NEWARK, Del. — The large cardboard box in Debra Lynch’s living room contained enough pills for 162 medication abortions. Last summer, such a shipment would last a month. Then she needed to reorder every two weeks. Now she goes through a box like this every week.
“We’re mailing a lot to Texas,” said Jay Lynch, who handles most of the packaging and postage for Her Safe Harbor, an abortion-drug-by-mail service spearheaded by his wife.
Debra Lynch, a nurse practitioner, prescribes the pills via telehealth under Delaware law. Her husband drops the medications into white, bubble-padded envelopes that will cross state lines and defy state bans to reach the hands of anxious women.
From the kitchen table in the couple’s split-level suburban home, Jay Lynch thumbed through the shipping labels for the next two dozen orders: Alabama. Indiana. Georgia. Several in Florida. And plenty in Texas: Tomball. Houston. Beaumont. Fulshear.
“Everybody – Aid Access, ourselves, some of these other small groups – we are all shipping to Texas,” Debra Lynch said. The orders kept coming in – “I just got one from El Paso,” Jay Lynch told me later that afternoon, after his laptop and cellphone chimed – underscoring the inescapable fact that Texas’ bans have not erased Texans’ demand for abortion.
Scores of telehealth abortion providers have cropped up since the U.S. Supreme Court’s Dobbs decision in 2022 allowed states to prohibit the procedure. Some telehealth providers serve patients only in states that allow abortion. But some – including major players Aid Access and the Massachusetts Medication Abortion Access Project, as well as smaller startups like Her Safe Harbor – are designed to serve patients anywhere.
In short order, these providers have had a seismic impact. Not long ago, in April 2022, about 1 in 25 abortions in America were from pills prescribed via telehealth. By June 2024, it was 1 in 5, according to the latest #WeCount report from the Society of Family Planning.
Nearly half of those prescriptions went to patients in states with abortion bans or restrictions on telehealth abortion.
Texas has outlawed most abortions (providers risk up to 99 years in prison and at least $100,000 in fines) and forbids sending abortion medication through the mail. That didn’t stop about 2,800 Texans per month from receiving abortion medication by mail in the first half of 2024 – more than any other abortion-restricted state, according to #WeCount data. (Notably, Texas criminalizes only the act of sending the pills, not receiving them.)
ABORTIONS IN DELAWARE:State saw one of the highest increases in legal abortions in 2023
Looking at the national picture, more than 1 million Americans terminated pregnancies in 2023 – the highest number in more than a decade – despite the fact that 12 states have outlawed abortion and four others ban the procedure after six weeks, before many people know they’re pregnant. About 170,000 Americans (including more than 34,000 Texans) flew or drove across state lines in 2023 to get an abortion, according to the Guttmacher Institute, which supports access to abortion. But many others ended their pregnancies with pills that came in the mail.
Some are even buying pills preemptively, just in case they’re needed later.
All of which makes these pills a central target for those who oppose abortion. Texas lawmakers and members of the incoming Trump administration could try to curb access, and Texas Attorney General Ken Paxton has been escalating the fight. A week after I visited Her Safe Harbor’s Delaware operations in early December, Paxton sued a similar provider in New York.
“In Texas, we treasure the health and lives of mothers and babies, and this is why out-of-state doctors may not illegally and dangerously prescribe abortion-inducing drugs to Texas residents,” Paxton said in a statement then.
ABORTION IN DELAWARE:ACLU prioritizing abortion rights during Trump presidency. What Delaware already protects
When I caught up by phone with Debra Lynch, she was unsurprised and undeterred. “I don’t fear Ken Paxton,” she said. “I don’t fear getting arrested or anything like that.”
What scares her the most is the possibility that Texas women “might do something dangerous to themselves because they feel desperate and isolated,” she said. “I want women to know that there are people out there working to help them.”
More:Examining first test of shield laws and what it means for Texas women seeking abortions
Two events supercharged telehealth abortion
Debra Lynch’s nursing career led her to hospitals, hospice care, homebound patients and even the subway tunnels of Philadelphia, where she offered checkups and COVID-19 vaccinations to people experiencing homelessness. By the time Lynch grew worried about another set of patients cut off from care – those living under abortion bans – two events made it possible for her and other organizations to reach across state lines to help.
First, the pandemic prompted the U.S. Food and Drug Administration to drop the requirement for an in-person visit for patients to obtain mifepristone, the first pill in the medication abortion regimen for patients up to 10 weeks into a pregnancy. (Patients take the second medication, misoprostol, on their own 24 to 48 hours later.)
Then in 2022, as the Dobbs decision came down, some states started passing “shield laws” to protect medical providers in their communities from investigations or lawsuits if they provided abortions to patients from other states. Now, 23 states and the District of Columbia have shield laws of varying degrees.
New York’s shield law, for instance, prohibits its agencies from cooperating with an out-of-state investigation, honoring subpoenas or extraditing defendants.
That makes it “virtually impossible for a prosecutor or civil attorney” to build a case against an out-of-state doctor, according to the anti-abortion Charlotte Lozier Institute, which says shield laws enable “pro-abortion states” to “force abortion on life-affirming states.”
Aid Access, which got its start serving U.S. patients from overseas, moved into five shield law states in June 2023. The Massachusetts Medication Abortion Access Project, led by Cambridge Reproductive Health Consultants president and co-founder Dr. Angel Foster, launched a few months later.
“We’re now serving about 2,500 patients a month,” Foster said of her program, better known as the MAP. “About a third of those patients are from Texas, and 95% of our patients are from states where there are abortion bans, restrictions or bans on telemedicine.”
Illustrating the impact of this effort, Foster pointed to Mississippi, which had about 3,600 abortions a year before the Dobbs case shuttered the state’s last abortion clinic.
Now, with the combined efforts of Aid Access and the MAP, “we’ll probably provide care to over 4,500 patients in Mississippi in 2024,” she said. And that care is more affordable, too: The MAP uses a pay-what-you-can model starting at $5, and Aid Access charges up to $150, while clinic-based medication abortions typically cost more than $500.
That’s not to minimize the harm inflicted by abortion bans, including the fact that some patients still can’t access care, Foster said.
“But it is easier and cheaper to get a medication abortion in Mississippi today than it was four years ago,” she said, “and I think that is a pretty incredible thing that’s happened because of the shield laws in the post-Dobbs environment.”
Both sides planning countermoves
Joe Pojman, the founder and executive director of the Texas Alliance for Life, is also astonished by the rise of telehealth abortion – for entirely different reasons.
“It makes no sense that any responsible doctor would send pills to a woman out of state without ever examining that person personally, and without having a license to practice medicine in Texas,” said Pojman, who also asserted that medication abortion is dangerous, despite more than 100 studies finding it to be safe and effective. “If it were happening in any other specialty of medicine, I think people would be outraged.”
He applauded Paxton’s lawsuit against the New York doctor, hoping the courts will strike down the shield laws. But no one is confidently placing bets.
When I asked abortion law expert Mary Ziegler, a professor at the University of California at Davis School of Law, whether shield laws are likely to withstand judicial scrutiny, she replied, “I think the short answer is ‘who knows,’ combined with a fair amount of ‘it depends.’”
In the meantime, Texas lawmakers are looking to fortify the state’s abortion bans. One proposal, House Bill 991 by Rep. Steve Toth, R-The Woodlands, aims to cut off access to medication abortion by empowering private citizens to sue internet service providers who fail to block such websites in Texas.
Plan C, one of the websites singled out by name in HB 991, provides state-by-state information and links to places people can obtain pills. Plan C co-founder and co-director Elisa Wells said the site typically receives about 5,000 to 6,000 visitors a week from Texas. That number shot up to 23,000 the week that Donald Trump won the presidential election.
“I think everybody is planning for the worst,” Wells told me. “I mean, you have to assume that what’s written in the Project 2025 plan is something that will be a road map for the Trump administration.”
The plan, written by the Heritage Foundation and other conservative groups, calls for immediately reinstating the requirement that mifepristone be dispensed in person, essentially outlawing telehealth abortion; and ultimately revoking the FDA’s approval of mifepristone, which would take that drug off the market entirely (something the U.S. Supreme Court declined to do in 2024).
Project 2025 also argues the feds should reanimate the Comstock Act – a long-dormant anti-obscenity law from 1873 – to prosecute anyone who sends abortion-related items through the mail.
Asked last month on “Meet the Press” whether his administration would restrict the availability of abortion pills, Trump said, “The answer is no.” But he refused to make a firm commitment, noting “things change.”
Wells said if the feds crack down on the mailing of abortion pills, “there are alternate routes of access that we know about that we’ve been researching for the last 10 years, that we believe will still be operational.”
They’re already listed on the Plan C website: Telehealth providers based outside the U.S.; websites that sell pills without providing medical support; and volunteer-run community support networks that provide pills for free.
Under Texas law, patients cannot be charged for seeking or obtaining an abortion. The bans target providers. Still, there are legal risks. Anyone helping a patient – say, a partner or relative paying for the pills – could be sued in Texas for abetting an abortion. And in rare cases, authorities overreach: Starr County prosecutors in 2022 charged a South Texas woman with murder for a self-induced abortion, subjecting her to public humiliation before the charges were dropped three days later.
“But at the end of the day, there is just this absolutely relentless network of activists and organizations all over the country who are dedicated to helping people access abortion, no matter what the law says,” said Amelia Bonow, founder of the advocacy group Shout Your Abortion. “And that’s not going anywhere.”
\’There\’s almost a pleading in their voice\’
From the kitchen table headquarters of Her Safe Harbor in Delaware, Debra Lynch told me she planned to order as many pills as she could before Trump takes office. If the landscape changes and she needs to move outside the country to continue this work, she said, she will.
“No matter what obstacle might come down, we’re trying to think ahead and make sure that we can figure out another way around it,” said Lynch, who has more than a dozen volunteers helping with Her Safe Harbor. “Because the ultimate goal is to make sure the medication is available to the women who need it.”
It was time for Lynch to call a young woman who had sent a worried message through the website. The patient had finished the second step of the abortion medications four days ago and was still cramping and bleeding heavily. Is this normal? the patient wondered.
Lynch asked detailed questions of the woman, who agreed that I could listen to the call. I didn’t know her name or location. Her soft replies of “yes, ma’am” suggested somewhere South.
Lynch finally told the patient to rehydrate with a drink packed with electrolytes and then plan on taking another dose of misoprostol in a few hours.
“Would you be OK if I did a check-in call with you tonight?” Lynch asked.
“Yes,” the woman said, relieved that she wasn’t on her own. “That would be great.”
When they hung up, Lynch turned to me. She has two daughters, now in their 20s. She hears their voices, scared and alone, on these patient calls.
“You can hear them trying to steel themselves and not let their voice shake,” Lynch said. “But then there’s also almost a pleading in their voice, like, ‘Please tell me whatever you can to make me feel cared for, that somebody is going to make sure I’m OK.’”
She stewed over the emptiness of the abortion bans. They hadn’t stopped her from mailing the medications. They hadn’t stopped patients from receiving them. They just created hundreds of miles between patients and providers. They left women feeling isolated and afraid to access a procedure that’s legal in half the country, and which had been legal everywhere in the U.S. for half a century.
“They’re truly alone. That frightens the hell out of me,” Lynch said. “The mom in me, the grandma in me, wants to reach through the phone and hold these girls during all of this.”
The patient reached out again two hours later, saying her cramping and bleeding had “lessened immensely” after she rehydrated. Lynch told her the additional misoprostol wouldn’t be needed. The woman’s uterus had finished contracting on its own.
Lynch still urged the patient to get checked out for a possible respiratory infection, as the woman had mentioned having difficulty taking deep breaths.
“Do you know where you plan on going to get that (chest) X-ray?” Lynch asked.
“I’ll probably just do it at my local Baylor Scott & White,” the woman said.
The hospital chain serves Central and North Texas.
By the numbers:
- 4,700: Abortions provided in Texas per month in 2019, before any bans
- 5: Abortions provided in Texas per month, on average, in 2023, once state laws allowed the procedure only to protect the mother’s life
- 2,850: Texans traveling out-of-state each month for abortions in the second half of 2023
- 2,800: Telehealth abortions obtained each month by Texans in the first half of 2024
- Sources: Texas Health and Human Services; Guttmacher Institute; #WeCount report
Grumet is the Statesman’s Metro columnist. Her column contains her opinions. Share yours via email at [email protected], or via X or Bluesky at @bgrumet. Find her previous work at statesman.com/opinion/columns.
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