S1: I guess. First.
S2: Do you want to just introduce yourself and tell me what you do?
S3: Sure. My name is Dr. Mike Fleming. I’m a family medicine physician at the University of California, San Francisco, at a telehealth company called Hey Jane. And I’m a fellow with Physicians for Reproductive Health.
S1: I called up Dr. Flemming after the draft opinion overturning Roe v Wade leaked from the Supreme Court a draft opinion that appears to have the votes in some ways. Fleming was expecting this, but it didn’t make it easier to hear.
S3: It still was very upsetting to see the words that were written by Justice Alito. While folks who have been working in reproductive health and access have been talking about this for a long time, I’m hoping that the shock of this for not just us but for everybody really brings this issue into the mainstream.
S1: In her practice in San Francisco, Fleming provides all kinds of medical care, including abortion. She also does something else.
S3: I also provide telehealth, medication, abortion across five different states where I’m licensed to practice medicine through a company called Hygiene, and I’m doing so to help broaden access to care beyond my geographic bubble.
S1: Today on the show, a conversation with a doctor who helps facilitate abortion via the Internet. The pandemic changed the way abortion care could be provided online. So what happens now? I’m Lizzie O’Leary and you’re listening to what next? TBD a show about technology, power, and how the future will be determined. Stick with us. Before the pandemic. If you wanted a medication, abortion, where a pregnancy up to ten weeks gestation is terminated using a two pill regimen, you generally needed to get the first pill from a hospital or clinic. With the exception of a small telehealth research program, FDA rules meant that a patient who wanted a medication abortion had to see a provider face to face. COVID changed that first when a judge briefly lifted the FDA restrictions in 2020 and then in April of last year, when the agency itself temporarily allowed patients to get the drugs by mail. That meant a huge opportunity for telehealth.
S3: A lot of the care that we’ve been providing in person can be carried out just as well and just as safely over the phone or through virtual video visits as in-person visits. Abortion care was one of those things. In the middle of the COVID 19 pandemic, there was a huge study that came out of England and the National Health Service there that demonstrated over tens of thousands of people who obtain medication. Abortion via telehealth in Great Britain were able to do so very, very safely and actually with fewer complications than the previously published number is on safety for medication, abortion. And so we were able to replicate a lot of those studies here in the United States, again, reconfirming and demonstrating just how safe and effective medication abortion over the phone is.
S2: I was really struck looking at that study. You know, it compared groups of women who’d had in-person appointments for a medication, abortion, and they’d gotten a sort of traditional appointment with a sonogram. And then groups who had who had gotten it via telehealth. And essentially the rates of of complications were pretty much the same.
S3: Right. And I do want to quickly emphasize and stress that it is not only women who obtain abortion care. People of all genders who have a uterus and have the capability of becoming pregnant do seek and obtain abortion care. So I think it’s important to be inclusive in the language that we use. Absolutely. But, you know, whether a person is prescribed medications from an in-person clinic or a telehealth clinic or whether they order their own medications online, these medications in the abortion process are the exact same across the board and proven to be very, very safe.
S1: Based on studies like this and data from its own temporary rule change, the FDA decided to permanently allow patients to get abortion medication in the mail at the end of last year. That means platforms like Hey Jane, where my Flemming works are able to provide virtual services in states where telehealth abortion is legal with.
S2: A platform like, Hey, Jane.
S1: Do you have conversations with people who are on the fence or do most of the patients who you are talking with.
S2: Do they know what they want?
S3: Like any medical care, there is no one size fits all for a patient encounter. And in any field, some people know exactly what they need and what they want, and we are happy to help facilitate that in a safe way. There are people who may not feel 100% certain at the time that they start engaging with us, whether this is something that they want to proceed with. And we talk with folks through that.
S2: Do you have it? A typical patient? I know that’s a tough question. And I am so interested in kind of the stats. You know, I’m sure you’ve seen there’s a sort of a New York Times thing that they have resurfaced in the past day saying a typical patient already has children is.
S1: Probably in their late twenties. I wonder if you have seen.
S2: Commonalities among your patients, particularly the ones who are doing this online.
S3: Generally, I see a whole range of people coming from all different experiences and backgrounds. Some people are already parents, absolutely, and are making a decision that best fits what they need for their current families. Some folks are not parents and have never been parents, and people have never had an abortion. Some people have had abortions before. There is not one abortion patient and there is not a typical abortion patient. A common statistic that that folks reference is that one in four people of reproductive potential may need at least one abortion in their lifetime. And so most people know somebody who’s had an abortion, regardless of who you are or what your circumstances are.
S1: Where do your patients typically live? Obviously, you’re physically based in California, but you’re licensed in a number of states. And I’m wondering, are they, you know, in a rural part of the state and they can’t physically get to a clinic because there isn’t one near them?
S3: Yeah. So that also ranges. I have had patients from very remote areas where the nearest abortion provider might be three or more hours away and patients who live in a big city where abortion might be accessible. But the wait times are weeks long.
S1: I wonder if you could talk a little bit from your perspective as a provider.
S2: Of what it’s been like to.
S1: Have the Internet as another tool in your practice? You know, you’ve been doing this work for a while, and I wonder if having.
S2: The expanded reach of the Internet has made you think about being able to to reach people who you couldn’t reach before.
S1: What is that been like? Because it’s been a pretty profound change over the past two years.
S3: For folks that have ready access to Internet and phone, the ability to be able to provide care in the safety and comfort of a person’s own home. Really means a lot to some people, and particularly when we talked about very stigmatized care. Right. Where a person doesn’t have to travel for sometimes hours, sometimes days to access care. They may not have to get child care. They may not have to travel through angry protesters to try to reach their doctor or their health care provider in order to access this care. It has been a really important avenue.
S1: Of course, the digital divide means that people who don’t have reliable Internet access have a harder time getting telehealth abortion care.
S3: Outside of kind of the Internet access piece. Not everybody has access to a safe space in their own home or in their own situation in order to access care. Whether folks are victims of interpersonal or domestic violence, folks have been victims of trafficking or don’t feel safe disclosing the type of medical care that they need with their family or other people who live in their household. It is for those reasons. Telehealth is not the answer. It doesn’t actually address the root issue, which is the overall lack of accessibility in the first place and is only accessible largely in the states with permissive abortion laws. We already know that, you know, many states already have. And if they don’t already have, they’re working on it. Legislation to restrict and eliminate abortion access via telehealth and some and for some, just medication abortion in general.
S1: When we come back, what those telehealth abortion laws mean for patients. Despite the FDA rules, 19 states restrict the use of telemedicine for abortion care. That can either mean an outright ban or requiring that a clinician is present when the pills used for medication abortion are administered, which in effect means telemedicine can’t be used.
S3: For the people who are in the states where they are not able to use telemedicine for medication abortion. If abortion is still accessible in those states, they may be traveling very far distances to obtain care. If not, they may be traveling to distant states in order to access care. Some people may be ordering their own pills online. I think the biggest risk with folks self-managing their abortions at home is not the medical piece. We’ve already well established in this whole talk how safe these medications are for people. But it’s really the the potential legal repercussions. We’ve seen criminalization of folks who have self-manage their abortion. And even by extension, we’ve seen criminalization of people who are actually suffering a miscarriage, where a person who they have reached out to for help and for medical care has reported them for suspicion, for a self-managed abortion or self-induced abortion, when in fact, it’s really a miscarriage. Right. So it’s not surprising that the folks who are most at risk of being criminalized are the same folks that are at highest risk of being criminalized in our country in general, folks of color, folks who are undocumented and gender diverse folks, folks who are in lower income communities. And I worry about the state of increasing restrictive and punitive climate on the ways in which people on the ground may end up translating those restrictions and laws into criminalizing patients who are seeking medical care.
S1: You know, the Internet has has made meds easier to get even.
S2: If you are not talking to a.
S1: Board certified doctor like yourself. I wonder.
S2: If we are contemplating this.
S1: Post row future. Will those informal networks get bigger? Will the Internet play an even larger role here?
S3: We have a lot of experience of what a post-racial world will look like in the state of Texas. There was a study that looked at how the demand and request for medications through aid access changed in Texas after the implementation of SB eight and the number of requests, honestly, not only in Texas but actually across the country, increased by a very significant degree by by multiple magnitudes. And they don’t have those numbers off the top of my head. But if that’s any indication, I wouldn’t be surprised if if that would happen. But we have yet to see.
S2: Can you imagine a future where you’re helping people in those states get medication over the Internet?
S3: Regardless of what the law is in any given state, there are always going to be people whose goal and mission is to help folks access safe care, whether that be through logistical means of helping folks travel across state lines if they’re able to, and providing monetary and logistical support to do so or helping get folks the information that they need to safely manage their own care where they are.
S2: Dr. Mike Fleming, thank you so much for talking with me.
S3: Thank you so much.
S1: Dr. Mike Fleming is a family medicine physician and fellow with Physicians for Reproductive Health. That is it for the show today. TBD is produced by Ethan Brooks, where edited by Tori Bosch. Joanne Levine is the executive producer for What next? Alicia montgomery is the executive producer for Slate Podcasts. TBD is part of the larger What Next Family, and it’s also part of Future Tense, a partnership of Slate, Arizona State University and New America. For a broader understanding of what happened at the Supreme Court, I recommend that you listen to Wednesday’s episode of What Next? Mary Harris talks with the invaluable Dahlia Lithwick. We’ll be back on Sunday with another episode. And Lizzie O’Leary. Thanks for listening.