The Abortion Pill Fight

https://www.nytimes.com/2023/03/08/briefing/abortion-pills.html

Version 0 of 1.

Since the end of Roe v. Wade last June, access to abortion pills has muted some of the effect of the severe restrictions on abortion that 14 states have imposed. Abortion opponents have responded by trying to reduce access to those pills. The resulting struggle has become the main battle to watch in the post-Roe landscape.

Today’s newsletter examines the latest developments — including a court ruling expected soon — and explains what’s likely to happen next.

The most effective and safest method of medication abortion requires two drugs. The first, mifepristone, ends the pregnancy. The second, misoprostol, causes cramping and bleeding to empty the uterus, like a miscarriage. In approving this regimen in 2000, the F.D.A. imposed restrictions on mifepristone because of questions then about its safety. Among other rules, patients had to visit a clinic, doctor’s office or hospital to receive the medication.

In 2021, during the pandemic and after President Biden took office, the F.D.A. lifted the in-person requirement. The shift opened a new avenue for telemedicine abortions. In about 30 states, women could legally end their pregnancies at home, with pills prescribed through an online consultation and mailed to them. If they had questions, they could call a private national hotline to talk to medical professionals.

After the Supreme Court overturned Roe last year, demand surged for abortion pills by mail. An international organization, Aid Access, provided prescriptions for the pills from European doctors, often filled in India, to patients in states with bans. Overseas pharmacies, advertising online, also ship abortion pills without a prescription to every state.

These offshore routes to access, which operate in a legal gray area in states with abortion bans, will probably remain open. But they carry potential legal risks for women and it can take a few weeks for the drugs to arrive from overseas, a delay that can create problems since medication abortion is more effective and less likely to cause complications early in pregnancy.

Opponents of abortion have a bold counterstrategy. They want to block the use of mifepristone not only in states with abortion bans but also nationwide.

In November, anti-abortion organizations and doctors sued in Texas to challenge the F.D.A.’s approval of medication abortion 23 years ago. They argue that mifepristone is unsafe. In fact, research has clearly established the safety and efficacy of the F.D.A.’s approved regimen. Serious complications are possible but rare. So, on the merits, the suit may seem far-fetched.

But the plaintiffs made sure to file suit (a practice some experts call “judge shopping”) in a division of a Federal District Court with one judge, a Trump appointee named Matthew Kacsmaryk who has longstanding views against abortion. If he blocks the F.D.A.’s approval, it would be unprecedented, experts said in an amicus brief.

Separate from the Texas case, the national divide over abortion is playing out in pharmacies.

In January, Walgreens, CVS and other companies said they would apply for a newly available certification from the F.D.A. to dispense both drugs in states where abortion remains legal. But 21 Republican attorneys general — including four in states where abortion is still legal — threatened legal action against the pharmacy chains. Walgreens promised not to provide the pills within those states.

The chains see an opportunity for another new market. Their interest signals that medication abortion is becoming mainstream. In large parts of the country, that’s unwelcome.

Other lawsuits are trying to protect access to abortion pills. One, filed by states where Democrats are in power, asks a judge to affirm the F.D.A.’s approval of mifepristone and remove the remaining restrictions on the medication. Another, by a U.S. manufacturer of the medication, is challenging state bans on the pill.

For now, mifepristone and misoprostol remain widely and quickly available in states where abortion is legal. And the medications can be obtained through avenues like Aid Access, with a delay, in states where abortion is not legal.

Taken together, the drugs are more than 95 percent effective, research shows. Alternatively, people can take only misoprostol in higher doses, but this method is 88 percent effective, according to a study in the U.S. published last month, and is also more likely to cause side effects like nausea and diarrhea.

A ruling from Judge Kacsmaryk could come any day. If he issues a nationwide injunction to block the provision of mifepristone, his ruling could increase health risks and physical discomfort for women.

“The Texas lawsuit is based on the false claim that mifepristone is unsafe and leads to a high need for physician intervention,” Abigail Aiken, one author of the new study, said. “And yet, if we move to a miso-alone protocol, the need for physician intervention will, if anything, be increased.”

A nationwide injunction would be immediately appealed. It’s also possible that Judge Kacsmaryk can’t actually stop the legal provision of mifepristone, at least in the short term, three law professors argue. Congress set procedures for the F.D.A. to withdraw approval from a drug, and the process takes time to follow. A judge can order a review but shouldn’t have the power to circumvent the rules, the law professors say.

The F.D.A. also has a workaround: When the risk is low, the agency can give manufacturers permission to keep distributing products, like some baby formula, which violate the law in some way.

It’s a strange idea: a federal agency using its discretion to avoid enforcing a court ruling. But it could also be the only way for women in the U.S. to continue accessing the safest and most effective method of medication abortion — as long as a president who supports abortion access is in office.

The New York Legislature is considering a bill to protect clinicians who mail abortion pills to patients elsewhere.

See the states where restrictions on abortion pills could have the most impact.

Makena, the only drug aimed at preventing preterm birth, will be pulled from the market after F.D.A. advisers said it largely didn’t help.

Intelligence suggests that a pro-Ukrainian group sabotaged gas pipelines linking Russia to Western Europe last year. Ukraine’s government denies involvement.

Millions of people in France demonstrated against a plan to raise the retirement age. The resistance stems from a commitment to work-life balance.

Mexican authorities found four missing Americans: two killed by gunmen, two kidnapped but alive.

The Mexican military illegally used surveillance tools against citizens trying to expose its misdeeds.

An Israeli raid in the West Bank aimed at arresting a shooting suspect ended in a firefight, killing six Palestinians.

Biden will propose tax increases for corporations and high earners to reduce deficits over the next decade.

“The whole thing seems insane”: More messages from Rupert Murdoch and Fox News hosts reveal their skepticism of Donald Trump’s false claims of a stolen election.

House Republicans promoted Tucker Carlson’s report falsely portraying the Jan. 6 attack as largely peaceful, while Senate Republicans condemned it.

Oklahoma voters decided against legalizing recreational marijuana.

To slow inflation, the Federal Reserve will probably raise interest rates more than projected.

The Justice Department sued to block JetBlue Airways from buying Spirit Airlines, saying a merger would reduce competition.

“There’s a lot of value to be won or lost”: Tech giants are competing to use A.I. for their benefit.

Prime Minister Narendra Modi’s war against Kashmiri journalism portends a larger campaign to limit press freedom in India, Anuradha Bhasin writes.

ChatGPT is a statistical engine based on big data. True intelligence is creative, explanatory and moral, Noam Chomsky, Ian Roberts and Jeffrey Watumull write.

A scrappy nine: The Czech Republic’s roster for the World Baseball Classic is full of guys with regular jobs.

No spots: Parking lots are shrinking across the U.S.

Keanu Reeves’s latest role: He’s a fungus-killing bacterial compound (sort of).

Ask Well: Is cannabis good or bad for sleep?

Advice from Wirecutter: These stain-resistant shirts repel almost everything.

Lives Lived: David Lindley’s mastery of stringed instruments made him a sought-after sideman in 1970s Los Angeles, and his long association with Jackson Browne won him a degree of stardom. Lindley died at 78.

Jackson hits the market: The Ravens placed a nonexclusive franchise tag on Lamar Jackson, which means the quarterback can field offers from other teams. It’s a big risk for Baltimore.

Heels in danger: A microscope is focused on North Carolina this week, as the Tar Heels try to sneak into the N.C.A.A. Tournament.

High stakes: Daniel Jones will remain the Giants’ quarterback after agreeing to a four-year, $160 million deal.

David Chipperfield, a British architect known for merging modern spaces with historic buildings, won the Pritzker Prize.

The jury cited Chipperfield’s recent restoration of the 16th-century Procuratie Vecchie in Venice, a beloved landmark on St. Mark’s Square, and noted his renovation of the Neues Museum in Berlin, which saved elements of the World War II-damaged building. “With it, Berlin has one of the finest public buildings in Europe,” the Times architecture critic Michael Kimmelman wrote in 2009.

Parmesan cabbage soup, thickened with rice, is nourishing.

“History of the World, Part II” is a screwball tour of civilization.

These new psychological thrillers deliver chills.

Stephen Colbert called Kari Lake the “governor of the state of denial.”

The pangram from yesterday’s Spelling Bee was microfilm. Here is today’s puzzle.

Here’s today’s Mini Crossword, and a clue: On edge (five letters).

And here’s today’s Wordle.

Thanks for spending part of your morning with The Times. See you tomorrow.

P.S. Iran cut diplomatic ties with Britain after demanding that its government denounce Salman Rushdie and “The Satanic Verses,” The Times reported 34 years ago today.

Here’s today’s front page.

“The Daily” is about the Nord Stream pipelines.

Matthew Cullen, Lauren Hard, Lauren Jackson, Claire Moses, Ian Prasad Philbrick, Tom Wright-Piersanti and Ashley Wu contributed to The Morning. You can reach the team at themorning@nytimes.com.