Telemedicine Abortion Provider Alison Case: “Helping People in Texas Access Abortion Care”

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Medication abortion uses two types of pills: mifepristone, which interrupts the flow of the hormone progesterone that sustains the pregnancy; and misoprostol, which causes contractions to expel the contents of the uterus. (Robin Marty / Flickr)

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.

Dr. Alison Case is a family medicine doctor in Indiana, who also works for Whole Women’s Health and Planned Parenthood providing in-clinic abortion services in the state. Originally from the Midwest, Case received additional training and became licensed to practice medicine in New Mexico, then returned to Indiana. After Texas banned most abortions last year and Texans began flooding into New Mexico for abortion health care, Whole Woman’s Health offered Case the opportunity to provide telemedicine abortion to patients in New Mexico.

Ms. spoke to Case about her work providing telehealth abortion services in New Mexico.

Carrie Baker: Can you tell me about your medical background and your practice?

Alison Case: I’m a family medicine doctor in Indianapolis. I see the whole spectrum from newborn babies all the way up to elderly folks. I also deliver babies and work with our OB team. That’s my full-time job, and then I also work at Whole Woman’s Health where I provide medication abortion in clinic and telemedicine medication abortions to patients in New Mexico. I just started working for Planned Parenthood in Indiana as well. I don’t do any telemedicine abortion in Indiana because it’s illegal. This is something that we should be able to do everywhere.

Baker: Do you do medication abortion at your family medical practice as well?

Case: I don’t because I work for a federally qualified health center. Because of the Hyde Amendment, we can’t do any kind of abortion care with federal money. It’s within my scope of practice, but this very specific thing is not something I can do for my patients. I have to work at separate facilities in order to provide that care. It is generally difficult to provide abortion care anywhere in Indiana outside of designated facilities because of all the restrictions in place in the state.

Because of the Hyde Amendment, we can’t do any kind of abortion care with federal money. I have to work at separate facilities in order to provide that care.

Baker: Can you tell me about Whole Woman’s Health?

Case: Whole Woman’s Health has brick and mortar clinics in Texas, Virginia, Indiana, Maryland and Minnesota. The clinics in Virginia and Minnesota offer telemedicine abortion at this time, with plans for expansion in the near future. Whole Woman’s Health is also offering telemedicine services in New Mexico as of fall 2021.

New Mexico has been completely overwhelmed by the number of people coming from Texas. It’s one of the closest states, particularly for people in the Western part of Texas. New Mexico providers are busy seeing people in-clinic for procedural abortions, so if we can have some of the folks who elect for medication abortion shifted to telemedicine, that helps a lot.

Whole Woman’s Health is dedicated to compassionate clinical care but also to advocacy work in the states where they do work as well as at the federal level. Because they have clinics across the country, they can help direct patients to care and eliminate additional barriers to access.

Because Whole Woman’s Health has clinics in Texas, they know firsthand how hard it’s been for these patients to get care. They have been trying to figure out how they can help patients get the care they need. One way is to do telemedicine abortion in nearby states where it’s legal. What happens is patients go to New Mexico, and as long as they’re in New Mexico, I can treat them with my New Mexico license. So, they’re often driving to hotels or families’ homes, and getting the medications at those addresses. And then New Mexico patients are getting telemedicine abortion care with Whole Woman’s Health to free up spots in clinics for people who are coming from Texas who might need in-person care, because they may be too far along or prefer a procedural abortion.

New Mexico has been completely overwhelmed by the number of people coming from Texas. If we can have some of the folks who elect for medication abortion shifted to telemedicine, that helps a lot.

Baker: How many of your patients are from Texas?

Case: About 50 percent of my telemedicine abortion patients are Texas residents traveling for virtual care. Patients who are unable to receive care in Texas may be connected to Whole Woman’s Health Virtual Care services, which currently operates in the states of Virginia, Minnesota and New Mexico. I am currently the only provider offering telemedicine abortion in New Mexico.

Patients do not need to be a resident of New Mexico, but they must be in the state at the time of their telemedicine visit and provide a shipping address within the state where they are receiving telemedicine care. They provide their name and an address in New Mexico and that’s all we need. If we have that, we can get the medications to them. We’ve had people use hotel addresses, and we’ve had people use family addresses. They can also use General Delivery to a New Mexico post office. Some people stay at hotels until their medications arrive. We use American Mail Order Pharmacy. They are able to ship the medications next day delivery so most of the time it’s a one to three day turnaround.

This is a huge barrier and ordeal for people to have to go through to get care. It’s a great example of how these laws are impacting people’s lives and what we could be seeing in a lot more places around the country this summer, depending on what happens with the Supreme Court decision.

Baker: Does Whole Woman’s Health offer telemedicine abortion to patients in Indiana?

Case: No, we can’t do offer telemedicine abortion in Indiana because there are laws against it. It’s wild because I do telemedicine as a family doctor, especially during COVID, and prescribe medications that are so much more dangerous than mifepristone like insulin and warfarin—a blood thinner—but then I can’t prescribe mifepristone, which is much safer. It’s just ridiculous.

Baker: How do you do telemedicine appointments?

Case: We have been doing a mix of video and telephone visits, depending on how good our connection is. The patients first meet with a care coordinator at Whole Woman’s Health. They do the counseling, go through the patient’s medical history and the risks, and explain how to use the medications. Then the patient meets with me. I go over the risks again. Even though they’re very, very small, we want people to know what to look for. I then briefly go over how to take the medicine and review whether they would like any birth control again.

Baker: Where are the people when you’re talking to them?

Case: I’ve had people in hotel rooms, people in their cars, people at home.

Patients do not need to be a resident of New Mexico, but they must be in the state at the time of their telemedicine visit and provide a shipping address within the state where they are receiving telemedicine care.

Baker: How long do telemedicine abortion visits normally take, between the staff counseling and your visit with them?

Case: It’s somewhere between 30 and 40 minutes: probably between 20 and 30 minutes with the care coordinator and then 10 to 15 minutes with me. It’s not a lot and that’s very consistent with my in-person visits. I’m there to answer any questions, tell them what to look for and get them the medicine.

Baker: What kind of follow up care do you provide your patients once they get their pills?

Case: Whole Woman’s Health has a 24-hour nursing line where people can call if there are any problems as they go through the process. Patients have follow-up appointments scheduled with our staff a couple weeks later to check in and make sure everything’s okay.

Bake: How have your patients responded to telemedicine abortion?

Case: People do fine. Overall, it’s extremely safe. We’ve had one person who ultimately ended up needing a procedural abortion. That happens in-person too. It had nothing to do with the care being virtual. It just sometimes happens. It was an expected statistical outcome.

Baker: What does Whole Woman’s Health charge for telemedicine abortion?

Case: Our telemedicine services are $400 for medication abortion by mail. Financial resources may be available to those who qualify, but we unfortunately cannot accept insurance or Medicaid due to state and federal laws.

Baker: Do you offer advance provision pills?

Case: I do not believe that we do that.

Baker: Do you offer missed period pills?

Case: No, we are not doing that.

I do telemedicine as a family doctor and prescribe medications that are so much more dangerous than mifepristone like insulin and warfarin—a blood thinner—but then I can’t prescribe mifepristone, which is much safer. It’s just ridiculous.

Baker: When can people get appointments with you?

Case: I do them every Thursday morning.

Baker: Who are your telemedicine patients?

Case: It’s a whole mix of people, younger people, older people. The majority already have families. People who need abortion care are from all kinds of backgrounds, all kinds of situations, just trying to plan their own future and family. Some do not speak English as their first language. We have interpreter services to make sure care is accessible for all.

Baker: Do they tell you why they’re using telemedicine?

Case: If they’re from Texas, usually they’re not going in person because they know they’re over six weeks. People are really grateful that they can get these medications.

Baker: Do your patients talk to you about the challenges they are facing to get care?

Case: There’s definitely concern and frustration and confusion. It’s clearly super stressful for people. They’re trying to figure out where they’re going to stay. I’ve had people have to change their mailing address because we found out the post office where we were going to have it sent was going to be closed.

Baker: So, you’ve mailed pills general delivery to post offices so patients can pick them up there?

Case: That’s a situation I have encountered, but it’s not widely used. It is an option for people traveling out of state, though!

Baker: How are Texas patients finding you?

Case: One way people are hearing about it is from clinics in Texas. Also, providers in New Mexico are overwhelmed and tell people to call Whole Woman’s Health for a telemedicine visit. It’s a small, pretty well networked group of organizations offering this care.

Baker: How many patients have you seen so far?

Case: I see about five a week, and I’ve been doing it since October, so I’ve probably seen between 30 and 40.

Baker: What are your motivations for offering telemedicine abortion?

Case: I think that we should be able to offer it everywhere. This is necessary medical care that’s part of normal medical practice. We ought to be able to offer this just like anything else.

I think that we should make sure that people have their own autonomy in making these decisions for themselves about when to have a family and when not to have a family. These are really basic things. If we can’t get those services to people in person, then it’s great that we can offer them virtually. Particularly in the case of Texas, where we know there’s a whole state where people are not able to access care. Making sure that they can get that care is important.

Baker: Was Whole Woman’s Health motivated to begin offering this service last fall because of the Texas abortion ban going into effect in September?

Case: Yes, that’s why they chose to begin offering services in New Mexico, which is right next to Texas. They’re really committed to helping people in the South access abortion care.

Baker: How does it feel to be able to help people in this way?

Case: Really, really wonderful. So many of us who are not in Texas or in places where people can’t access care feel powerless, like we can’t help. We can donate. But there are so many people who can’t get care. So it feels great to be able to provide that for people.

Baker: Have you experienced any harassment for offering telemedicine abortion or are you concerned about that?

Case: I haven’t. As a person who already provides abortions in a very conservative state, it felt like not a big deal to offer telemedicine abortion. Indiana is hard, just like a lot of conservative-led states are. Your name is publicly accessible. Abortion providers are well-known to the anti-abortion people who keep track of these things, but I haven’t had anyone talk to me about providing telemedicine services.

Baker: How would telemedicine abortion in Indiana help increase access in your state?

Case: Abortion services are available in a few cities across the state: Indianapolis, South Bend, Merrillville, West Lafayette, and Bloomington. It was a big deal when Whole Woman’s Health opened a clinic in South Bend because Northern Indiana did not previously have services outside of the far northwest corner of the state. I’m originally from the northeast part of Indiana so it’s really important to me to make sure that we have services in the northern part of the state. WWH is only currently open two days per week (one day for counseling and ultrasound, the second day for medication since we have a waiting period law in the state). The clinic will be expanding in the coming months to provide in-clinic abortion care, which is a much-needed service in northern Indiana. I think a lot of small places that are offering services in conservative states are like that too, just because they don’t have the staff to offer services more often than that. If we could do telemedicine in Indiana, many more people would get care. But we can’t because there’s a law blocking telemedicine abortion and we have a huge, very powerful anti-abortion movement in the state. There’s still plenty of places in Indiana and probably across the country where you can’t even get mifepristone for miscarriage management.

Baker: It must take a lot of courage to offer abortion care in Indiana since it’s such an abortion-hostile state. How do you deal with that pressure? What do you do to protect yourself?

Case: My goal was to come back to the Midwest and practice rural medicine. But what I realized was that I could never practice in a rural town in Indiana and do abortions. You just can’t do it. You will lose your job. There are probably some laws against firing for people for this kind of thing, but the truth is if you’re in a small town in Indiana, even if I was providing abortions in South Bend but I practiced in Fort Wayne, these people will find your practice and come and protest in front of your practice. People that I know in the state who have gone back and tried to do things in smaller parts of the state have said they’ve had anti-abortion protestors threaten them and their families and say, “we will make it so you can’t provide services for your patients.” I made a very conscious decision when I came back to move to Indianapolis because it’s the biggest city in the state, and there is less chance that anti-abortion protestors will target you. I’d say that’s one way you protect yourself. You live in the city. But then the other way is to find your fellow advocates and stay close to other abortion providers across the state. It’s a pretty close-knit network.

Baker: Have you advocated for better laws in Indiana?

Case: Throughout my career in medicine, I’ve been very involved in advocacy, policy work and grassroots organizing. For a year after med school before going to residency, I worked for the American Medical Student Association (AMSA) outside DC doing grassroots organizing and policy work. I worked on the EACH Woman Act, to end the Hyde Amendment and restore insurance coverage for abortion. That really opened my eyes to just how widespread and ridiculous this whole thing is. It really enraged me seeing how the issue was so politicized and how this mainly impacted poor women, especially poor women of color. Working with AMSA definitely radicalized me as a person. It’s a great organization that does a lot of progressive work. Medicine as an institution is not particularly great at pushing forward progressive ideas, so it was great to find an organization where I could fight for the things I believed in. I’m now the leader of our Reproductive Health Access Project (RHAP) chapter here—we call it a cluster. RHAP does a really great job connecting people who care about reproductive health across the state. We work at the state level around policy. It’s super important to have that group because you have people to talk to and commiserate with and also to build political power.

There are lots of ways to stay involve with reproductive health advocacy. I’ve met with my elected officials regarding reproductive health legislation. Our RHAP cluster recently worked on a physician sign on letter to send to the legislature opposing further bans on abortion access.

Baker: Did you get any training in medical school on abortion?

Case: Medical education does not generally include much education around abortion. I did not get much exposure during medical school, though I think things are changing. Through the American Medical Student Association, I was involved with papaya workshops, which help providers in training work on procedural abortion skills, and was introduced to advocacy around reproductive rights. Most of the clinical training I received was in residency and in some additional training after residency. I completed residency in Fort Wayne, where there are no options for abortion training. I went through the Midwest Access Project, which connects experienced providers to people who need to get training and who are in very conservative areas. They focus on the Midwest, but they help people in other parts of the country as well. Through Midwest Access Project I went to Minneapolis, and that’s actually how I got introduced to Whole Woman’s Health.

Baker: Any final thoughts?

Case: This service should be available everywhere. It’s no different than any other medical care that I provide. People who want to help increase abortion access should look for ways to get involved with reproductive justice groups in their state as well as state/local abortion clinics and funds.

When Dr. Case finished her residency in 2019, she travelled for three months and interviewed providers and advocates across the country about abortion access in their state and made a podcast series called For the Love of Roe about abortion restrictions in different states across the country. Listen to the podcast here.

Explore the full collection of online abortion providers profiles: