Providing Care After Roe, These Doctors Met a Hurdle They Didn’t Expect

One chilly morning last December, Rose, a family medicine doctor who lives in the northeast of the U.S., woke up to an inconvenient surprise: She’d been booted off Square, the online payments platform.

For many this might seem like a simple annoyance. For Rose it was much more consequential. 

For nearly six months, Rose, whose name has been changed to protect her identity, had been prescribing and mailing abortion pills to patients across the country, predominantly to individuals in states with severe restrictions—or outright bans—on abortion. She handles all her patient payments through a combination of online payment processors, like Square. Without them, she can’t get paid, and if she can’t get paid, that will bring her caseload of online abortion services—which can comfortably exceed a thousand a month—to a grinding halt.

Rose is one of just over a dozen U.S. healthcare providers leveraging so-called telemedicine shield laws—legislation that has come into effect largely in response to Dobbs v. Jackson Women’s Health Organization, the landmark 2022 Supreme Court decision that bulldozed a woman’s constitutional right to an abortion in the U.S.

The shield laws, which have so far—starting in 2022—been enacted in eight Democratic-led states, are designed to explicitly protect licensed doctors, nurse practitioners and midwives who are prescribing and sending abortion pills to patients in other areas of the country where abortion access is deeply restricted or under threat.

Ever since Rose started sending pills to patients in states including Texas, Louisiana and Arkansas, she’s known that she’s a pawn in a battle between those who think women should be able to end a pregnancy via mailed pills and those who don’t. The obstacles to providing care in a field of medicine that’s become a monumental political battleground are well-established. As of August, more than 20 states have banned abortion outright, or have enforced severe restrictions on the procedure. What’s unexpected, though, are the significant headwinds stemming from the tech sector.

She knows she’s a pawn in a battle between those who think women should be able to end a pregnancy via mailed pills and those who don’t.

Rose says that when Square booted her from the platform it did so overnight and without warning. A spokesperson for Square, when contacted by The Persistent, said, per its terms and conditions, the platform does not support so-called “card-not-present payments for any type of medication or pharmaceuticals”—which include online, mail order or telephone orders.

This makes sense to Rose, but what she doesn’t understand is why at first she was able to use the platform and then suddenly she wasn’t; it’s a flip-flop that has seriously curtailed her ability to do her work. (According to a payments industry veteran, the flip-flop is, in fact, caused by a lag between acceptable use policy review and enforcement at the merchant level. This can take months or, in some cases, even years.)

How It Works

In theory, abortion services via telehealth—as provided by people like Rose—can extend life-lines to individuals needing or wanting to terminate a pregnancy. 

A patient, regardless of where in the U.S. they’re based, can fill out an online intake form that’s then reviewed by a medical professional. Patients aren’t required to have a face-to-face video call. This so-called asynchronous consultation is dynamic, meaning that as a patient progresses through the questionnaire, the questions change based on the responses. If, for example, a patient indicates that they’re already 20 weeks pregnant, they’ll be informed that they’re too far along for a medical abortion using pills. 

Other questions the patient needs to answer on the intake form relate to medical history and medications, allergies, previous pregnancies and whether they have access to a hospital or other healthcare resources. Patients are asked whether they’re pregnant but don’t need to provide a pregnancy test or ultrasound as proof. “We trust women,” says Rose. 

If the patient is in a state in which abortion is restricted, they can legally be prescribed abortion pills and receive these in the mail from the prescribing clinician, as long as the prescribing clinician is in one of the eight states covered by the shield laws: California, Colorado, Maine, Massachusetts, New York, Rhode Island, Vermont, and Washington. 

Some clinicians have been buying the pills themselves, packaging them, labeling them and mailing them directly to the patient. Others submit an electronic prescription for the pills to a mail-order pharmacy that then takes care of the logistics. At first, Rose was doing all of the labeling and mailing herself, but she’s recently started collaborating with a pharmacy that takes care of those logistics, allowing her to focus on providing the care that her patients need. 

“I was operating at a loss, which was scary. But I wasn’t alone. I actually don’t know of a single provider of abortion services like these who has not encountered this problem.”

Generally, Rose charges $150 for abortion services—which includes an asynchronous consultation, the prescription and mailing the pills (the pills alone cost her about $70)—but like some other providers she offers a sliding scale: If a patient can’t pay, she’ll ask what they can afford and bridge the gap herself.

The costs are burdensome for many patients. Some don’t have insurance or don’t want to rely on the insurance they do have because it’s a shared plan and they don’t want the primary insurance holder to be alerted, according to research by the School of Public Health at the University of Washington. Rose doesn’t accept insurance and many insurance plans don’t cover any abortion services anyway.

In cases in which patients don’t have their own credit card or bank account, friends, family or acquaintances who are willing to step in to cover costs, have relied on payment solutions like Stripe, Square, PayPal, Zelle and Venmo. All of Rose’s fees are collected through payment platforms like these. 

Providers working with payment platforms

In the weeks that followed her experience of being denied Square’s services, Rose tried another payment solution, Stripe, but again she was kicked off the platform after about three months, she says. But Stripe’s rationale was confusing.

Rose says the reason Stripe gave her was that she’s in the business of marijuana. According to Stripe’s terms and conditions, it will not provide services to any business that buys or sells “cannabis products.” 

Rose explains that—in her capacity as a family doctor—she issues medical marijuana certifications required by individuals wanting to use it for palliative care. But she doesn't buy or sell cannabis products. “I’m just stating that someone has a medical reason to take it.” 

When I reached out to Stripe for further clarification, a spokesperson declined to comment, but pointed me to the company’s restricted businesses list, which states that online pharmacies, prescription delivery services and telemedicine providers cannot use Stripe’s services without pre-approval from the company. “In general, payments for prescription medication need to occur outside of Stripe,” the spokesperson told me. 

Meanwhile, the service agreement for Zelle, a payment platform which Rose hasn’t used, stipulates that users agree not to send or receive money related to “pharmaceuticals and other controlled substances.” (Zelle did not respond to The Persistent’s request for comment.) PayPal, which owns Venmo, requires pre-approval to accept payments for services including “prescription items” and “telemedicine services.” A spokesperson for PayPal declined to comment further.

Carmel Shachar, an assistant clinical professor of law, and the faculty director of the health law and policy clinic at Harvard Law School, says that to her, the tech platforms’ caution isn’t surprising. “Payment companies operate in multiple states and have a strong interest in being able to provide services in all states,” she says. “So they are under a lot of pressure to respect state abortion bans, even if shield laws would give them cover.”

One of Many Hoops

Considering the significant headwinds that women trying to get an abortion are already navigating, concerns about payment platforms might seem minor, but the reality is that blocking payment platforms has the potential to bring these services to a grinding halt. 

Emily, an obstetrician and gynecologist who’s based on the East Coast and whose name has also been changed to protect her identity, says that she, like Rose, started mailing abortion pills to patients across the country in June 2023, when the telemedicine shield laws were first enacted.

After a few months, “I was shut down by every payment platform I tried,” she says, naming Square, Stripe and PayPal. She says she was never able to get an answer out of the platforms as to why she was kicked off. “I didn’t know whether the problem was me and my work, or something else entirely,” she adds, noting she didn’t hear back.

Soon Emily started hearing from other physicians, who were also providing abortion services through telehealth. Online payment platforms were not only denying them access, but were preventing them from accessing patient payments that were being transacted through the platform.

And then it happened to Emily: One payment platform “held” $15,000-worth of accrued patient payments for the prior six months. She could see on the app that she’d received money, but the payment platform didn’t release it into her personal bank account for half a year. Several sources at different payment platforms told me that this was common protocol in the industry—a practice companies use if they suspect a breach of the user agreement or illicit behavior. 

“I was operating at a loss, which was scary,” Emily says. “But I wasn’t alone. I actually don’t know of a single provider of abortion services like these who has not encountered this problem.”

1,500 Patients a Month

With demand for their services surging, the challenge of securing a reliable payment platform has become more urgent than ever. 

According to the Abortion Coalition for Telemedicine—an advocacy organization working to advance telemedicine abortion in all states—about one-fifth of all abortions are already done remotely, through telehealth. This number is growing. For a single provider, like Rose or Emily, this can mean virtually consulting as many as 1,500 patients in a single month in order to meet demand.

Elisa Wells, a public health specialist and the co-founder and co-director of Plan C, an information resource for self-managed, at-home abortion with pills, explains that this high demand means that it’s important for providers to have a reliable way to process payments to ensure the sustainability of their services.“These patients are often at a point of real crisis. They don’t need to be going here, there and everywhere to be able to get what they need. They need to be able to rely on one provider and one payment method for everything they need,” she says. 

There are parallels to be found with the cannabis industry, where payments are also an issue. 

There’s a “whole cottage industry of payments-startups that have cropped up to service the cannabis industry,” says Jeremy Berke, the founder and editor in chief of Cultivated Media—a newsletter about the cannabis industry—who has covered the cannabis industry for years. 

Some e-commerce CBD brands now use high-risk payment processors that charge huge fees. Other dispensaries use third-party payment processors that charge customers high fees to use their debit or credit card to check out, he says. They may also “manipulate their merchant contact code to show they are a restaurant or a bakery or a business that doesn't sell cannabis, though this is illegal.”

Oregon-based LegitScript provides another potential solution. The company offers a certification service to vendors. Once certified, vendors can present their certificate to payment platforms to facilitate the approval process. It’s particularly designed to accommodate vendors in so-called “high-risk industries,” like CBD products and the sex trade (or “adult entertainment,” as payment providers tend to refer to it) for example. 

But where LegitScript may have worked for some vendors in the cannabis industry, it’s hardly a panacea for abortion service providers, says Wells—particularly those providers that are offering new types of services such as asynchronous telehealth care or are operating under shield laws. 

First, getting certified can be expensive, and second, some providers are concerned about sharing information with a third party—particularly information that might be used against them in a legal case. 

Providers concede the challenges are significant, but they keep going because, as Emily puts it, the impact of not being able to get an abortion can be “seismic.”

A major study published by the University of California, San Francisco—UCSF—in 2020 found that women seeking an abortion who were turned away and went on to give birth, experienced an increase in household poverty lasting at least four years relative to those who received an abortion. It also found that years after an abortion denial, women were more likely to be short on funds to cover basic living expenses like food, housing and transportation, and that being denied an abortion lowered a woman’s credit score, increased her debt, and raised the chances of her experiencing other “negative public financial records” such as bankruptcies and evictions.

The study, which was conducted across a thousand women in 21 states—both red and blue—making it the largest of its kind at that time, also concluded that physical violence from the man involved in the pregnancy decreased for women who received abortions but stayed the same for the women who were denied abortions and gave birth. 

A separate study, published in the Journal of Midwifery and Women’s Health, in December 2023, found that telehealth, in particular, improved access for patients seeking abortion services. “Removing restrictions on telehealth for the provision of abortion services may further improve access to care and promote greater health equity,” the authors of that study concluded.

"We need greater investments in building sustainable systems to help people access abortion online. Right now, abortion providers themselves are subsidizing care.”

There’s also the fact that abortion pills are now by far the most commonly used method to end a pregnancy in the U.S.

Cecile Richards, the former president of Planned Parenthood and a co-founder of Charley—a chatbot that helps individuals access abortion care—told The Persistent that “interest in pills by mail has skyrocketed in recent months—especially in states with abortion bans or severe restrictions”. “They are an incredibly vital resource for abortion seekers in places where they may have no other options,” she said.

But time and time again, we’ve seen that “politics can stand in the way of even the best technology and the highest quality health care,” said Richards.

“In addition to fighting these battles in the political arena, we also need much greater investments in building sustainable systems to help people access abortion online,” Richards said. “Right now, abortion providers themselves are subsidizing care.”

Championing Reproductive Rights

The abortion providers I spoke to for this piece acknowledged the importance of payment platforms having a robust user agreement to protect customers from illicit and dangerous substances that might be sold under false pretenses or by rogue pharmacies. (Indeed, the United States Food and Drug Administration recently warned of bad actors.)

Nevertheless, one of the things that particularly frustrates the providers about the payment problem, is that—although the tech companies are of course entitled to establish the terms and conditions they want and feel comfortable with—many have vocally advocated for reproductive rights, both in the lead up to, and in the aftermath of, the Dobbs decision. 

In its 2023 corporate and social responsibility report, for example, Block Inc., the parent company of Square, announced that “throughout 2023, Block continued to cover comprehensive reproductive health services in the U.S., including voluntary and involuntary abortion services.” It also said that it had “expanded medical travel and lodging coverage to include abortion services for any employee and/or their dependent who has to travel more than 100 miles from home to access in-network services.” 

Jack Dorsey, the chief executive of Square, in 2019 also put his name to a full-page ad in the New York Times calling on companies to “stand up for reproductive health care.”

“It shows hypocrisy,” says Rose. “They are all concerned with their liability and profits over commitment.”

“It feels like virtue signaling,” says Emily. “It’s been so hard to get strong and powerful advocates on board and to me it feels like huge corporations are cowering. They’re afraid to join the fight,” she adds.

For now, both Rose and Emily say it’s day to day as they keep an eye on the legal landscape and political backdrop.

Donald Trump, in his campaign for reelection in November, has so far steered clear of strict abortion language. He has, however, taken credit for setting up the 2022 reversal of Roe v. Wade by the Supreme Court. The American Civil Liberties Union, meanwhile, in a recent report warned that a second Trump presidency “would present an existential threat to abortion access nationwide, imperiling the ability of anyone to get an abortion anywhere in the country under any circumstance.” His running mate JD Vance has been a vocal opponent to abortion. 

Kamala Harris, the presumptive Democratic nominee for president, meanwhile has pledged to “restore reproductive freedom," which her campaign has elaborated, means restoring Roe v. Wade.

Emily says that regardless of the outcome in November’s election, legal cases are likely to be on the horizon. “So for now I’m just going to keep following the law and doing what I’m doing.” 

Rose is not giving up, either. “What other choice do we have?” she says. “As long as these basic rights are under threat, I’m going to keep doing what I’m doing. As a physician, that’s just my duty.”

Josie Cox is a journalist, author, broadcaster and public speaker. Her book, “WOMEN MONEY POWER: The Rise and Fall of Economic Equality,” was released in March.