A pharmacy technician fills a container with pills to put into a drug dispensing machine for an automated line at a pharmacy in Midvale, Utah. As prescription drug prices continue to rise, states increasingly have been turning to lawsuits to fight the power of pharmacy benefit managers — the middlemen in the drug supply chain. (George Frey/Getty Images)

Last month, the Federal Trade Commission released a scathing report suggesting that pharmacy benefit managers, the middlemen in the drug supply chain known as PBMs, are “profiting by inflating drug costs and squeezing Main Street pharmacies.”

The FTC found that because of consolidation in the industry, the three largest PBMs now manage nearly 80% of all prescriptions filled in the United States. PBMs use that power, the agency concluded, to raise drug prices, control patients’ access to them, and steer people away from independent pharmacies and toward the pharmacies they own.

A week after the FTC released its report, Vermont filed a lawsuit against CVS, Evernorth Health Services (a subsidiary of insurance giant Cigna) and nearly two dozen affiliated entities, claiming they have “distorted the market to their benefit at the expense of Vermont patients” and the state. The PBMs, the suit claims, “are driving up drug prices and foreclosing patients’ access to life-sustaining treatments in order to increase their profits.”

Vermont was the first state to file a lawsuit specifically citing the FTC report, but it probably won’t be the last.

States increasingly have been turning to lawsuits against PBMs in their drive to lower prescription drug prices. They’ve done so partly because of the barriers they’ve faced in trying to address the problem through legislation, including fierce lobbying by PBMs and a federal law that prevents them from helping the two-thirds of Americans who get their health coverage through their employers and so-called self-funded plans.

In taking their fight to courthouses, states also are turning the tables on corporations that have used lawsuits to block legislative attempts at regulation.

“Pharmaceutical companies themselves have a scorched-earth policy towards any legislative or regulatory changes. In other words, the industry will throw every claim it can think of at the states to try to block implementation of the law,” said Robin Feldman, a professor at UC Law San Francisco and an expert on pharmaceutical law.

State legislators and policymakers “have decided that if [their laws] are going to end up in court, perhaps they might have their own claims to bring,” Feldman told Stateline.

In the past couple of years, Arizona, Hawaii, Indiana, Kentucky, Ohio and Utah have sued PBMs, and complaints from dozens of states and municipalities across the country have been consolidated into multidistrict litigation in New Jersey.

And in June, 32 state attorneys general and five pharmacist trade groups joined a lawsuit in support of an Oklahoma law that would place tough new regulations on PBMs — but which the companies have blocked in court.

Illinois Democratic state Sen. Laura Fine, who serves on the Health and Human Services Committee and has pushed for new regulations on health care companies, said she has been frustrated by the limitations of legislation.

“I’m glad that we have attorneys general who will take on these issues and these causes on behalf of the people in our state,” Fine told Stateline. “I think it’s an important tool in the toolbox for everyone to know that if we cannot accomplish what needs to get done, we have our attorneys general behind us to make sure that they can be out there to protect the consumer.”

Major players

As intermediaries in the drug supply chain, PBMs determine which drugs are available under a person’s insurance plan, set copayments and decide how much pharmacies must pay to acquire drugs.

The PBMs argue that they use their bargaining power to negotiate lower drug prices for consumers and pharmacists. They blame drug manufacturers — often known as Big Pharma — for prices that are higher in the United States than anywhere else.

Greg Lopes, vice president of public affairs and communications for the Pharmaceutical Care Management Association, a trade association representing PBMs, wrote in an email to Stateline that “any notion that PBMs are increasing prescription drug costs is patently false.”

“Employers choose to hire PBMs because they have a proven track record of lowering drug costs for health plan sponsors, which translates to lower premiums and lower out-of-pocket costs for patients,” Lopes wrote. “PBMs protect the ability of employers to offer quality health coverage by serving as the only check against Big Pharma’s unlimited pricing power.”

David Winthrop, vice president of external affairs at CVS Health, which owns the PBM CVS Caremark, said the company “is proud of the work we do to make medicine more affordable for American businesses, unions and patients.”

“Any policies that would limit PBM negotiating tools would instead serve as a handout to the pharmaceutical industry, leaving those who pay for prescription drugs at the mercy of the prices drugmakers set,” Winthrop said.

The Federal Trade Commission sees the problem differently.

It notes in its report that CVS Caremark is among the three major players that dominate the PBM landscape, along with Express Scripts and Optum Rx. Express Scripts is a subsidiary of Cigna, and Optum Rx is owned by UnitedHealth. Together, the FTC asserts, the three companies use their supremacy to “wield enormous power and influence over patients’ access to drugs and the prices they pay.”

“This can have dire consequences for Americans, with nearly three in ten surveyed Americans reporting rationing or even skipping doses of their prescribed medicines due to high costs,” the FTC report states.

The agency also notes that PBMs harm independent pharmacies, “who struggle to navigate contractual terms imposed by PBMs that they find confusing, unfair, arbitrary, and harmful to their businesses.” Between 2013 and 2022, the report states, about 10% of independent retail pharmacies in rural America closed.

“Health plans and PBMs are often just trying to protect the status quo as it remains today, for obvious reasons, because the environment has benefited them significantly,” said Antonio Ciaccia, CEO of 46brooklyn Research, a nonprofit that studies drug pricing data.

Daniel Aaron, an associate professor at the S.J. Quinney College of Law at the University of Utah who specializes in health care policy, pointed out that pursuing litigation allows states to sidestep PBMs’ lobbying power in legislatures.

Aaron argued that legislation and litigation can work in tandem.

“Lawsuits can actually help form policy,” Aaron said in an interview. “And because these lawsuits attract a lot of attention and capture the public interest and expose a lot of documents, they can actually buttress policymaking and attract even more public attention.”

He also noted that by taking on unpopular defendants, state attorneys general can raise their political profiles — and many of them aspire to be governors.

Ben Widlanski, the co-lead attorney in a lawsuit involving insulin prices, agreed that lawsuits are valuable because they shine a light on companies’ conduct in a way that state and federal regulators have been unable to do.

“Because there’s not a lot of oversight and because the government agencies responsible for it have not really been doing their jobs for a very long time, the only immediate response that has any chance of making a difference is litigation,” said Widlanski, a partner at Florida-based Kozyak Tropin & Throckmorton.

In suing large corporations, state attorneys general often hire outside law firms on a contingency fee basis.

The limits of litigation

Aaron said successful lawsuits “can hold parties accountable, at least in theory, for illegal conduct and for causing harm. It can increase the cost of engaging in illegal conduct by making that conduct more expensive.”

But Ron Howrigon, a former Cigna executive, cautioned that using litigation to rein in deep-pocketed corporations isn’t as effective as enacting strong laws — however difficult that might be. Howrigon said many large health corporations consider expensive legal settlements to be merely the cost of doing business.

“I don’t think they’re really necessarily worried that the individual litigation is something that’s going to shut it down,” said Howrigon, who is now president and CEO of Fulcrum Strategies, a firm specializing in insurance contracts. “As a friend of mine put it, it’s putting ‘Band-Aids on bullet wounds.’”

What health care corporations are really scared of, Howrigon said, are sweeping policy changes.

“If I’m an insurance company, I’d much rather pay millions of dollars in fines than have a new law that I have to comply with going forward,” he said. “So, I’m not going to say that lawsuits don’t have any impact. But they don’t have nearly the impact as what legislative change would have.”

Stateline is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Stateline maintains editorial independence. Contact Editor Scott S. Greenberger for questions: [email protected]. Follow Stateline on Facebook and X.

A group of politically connected lawyers formed a venture to go after insurers and made millions from one of the largest Medicaid settlements in history. Above, Centene Corporation headquarters in Clayton, Missouri. (Jeff Roberson/Associated Press)

Shalina Chatlani examined the health care system in Mississippi as a part of The New York Times’s Local Investigations Fellowship. This story cannot be republished.

In 2018, when Mike DeWine was Ohio’s attorney general, he began investigating an obscure corner of the health care industry.

He believed that insurers were inflating prescription drug prices through management companies that operated as middlemen in the drug supply chain. There were concerns that these companies, known as pharmacy benefit managers, or P.B.M.s, were fleecing agencies like Medicaid, the government-run health insurance program for the poor.

Three years later, after DeWine became governor of Ohio, the state announced an $88 million settlement with one of the nation’s largest insurance companies, Centene.

The case led to a nationwide reckoning for the company, as attorneys general in one state after another followed Ohio’s lead, announcing multimillion-dollar settlements and claiming credit for forcing Centene to reform its billing practices.

On the surface, it appeared that these settlements, which now total nearly $1 billion, were driven by state governments cracking down on a company that had ripped off taxpayers.

But a New York Times investigation, drawing on thousands of pages of court documents, emails and other public records in multiple states, reveals that the case against Centene was conceived and executed by a group of powerful private lawyers who used their political connections to go after millions of dollars in contingency fees.

The lawyers were first hired in Ohio, without competitive bidding. Then, they gathered evidence against Centene of questionable billing practices across the country.

Using information they acquired from Centene and other sources, they negotiated with the company to set the basic framework of an agreement that could be applied in other states. With that in hand, they approached attorneys general in multiple states and made a compelling offer: hire them, at no direct cost to taxpayers, and recoup millions of dollars Centene had already set aside.

So far, the lawyers have been awarded at least $108 million in fees.

The Centene case is just one example in a thriving industry that allows private lawyers to partner with elected attorneys general and temporarily gain powers usually reserved for the government. Under the banner of their state partners, these lawyers sue corporations and help set public policy while collecting millions of dollars in fees, usually based on a percentage of whatever money they recoup. The practice has become standard fare in the oversight of major industries, shifting the work of accountability away from legislators and regulators to the opaque world of private litigation.

Private lawyers do not have to publicly defend the deals they make or prove how aggressively they went after a company accused of wrongdoing. Nearly all their work happens in secret, especially if companies settle before the stage of a lawsuit when evidence is filed with the court.

The lawyers do not even have to disclose who worked on a case or who was paid, so the public may be left unable to monitor potential conflicts of interest even as the lawyers pursue litigation on behalf of the people.

The Centene case was organized by the Mississippi-based law firm Liston & Deas along with at least three other firms, several with close ties to former Gov. Haley Barbour of Mississippi, who was once considered one of the most influential Republican power brokers in the nation.

The lawyers included Paul Hurst, who served as Barbour’s chief of staff when he was governor and who married into Barbour’s family, and David H. Nutt, one of the richest men in Mississippi, who amassed a fortune funding state lawsuits against tobacco companies. Cohen Milstein, a huge national law firm with deep experience in contingency work for state attorneys general, was also part of the venture.

Though he is not listed in any government contracts as a lawyer of record, Barbour himself was a member of the legal team when Liston & Deas vied for the contract in Ohio.

At the time, Barbour also worked for Centene as a federal lobbyist.

Even now, close to three years after Centene signed its first settlements, no one has fully explained Barbour’s role in the case for the company. There is no way for the public to know whether he influenced the outcome or to measure whether Centene paid its full share, because the data used to calculate what Centene overcharged remains hidden from the public under provisions designed to protect attorney work product.

Barbour and other lawyers said that the former governor worked on the case for less than a year when the group was examining several insurance companies, and that he cut ties when Centene emerged as the primary target. Barbour said he informed Centene and his colleagues about the development and was never involved in negotiations or legal matters. He continued representing Centene as a lobbyist, he said, but his role in the case on behalf of the company was as “more of an observer.”

The lawyers said that Barbour was never paid for his work and that the settlement was not influenced by Barbour’s connections to Centene or to the lawyers who remained. They said each state attorney general reviewed Centene’s billing practices when deciding whether to enter a settlement agreement.

In recent years, P.B.M.s have been widely criticized, including by members of Congress, who have held multiple hearings and proposed legislation. The Centene settlements stand as the most successful attempt to hold a company operating in the industry accountable.

Liston & Deas and its partner law firms uncovered that Centene had arranged discounts with CVS Caremark on certain drugs and then pocketed the savings instead of passing them on to Medicaid. In some states, they revealed that Centene layered on unnecessary management fees that it had not disclosed. Although Centene settled without admitting guilt, the company agreed to be more transparent in how it sets reimbursement rates.

The lawyers noted that they spent several years investigating Centene and negotiating with the company at their own risk, saving states the cost of building a case.

Nutt, one of the lawyers who pursued the case, said states were happy with the terms of the settlements.

“Almost every one of those states audited to determine if our damage model was fair,” Nutt said.

“The formula was based on a triple damages model that we developed. And everybody was quite satisfied with it, because it was three times what anybody could have proven in court.”

Hiring outside counsel

For most of their history, state attorneys general were largely focused on advising state officials on legal matters and representing local agencies in court.

That changed drastically almost 30 years ago, when states came together to sue tobacco companies and won a $206 billion settlement to cover the cost of medical care related to smoking. The lawsuit helped redefine the role of the attorney general as one of the most powerful positions in state government and a natural place to start a political career.

Through high-profile lawsuits against corporations, an attorney general could directly affect policy and build a reputation as a champion of the people.

But complex litigation against large companies can require years of investigation and legal work, with no guarantee of success. Increasingly, states have turned to private lawyers willing to work on contingency as a way to stretch limited resources.

The rise of contingency fee cases kicked off a new wave of lobbying across the nation. Law firms looking for contracts have poured money into attorney general election campaigns and sponsored conferences at high-priced resorts, where private lawyers mingle with attorneys general and pitch their latest ideas for lawsuits.

Many states have capped how much lawyers can be paid in contingency fees and have increased oversight of private firms working for the government. But there remains concern about undue political influence and potential conflicts of interest.

“In theory, there’s an incentive to have the settlement be as big as possible, and of course that’s great for the state,” said Paul Nolette, a professor at Marquette University who has studied how the role of attorneys general has changed over time.

But in reality, lawyers have an incentive to recover the largest amount of money in the shortest amount of time, which could pressure them to water down settlements and compromise on punitive measures, Nolette said.

“I think that does raise some questions about how forcefully A.G.s and private attorneys are prosecuting a particular case,” he said.

Several experts said that contingency cases had recouped billions of dollars on behalf of the public and had become a critical way to regulate the behavior of powerful industries and large corporations.

But inviting private lawyers to help set public policy has inherent risks, they said.

Private lawyers may be more likely to have conflicts of interest because they generally represent many businesses and individuals, not just the citizens of a state.

And unlike most attorneys general, private lawyers are not elected officials. They are not generally governed by open records laws or subject to public pressure, as from legislators setting their budgets.

In the Centene case, Barbour’s associations with both Centene and the private lawyers raise “important questions” about who controlled the case to make sure it was pursued in the best interests of states that settled, said Kathleen Clark, a professor of legal ethics at Washington University in St. Louis.

“Did state A.G.s proactively pursue these cases, or did they passively accept the ‘free money’ or ‘easy money’ of the proposed settlements that the law firms had already negotiated with Centene?” Clark asked.

Christina Saler, a partner at Cohen Milstein, said Barbour’s early association with the legal team was not a conflict of interest because Barbour withdrew from the case before lawyers started investigating Centene.

“After Barbour’s disassociation, we had no further contact with Barbour on this matter,” she said.

A well-connected team

Barbour’s involvement in the Ohio case against P.B.M.s illustrates the potential for favoritism when states hire private lawyers.

Hurst noted the involvement of Barbour when seeking the contract in Ohio, according to emails acquired from the Ohio attorney general’s office through a public records request.

In a June 22, 2018, email exchange, just a few days before the state hired Liston & Deas, Hurst recalled meeting with the attorney general’s staff in Ohio.

Hurst went on to note that members of his team had worked with Barbour while he was in office and that they all “continue to work together now.”

In an email a week later, an assistant attorney general shared Barbour’s cell number with DeWine, saying that Barbour had shared it so he could “call him about this case anytime.”

Barbour, who had served two terms as governor of Mississippi, was a former chairman of the Republican Governors Association and a former chairman of the Republican National Committee. Known as a prolific fund-raiser, he was credited with bringing in hundreds of millions of dollars to support Republican candidates across the nation.

In 1991, Barbour co-founded BGR Group, a lobbying firm that quickly became one of the most influential in Washington.

Barbour had known DeWine since he was first elected to the Senate in 1995.

Two decades later, when DeWine was in the midst of a hard-fought campaign for governor, Barbour’s close associates solicited him for the legal work on the Centene case. In October 2018, less than three months after DeWine hired Liston & Deas, he traveled to Washington to visit Barbour’s lobbying firm for several hours, according to calendar records.

At the time, Barbour and others at BGR were registered lobbyists for Centene.

Saler, of Cohen Milstein, said there was no need to inform state officials because Barbour had not been involved in the Centene portion of the case and had exited the venture several years before states hired the lawyers.

Barbour has never been named in state contracts as one of the private lawyers on the case in Ohio or anywhere else.

At least four law firms were involved in the case in two or more states, according to retainer agreements and financial records showing broadly how settlement funds were disbursed.

According to Max Littman, a former data analyst with HealthPlan Data Solutions, the analytics firm that helped identify Centene’s overcharges in Ohio, one important role for many of the lawyers was to use their connections as they presented the overcharges to various states.

Littman, who said he worked closely with the legal team, described the dynamic: Liston & Deas, with roots in a deeply red state, would approach Republican attorneys general, and Cohen Milstein, “who were our Democrats,” would focus on Democratic states.

When The Times asked for records showing Liston & Deas’s qualifications to be hired to represent the State of Ohio, the attorney general’s office said no records existed. Cohen Milstein and other law firms had submitted such documentation in the past when seeking contracts in Ohio.

Settling with states

In June 2021, nearly three years after Ohio hired its outside counsel, two states announced the first settlements with Centene on the same day: Ohio would get $88 million, Mississippi $55 million.

After that, Centene settled in one state after another, often with just months between announcements.

In fact, Centene had already set aside $1.1 billion to handle all subsequent cases. The company estimated the amount after early discussions with the private lawyers that did not involve the state attorneys general who would later work with them.

With a settlement in hand and an estimate of how much each state could collect, the private lawyers had a powerful pitch. The team also had the option to file whistle-blower lawsuits, which can advance without a state attorney general’s having to hire outside counsel.

The team pursued whistle-blower lawsuits in Texas, California and Washington.

In Texas, the whistle-blower lawsuit came with a benefit for Attorney General Ken Paxton: Under Texas law, his office is allowed to recoup “reasonable attorney’s fees” for work associated with such cases. It collected nearly $25 million in legal fees on the Centene case while spending just 561 hours on it, financial records show. That comes out to more than $44,000 per hour of work. The Texas attorney general’s office declined to comment.

Saler said all the state attorneys general decided their own strategies in reaching settlements with Centene based on the best interest of taxpayers in their states.

In states that hired the lawyers on contingency, the attorney general closely reviewed Centene’s billing practices. But no state has revealed whether its own overcharge calculations matched those of the private lawyers.

State officials who hired Liston & Deas and the other firms knew that the lawyers had previously negotiated with Centene. But in a vast majority of states, officials did not explicitly address that fact when talking publicly about the settlements.

In addition, Liston & Deas and most of the states the firm worked for have not revealed exactly how much Centene overcharged for drugs or how settlement amounts were calculated. A few states have offered sparse descriptions, which vary widely.

The New Hampshire attorney general’s office wrote in its settlement announcement that Centene’s activities had a “$2.4 million negative financial impact.” Centene agreed to pay the state nearly 10 times that amount.

The attorney general’s office in Washington, one of the few states where officials agreed to discuss basic details about the settlement with The Times, said the $33 million it recovered amounted to treble damages.

A news release from the California attorney general’s office said the state recovered double its damages, for a total settlement of more than $215 million.

As of last month, Centene had settled in at least 19 states. The Liston & Deas website says Centene will ultimately pay about $1.25 billion to 22 states.

A sweetheart deal?

Some observers believe Centene would have faced stricter penalties if the federal government had taken up the case instead of private lawyers hopscotching from one state to the next.

Several experts in health care fraud litigation and whistle-blower cases said the best way to recoup money for taxpayers would have been to file a federal whistle-blower case, similar to what the lawyers did in state court in Texas and California.

A federal case could have triggered the involvement of the Justice Department, which might have investigated Centene more thoroughly. And a federal case probably would have gotten more attention and media coverage, required more transparency and taken longer to complete, the experts said.

Hurst and other lawyers in the case said they had not filed any type of federal action against Centene.

A spokesperson for the Justice Department confirmed that it had inquired about the P.B.M. and Centene cases in Ohio, but no further federal action was taken. The department declined further comment.

Mary Inman, a lawyer at Whistleblower Partners L.L.P. with decades of experience, said one of the reasons Liston & Deas wound up in state court might have been that its case relied on whistle-blowers the federal government was unlikely to approve.

The whistle-blower in Texas was Hurst. In California, the whistle-blower was Matthew McDonald, a lawyer at David Nutt & Associates and the son of Bryan McDonald, who worked in Barbour’s administration when he was governor.

Inman said whistle-blowers are typically insiders with firsthand knowledge of wrongdoing who share information at some risk to themselves, not lawyers who gain information while on the job.

“It’s very unusual,” Inman said. “And it’s something that I, as a longtime lawyer in this space, I would not want to do because atmospherically and reputationally it doesn’t look great.”

Barbour said he believes everyone walked away from the settlements happy — including executives at Centene. As evidence, he cited the company’s stock performance.

“I can’t speak for them, but if I had agreed to pay a big settlement and my stock went up after the first day, I would think it was a pretty good settlement,” Barbour said.

States Newsroom co-published this story with The New York Times as part of its?Local Investigations Fellowship, a one-year program where local reporters produce investigative work about their communities. It cannot be republished.

Lila Bonow, Alana Edmondson and Aiyana Knauer prepare to take abortion pill while demonstrating in front of the U.S. Supreme Court on Dec. 1, 2021. (Photo by Chip Somodevilla/Getty Images)

JACKSON, Miss. — The Pink House — otherwise known as Jackson Women’s Health Organization — was the center of the U.S. Supreme Court case that overturned the federal right to abortion in June. Today, the clinic, the only abortion clinic to serve Mississippi and the greater area for years, is shuttered. On a hot day in February, there are no protests outside the clinic’s gates, the air is still and quiet, the iconic walls on the outside have been painted white, and the medical equipment has been removed. A new owner has moved in and has begun converting it into a consignment shop for luxury goods.?

“I worry about those women a lot, that they no longer have means to health care in the state of Mississippi,” said Diane Derzis, former owner of the Pink House.?

The Pink House is just one of dozens of organizations across the South that have closed or stopped offering abortion services in the face of trigger abortion bans that went into effect right after Dobbs v. Jackson Women’s Health Organization overturned Roe v. Wade.?

Derzis said selling the building that housed the clinic was a “business decision.” She said the Jackson clinic’s operations, medical equipment, and furniture have moved to Las Cruces, New Mexico, in the face of Mississippi’s 15 week abortion ban. She also has clinics in places like Columbus, Georgia, and Richmond, Virginia. Now, many people in the South are traveling out of state to seek an abortion — either in-clinic or via medication abortion, she said.?

Derzis says she’s getting ready to open a clinic in Chicago, Illinois.?

But all those clinics and others still operating could soon face new restrictions as a federal judge in Texas decides on a lawsuit filed by anti-abortion groups that directs the U.S. Food and Drug Administration (FDA) to withdraw its approval of mifepristone — a widely used drug used in medication abortion that’s been around for decades.?

“I think that women need to pick up their guns and take to the streets, and I’m serious. This is a crusade against women,” Derzis said.

A broad lawsuit that leaves room for questions

Medication abortions account for over half of all abortions in the United States, according to the research group Guttmacher Institute. A ruling in favor of the anti-abortion groups would not only make legal abortion more challenging, it would also erase some of the limited options left for people in states where there are strict abortion bans. These restrictions are most prominent across the southeastern United States, where maternal health care deserts are growing.?

The likely immediate impact would be that manufacturers would not be allowed to ship mifepristone anywhere in the United States, and providers would no longer be able to prescribe it. It’s still unclear what could happen with misoprostol, a drug that’s used in medication abortion as well as to treat ulcers.

The typical regimen used in medication abortion involves the use of mifepristone and misoprostol, and has been prescribed by doctors since the 2000s.?

Elizabeth Nash, principal policy associate at Guttmacher, says it’s likely that only misoprostol would be used for medication abortions — which Nash says has been done in other countries. But she says, the issue is that the lawsuit is broad in some areas, so there are still a lot of unknowns.?

“How many providers would switch to a misoprostol regimen? Not every provider would do that. Secondly, it’s unclear how patients would feel about using a misoprostol-only regimen especially because it has a higher dosage. They may be asking for more procedural abortions and that may make it harder because in-clinic abortion takes more time and resources for clinic staff,” Nash said.

Erik Baptist, senior counsel with the Alliance Defending Freedom, one of the groups that filed the lawsuit, said the lawsuit also asks the FDA to ban the use of misoprostol in medication abortion.?

“This lawsuit focused on the FDA’s approval of both mifepristone and misoprostol for its use in medication abortion. Whether a doctor could approve the use of these drugs off-label is not in the scope of this lawsuit,” he said. “I think it’s important to note that this lawsuit doesn’t target the use of [misoprostol] for benign issues such as Cushing’s disease or gastric ulcers.”?

The plaintiffs argue that the FDA did not follow protocol to evaluate whether these drugs were safe to be prescribed for medication abortion. Although, numerous studies have shown the regimen to be safe and effective.

“We will evaluate the court’s decision no matter how he may rule and determine what to do from there. We are currently focused on prevailing at the district court,” Baptist said.?

Clinics strapped to provide care, patients with fewer options

While it’s still unclear what could happen after the ruling, what is known is that people in abortion restricted states who used to go to clinics like the Pink House in Jackson are already having a tougher time seeking legal abortion.

“People are still needing and wanting abortion services. It’s just making it harder for Mississippians. It’s more expensive having to travel farther and take longer periods off of work. Some folks have had to fly to either Florida and New York. Some of these people are experiencing their first time being on a plane,” said Michelle Colón, executive director of Sisters Helping Every Woman Rise and Organize (SHERo), an abortion-rights organization that helps connect people of color to legal abortion services.?

In Florida, abortion is illegal after 15 weeks, although soon that could be reduced. In New York, that timeframe is through viability of a fetus, which is about 24 weeks of pregnancy.

Clinics in northern states are already feeling the pressure of the increased demand, said Mara Pliskin, patient navigation manager at Planned Parenthood in Illinois.?

“We’re in the trenches. We are doing the best we can and have systems in place to get scheduled as fast as we can and get them here,” Pliskin said. “We hear patients say, ‘I don’t know how to make this happen.’… We’ve definitely seen an increase in patients from the South — Louisiana, Mississippi, Tennessee, Florida, all of these states.”

Pliskin says many patients are facing dangerous situations, especially if they are in states where they have to be mindful of confidentiality or dealing with issues like intimate partner violence.?

Pliskin said that like many abortion clinics around the country, clinics in Illinois have long waitlists and resources are stretched. And, those waitlists will likely get longer if medication abortion becomes restricted, as more patients will opt for the surgical procedure.?

In fact, data from Planned Parenthood Illinois shows that for patients from Louisiana, Mississippi, Alabama, Georgia, and Florida, 38% had a medication abortion and 62% had an in-clinic procedure between Nov. 1, 2022? to Feb. 28, 2023. Meanwhile, for the overall abortion population at that clinic in the same time period, 54% had medication abortion and 46% had an in-clinic abortion for the same time period.

“We will continue to offer medication abortion with misoprostol. There is already a method for it. The only thing is that it will take longer — it’s more medication over a longer period of time and it just makes it that much more difficult for people who travel,” Pliskin said. “That means patients will have to stay in Illinois longer … before they can return home to a state where it’s illegal or restricted.”?

Even when it comes to telehealth, Pliskin says the patient still has to come to Illinois when they are actually taking the medication. That means patients will also have to spend more money and time, adding to the emotional toll and financial strain they may be experiencing, said Colón. In turn, that makes it more difficult for advocates too.?

“It’s put a burden on all of the abortion funds that are in partnership with supporting folks from Mississippi,” she said. “When somebody calls you and they need you at the drop of a hat … it’s hard and it’s just wrong and sad. This is torture and government sanctioned oppression. But we’re doing what we can.”?

A future of more health and legal safety risks around reproductive care?

Anti-abortion groups argue that medication abortion is unsafe. Terri Herring, leader of pro-life group Choose Life Mississippi, says womens’ lives are at risk.?

“Abortion pills without confirmation of gestational age and consultation with a physician are dangerous for women,” Herring said. “We need to continue to educate women about the dangers of abortion on both their physical and emotional health.”

Other groups say they’re prepared to help people who have no choice but to give birth.

“I think that the pro-life movement has shown that we are here for women and we will continue to support women whether they are pursuing abortion or not,” said Sarah Zagorski, a spokeswoman for Louisiana Right to Life. “Of course, there are improvements that can be made, but I think we’ve come a long way in supporting women in crisis.”?

But reproductive health care in some southern states is lacking, causing some of the highest maternal mortality rates in the country, especially for people of color. CDC data from 2020 show that while the national rate for maternal mortality is 20.4 maternal deaths per 100,000 births, the rate is 30.2 in Mississippi, 31.8 in Louisiana, and 36.2 in Alabama.

“This is about control. This is about obliterating liberation of not only women, but of marginalized Mississippians, Black and brown Mississippians, queer Mississippians, and low income, poor Mississippians,” Colón said, adding that people who aren’t able to have a child will seek abortion anyway, but that the process will be much less safe for them.?

There are also more legal risks ahead for both providers and patients in the wake of a potential ruling to limit medication abortion, said Kelsea McLain, deputy director of the Yellowhammer Fund in Alabama.?

Alabama’s abortion law is highly restrictive and criminalizes anyone that aids a person seeking an abortion, McLain said. Yellowhammer has had to effectively stop most of its abortion-related services. They can only provide information that’s already available in the media.?

“We really effectively can’t do anything since the Dobbs decision … we’ve had to lean heavily into our programs that support new parents,” said McLain.?

McLain said it’s been tough hearing from people who they aren’t able to help in specific ways. The other concern, she says, is that there’s a pre-filed bill in Alabama that could make abortion akin to homicide.?

“The abortion haver would be charged with the crime,” she said, noting that the ruling on medication abortion could open up room to investigate people who have miscarriages to see whether they used medication or they had it naturally.?

“We are unsure looking at a future where multiple forms of pregnancy loss are facing criminalization or investigation,” she said. “So people are going to need to be more clandestine and intentional about when they visit a doctor and disclose if they are pregnant.”?