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Texans still getting abortion pills by mail with out-of-state help

Reproductive health groups like Plan C and Aid Access help Texans access abortion medications, even though shipping the pills is illegal in the state.

A virtual web of reproductive health groups is openly helping Texans circumvent legal and logistical barriers set in place by strict anti-abortion laws, including those that ban shipping abortion medications by mail.

With a few clicks of the mouse, Texans seeking abortion pills can view a list of vetted providers, visit virtually with a clinician in Massachusetts and arrange for medication to be sent directly — even though prescribing the pills is illegal in the nation’s second-largest state.

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The network of pill providers and educators — which existed long before the U.S. Supreme Court overturned federal protections — is ramping up efforts to reach women in states that passed laws making abortion illegal.

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“It’s just so important that people know that they still have options, even in Texas,” said Elisa Wells, co-founder and co-director of the abortion information nonprofit Plan C.

Ads for abortion pill access hit the radio this summer as part of an awareness campaign for Plan C in major markets across the country, including Dallas, Houston and the Rio Grande Valley. The group’s ads on social media are reminiscent of prescription drug advertisements.

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“I found out people were getting abortion pills by mail in nearly every state, so that’s what I did,” said a mom while braiding her daughter’s hair in a Plan C online video ad. “I spoke to someone about the possible legal risks and got answers to my medical questions for free.”

Screenshot of a Facebook ad from Plan C, a nonprofit under the umbrella of the National...
Screenshot of a Facebook ad from Plan C, a nonprofit under the umbrella of the National Women s Health Network. Plan C doesn't sell pills. It only offers a centralized hub of options and advice.(Screenshot)

Pills by mail are a thorn to abortion opponents that spent decades trying to ban abortions nationwide and found victory with the Supreme Court’s decision last year.

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Amy O’Donnell, communications director for Texas Alliance for Life, said the nonprofit dedicated to protecting the “right to life” beginning at conception is acutely aware of groups that provide abortion pills to Texans.

“This is something that we proactively work to bring legislation for that would provide a deterrent for any who would wish to illegally traffic those mail-order drugs to Texas women from within our state or from another state,” O’Donnell said.

Lay of the legal land

Texas enacted Senate Bill 4 in 2021, prohibiting shipping abortion pills through the mail. The law targets those who provide the pills, not those who take them. Online vendors provide them anyway.

Violating the law is a felony, punishable by six months to two years in jail and a fine of up to $10,000.

Each organization granting online abortion resources protects itself in different ways.

Founded in 2015 under the umbrella of the National Women’s Health Network, Plan C doesn’t sell pills. It offers a centralized hub of options and advice.

Plan C’s website refers users to a network of domestic and international abortion rights groups such as Aid Access and Las Libres that can provide pills.

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Aid Access, a collection of medical professionals who prescribe abortion pills via telemedicine, rely on shield laws that are meant to protect residents who help someone in an anti-abortion state undergo the medical or surgical procedure. These types of untested laws came to life after May 2022.

There’s fear within the online abortion pill market that states passing increasingly aggressive anti-abortion legislation could bring the system to a halt. Some Aid Access providers don’t share their names publicly. Only about seven doctors and nurse practitioners have joined the initiative.

Republican leaders in the Texas Legislature unsuccessfully tried to ban Plan C’s IP address during the 2023 session. House Bill 2690, also known as the Women and Child Safety Act, would require Internet service providers to “make every reasonable and technologically feasible effort to block Internet access to information or material intended to assist or facilitate efforts to obtain an elective abortion or an abortion-inducing drug.” The bill, sponsored by Rep. Steve Toth, R-The Woodlands, specifically cites Plan C and Aid Access.

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The traveling abortion kit

The process is intentionally easy and user-friendly. A turquoise button that reads “Find Abortion Pills” sits near the center of the Plan C landing page. Colorful illustrations — of a hand holding five tablets, of red mailboxes on a blue post — guide users through options tailored to where they live.

Plan C generates nearly 30 options between $0 and $470 for Texas residents. Pills can land at someone’s doorstep in a matter of days.

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A yellow caution symbol pops up on the Plan C page for Texas. There are several relatively cheap and accessible abortion pill options, even with current state restrictions, the alert reads. It also links to a list of potential legal risks.

Clients who are less than 13 weeks pregnant can stay where they are using telehealth services, community support networks and websites that sell pills. Mailed abortion kits have five pills, one mifepristone and four misoprostol tablets, although some users require additional misoprostol pills based on how far along they are in pregnancy.

The three pills-by-mail categories range in price and level of privacy. Aid Access, the only U.S.-based telehealth abortion pill provider currently working in Texas, requires an ID and a virtual consultation.

Community support network Las Libres, based out of Mexico, mails generic pills through volunteers located in the U.S. No medical consultation or prescription is required.

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Plan C details 25 websites that sell pills, organized by price and delivery time. The initiative tests the pill providers to make sure they send the pills in the time frame that’s promised.

Only the four cheapest options are initially shown. To get to the others, a user has to click to another page, a fact that has led to competition between sellers to lower pill prices.

“Those top four listings are like prime real estate, and people are competing with each other to get in those first four slots,” Wells said. “These lower price options are a lot more appropriately priced because we know that the cost of these little pill packs wholesale is probably about $2.”

Cost varies based on the seller. Las Libres offers the pills for free for those who can’t pay, while Aid Access operates on a sliding scale that starts at $150 and goes lower as needed. Third-party website prices go from $47 to nearly $500.

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It typically takes three to 12 days to receive the pills, delivered in confidential envelopes. Aid Access medical provider Lauren Jacobson said she packages and mails about 50 prescriptions a day from her Massachusetts home, not including Sundays.

The Texas Heartbeat Act made it possible to sue individuals that aid and abet an abortion, significantly raising the barriers for women seeking abortions and for those providing them.

Requests for abortion pills from Aid Access nearly tripled in the three months following the enactment of the Texas Heartbeat Act, from 11 requests a day to almost 30, according to a UT Austin study conducted by Abigail Aiken, principal investigator of Project SANA.

Nationally, Aid Access saw pill requests increase 160%, from 83 per day to 214 requests per day after the Dobbs vs. Jackson Women’s Health Organization ruling. From September 2022 to March 2023, the average daily requests climbed to 234, according to another study by Aiken published in the Journal of the American Medical Association Network Open.

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“People from restricted states, of course, they still need abortions,” Jacobson said. “That they were able to find and access and feel empowered enough to use this service, I mean, that just speaks to how much people need the services right now.”

A mosaic of abortion laws

At least 23 states have enacted shield laws or executive orders meant to safeguard providers and patients in states with abortion bans, according to the Guttmacher Institute, a research and policy organization focused on reproductive health that supports abortion rights.

Arizona’s governor was the latest to issue such an executive order in July.

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Shield laws and executive orders have yet to be legally tested and leave abortion activists working under the laws in limbo, said Dena Sharp, a lawyer with Girard Sharp LLP in California with expertise in women’s advocacy.

“Abortion and reproductive rights are in a very unique space right now,” Sharp said. “Because where there used to be a single federal law, suddenly there’s a vacuum. And that is why we see this mosaic of laws and ideas and legislative policies sort of coming into focus.”

The majority of such laws say the state with shield protections would refuse to cooperate with other states’ attempts to investigate, extradite or prosecute abortion seekers or providers.

“And the consequence (of shield laws) is that states want to be able to exercise their rights to allow for reproductive choice, as best they can for their own citizens, even if that might mean stepping on the toes of another state,” Sharp said.

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Aid Access moved its operations from Europe to the U.S. this summer because of shield law protections. The organization doesn’t know if the laws will hold up in legal battles.

Users are nervous, too. Some order the pills using VPNs and burner email addresses. People from states with strict abortion bans post questions about medication abortions on the social media forum Reddit under generic, untraceable usernames.

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Plan C and Aid Access come up frequently in subreddits, as do other services that aid in the abortion pill process. Are the sites legitimate? Do the pills come as quickly as they say? Can a Texas resident get in trouble for accessing those resources?

The groups intentionally track very little data about their clients in order to protect identities from states with bans. They often direct people to the Repro Legal Hotline, which offers free advice about possible legal risks.

Should the abortion law landscape change once again, Aid Access said it will adjust.

“We have backup plans so we’ll continue to provide mifepristone and misoprostol to all 50 states,” Jacobson said. “We have backup plans to our backup plans, so that will continue to happen.”