Experts have said that a U.S. Supreme Court ruling on the use of mifepristone, a key abortion medication, could have implications for drug approval by the U.S. Food and Drug Administration. (Getty Images)

This year will end on a major cliffhanger for abortion access.

Last November, anti-abortion activists via a powerful conservative Christian law firm asked a federal court to effectively ban or widely restrict the abortion drug mifepristone. Finally on Wednesday, the U.S. Supreme Court agreed to take the case, making Alliance for Hippocratic Medicine v. U.S. Food and Drug Administration the high court’s first abortion-related case since overturning the federal right to an abortion in June 2022.

As abortion access advocates, providers, people of reproductive ability and anti-abortion proponents wait until mid-2024 for the results of this case, other ongoing abortion litigation (a Texas woman left the state after her request for an emergency abortion was granted before being blocked by that state Supreme Court) and a presidential election, uncertainty and fear about the future of reproductive health access remain high.

Abortion via a two-step medication process of mifepristone and misoprostol has become the predominant way Americans terminate pregnancies post-Dobbs, particularly those living in states with bans or in areas with no providers. Mifepristone blocks the progesterone hormone, which is necessary to continue a pregnancy.

“We should never be in a position where judges are deciding whether people can get effective medicines,” said Elizabeth Ling, an attorney for the legal advocacy group If/When/How, in a statement. “Mifepristone access is essential to people’s ability to determine their own future and actualize self-determination by ending a pregnancy, including self-managed abortion.”

Though the anti-abortion plaintiffs in this case asked the Supreme Court to fully reverse the FDA’s 2000 approval of mifepristone for first-trimester abortions, the high court is expected to review questions around restrictions that were lifted during the last decade because of mifepristone’s proven safety record. Depending on how the court rules next year, mifepristone will likely remain legal but could prove much harder to access, especially if the court strikes down the ability to obtain the drug via telemedicine. Legal and pharmaceutical experts have said this case could have far-reaching implications on approval for medications beyond abortion drugs.

“The future of telehealth for medication abortion care now hangs in the balance,” said Dana Northcraft, founding director of Reproductive Health Initiative for Telehealth Equity & Solutions, in a statement. “Telehealth for medication abortion is safe and effective and helps people overcome barriers to care, whether it be long travel distances or getting time off from work or school. Everyone deserves compassionate, accessible, and inclusive abortion care.”

Mifepristone is also used for miscarriage management but has become harder to access, doctors report.

For providers who spoke with States Newsroom on Wednesday, it’s not just about what restrictions will or won’t stand after a ruling from the U.S. Supreme Court, but the fact that the case got this far in the first place.

Dr. Erin Berry, an OB-GYN in Seattle who works at 15 Planned Parenthood clinics around the West, said it’s hard to sit with the idea that nine judges are making a decision about the medical science and safety of a drug.

“That’s just unprecedented, they are not to be the experts in that, and them getting to have a say on that, that’s a big deal to me,” Berry said. “And it has implications on all of our lives.”

Berry sees patients from all across the country in various clinics, including people from as far as Louisiana and Texas who travel to Seattle, often because they know someone who can help drive them home from an appointment and offer them a place to stay. But that alone is disruptive to a person’s privacy, she said, because if care was accessible in their home state, they might have been able to keep a very personal event to themselves.

Cynthia Dalsing, a retired nurse midwife in Sandpoint, Idaho, said restrictions have made local providers more wary about how they interact with pregnant patients, including how they reflect a patient’s demeanor in a medical chart. Abortion restrictions have made people second guess their decisions about evidence-based medical care out of fear, she said.

Dr. Caitlin Gustafson, an OB-GYN in a rural area of central Idaho, still regularly prescribes mifepristone for miscarriage management, and based on evidence, she said using it for that care results in fewer visits to the emergency room and a reduced need for procedures that empty the uterus. Access to the medication in Idaho is already more restricted because only providers can dispense it, not local pharmacies. Some people already have to drive more than an hour to get to a clinic in the case of a miscarriage, she said.

“As we lose providers (to other states) and then further lose access to this medication, if that’s what the Supreme Court does, it will make that experience harder,” Gustafson said.

In the year and a half since the abortion access landscape exploded into chaos and confusion, attorneys like Ling spend their days answering desperate phone calls on the Repro Legal Helpline, which is managed by If/When/How. Earlier this year, If/When/How joined a network of reproductive rights legal assistance groups and law firms called the Abortion Defense Network.

The helpline has been around for a few years, but the end of Roe v. Wade saw inquiries increase by 2,460%, If/When/How’s legal support director Kylee Sunderlin told States Newsroom earlier this year. Sunderlin said many people call before they ever see a provider about a suspected pregnancy or a pregnancy that’s turned into a health emergency because they’re scared about the legal consequences. She said most people don’t understand what is and isn’t legal these days.

On Wednesday, Ling reiterated that If/When/How is committed to helping people navigate these complex and ever-changing laws.

“This case is a further weaponization of the courts to deny people bodily autonomy,” Ling said. “But no matter what the court says, people will always have abortions. Myself and the rest of If/When/How are here to provide people the legal support they need to access the abortions they want and help them fight back against state violence.”

In states with extremely limited abortion access, like Idaho, some people are actively avoiding pregnancy.

Makayla Sundquist, 27, lives in North Idaho and said she has been with her partner for seven years and would consider having children if abortion access was available. She lives in Sandpoint, a rural area of about 9,000 people, where OB-GYN services are no longer offered at the county’s only hospital after the unit closed in March, citing staffing issues and the political environment of the state, where a near-total abortion ban has been in effect since 2022. The closest area with OB care is Coeur d’Alene, which is an hour-long drive both ways.

“We saw it when Roe fell, the number of vasectomies in young men rose dramatically, and I think so many people in red states are realizing that if they want children, this is not the place for them, and I fall into that demographic,” Sundquist told States Newsroom on Wednesday.

Sundquist said she can’t fathom a reason why the U.S. Supreme Court would further restrict a safe and well-tested medication when the other option for an abortion — a procedure that empties the contents of the uterus — is more invasive, but she thinks it’s a real possibility. According to the FDA, 28 deaths out of an estimated 5.6 million people in 23 years have been associated with mifepristone’s regimen for terminating a pregnancy, which is a markedly lower rate than many common FDA-approved drugs, like Tylenol and Viagra. The FDA notes that a small number includes fatal cases “regardless of causal attribution to mifepristone,” including people who died from homicide, suicide, and pulmonary emphysema.

“I will be angry and scared for the people in my life that would need (an abortion), me included if it came to it, but I would not be surprised if that’s what happens, unfortunately,” Sundquist? said.