Virtual clinic telehealth abortion services in the United States one year after Dobbs: a landscape review

Background: Telehealth abortion has taken on a vital role in maintaining abortion access in the year since the Dobbs v. Jackson Women’s Health Organization Supreme Court decision. However, little remains known about the landscape of new telehealth-only virtual clinic abortion providers that have expanded. Objective: To document the current landscape of telehealth-only virtual clinic abortion providers in the United States one year after the Dobbs decision. Methods: We conducted web searches and reviewed abortion directories to identify operational virtual clinics in September 2022 and June 2023. We also described each virtual clinic’s policies, including states served, costs, patient age limits, and pregnancy duration limits. Results: We documented 20 virtual clinics providing services in 27 states and Washington, D.C. Most (n=16) offered care to minors, 8 provided care until 10 weeks of pregnancy (n=8), and median costs were $259. Two accepted private insurance and one accepted Medicaid, within select states. Most (n=16) provided some form of financial assistance. Conclusions: Virtual clinics have proliferated since the Dobbs decision. Increased access for minors, extended pregnancy duration limits, and expanded insurance and Medicaid acceptance are critical to ensure equitable telehealth abortion access.


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INTRODUCTION
Following the 2022 Dobbs v. Jackson Women's Health Organization United States (U.S.) Supreme Court decision, demand for abortion has surged in states where abortion care remains legally accessible. 1 Telehealth medication abortion has emerged as an important model of abortion provision in the U.S. in recent years.In 2021, the U.S. Food and Drug Administration lifted a restriction that required mifepristone, the first drug in the regimen, be dispensed only in medical facilities.This change paved the way for telehealth abortion care to expand.Telehealth plays an increasingly vital role in safeguarding abortion care by reducing geographic barriers 2 and decreasing wait times to care. 3,46][7] Patients typically complete either synchronous (over videoconferencing or a phone call) or asynchronous (using secure messaging) screening with a clinician to assess for medical eligibility.Once deemed eligible, patients are mailed medications, typically from a mail-order pharmacy.They then take the medication, pass the pregnancy, and complete follow-up interactions with their provider, from home. 8irtual abortion clinics, defined as abortion providers without brick-and-mortar facilities in the state where they are providing access, have also proliferated.As of December 2022, virtual clinics provide 11% of all abortions in the U.S. healthcare system. 1 However, because virtual abortion clinics are so new, little else is known about their availability, reach, and policies.We aim to document the current landscape of virtual clinic abortion care in the United States, describe changes in the availability of virtual abortion clinics over time between September 2022 just after the Dobbs decision to June 2023, and document structural factors that may perpetuate inequities in virtual clinic abortion access.

METHODS
We conducted a landscape review using web searches and by reviewing three websites that document abortion availability: abortionfinder.com,ineedana.com,and planc.org.For the Google searches, we used a combination of terms including "telehealth," "telemedicine," "online," "abortion pills," "medication abortion," "mifepristone," and "misoprostol."The first two authors (L.R.K and J.K.) conducted the first search in September 2022, and the second in June 2023.
We documented the number of virtual clinics and the states each virtual clinic served.For each virtual clinic, we also identified the following service policies: ages served, costs, insurance and Medicaid acceptance, pregnancy duration limits, languages provided, synchronicity of care (whether the service offered synchronous care involving video or phone interactions, or asynchronous care entirely over secure messaging), and whether the virtual clinic provided medication abortion through advanced provision.

RESULTS
In September 2022, 10 virtual clinics were providing telehealth abortion care in 25 states and Washington, D.C.By June 2023, 20 virtual clinics were providing telehealth abortion care in 27 states and Washington D.C. (Figure 1).

States, June 2023
In June 2023, pregnancy duration limits ranged from 10 weeks, 0 days to 13 weeks, 0 days, though the most common pregnancy duration limit was 10 weeks, 0 days (n=8, Table 1).Several virtual clinics did not provide care to patients under age 18 (n=4).Eight virtual clinics provided only synchronous care, six provided asynchronous care, and six offered both synchronous and asynchronous care.Additionally, six virtual clinics provided medication abortion by advanced provision.
Costs for telehealth medication abortion care ranged from $90 to $600, and median costs were $259.Few (n=2) accepted private insurance and two accepted Medicaid in certain states.Most virtual clinics (n=15) advertised offering sliding scale payments, funding from an abortion fund, or other forms of financial assistance to patients.Over half of virtual clinics advertised services in languages other than English (n=11).However, while some of the virtual clinic's providers were multilingual, many virtual clinic platforms were only available in English and some charged additional costs for translations.

DISCUSSION
We found that the presence of virtual clinics has increased dramatically in the U.S. between 2022 and 2023.While telehealth could help to mitigate geographic inequities in abortion access, nearly all states in the South and Midwest ban abortion entirely or permit abortion care but prohibit telehealth, limiting telehealth's potential to help maintain abortion access. 9e documented several structural barriers in the current landscape of virtual clinic abortion that are critical to address to improve equity in access to telehealth abortion care.Most virtual clinics we examined offered medication abortion care up to 10 weeks of pregnancy.The World Health Organization guidelines include medication abortion care up to 12 weeks, 0 days, and medication abortion is commonly provided off-label in the United States until 11 weeks, 0 days. 10,11As abortion bans create additional logistical hurdles that extend the time it takes to obtain abortion care, it is critical to expand pregnancy duration limits to serve patients throughout the first trimester.
A few virtual clinics maintain minimum age requirements that are not legally mandated in the states they serve.These restrictions limit abortion access for minors, who face enormous barriers to abortion access, 12 and who stand to benefit from the privacy and ability to avoid travel that telehealth offers.In addition, few virtual clinics accepted private insurance or Medicaid, highlighting an important gap in accessibility.
Most of the virtual clinics we identified offered only asynchronous or synchronous care.Research has demonstrated the safety and effectiveness of both synchronous and asynchronous abortion care and that each offers unique benefits to patients. 3,6,13It is also critical that virtual abortion clinics expand their services to languages other than English to reach including immigrant and undocumented populations, groups for whom travel for abortion care may be especially difficult.
We may have omitted virtual abortion clinics not documented on the websites we examined or in our searches.However, these results provide a picture of the current landscape of telehealth abortion care from virtual clinics in the United States.Virtual clinics are emerging as key providers in the U.S. abortion landscape in the face of dire restrictions on abortion access.Yet many states, including those that allow abortion, have legal restrictions on this model of care.Expanding access to telehealth abortion is key to increasing health equity.