Hansen called the Planned Parenthood facility near her home in Savannah, Georgia, to inquire about abortion services and was told the procedure would cost $500 and require four to six hours at the clinic.

Hansen didn’t have that kind of time. Her son was at home, attending school online, and needed supervision. While Googling for alternatives, she came across Carafem — a nonprofit that delivers abortion pills to a patient’s home after a telemedicine visit for .

“It just seemed almost too good to be true,” Hansen recalled.

Patients like Hansen have benefited from a quiet but monumental shift in abortion access enabled by the covid-19 pandemic. In July 2020, in response to advocates’ concerns about the risks posed by in-person visits in a pandemic, a federal court placed on hold a long-standing that required mifepristone — the first pill in a two-step regimen used in medical abortions — to be dispensed in clinics. After the Trump administration appealed that decision, the conservative-majority the rule, with Chief Justice John Roberts writing that courts should defer to government experts who set the rules. The Biden administration in April during the remaining public health emergency and said it is .

In the meantime, telemedicine abortion operations are growing in some places, although not in such states as Texas and Alabama with strict laws designed to curb or end abortions.

A new slate of digital abortion options like Just the Pill, Hey Jane, Abortion on Demand and Choix proliferated, mailing abortion pills to patients in many states after a telemedicine visit. Carafem, which had been mailing the pills to patients in Georgia before the pandemic as part of a research project, streamlined its process for patients who are eligible for medical abortions.

These services can be a lifeline for patients who haven’t hit the 10- or 11-week threshold typically used for medical abortion and who can’t get to a clinic or need a less expensive choice. But reproductive health advocates worry that telemedicine abortion options don’t reach the patients who need it the most because they live in states with laws that actively discourage abortions and have made in-clinic care harder to access. At the same time, these new options could be endangering brick-and-mortar clinics by siphoning away the first-trimester visits that make up of abortions.

“If [clinics] lose a considerable amount of the clientele for first-trimester abortions, they might have to close, or some of them will,” said Carole Joffe, a professor focusing on reproductive health at the University of California-San Francisco and co-author of “Obstacle Course: The Everyday Struggle to Get an Abortion in America.” “Potentially, we see people needing second-trimester procedures, not to mention even later ones, with literally nowhere to go.”

Many clinics, which charge higher prices to support the costs of running a building and providing security, are closing around the country amid an avalanche of state restrictions. That is especially true of independent clinics, which , according to the Abortion Care Network, an association of independent providers. Since 2012, .

Concerns about access to abortion deepened this week when a Texas law took effect banning abortions after six weeks of pregnancy and a divided Supreme Court did not block it, at least for now. The court is also scheduled to hear a case this term on Mississippi’s 15-week abortion ban. If the justices allow either state law to stand, it would likely lead other states to further restrict abortion, forcing patients in many conservative states across the South, Midwest and West to travel for services or seek out overseas options like Aid Access, according to Mary Ziegler, a Florida State University law professor who focuses on legal issues surrounding reproductive health and sexuality.

“If you’re in New York or California or Boston, you can get abortion pills online, you can go to a clinic — there are tons of options. Whereas if you’re in a state like Alabama, you’re probably going to be worried that you can’t do any of those things,” Ziegler said.

Carafem, which operates clinics in Georgia, Illinois, Tennessee and Maryland, began mailing abortion pills to patients in Georgia in 2019 when it joined the , an ongoing project run by the reproductive health nonprofit that received federal permission to study the safety of telemedicine abortions. Over four years, abortion providers mailed 1,390 medication packages to patients in 13 states and Washington, D.C. Researchers , including five cases of patients needing blood transfusions, none of which could have been avoided by an in-person visit, the researchers said. Participants made 70 unplanned visits to emergency rooms or urgent care centers.

Anti-abortion advocates, however, stress that medical abortion should require in-person exams.

“Women deserve excellent health care, and excellent health care does not involve talking to someone online,” said Dr. Christina Francis, board chair of the American Association of Pro-Life Obstetricians and Gynecologists. “It involves actually being seen and being evaluated to make sure that if she’s going to make this decision, she’s an appropriate candidate to make this decision and she’s not putting herself at severe risk by taking these medications.”

Many states require in-person counseling or ultrasounds before an abortion, forcing patients to make more than one trip to a clinic. In 19 states, laws require a physician who prescribes a medical abortion when the medication is administered.

Alabama is one of those states. “I use telemedicine all the time because I’m a full-spectrum OB-GYN,” said Dr. Sanithia Williams, an abortion provider at Alabama Women’s Center for Reproductive Alternatives in Huntsville. “But for the abortion portion of my practice, it just is completely nonexistent.”

Even in states with relatively few abortion restrictions, patients with medical risk factors, unreliable periods, unsafe living situations or pregnancies beyond 11 weeks generally can’t get care online. “There will always be a need for clinic-based health care,” said Melissa Grant, chief operations officer of Carafem. “This is not a panacea.”

On a Thursday morning in late June, Leah Coplon, a certified nurse midwife, sat down in the Augusta office of Maine Family Planning for a televisit with a patient seeking an abortion who was in her home miles away. The young patient nodded and messaged her boyfriend, telling him to go buy her menstrual pads, as Coplon ran through a detailed list of warning signs like excessive bleeding that should prompt a call to the clinic or trip to an emergency room. “This is all very rare, but I’ve got to tell you the scary things. That’s my job,” Coplon said, the blue light of the monitor reflecting off her glasses.

For uninsured patients, the out-of-pocket cost for a telemedicine visit like this is $500, about average for brick-and-mortar clinics.

Maine is among a minority of states that cover abortions under Medicaid. The state also requires private plans to . Yet even here, with 8% of the population uninsured, cost is the biggest barrier Coplon’s patients face, she said. To meet the needs of low-income patients, clinics like hers haven’t raised their out-of-pocket rates in years. If the price of abortion had kept pace with medical inflation, a procedure that cost $200 in 1974 would cost $2,686 today, according to a Bloomberg Businessweek last year.

Maine Family Planning has 18 locations across the sprawling, mostly rural state. In 2014, it became one of the first clinics to launch a telehealth pilot program. When covid struck, providers like Coplon used existing telemedicine equipment to shift to a “no-test” protocol, bypassing ultrasounds and blood tests that research shows can be safely skipped in order to minimize contact with patients.

For many patients choosing between a clinic and an online service, cost will be a deciding factor — and that concerns Dr. Jamie Phifer, founder of Abortion on Demand, which serves patients in 20 states and Washington, D.C. Like many other digital options, Phifer’s service does not take insurance, but she worries her low out-of-pocket price — $239, or less than half of what a typical clinic charges — could put abortion clinics out of business.

“I am very worried that in-person clinics are already bearing the brunt of the challenges of abortion access,” Phifer said. “They already have to hire security and deal with protesters, and they have been on the ground working for access for 50 years, longer than I have been around.”

Phifer, who lost her job as a primary care doctor following a profile of her work on Abortion on Demand in a magazine, plans to donate 60% of the profits from her business to the Abortion Care Network to support brick-and-mortar clinics.

“I didn’t want to contribute to creating a two-tiered system,” Phifer said.

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Hofberg enlisted help from local health care providers and the American Civil Liberties Union, which sent letters to the Mendocino Coast Health Care District that operates the hospital in Fort Bragg and other medical services. The letters noted that the state constitution requires public hospitals to offer abortions if they offer other pregnancy-related care.

Late last year, district CEO Wayne Allen granted a doctor at its North Coast Family Health Center permission to start providing , which involve two drugs that can end a pregnancy.

But Hofberg and others worry that the community’s newly won abortion access could be in peril. With a net loss of in the 2018 fiscal year alone, the district says its only shot at survival is to lease its operations to Adventist Health, a Roseville, California-based system affiliated with the Seventh-day Adventist Church, which opposes most abortions.

Voters will decide whether to approve the 30-year lease agreement on March 3.

Adventist officials said that despite their religious teachings that abortions should be limited to cases of life- or health-threatening pregnancies, rape, incest or severe fetal anomalies, they will not restrict the use of medication abortions at the clinic.

“We don’t control our physician practices in the way some others do and we don’t put constraints around what they can and can’t prescribe,” said Bob Beehler, an Adventist Health mergers and acquisitions executive.

Beehler said the introduction of abortion-inducing pills had changed the system’s approach to abortions. “Our historical position has been based on the way they used to be done, in a hospital.”

But abortion-rights supporters still fear what could be coming.

“Obviously, we do have a lot of concerns about Adventist’s position with respect to restricting abortion access in its facilities, and so we’re going to keep a close eye on the situation,” said Phyllida Burlingame, director of reproductive justice and gender equity for the ACLU of Northern California.

Burlingame said the deal also raises broader concerns about the spread of religious health systems that restrict care. “Not only are they taking over the private marketplace, but now they’re even spreading into these public spheres,” Burlingame said.

Similar objections from the ACLU and staff at the University of California-San Francisco last year scuttled a between UCSF Medical Center and Dignity Health, a Catholic-affiliated system that restricts reproductive and transition-related care for transgender patients.

The expansion of religious systems can leave leaders of struggling hospitals with few choices when they seek to affiliate. Of the five systems to which the Mendocino hospital district issued its request for proposals last year, three were faith-based. Two responded, and Adventist was the only one that met the community’s needs, according to the district board’s treasurer, John Redding.

Nationwide, four of the largest 10 health systems and 1 in 6 acute care hospital beds are Catholic-owned or -affiliated. Seventh-day Adventists are Protestant Christian, and Adventist-affiliated systems run in the United States, according to the Adventist Health Policy Association.

As these systems have grown, rural health care districts across California are struggling with waning patient volume and a lack of leverage to negotiate with insurers, said Sherreta Lane, senior vice president of finance policy at the District Hospital Leadership Forum, a trade association that represents all the state’s district and municipal hospitals. Many of these hospitals have closed or affiliated with private systems.

When the forum launched a decade ago, 45 districts or municipalities ran hospitals; now 35 do, Lane said.

While Catholic-affiliated systems like Dignity have received greater scrutiny for policies that restrict access to abortion, contraception, sterilization and end-of-life care, the impact of Adventist teachings on church-affiliated health systems is less known. In October, the Seventh-day Adventist Church raised concerns among reproductive health care advocates when it approved a statement saying it “considers abortion out of harmony with God’s plan for human life.”

Officials at the time that they would develop updated protocols for church-affiliated health care institutions, where, they emphasized, few abortions are performed.

Adventist Health spokesperson Jill Kinney said in an emailed statement that the hospital system’s usual practice “is not to provide elective abortions, but we respect that patients may wish to have them.” If that’s the case, she added, “clinicians help coordinate referral and transfer to capable facilities without prejudice.”

In a to detailed questions from California Attorney General Xavier Becerra before his office approved the system’s takeover of Delano Regional Medical Center in November, Adventist Health said it bans “elective abortions” but allows the procedure “for fetal distress and other medical reasons.” It added: “Medical abortions are performed in Adventist Health facilities,” without providing details.

In 2014, Adventist Health purchased a clinic in Fort Bragg where Dr. Eric Gutnick and his colleagues had provided reproductive health services since the 1970s. Under a contract with Adventist, Gutnick continued to see abortion patients for preoperative care in the clinic and performed surgical abortions at the Mendocino Coast District Hospital, until he retired later that year.

The Seventh-day Adventist Church’s teachings can influence other issues, too. It has opposed what it calls “transgenderism,” stating that gender identity “is determined by our biological sex at birth,” and has called homosexuality “a manifestation of the disturbance and brokenness in human inclinations and relations caused by the entrance of sin into the world.”

Arneta Rogers, an attorney for the ACLU of Northern California, voiced concern about these beliefs. “It’s not about shutting down religious entities; we just don’t want people to be discriminated against,” Rogers said in an interview.

Jason Wells, president of the Adventist Health hospitals in Ukiah and Willits, said the system cherishes diversity and its LGBTQ employees. In its statement to the attorney general, Adventist said some of its physicians provide hormones for transgender patients but none of its facilities offer “gender reconstruction surgery.”

In a statement provided by Kinney, Adventist Health said that it “strives to be free from biases related to gender identity” but that its hospitals “are not currently equipped to offer the complex, comprehensive programmatic approach necessary to provide gender reassignment treatments and surgeries.”

For many in the Mendocino community, uncertainty over the hospital’s finances has overshadowed concerns about Adventist Health’s religious affiliation as residents prepare for the vote next month. “If the affiliation doesn’t go through, I don’t know how we’ll stay in business,” said Karen Arnold, secretary of the district board.

Redding said lease payments from Adventist would allow the district to afford the estimated $24 million needed to finance upgrades required by the state to protect against catastrophic earthquake damage to its facilities.

“I wasn’t sure how we were going to do this, and now I feel that we’ve secured the future of a hospital here on the coast,” Redding said.

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