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--:-- Sean Rameswaram: Today is a solemn moment. Just a few hours after the Supreme Court of the United States overturned Roe v. Wade, President Biden addressed the nation. He wanted to talk about pills. Some states are saying that they'll try to ban or severely restrict access to these medications. He wanted to make sure people knew he would fight for access to abortion pills.
--:-- Sean Rameswaram: Ahead on Today Explained, abortion pills, how they work, how to get them, and the battle over access.
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--:-- Sean Rameswaram: Support for this show comes from strawberry.me. Be honest. Are you happy with your job or are you stuck in one you've outgrown or never wanted in the first place? Sure, you can probably list the reasons for staying, but are they actually just excuses for not leaving? Let a career coach from strawberry.me help you get unstuck. Discover the benefits of having a dedicated career coach in your corner. Go to strawberry.me slash unstuck to claim a special offer.
--:-- Sean Rameswaram: Rachel Cohen, senior policy reporter at Vox, the Supreme Court overturned Roe on Friday. That means millions of people in America no longer have access to a clinic that can provide a safe, legal abortion. What are those people's options other than, say, getting on a plane, getting in a car and driving to a state that will provide an abortion?
--:-- Rachel Cohen: So the biggest alternative option for people who no longer have in-person clinic care, and to be clear, there are still clinics open, but more states are moving to ban abortion entirely now that Roe overturned. The big sort of alternative option is what's known as medication abortion.
--:-- Sean Rameswaram: These are two drugs. One's called mifepristone, the other's called misoprostol.
--:-- Rachel Cohen: My provider told me that I could take Mifeprex, or Miphy, on the first day. Then, about 24 to 48 hours later, I would take the second medicine, the four mesoprostol pills.
--:-- Sean Rameswaram: You're effectively inducing a miscarriage. You're ending your pregnancy by producing the same physical experience as having a miscarriage.
--:-- Rachel Cohen: Miphy ends a pregnancy by blocking progesterone. The second pill makes the uterus contract like it does during a period, and the pregnancy gets pushed out of the body.
--:-- Sean Rameswaram: Okay, so mifepristone and misoprostol, are these kind of like plan B, like the morning after pill situation?
--:-- Rachel Cohen: They're not the same. It's important to understand the difference. Plan B, the morning after pill, is what we call emergency contraception, and those prevent a pregnancy. Mifepristone and misoprostol end in early stage pregnancy. So that's the difference.
--:-- Sean Rameswaram: How often are Americans using these pills? They now account for more than half of all U.S. abortion.
--:-- Rachel Cohen: And that's for, you know, a couple of reasons. One is that they can be a lot cheaper than getting in-person abortion care. They can be a lot more accessible. You can get them in the mail. So if you live really far from a clinic, you can get it that way. And some people just prefer to do the whole thing in the comfort of their own home.
--:-- Sean Rameswaram: What kind of abortions are these useful for?
--:-- Rachel Cohen: The drugs are recommended to be used in the first 10 to 12 weeks of a pregnancy. So that's the first trimester. But I think it's also important to know that over 90 percent of abortions do occur in the first trimester. You know, it overlaps well when you can use the pills safely. Also overlaps when most abortions happen.
--:-- Sean Rameswaram: Are these pills safe?
--:-- Rachel Cohen: They're very safe. Decades of research has shown that it's a safe way to end a pregnancy with very little risk of complications. Less than 0.4% of patients required hospitalization, according to the Guttmacher Institute.
--:-- Sean Rameswaram: How long have mifepristone and misoprostol been around?
--:-- Rachel Cohen: So misoprostol has been around since the early 1970s. It's used for all sorts of things. It was first developed in the U.S. to treat stomach ulcers. It's sold over the counter all over the world for a lot of things. It's also used to manage miscarriages.
--:-- Sean Rameswaram: The history of learning to use these pills was in the late 1980s and early 1990s in Brazil.
--:-- Rachel Cohen: They learned sort of how to use these pills to induce abortions because it was illegal in Brazil and they couldn't do it in a hospital, you know, in another formal setting.
--:-- Sean Rameswaram: The other drug, mifepristone, that was first approved in the U.S. by the FDA in 2000.
--:-- Rachel Cohen: So it's been legal for over two decades. There was another generic version of it approved in 2019.
--:-- Sean Rameswaram: Why is one more regulated than the other?
--:-- Rachel Cohen: You know, one has been around for a longer time and used for just a lot of other things. There's a lot of expert opinion that these drugs are over highly regulated, especially in the U.S.
--:-- Sean Rameswaram: You mentioned that some countries have these pills available over the counter. Does the United States?
--:-- Rachel Cohen: You can't get them over the counter. And, you know, in fact, before COVID, we had rules that, you know, they literally had to be dispensed in the presence of a physician.
--:-- Sean Rameswaram: Since the pandemic, the FDA has allowed abortion pills to be dispensed via the mail to people who need it, although there are still states that have bans on getting it by mail.
--:-- Rachel Cohen: Texas is one of 19 states that ban abortion visits through telemedicine. Pro-choice groups believe several other states may soon follow.
--:-- Sean Rameswaram: How much do these pills cost?
--:-- Rachel Cohen: It can vary. It can vary by your state. In some states, it could be covered by your insurance if you have insurance that covers abortion care. U.S.-based providers, it's generally a couple hundred dollars. There is also a European-based provider that you can order from that offers it for $150.
--:-- Sean Rameswaram: Since they're not like wildly expensive, I wondered if people keep them around just in case, like in the medicine cabinet, along with everything else. Or do you think that might start happening more now?
--:-- Rachel Cohen: Yeah. So I actually wrote a story about this last week. This is an idea, it hasn't gone mainstream yet, but there are more reproductive health experts that are saying we do need to be talking about this option more, given what we know about the safety of using the pills and given what we know about the coming restrictions we're going to have.
--:-- Sean Rameswaram: Rachel Cohen returns in a minute on Today Explained.
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--:-- Sean Rameswaram: What is Adio?
--:-- Rachel Cohen: [Returning to the conversation] Rachel Cohen returns in a minute on Today Explained.
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--:-- Sean Rameswaram: We all have moments where we could have done better, like cutting your own hair. Oh, yikes. Or forgetting sunscreen, so now you look like a tomato. Ouch. Could have done better. Same goes for where you invest.
--:-- Rachel Cohen: [Returning to the conversation] Rachel Cohen returns in a minute on Today Explained.
--:-- Sean Rameswaram: Level up and invest smarter with Schwab. Get market insights, education, and human help when you need it. Learn more at schwab.com.
--:-- Rachel Cohen: [Returning to the conversation] Rachel Cohen returns in a minute on Today Explained.
--:-- Sean Rameswaram: Today explained Rachel Cohen box with with Roe overturned. Abortion pills seem like a new battleground between those who want people to be able to access abortion and those who don't.
--:-- Rachel Cohen: What's the conversation been like around these pills since Friday?
--:-- Sean Rameswaram: In the last few days, pills have been coming up a lot. Biden gave a speech on Friday saying he was going to work to make sure that these pills remain available nationwide.
--:-- Rachel Cohen: Attorney General Merrick Garland said he was going to use the powers of the Justice Department to crack down on states trying to ban medication abortion.
--:-- Sean Rameswaram: I think a really big question that we don't have clear answers to right now is how these battles between the federal government and the states are going to play out when there's no longer a constitutional right to abortion.
--:-- Rachel Cohen: How can states ban medicine that the FDA has approved? What rights do states have to set these rules if it's legal in other states?
--:-- Sean Rameswaram: These are all really uncharted questions that are going to be shaking out in the post-Roe era.
--:-- Rachel Cohen: Do we know if state governments in states where abortion is now illegal or about to be illegal can go after people who obtain and use these pills?
--:-- Sean Rameswaram: This creates a lot of really complex new questions.
--:-- Rachel Cohen: How we both obtain and provide abortions has changed a lot since 1973, thanks to telehealth medicine, thanks to medication abortion, thanks to mail order pharmacies.
--:-- Sean Rameswaram: So, for example, while laws around telemedicine generally defer to the location of the patient, if you're a provider in New Jersey where abortion is legal, could you face criminal penalty for mailing pills to a patient who lives in a state where abortion is illegal if the patient traveled to New Jersey for their appointment with you?
--:-- Rachel Cohen: Or what if the pills were sent to an address in a liberal state like Delaware and then forwarded on through the mail to Texas where it's illegal, either by friend or a mail forwarding service?
--:-- Sean Rameswaram: These are sort of all these questions that it's not clear who's going to have jurisdiction over which state.
--:-- Rachel Cohen: And, you know, aggressive prosecutors people think might be sort of eager to test the limits of the laws of their states.
--:-- Sean Rameswaram: Yeah, it kind of makes me wonder in the Texas case if like someone could sue the United States Postal Service for delivering these pills to someone.
--:-- Rachel Cohen: Right. I think it's important to sort of point out that the anti-abortion movement's goal is not to have a patchwork of states that are abortion restrictive and other states where you can get abortion. Like they want to make abortion illegal and inaccessible everywhere nationwide.
--:-- Sean Rameswaram: That is the end goal. And so in this new post-Roe era, there's going to be efforts to sort of push the limits of how state restrictions can spread into other states.
--:-- Rachel Cohen: There's going to be efforts to see, OK, can I go after a provider in New Jersey who gave an abortion to, you know, a woman in my state?
--:-- Sean Rameswaram: We don't know yet how those efforts are going to shake out.
--:-- Rachel Cohen: Have we seen any efforts to police abortion pills and access to them already?
--:-- Sean Rameswaram: Yeah. So a majority of states already have, you know, some sort of restriction on medication abortion. But there are no states that have banned the medication outright.
--:-- Rachel Cohen: And there's a lot of questions about like whether that would be legal since it's an FDA-approved drug.
--:-- Sean Rameswaram: There's a lot of talk now about kind of trying to do that, especially as now states just ban abortion outright.
--:-- Rachel Cohen: Up to this moment, most restrictions on medication abortion have been around like, how you can get it? Do you have to get it in person? Does it have to be dispensed by a physician? Can it be sent through the mail? At what week?
--:-- Sean Rameswaram: You know, Texas last year, Texas passed a new law saying that you can't get medication abortion after seven weeks in a pregnancy, even though the FDA has approved it up through 10.
--:-- Rachel Cohen: I'm sure some states are going to try to just ban it outright. Other states are just going to try to keep chipping away to make it harder and harder to access.
--:-- Sean Rameswaram: But the flip side and the sort of the upside is that it's going to be really, really difficult for them to police now that these pills can be mailed.
--:-- Rachel Cohen: People will be taking on new risks for each other, but there's going to be an underground passageway of these pills. And that's just a reality that couldn't and didn't exist before Roe.
--:-- Sean Rameswaram: Can pro-abortion states do anything to protect abortion providers or people traveling to their states to seek care?
--:-- Rachel Cohen: So what we are seeing now in the past couple months, there has been a new effort by Democratic-controlled states to pass what they're calling shield laws, basically different laws to try to protect providers from out-of-state prosecution, from out-of-state complaints.
--:-- Sean Rameswaram: There's all these different ways that if you get too many complaints and you're a medical health provider, then your insurance costs go up. You can lose your license if you have too many different complaints.
--:-- Rachel Cohen: There's all these different ways that you can get harassed or it can make it too difficult to provide the care.
--:-- Sean Rameswaram: So blue states are looking at ways to kind of help shield providers in their states from that kind of harassment or intimidation or legal prosecution.
--:-- Rachel Cohen: It is an open question, though, right now about whether or not these providers can be held liable for certain harms that red states might allege.
--:-- Sean Rameswaram: I think another important question is like, to what extent does a prosecutor in Alabama have, what powers do they have to actually make a doctor in New York show up at court if the doctor refuses to participate?
--:-- Rachel Cohen: And we don't really know.
--:-- Sean Rameswaram: How are the people who live in states with strict abortion bans who aren't traveling across state lines typically getting these pills?
--:-- Rachel Cohen: People living in those states that have restrictions, a lot of them are turning to this nonprofit based in Europe called Aid Access.
--:-- Sean Rameswaram: We have a unique opportunity with Dr. Gompertz being in Europe that we're able to provide telehealth abortion to all 50 states.
--:-- Rachel Cohen: So Aid Access was founded in 2018 by a physician and abortion provider named Rebecca Gompertz.
--:-- Sean Rameswaram: She has been providing abortion around the world for several decades.
--:-- Rachel Cohen: I will start now talking a little bit about our work and I will start with the work of Women on Waves.
--:-- Sean Rameswaram: Women on Waves was founded 20 years ago.
--:-- Rachel Cohen: And the idea was that if you have a ship, then you can go to a country where abortion is illegal and you can take women outside international waters because the local criminal laws don't apply anymore.
--:-- Sean Rameswaram: But she actually avoided helping out the U.S. because unlike many other countries, we, up until Friday, had a constitutional right to abortion.
--:-- Rachel Cohen: Obviously, access was scattered in the U.S. But Dr. Gompertz had sort of dedicated her career to helping women access abortion pills in states where it was just purely illegal.
--:-- Sean Rameswaram: In 2018 she founded Aid Access because after Trump was elected people were giving so many requests for help.
--:-- Rachel Cohen: To date of 2018 I have counseled around 11 women And of these I provided the prescription for 2 women
--:-- Sean Rameswaram: Her whole, basically, model is that if you live in one of these states that has restrictions on medication abortion, well, it's not illegal for her, based in Austria, to dispense the pills.
--:-- Rachel Cohen: So you can put in a request through aid access.
--:-- Sean Rameswaram: And basically, even though Alabama or Texas or prosecutors in Georgia don't want Dr. Gompertz to be sending pills to people living in their states, she's kind of out of their jurisdiction of the law.
--:-- Rachel Cohen: The drug regulator in America has told you to stop. Will you? As a doctor, I have the obligation to care for patients that reach out to me and that need my help.
--:-- Sean Rameswaram: and the FDA has no say over my medical practice.
--:-- Rachel Cohen: So as long as I can help women, I won't stop.
--:-- Sean Rameswaram: And if you're not going with this group Aid Access based out of Austria, are there other places on the internet? Are there shady corners on the dark web where you can find these kinds of pills?
--:-- Rachel Cohen: So, you know, I think it is really important to like get vetted medication, You know, so this organization called Plan C Pills, they do a really good job of finding places where you can get safe medication abortion online.
--:-- Sean Rameswaram: I mean, people are going to resort to lots of different methods.
--:-- Rachel Cohen: We've already seen reports of people crossing into Mexico to get mesoprostol where you can get it over the counter.
--:-- Sean Rameswaram: But I would say you definitely want to be careful about what websites you order and make sure that the online pharmacies are vetted.
--:-- Rachel Cohen: And I guess in addition to vetting these pills, the other question is privacy, especially when so much of this is happening online.
--:-- Sean Rameswaram: There's been a lot of concern here about how much your data is going to be tracked when you try to secure an abortion online.
--:-- Rachel Cohen: Do we have any idea how that pertains to pills?
--:-- Sean Rameswaram: Yeah, I mean, this is a really important question.
--:-- Rachel Cohen: This is a huge difference from pre-Roe times. We just didn't have all this sort of tracking data technology.
--:-- Sean Rameswaram: You know, there was sort of a lot of media attention on things like period tracking apps and stuff like that.
--:-- Rachel Cohen: But what a lot of digital security experts say is really kind of some of the biggest vulnerabilities that people face is like text messages or emails or things that just like basic things, not even just your Internet search history, although that is something to be mindful of.
--:-- Sean Rameswaram: I would say right now there's a couple of things. The first one is that, like, yes, you should be mindful about your internet searches and so on, especially if you're thinking about potentially trying to bypass a restriction or figure out a legal loophole.
--:-- Rachel Cohen: Like you want to be careful kind of what you're saying, what you're doing that on.
--:-- Sean Rameswaram: A lot of experts recommend using Signal, which is an encrypted messaging app, etc.
--:-- Rachel Cohen: I think the bigger point is all of these concerns point to the need for the federal government to follow the steps of other countries and pass stronger consumer protection, digital privacy laws.
--:-- Sean Rameswaram: Like we shouldn't be so scared of criminal prosecution for just searching basic questions about health care on the Internet.
--:-- Rachel Cohen: You know, in talking about this trigger ban situation on this show yesterday, our guest called the current status of abortion in the United States chaos.
--:-- Sean Rameswaram: And now talking to you about the abortion pill situation in the United States, it just feels even more chaotic.
--:-- Rachel Cohen: Should we just be bracing ourselves for this deluge of legal battles for the next few years?
--:-- Sean Rameswaram: I think we should.
--:-- Rachel Cohen: I think not just legal battles, but there's going to be new tactics of resistance and fighting back both politically and through activism.
--:-- Sean Rameswaram: I think the only thing that we can really say for sure is that we are not just returning to a pre-1973, pre-Roe v. Wade time.
--:-- Rachel Cohen: Many anti-abortion activists and conservative legal scholars have sort of long said that if we just overturn Roe v. Wade, then we're going to have this simpler legal landscape.
--:-- Sean Rameswaram: We're going to kind of free the courts from this abortion umpiring business, as Justice Scalia said, you know, back in the 1990s.
--:-- Rachel Cohen: This idea that we'll just let states decide, but that's really just not going to happen.
--:-- Sean Rameswaram: We're going to have a much more chaotic landscape, and we're probably going to have this all wind up back at the Supreme Court again to weigh back in on these questions about out-of-state prosecutions and what rights states have to regulate conduct of their own citizens.
--:-- Rachel Cohen: So you're saying this is going to be a total shit show?
--:-- Sean Rameswaram: Unfortunately, yeah. Probably.
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--:-- Sean Rameswaram: The rest of the Today Explained team includes Paul Mounsey, Halima Shah, Avishai Artsy, Hadi Mawagdi, Victoria Chamberlain, and my co-host, Noelle King.
--:-- Sean Rameswaram: Extra help this week from John Ahrens.
--:-- Sean Rameswaram: Our audio fellow is Tori Dominguez.
--:-- Sean Rameswaram: Our supervising producer is Amina Alsadi.
--:-- Sean Rameswaram: Vox's VP of audio is Liz Kelly Nelson.
--:-- Sean Rameswaram: We use music by Breakmaster Cylinder and Noam Hassenfeld.
--:-- Sean Rameswaram: I'm Sean Ramos from Today Explained.
--:-- Sean Rameswaram: is part of the Vox Media Podcast Network, and we're on the radio in partnership with WNYC.
--:-- Sean Rameswaram: Thank you.
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