As we await the fate of Roe v. Wade, Ms.’s “Online Abortion Provider” series will spotlight the wide range of new telemedicine abortion providers springing up across the country in response to the recent removal of longstanding FDA restrictions on the abortion pill mifepristone.
Julie Amaon is a family medicine doctor working for Just the Pill, a non-profit telemedicine abortion provider based in the Twin Cities and serving people in Minnesota, Montana and Wyoming, as well as people coming from surrounding states.
Ms. spoke to Dr. Amaon about how and why she began offering telemedicine abortion services.
Carrie Baker: Tell me about your background and practice.
Julie Amaon: I was a little bit of a late bloomer. I went back to medical school at 35. I went to American University of Antigua, a Caribbean med school, and graduated in 2017. Then I found a residency that I was super excited to go to. It was RHEDI a program—reproductive health education in family medicine—at the University of Minnesota Medical Center. They train family medicine physicians to be abortion providers. I was introduced to Just the Pill in June of 2020 right before I graduated, and was hired as medical director in July. I got my perfect job right out of residency!
Baker: Wasn’t that the same month a Maryland federal court ordered the FDA to allow mailing of abortion pills?
Amaon: Yes. Our executive director wanted to do a mobile clinic but then right as I came on, that decision came down and we pivoted. We were like, let’s mail, we can do it. It took a few months for pharmacies to get ready and we started seeing telemedicine patients in October 2020.
Baker: What are your motivations for offering telemedicine abortion?
Amaon: Before going back to med school I worked in all three Planned Parenthood locations in Austin. I was a patient educator in our federally funded clinic downtown, then I managed a clinic in North Austin for five years and then I worked in the surgery center right before going back to med school. While I appreciate our brick and mortars and know they need to be there for people, I just felt like abortion care needed to be done a little bit different. We were always getting calls from patients at the clinic asking, “Do I really have to come in for this?” Or comments like, “I don’t need counseling, can I just pick up my pills?”
These experiences stuck with us when we started Just The Pill. We asked ourselves, What would it mean to really center the patient and give them what they have been needing in the way that feels most comfortable for them? In the pandemic, it was very obvious that people wanted the security and privacy of doing this in their home.
At brick-and-mortar clinics, even for medication abortions, you still have to be in the clinic for several hours because they have to do your counseling, and then they do your ultrasound and lab work, and then you have to wait in between procedures to see the physician. It doesn’t have to be that way. We were just trying to think outside the box to make abortion more accessible.
In Minnesota, all of our clinics are in the urban centers in Duluth, the Twin Cities, and Rochester. The rest of our state is out of luck. In Montana and Wyoming, it’s even worse, with only a couple of clinics here and there. We’re trying to increase access for patients and make it as easy as possible for people.
At brick-and-mortar clinics, even for medication abortions, you still have to be in the clinic for several hours. … It doesn’t have to be that way. We were just trying to think outside the box to make abortion more accessible.
Baker: Did you talk to other providers or organizations to help you as you started?
Amaon: Definitely. In Minnesota, we first talked to local clinics to make sure we were not advertising in the same area. We’re not trying to sabotage our brick and mortars. We were trying to get the people who were falling through the cracks. We also reached out to UnRestrict Minnesota, which is a coalition of partners that are trying to educate Minnesotans and repeal all of the abortion restrictions in Minnesota, among other things. And then, we talked to people at Choix and Hey Jane and then Dr. Jamie Phifer, who started Abortion on Demand. It’s been awesome, very collegial. We also got help from Plan C. They have been great with referring us to people and helped with a small amount of funds to help us get started.
Baker: How do you provide telemedicine abortion care?
Amaon: In Minnesota and Montana, we offered video visits to start, but honestly a lot of our patients live in rural areas and they don’t have very good broadband internet. So phone was the easiest thing to do. We do most of our conversations via phone now. Wyoming has a little bit stricter version of what a telehealth visit is, so we do video visits for all of our Wyoming patients. But I would say the majority is via the telephone.
Baker: Do you have a lot of people coming from states that are more restrictive?
Amaon: Yes, we see people who cross over the border from more restrictive states. On video calls, I see people sitting in their car on the border, using their cell phone. In Minnesota, we get people from North Dakota, South Dakota and Wisconsin. In Montana, we get people from the western side of North Dakota and South Dakota. We get people from Idaho driving to Montana and Wyoming, and people from the south. It’s really opened up a lot of access for people. With the Supreme Court decision coming up this June, we’re looking at expansion to other states that border those states where abortion might become illegal if Roe is overturned.
Baker: Which states are you thinking about expanding to?
Amaon: We are looking currently at Colorado. Then in the future, maybe Illinois to try to get the eastern part of the state. Our executive director has wonderful, out-of-the-box thinking—she’s like, “can we have a boat down on the Mississippi? Can we go in federal waters in the Gulf of Mexico?” We’re trying to think of all the things that we can do to open up access for people.
Baker: Interesting! That reminds me of Rebecca Gomperts and Women on Waves.
Amaon: Yep. She has been our inspiration. We had conversations with her in the very beginning when we first started . Recently our executive director has been meeting with her monthly as a sort of international effort/coalition. She’s such an inspiration for people. She’s amazing.
Baker: How do patients find you and how does the process work?
Amaon: About 80 to 85 percent of people find us on Google, just by searching. That’s how we advertise. Then the patient will fill out forms online, sign our consent forms, and upload a picture ID. When we started, we offered patient education over the phone but we do it by text now. That’s just most convenient for patients—it’s easier to fit around work or childcare issues.
About 80 to 85 percent of people find us on Google, just by searching. That’s how we advertise.
Baker: What’s entailed in the patient education?
Amaon: We explain how the process works, what’s expected as far as follow-up visits—we have a seven day and a four week follow-up—how they get ahold of us with any concern, what to look out for as far as side effects. We discuss financial aid that they might need, we work with a bazillion different funds that offer resources for childcare, hotels, travel, anything like that. Sometimes people might need a hotel to go to for a safe place to take the pills while somebody takes care of their kids at their house.
Baker: Once they’ve finished the paperwork, how long does it take to get an appointment?
Amaon: A couple of days. We have pretty open appointment schedules.
Baker: What happens at the telephone appointments?
Amaon: It’s about a 15-minute appointment. We have appointments Monday through Friday but if patients can’t make it during our normal business hours, I see people in the evening sometimes and sometimes on the weekend. We try to meet patients where they’re at, but most people can take a few minutes out of their lunch to talk with me. I review their health history, make sure everything looks good and that they’re appropriate for the medication. I go through what to expect after taking each pill and answer any questions they have. I make sure they understand the process for follow up and what to look out for. And then for Minnesota, I have to read a 24-hour consent beforehand, which is very irritating and not medically necessary, but it’s something that we have to do.
We have a 24/7 call line and I tell them that if there’s something that’s not going as expected, they should get a hold of us. People can text or call us anytime. Also, we offer translation services and all of our staff with patient contact are bilingual in Spanish and English. We’ve used that probably 30-50 times.
Baker: How do you send the pills?
Amaon: We use two different mail order pharmacies, American Mail Order Pharmacy, which is out of Michigan, and Honeybee Health, which is out of California. Which we use depends on the state and shipping address. It takes two to three days with FedEx and UPS, and four to five days with USPS.
Baker: Are you finding that you’re able to help most of the people who contact you through telemedicine alone?
Amaon: Yes. I can probably count on both hands the number of patients I send for an ultrasound.
Baker: What do you charge?
Amaon: We charge $350. If they want expedited shipping, they pay an extra 25 bucks.
Baker: Do you take insurance?
Amaon: We have been trying to become Medicaid providers for the last year, but we have not been able to do that just yet. We don’t accept private insurance currently. But we don’t turn anybody away for payment. We work with them. We’ve just started an internal fund as well.
Baker: How does applying for financial support work?
Amaon: We direct patients to several national and state funds which they call to get funding. We’re also trying to work out with some of the funds to get monthly donations so the patient doesn’t have to call anybody for funding, which is how traditional funding has worked for abortion care forever. We’re really trying to change that. Repro Care is working on that kind of approach.
Baker: How many patients have you seen?
Amaon: We have seen 1400 patients since October 2020.
Baker: Tell me about who your patients are.
Amaon: They are all over the map. We see minors in all of our states. The oldest patient that I’ve seen was 49, and they’re everywhere in between. A lot already have kids at home, and some this is the first pregnancy. We have people getting funding, we have people that are paying full fees. I would say they skew towards rural rather than urban.
The oldest patient that I’ve seen was 49, and they’re everywhere in between.
Baker: Why are people using telemedicine abortion as opposed to in-clinic care?
Amaon: We do a survey at the end of our care: 45 percent said they chose to seek care online for privacy or confidentiality reasons; 40.6 percent said a barrier to receiving care in person was the location of the clinic being too far or not having transportation; 31 percent said they chose online care due to convenience or because they had limited time to try a different option; and 14.7 percent said they chose online care because there was no clinic in their area or they had no transportation. Transportation is a big reason why people see us. Also 34 percent said without abortion services online, they would either continue their pregnancy or have to delay care more than two weeks.
There was one patient a couple of days ago who’d had cancer a few years ago and was in remission after surgery and radiation. At 40, she’d been given a diagnosis of infertility. Then at 44, she got pregnant. She didn’t want to go to a clinic where she’d have to go through protesters. This was just so much easier and private.
Baker: Do many of your patients mention not wanting to cross protest lines?
Amaon: Definitely. Some say, “I drive by that clinic all the time and I just really didn’t want to deal with the protesters.” That is a reason that a lot of people state. Others say, I had a clinic close to me, but it was like two to four weeks to get an appointment. Once the Texas abortion ban S.B. 8 came into effect, wait times have just exploded. Clinics are getting slammed.
Baker: You’re feeling the effects of S.B. 8 all the way up to where you are?
Amaon: Yes. It radiates out. We have people requesting our services from Texas even. People that either want to drive up here or fly up here. And because it’s regional, people in like Oklahoma and New Mexico and Colorado are affected. It’s been pretty remarkable how long the wait times are all over the place. The FDA time limit for using abortion pills is 10 weeks, so wait times can mean you’re not be able to get the type of services you wanted, and the abortion is more expensive the later you wait.
Baker: What kind of follow-up care do you offer?
Amaon: Our first follow-ups are by phone, text or email, whatever their comfort level is. For the seven-day follow-up, it’s four simple questions: Did you feel like you bled as much or heavier than a period? Do you feel like you passed tissue and clots and that the pregnancy has passed? Are your pregnancy symptoms gone? And is your bleeding and cramping better? If all those are yesses, we know that the process is complete. And we do a urine pregnancy test at four weeks just to make sure.
Baker: Do most patients do the follow-up care?
Amaon: About 50 percent, which is pretty high compared to what I remember in clinics. The medications are so safe, and there’s so little that you really need to worry about afterwards. I think that people have their abortion and they’re fine, and they don’t want to talk to me anymore. And that’s fine by me.
Baker: How do patients experience the medication abortion process?
Amaon: It varies so widely. The part that always surprises me is it makes no difference whether someone has had a vaginal delivery or not. Everybody responds really differently to the bleeding and the cramping. Everybody experiences pain and discomfort differently. Some people are like, it’s totally fine. I was just having a heavy period and it was fine. A few people are like, “Oh my gosh. That was the worst pain ever.” But not many. Most people deal very well with it.
Baker: Have your patients had successful abortions?
Amaon: Yes, the majority have. Out of 1,400 patients, I feel like we’re pretty close to the 2 percent “failure rate” expected. I send those to our local clinics for suction procedures and we cover that cost. I’ve had only a couple people who needed a suction in the ER due to heavy bleeding and one who had an ectopic pregnancy and had to have surgery.
Baker: Do you offer advance provision abortion pills?
Amaon: We do not. We do that in other parts of medicine. That is definitely something that we’re looking into for the future. But we don’t offer it currently.
Baker: What about missed period pills?
Amaon: I haven’t done that, but I think that’s an interesting concept for people that have been pregnant before, that know what it feels like and they have symptoms. Or maybe you don’t want to know you’re pregnant. I mean these pills are safe. If you weren’t pregnant, they would just bring on cramping and bleeding and you might have some nausea and vomiting as a side effect. That might not be fun, but no harm.
Baker: Do you have a brick-and-mortar office? Or are you totally remote?
Amaon: We do have our brick-and-mortar office in the Twin Cities. Between January and April of 2021 when the SCOTUS decision blocked mailing abortion pills, we used a Class B RV to deliver pills as a mobile clinic. Our executive director and I are working on new mobile clinics that will hopefully be going to Colorado to help Texans so that they can come over the border to have a telehealth visit and pick up the pills. And then we’re also going to have a procedural van where we can hopefully do manual vacuum aspirations during the first trimester. That will be the first one in the country, but that’s what we’re hoping to do.
Baker: Wow! When are you going to start this?
Amaon: My best guess is early spring.
Baker: Have you mentored other providers to begin providing this service?
Amaon: Yes, we were actually part of making the Access Delivered toolkit—a guide for how to offer medication abortion service within a primary care practice. I also train residents through the Midwest Access Project. And then I am always willing to talk on panels and talk to anybody that’s interested in doing this. I’ve talked to college campuses and have a speaking engagement at high school in D.C. It’s been pretty awesome.
Baker: How does it feel to be able to help people by offering telemedicine abortion services?
Amaon: I love my job every day. Patients tell me “thank you,” “I’m so glad that I found you,” and “You made this so easy.” Yeah, I love my job. It’s wonderful. Very rewarding.
Previous profiles:
- Online Abortion Provider and “Activist Physician” Michele Gomez Is Expanding Early Abortion Options Into Primary Care, Ms., Jan. 19, 2021.
- Online Abortion Providers Cindy Adam and Lauren Dubey of Choix: “We’re Really Excited About the Future of Abortion Care,” Ms., Jan. 14, 2021.
- Telemedicine Abortion Provider Dr. Deborah Oyer Supports Patient Autonomy and Control: “No Different Than When They’re in Clinic,” Ms., Jan 12, 2022.
- Online Abortion Provider Robin Tucker: “I’m Trying To Remove Barriers. … It Feels Great To Be Able To Help People This Way,” Ms., Jan. 4, 2022.
- Abortion on Demand Offers Telemedicine Abortion in 20+ States and Counting: “I Didn’t Know I Could Do This!” Ms., June 7, 2021.
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