Abortion Pill Access Under Threat: A Coordinated Campaign and Shifting Political Landscape

The battle over abortion access in the United States is intensifying with a multi-pronged effort aimed at restricting the availability of mifepristone, a medication used in the majority of abortions nationwide. Anti-abortion activists are strategically targeting the Food and Drug Administration (FDA) with the goal of reversing decades of established access to the drug, employing a strategy they’ve internally dubbed "Rolling Thunder."

This campaign encompasses several key elements: pressuring the FDA to reinstate stringent regulations on mifepristone; initiating lawsuits against doctors who prescribe abortion medication; and actively lobbying for the drug’s complete removal from the market. Central to their strategy is a recently released report that alleges a significantly higher rate of health complications associated with mifepristone than previously documented – a claim that sharply contradicts the findings of numerous rigorous scientific studies and decades of real-world usage.

Republican Senator Josh Hawley has already seized upon this report, introducing legislation that seeks to reimpose restrictions on mifepristone and to empower patients to sue telehealth abortion providers who prescribe the medication. Furthermore, a New York abortion provider is facing unprecedented criminal charges for prescribing abortion pills to the mother of a pregnant minor in Louisiana, setting a potentially dangerous precedent.

Mifepristone received FDA approval 25 years ago and has become an essential component of abortion care in the United States, accounting for approximately two-thirds of all abortions performed. The accessibility, relative safety, and lower cost of abortion pills have contributed to their widespread adoption, especially as access to in-person abortion services has been increasingly restricted in many states following the overturning of Roe v. Wade in 2022.

Despite escalating state-level abortion restrictions, access to abortion pills has actually expanded, largely due to the rise of telemedicine abortion services. These services enable patients to consult with abortion providers remotely and receive medication through the mail, providing crucial access to care for thousands of individuals in states where abortion is heavily restricted or outright banned.

The immediate focus of anti-abortion activists appears to be on eliminating telemedicine abortion access, intimidating physicians, and reducing the legally permissible timeframe for using mifepristone. However, leaders within the anti-abortion movement have openly stated their long-term objective is to achieve a complete ban on the drug.

The stance of the Trump administration on this issue remains uncertain. While Marty Makary, Trump’s potential pick to lead the FDA, has indicated he currently has "no plans" to restrict mifepristone, he also stated he "can’t promise" his agency won’t act on new safety data that "suggests something or tells us that there’s a real signal." Similarly, Robert F. Kennedy Jr., a potential Trump appointee, has pledged to study the safety of mifepristone and defer to the president’s wishes.

Adding to the complexity, the Department of Justice (DOJ) under the Trump administration recently requested a federal court to dismiss a lawsuit filed by three Republican states seeking to restrict access to mifepristone. However, this action was based on a procedural argument concerning the states’ legal standing to challenge the FDA’s authority, rather than an endorsement of mifepristone’s safety. Experts view this move as a strategic maneuver by the Trump administration to preserve its own ability to restrict mifepristone in the future by limiting the avenues for blue states to challenge such decisions.

Experts stress that any attempt to pull the drug from the market or impose significant new limitations would be a complex process that would necessitate substantial resources and compelling data to justify overturning the FDA’s existing findings.

Angela Vasquez-Giroux, vice president of communications for Planned Parenthood Action Fund, has emphasized the interconnectedness of these developments, stating that the "junk science ‘report,’ the Rolling Thunder campaign…it’s all part of the same coordinated effort to end abortion access by any means necessary.”

The aforementioned report, published by the Ethics and Public Policy Center (EPPC), a conservative think tank, claims that the rate of serious complications from abortion pills is far higher than previously reported. However, this report has not undergone peer review and is based on an analysis of insurance claims data, a methodology that has been criticized by experts.

The report alleges that nearly 11 percent of women who took mifepristone experienced serious adverse events such as infection or hemorrhaging, a figure that is more than 20 times higher than the rate listed on the FDA-approved drug label. Reproductive health experts have strongly refuted these findings, citing the large body of established research that affirms mifepristone’s safety.

Brittni Frederiksen, the associate director for women’s health policy at KFF, noted that while additional research is always welcome, the existing evidence supporting the safety of medication abortion is "so robust" that a single report is unlikely to change the established understanding.

Critics of the report’s methodology have pointed out that insurance claims data can be misleading due to overcounting for billing purposes and the difficulty of determining the true cause of health outcomes. The report’s claim that mifepristone can lead to ectopic pregnancies, which the medication cannot cause, has also drawn scrutiny.

Even Matthew Loftus, a physician who opposes abortion but also has concerns about the study’s methodology, believes the report warrants further review. He suggests that the ectopic pregnancy data could potentially highlight safety concerns related to telehealth abortions, as patients do not receive ultrasounds that could detect ectopic pregnancies. However, the FDA considered these concerns prior to approving mifepristone via telehealth.

Research indicates that telehealth may actually facilitate earlier diagnosis and treatment of ectopic pregnancies due to increased accessibility and earlier initiation of treatment. Kirsten Moore, director of the Expanding Medication Abortion Access Project, disputes the necessity of ultrasounds for ectopic pregnancy screening, arguing that the likelihood of detecting an ectopic pregnancy at the early stages when mifepristone is used is limited, even with ultrasound screening. She also notes that telehealth protocols include screening measures for ectopic pregnancies.

The FDA has responded cautiously, stating its commitment to safeguarding public health and ensuring the safety, efficacy, and quality of the products it regulates. The agency emphasizes its reliance on rigorous scientific evaluation and a balanced, science-based approach in its regulatory processes.

In the fall of last year, when attorneys general from Idaho, Kansas, and Missouri filed a lawsuit against the FDA seeking rollbacks on mifepristone access, it was widely anticipated that the Trump administration’s DOJ would abandon the Biden administration’s defense of the drug or even side with the states. However, the DOJ ultimately requested the case be dismissed or transferred, arguing that the states had relied on an incorrect legal argument.

Reproductive rights advocates, however, maintain that the administration’s fundamental hostility to abortion rights has not changed. Vasquez-Giroux of Planned Parenthood suggests that the administration’s procedural argument is a strategic move to preserve its ability to impose restrictions administratively, without directly addressing the merits of mifepristone’s safety.

Trump’s public statements on abortion have been inconsistent. While he has claimed he would "not support a federal abortion ban, under any circumstances," he also voted to maintain Florida’s six-week abortion ban. He has also suggested that new information could potentially change his position on limiting access to medication abortion.

Since winning the presidency, Trump and his team have generally avoided discussing abortion, although Trump did appoint Dr. Mehmet Oz, who is anti-abortion, to oversee the Centers for Medicare and Medicaid Services. Trump’s HHS secretary pick, Robert F. Kennedy Jr., has previously voiced support for abortion rights.

If the anti-abortion coalition succeeds in pressuring the FDA to restrict access to mifepristone, several regulatory changes could be implemented. These include reinstating requirements for in-person dispensing of the medication, reducing the approved timeframe for use from 10 weeks to 7 weeks of pregnancy, banning pharmacy dispensing of the medication, or even invoking the Comstock Act to prohibit mailing abortion medication entirely. Another possibility involves an HHS official issuing a memo claiming mifepristone represents an "imminent harm," which could empower the HHS secretary to remove the drug from the market.

The impact of such restrictions would extend far beyond states with abortion bans. Even in states where abortion remains legal, telehealth abortion services have significantly expanded access, particularly for individuals in rural areas, those with limited transportation options, or those who cannot afford to take time off work for multiple clinic visits.

The FDA’s response to the pressure remains uncertain. While anti-abortion activists are optimistic that the EEPC report will provide justification for revisiting restrictions, any significant action would likely require Trump’s approval. However, some observers remain skeptical that Trump will expend his political capital on this issue.

Moore of the Expanding Medication Abortion Access Project expresses skepticism about this path, adding that pharmaceutical manufacturers are likely to challenge the FDA in court if it attempts to roll back access to approved drugs.