Abortion care on wheels
As the nation braces for a decision that could come any day from the U.S. Supreme Court ending federally protected abortion rights — and making abortion a crime from the earliest stages of pregnancy in some states — women’s health care advocates have been thinking outside the box about ways to protect abortion access.
Here’s one idea: mobile abortion clinics in bullet-proof vehicles could patrol the borders of states where abortion remains legal, serving patients who cross over from the 26 states including Wisconsin where abortion has been criminalized.
Sound far-fetched? The effort is already underway.
Dr. Julie Amaon is the medical director of Just the Pill, a nonprofit, online clinic based in Minnesota that dispenses pills for medication abortion, birth control, and the treatment of sexually transmitted disease. Just the Pill, which has experimented with offering patient care in mobile clinics, is working on a big expansion. Through a collaborative effort with like-minded colleagues, other women’s health organizations and private donors, Just the Pill aims to get a fleet of vehicles on the road with the ultimate goal of running mobile clinics in every state where abortion remains legal, bringing patients across state lines to access both medical and surgical abortion.
Amaon grew up in Texas and managed a Planned Parenthood clinic in Austin for four years in the early 2000s. “Planned Parenthood was having to fly in providers from the coasts, because nobody wanted to work in Texas, just because of the volatility and the protests,” she says. To help fill the void, she decided she wanted to become an abortion provider herself, going back to school to become doctor at the age of 35.
“I’m a person in my life that has decided I did not want to have children,” Amaon says. Her own mother had raised two small children while working full time and studying at night. “She worked herself to the bone,” Amaon recalls. “It’s hard being a parent. It’s hard work financially and mentally. You want to be ready. That really stuck with me.”
“There are a lot of different reasons why people choose not to have kiddos,” she adds. “They have health issues; they’re not financially ready; they’re not mentally ready. There are so many reasons. And so I think it’s important to be able to control your own fertility and control your own body. That’s something that has always been super important to me.”
Amaon attended medical school in the Caribbean at the American University of Antigua. She chose the University of Minnesota Medical Center’s residency in family medicine because the program includes abortion training. “It’s suprising how hard it is to get abortion training in residency,” she says. “I think this is something that everybody should learn and get trained in.”
That situation is about to get worse in the 26 states where doctors will no longer be able to practice abortion. “We’re gonna lose a lot of training sites. That’s scary to me,” Amaon says. Among her ambitions for Just the Pill is to have residents come and train in its mobile clinics.
Perfect timing for the pandemic
When she was finishing up her residency in 2020 at the height the pandemic, the job market was slow and Amaon was planning to move back to Texas. Then, just a month before she graduated, she met the founder and executive director of Just the Pill (who stays out of the public eye in order to protect her family’s safety) and was inspired by her vision for serving low-income, rural populations and immigrant communities across Minnesota. Amaon came aboard in the summer of 2020, shortly after the group launched.
Just the Pill’s model — seeing patients via telehealth appointments and providing medication through the mail — was perfectly timed for the pandemic. The effort was aided when a federal district court in Maryland ruled that the Food and Drug Administration (FDA) had to suspend a rule requiring patients to go in person to a hospital or clinic to pick up the FDA-approved prescription drug, mifepristone, which is used in combination with another drug, misoprostol, to safely end early pregnancies. The court found that the requirement was onerous, unnecessary and exposed patients to an unreasonable risk of contracting COVID-19 by forcing them to pick up pills in person, even though the FDA had deemed the medication safe enough that they could take it by themselves later in the privacy of their own homes.
Amaon saw patients for telehealth visits and Just the Pill sent the drugs to them through the mail. Then, in January of 2021, the U.S. Supreme Court overruled the federal district court, allowing the FDA to restore the in-person visit requirement.
“So we actually rented a mobile clinic and drove around like 1,200 miles every week distributing pills in-person for people,” Amaon recalls. She and her executive director took turns driving the vehicle they rented, from January until March, when the FDA made sending pills through the mail legal again.
From the beginning, Just the Pill was determined to be flexible, to overcome barriers that patients could not.
As they drove around Minnesota, Amaon says, she noticed she was seeing a lot of patients from Wisconsin, North Dakota, South Dakota and Iowa — “people who have more restrictive legislation in their states.”
Minnesota requires a 24-hour waiting period between appointments before someone can have an abortion. But the first visit doesn’t have to be in-person. So patients would cross the border to have a 15-minute conversation with Amaon on the phone and get their pills delivered to a general delivery address at a Minnesota post office or to a UPS or FedEx dropoff location. “That’s how we were kind of serving our surrounding states that had more restrictive laws,” says Amaon.
“We were noticing that North Dakota, South Dakota — if you’re on the western side of the state, that’s a long drive to Minnesota,” says Amaon. So Just the Pill began providing services in Montana. “That helps us serve Idaho, Nebraska and Wyoming patients.” Last December, the group expanded to offer medication abortion in Wyoming, a very rural state with few providers and treacherous winter driving conditions in the mountains. The group has now been offering medication abortion in Minnesota for two years.
Crucial backup for overwhelmed providers
Cynthia Lin, a board member of the Women’s Medical Fund, one of the oldest abortion funds in the nation, is impressed with Just the Pill’s work. Since 1972 WMF Wisconsin has helped pay for abortion care for Wisconsin patients and also educates and organizes for abortion access. “I think their focus on offering streamlined approaches to medication abortion, leveraging telehealth, especially with the opening of mail options that were made possible at the beginning of the pandemic and now solidified, is a really important and crucial contribution to the spectrum of options that we need,” says Lin.
Just the Pill will provide crucial backup for providers in less restrictive states, who are preparing for a flood of out-of-state patients from places where abortion is outlawed after the anticipated Supreme Court decision, she adds.
In general, says Lin, abortion providers and supportive groups have been working together to figure out how to sustain abortion access and help patients overcome logistical hurdles including funding and transportation. “There’s just a lot more partnership and connecting of dots happening,” Lin says. “Just the Pill exists at the intersection of both offering direct access as well as funding support and partnering with other funds to be able to get people access.”
Long before Justice Samuel Alito’s draft decision overturning Roe v. Wade was leaked, Amaon and her colleagues at Just the Pill were talking about what would come next.
After the Supreme Court heard arguments in Dobbs vs. Jackson Women’s Health Organization, the Mississippi case that challenges the precedent set by Roe, “We knew that Roe was going to fall,” Amaon says. The group discussed which states would lose abortion access. “We started to look at going back to the mobile clinic idea and can we drive the borders to serve those states.”
An anonymous donor kicked in funding so Just the Pill could purchase two mobile clinics of its own — one to provide surgical abortion procedures and one for dispensing medication abortion pills.
Just the Pill considered deploying its new vehicles in Wisconsin. But the group chose Colorado instead, for its less onerous regulations on clinics and pharmacies. The first medication mobile clinic is scheduled to be on the road in June, and the procedure clinic will follow within a few months.
Amaon plans to travel to Colorado this month for the launch — but she won’t be driving. “This time around we are thankfully in a better fundraising spot than we were and we’re hiring drivers,” she says.
“And we are currently fundraising for a fleet,” adds Amaon. “Because, I think you know, Minnesota is going to be that safe haven state. Wisconsin is going to fall. We think North Dakota, South Dakota are going to fall and Iowa — so that’s going to be a huge area where there’s going to be an influx of patients.” Just the Pill is planning to deploy mobile clinics on all sides of Minnesota, to serve patients in those surrounding states.
Amaon, the only physician on staff, is currently covering Minnesota, Montana, and Wyoming. “I’m quite busy. So we’re hiring — I’m super excited,” she says. Just the Pill has been busy recruiting new clinicians and medical assistants in Colorado.
The evolution of reproductive health care
As it continues to make connections in new states, Just the Pill plans to work with local health care providers, including providers from Wisconsin, who cross the border to work with the group in Minnesota.
“Just the Pill is an interesting example of an organization that has addressed this need to expand abortion care delivery,” says Jenny Higgins, a family planning researcher at the University of Wisconsin — Madison.
She sees Just the Pill as part of an evolving view of reproductive health care that has moved from an era when only licensed doctors are allowed to provide abortion to a research-based understanding that nurse practitioners are just as capable of providing abortion safely. “The rise of telehealth has been a huge change in the way health care is delivered for many different services, including abortion care,” Higgins says. “I think what Just the Pill is capitalizing on is not just the shift to telehealth, but also this need at times to be able to be physically mobile versus a brick and mortar clinic.”
“It’s a totally novel way of delivering care. “However, the delivery of medication abortion care at Just The Pill follows the same clinical guidelines and standards as any other licensed abortion provider,” says Higgins. “The main difference is that their physical place of service moves around.”
Like Lin, she sees Just the Pill as part of an increasingly collaborative reproductive health care network.
“The family planning community in the U.S. is by and large an extremely collegial and supportive group,” says Higgins. “My sense is that people in that community seem supportive of Just the Pill and its new care modality.”
Just the Pill advertises its telehealth services through Google ads, and 85% of patients who use the group’s telemedicine and pills-through-the-mail services find the group online, Amaon says. During the three months of 2021 that Amaon spent driving around in the rented mobile clinic, patients still primarily found the service by searching the internet.
Amaon spent some very long days bringing her services to her patients. She would spend the first few days of the week taking telehealth appointments, “and then we’d get our Google maps out and figure out where everybody lives,” she recalls. “And then where can we meet them within an hour of everybody?”
“There were long nine- to 10- to 12-hour days to get around. So we know that’s not a sustainable way to continue.”
In Colorado, the group is piloting a new model, working with funders and clinics in restrictive states like Texas to refer patients and help them with travel and other logistics. “We’re kind of trying to do a group travel model where we have a group of people coming from out of state for one day,” says Amaon. Clinics in restrictive states can provide initial services like blood work and ultrasounds, making the whole process more efficient.
For obvious reasons, Just the Pill won’t announce ahead of time where the mobile clinics are going to show up. In bricks and mortar clinics, “Everybody is worried about protesters and violence,” Amaon says. “And that is exactly what we were worried about.”
“All of our mobile clinics are bulletproof,” she adds. Just the Pill is working with a network of community organizations that are comfortable having the clinic park on their property. Each location will only be disclosed to patients, and the clinics will move around, Amaon says, “and never be in the same place more than once a month.”
The mobile clinics are unmarked on the outside. On the inside, says Amaon, “It’s beautiful.” Like any doctor’s office, each mobile unit has a sink and chairs, an exam table with a curtain that can be drawn around it.
While Just the Pill has become adept at dispensing medication abortion from vans, the group will use an RV to do surgical abortions. In the future the group hopes to have even larger vehicles “with two and three rooms where they have a recovery room in the middle,” says Amaon. The current setup is “pretty bare bones,” she adds, “But you don’t need much to do a first trimester manual vacuum aspiration.”
The procedure only takes 10-15 minutes. Amaon has performed early trimester abortions in bricks-and-mortar clincs. But Just the Pill would be the first group in the United States to offer them in a mobile clinic.
In other countries mammograms and colonoscopies are being offered in clinics on wheels. “All sorts of things are being done in mobile clinics these days, so I think it’s very doable,” she says.
In the one-room procedural clinic the group could handle 12 abortions per day. The medication van can serve 40-50 patients per day.
Among the states on the list for expansion in the next phase are New Mexico and Illinois along with Pennsylvania and Virginia.
“If we can prove this model of group travel and meeting once or twice a week in different areas of the state, we hope to expand to all the safe states in the future with a fleet of mobile clinics,” says Amaon.
“It just gives me hope because we’re living in such a crazy world right now,” she says, “and if I weren’t doing something to combat it, I don’t know what I’d do”
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