report about complicated surgeries done through telemedicine, and started wondering if telemedicine would work as a way to administer a regimen of mifepristone and misprostol, which together are effective in ending pregnancies. The group has used telemedicine to treated 6,400 women since then, said Angie Remington, a spokeswoman for Planned Parenthood of the Heartland.

Here’s how it works: A woman goes into one of a handful of Planned Parenthood's health centers and talks with a nurse or medical assistant there. She then gets an ultrasound and some lab work done and is briefed on the specifics of the procedure. Finally, she has a video conference with a physician and the local clinician and decides whether a medically-induced abortion is the right course for her. If it is, the doctor checks a box on a computer screen, unlocking a cabinet holding the abortion medication. The woman takes the medication in the clinic while the doctor is watching and then takes the second pill at home 24 to 48 hours later.

“The intent was really for women to be able to receive the care they need without having to travel 500 miles round trip,” Remington said.

In Minnesota, where a clinic in Rochester uses telemedicine to link women to a doctor in St. Paul who can administer the drug, women have been grateful for the service, said Jennifer Aulwes, a spokeswoman for Planned Parenthood of Minnesota, North Dakota and South Dakota. They've reported that it allowed them to get the abortion earlier in their pregnancy, which they preferred. Getting the abortion earlier in the pregnancy also allows women to have a medicated abortion, rather than a surgical one.

“Through this program, there have been many women who have told stories like, ‘I don’t think I would have been able to get an abortion, if not through this service,’’’ she said.

But abortions did not increase in Iowa after telemedicine was introduced; instead, they decreased, part of a national trend in which abortions are decreasing, according to Daniel Grossman, a doctor and researcher at Ibis Reproductive Health.

Grossman studied abortions in Iowa in the two years before and after telemedicine went into effect. He found that after telemedicine was introduced, women in more remote parts of the state were more likely to get an abortion earlier in her pregnancyand this has significant consequences: Abortions in the first trimester are both medically safer and less expensive than second-trimester abortions. The number of abortions performed on women in the western and eastern parts of the state, away from the cities, also increased.

“From a public-health perspective, [telemedicine] does improve access to early abortion [and] decreases later abortion, and that would result in improved health outcomes,” Grossman said.

Some women who had telemedicine abortions preferred it to a more traditional clinic experience, especially since they take the second pill in the comfort of their own homes, Grossman found in a separate survey he conducted with other researchers.

But in August of 2013, the state’s Board of Medicine issued a new rule “to protect the health and safety of Iowans” that required a physician be physically present with a woman at the time an abortion-inducing drug is provided.

Planned Parenthood of the Heartland sued, and a judge allowed the group to continue to provide the medical abortions until the case was argued in court. Though a court initially ruled on the side of the Board of Medicine in August, the state’s Supreme Court agreed to take up the case, and is allowing the telemedicine abortions to continue as the case makes its ways through the legal system.

If the ban is upheld, the number of places where women can receive abortions in the state will decrease from nine to three, and two of those three are in Des Moines, the capital city.

“Everyone is trying to figure out how to incorporate telemedicine and how can they use it, but in this one area, we’re seeing it be restricted,” said Elizabeth Nash, a senior state-issues associate with the Guttmacher Institute, which advocates for access to abortion.

It’s not just telemedicine. Since the elections of 2010 ushered in a class of conservative legislators to statehouses across the country, more restrictions on abortion have been passed nationwide than were passed in the previous decade. But the bans on telemedicine represent a changing tactic in abortion restrictions, in which opponents target the clinics providing the abortions, rather than the women seeking them. If previous laws required women to wait 24 or 48 hours to have an abortion or listen to a lecture about health risks, current laws seek to limit the number of clinics where women can go to get an abortion.

When the number of places where women can get an abortion decline, abortions decline too—it’s simple economics. Focusing on limiting supply has proven a much more effective tactic for abortion opponents than attempting to limit demand.

Theodore Joyce, an economics professor at Baruch College, studied whether supply side or demand side laws that went into effect in 2004 had a greater influence on women's decision to seek an abortion. Demand-side laws required that women received in-depth information about an abortion 24 hours before the abortion was performed. Supply side laws required women who wanted abortions after 16 weeks of gestation receive the procedure in an ambulatory surgical center.

He found the demand-side laws had no effects, and the number of abortions before 16 weeks of gestation remained consistent, he wrote in a paper for the New England Medical Journal. But the supply-side laws "had dramatic effects," he wrote: The number of abortions performed in Texas after 16 weeks dropped 88 percent after the law went into effect, and the number of residents who left the state for an abortion quadrupled.

More recently in Texas, after three restrictive abortion laws went into effect in November 2013, abortions declined 13 percent throughout the state, even as riskier abortions in the second trimester increased, according to a separate study Grossman conducted, which will be published in the November issue of Contraception.

“Demand-side laws have generally not had much impact on the abortion rate,” Grossman said, in an interview. “Supply side restrictions have a much larger effect since they can make it very hard for physicians to provide abortion--and as we've seen in Texas, they can lead to the closure of clinics.”

It’s an indication that after decades of trying to figure out a way to push back against Roe v. Wade, abortion opponents have found a way to limit legal abortion. It’s not through requiring women to get permission from their parents to get an abortion, or by requiring them to see an ultrasound of their fetus. It’s through cutting down on the supply of clinics providing abortion, requiring women who want abortions to travel to their own Dr. Joel Fleishman.