Telemedicine access to abortion pill mifepristone is in legal limbo : NPR

The 5th U.S. Circuit Court of Appeals in New Orleans.

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Jonathan Bachman/AP

It’s been an eventful week when it comes to mifepristone, one of the medications used for abortion and miscarriage management.

A May 1 federal appeals court ruling immediately struck down access to mifepristone telemedicine nationwide. Two drugmakers immediately appealed to the Supreme Court. For several days, the concrete meaning of the appeal court’s decision was unclear.

Now, access to the pill via telemedicine is back. On Monday, the Supreme Court suspended the appeal court’s decision for a week. This means that mifepristone can still be prescribed via telemedicine and sent by mail until at least May 11.

There’s a lot to keep track of in the mifepristone legal saga – it can get really confusing. Here’s what you need to know.

1. How it all started

First, some context. When the FDA approved mifepristone in 2000, patients had to go in person to a clinic or doctor to receive it. That changed during the COVID-19 pandemic: As telemedicine expanded significantly, the FDA began allowing mifepristone to be dispensed at a local pharmacy or by mail.

The FDA made this policy official in 2023. At that point, the Supreme Court had struck down the country’s constitutional right to abortion. Dobbs decision. Since then, the use of telemedicine abortion has grown and now accounts for a quarter of abortions across the country.

This is largely the reason why the number of abortions has increased since Roe v. Wade was canceled almost four years ago and many states instituted restrictions. The most recent estimate from the Guttmacher Institute, a nonprofit research organization that supports abortion access, finds that there were 1.1 million abortions in the United States in 2025.

2. Why Louisiana

Louisiana is at the forefront of anti-abortion action, says Mary Ziegler, a law professor and abortion historian at the University of California Davis. It is the first state to list mifepristone as a controlled substance and to criminally charge a foreign doctor performing abortions via telemedicine.

Last fall, Louisiana sued the FDA, arguing that allowing patients to use telemedicine to receive the drug undermines its strict ban on abortion. Guttmacher’s latest estimate finds that there were 9,000 abortions in Louisiana in 2025.

A district court judge stayed the case in April, and then Louisiana appealed that decision to the 5th Circuit Court of Appeals, based in New Orleans.

That’s when things got dramatic. A panel of judges on that court agreed with the State of Louisiana’s argument and, on May 1, reinstated the in-person attendance requirement nationwide, effective immediately. (The Supreme Court suspended this decision for a week.)

Judge Stuart Kyle Duncan, a Trump appointee, wrote in his 19-page opinion that access to mifepristone via telemedicine “harms Louisiana by undermining its laws protecting unborn human life and also by causing it to spend Medicaid funds on the emergency care of women injured by mifepristone. Both injuries are irreparable.”

Ziegler says that when it comes to abortion access, Duncan’s order “is the most important decision we’ve had since Dobbs of a lower court.”

3. This case has national issues

Because the FDA’s drug prescribing rules apply nationwide, a change in the rules regarding access to mifepristone has a national impact. That means it affects states where access to abortion is constitutionally protected, states where abortion is banned, like Louisiana, and everything in between.

Nearly two dozen Democratic-led states submitted an amicus brief in the case, writing that the appeals court’s decision places the policy choices of states that have imposed bans above the choices of states “that have made different but equally sovereign decisions to promote access to abortion care,” and asking the Supreme Court to keep the decision on hold.

There are also issues related to the power of the FDA and other expert agencies to set rules. While the Trump administration’s FDA has yet to respond to the Supreme Court, a group of former agency leaders wrote about it in an amicus brief. They defended the FDA’s process for approving the drug and changing prescribing rules, and say the appeals court’s decision would “upend the FDA’s science-based and benchmark-based drug approval system.”

4. The patients most affected by the case

During pregnancy, days and hours count. The uncertainty surrounding the drug’s availability has sent a “shock wave” through the medical field, Ziegler says. Telemedicine abortion is particularly important in places where there is a shortage of providers, such as rural areas, and for low-income patients who cannot easily get to a doctor.

NPR spoke with Jane, a 44-year-old woman who lives in Florida, where there is a ban after six weeks of pregnancy. She asked NPR to use only her first name when speaking candidly about sensitive medical information.

She already had two children and found out she was pregnant in February 2024. “My husband and our children were treading water financially, psychologically and emotionally,” she says. She is the main breadwinner and has previously experienced complications during a pregnancy. “Having a third child didn’t seem like an option to me, so I had to very quickly – I kind of had a clock ticking in my brain – figure out how to have an abortion.” In her busy life, she found it easier to use a telemedicine provider and receive the medications at home. She said she was “relieved and grateful” to have the option.

Other patients living in remote areas of California, Louisiana and Georgia told NPR they rely on telemedicine to get mifepristone.

Some reproductive health providers have prepared to switch to a different, equally safe and effective medical abortion protocol that uses misoprostol, another drug that is not at all involved in this case. However, this protocol tends to have more serious side effects for patients.

5. What happens next in this case is up in the air

The Supreme Court’s one-week stay expires on Monday, May 11. At that point, Justice Samuel Alito could extend the temporary stay (as he did in the previous mifepristone case).

It could also grant a stay of the decision until it is formally appealed to the Supreme Court.

Finally, judges could refuse to stay the ruling, and access to telemedicine abortion would again cease nationwide while the court proceeding plays out.

6. This is not the first time the Supreme Court has ruled on mifepristone

The Supreme Court recently ruled on another case involving mifepristone, but there were some key differences.

In 2023, a federal judge in Texas, Matthew Kacsmaryk, ruled that mifepristone must be completely removed from the market. This decision also caused a very confusing scramble which eventually ended when the Supreme Court decided to stay the decision and hear the case. It was unanimously dismissed in 2024, as judges determined that the group of pro-life doctors who filed the lawsuit lacked standing.

Since then, anti-abortion politicians have filed new lawsuits against mifepristone, including this one. In fact, the case that the Supreme Court threw out in 2024 is still alive in Missouri.

In the Louisiana case, “I think there is a deliberate effort to try to correct the errors that doomed the first mifepristone trial,” Ziegler says. “Focusing on the in-person waiver requirement seems more politically modest.”

7. The Trump administration is in a difficult position

President Trump has been relatively quiet on abortion this term. He faced retaliation earlier this year from congressional Republicans when he suggested they be “flexible” on abortion restrictions in health care legislation. Abortion was also absent from Trump’s State of the Union address in February. Opposition to abortion is popular with Trump’s base, but independent voters, who played a key role in his victory, favor abortion rights.

Abortion advocates have noticed Trump’s lack of action on abortion and have called on him to be more forceful. At the start of this affair, the Ministry of Justice had called for everything to be suspended until the end of the year.

Ziegler says the fact that this case is generating big news during election season “is going to require every politician to speak out, and that doesn’t really give the Trump administration much room to do nothing.”