In the aftermath of Roe, telehealth startups rush to fill the abortion pill market

In October, the telemedicine abortion startup Hey Jane announced that it had secured a $6 million series A round, barely a year after it drew more than $3 million in seed funding. Since its launch in early 2021, Hey Jane has served nearly 20,000 patients and now provides medication abortions—a two-pill regimen that ends a pregnancy—in eight states. With its latest capital infusion, cofounder and CEO Kiki Freedman hopes to reach more patients and expand access to abortion pills.

“We just saw this massive influx of interest around the time of [the Dobbs decision],” she says. “This has been a really critical need for a long time, but I think it’s really at the forefront of people’s minds now. And I think people are also starting to realize you can no longer take a neutral stance.”

Hey Jane is operating in a space that’s been ripe for expansion since last year, when the FDA lifted restrictions on prescribing abortion pills via telemedicine—first in response to the pandemic, then as a permanent decision. A number of competitors, among them Choix and Abortion on Demand, are similarly focused on the abortion pill, while clinics like Carafem provide telemedicine abortions in addition to in-person care. Other telehealth startups, from Wisp to Carbon Health, have added medication abortion to their lineup of services over the last year.   

Many of these startups share Hey Jane’s mission—to make medication abortions more convenient and accessible at a time when legislators across the country are taking drastic measures to criminalize abortion. While their services will no doubt benefit people seeking abortions, it’s not clear that these companies can adequately serve the communities that face the greatest hurdles to accessing care, whether they’re residents of states where abortion is illegal or low-income folks who are more likely to experience an unintended pregnancy. “Almost by definition, the people who need abortion care in the most urgent way are poor, and they have very limited resources,” says Dr. Jamie Phifer, the founder and medical director of Abortion on Demand.

Most telehealth companies use a model similar to that of Hey Jane, which involves filling out a questionnaire and consulting with a physician before patients receive the abortion pill; the whole process is structured to take just a few days, to ensure people get the medication they need as quickly as possible. Beyond speed and convenience, telehealth allows companies to provide abortion pills for somewhere between $200 to $300, well below the national average of $560; companies like Hey Jane and Choix also use a sliding scale to make medication abortions more affordable for low-income patients. The majority of telehealth providers are operating in a handful of states that boast strong abortion protections—the likes of California and New York—with plans to expand further. (Abortion on Demand is a bit of exception, providing abortion pills across 23 states in some capacity.) 

Even as other companies wade into the business of abortion, it’s easy to see why investors believe Hey Jane has the potential to scale telemedicine abortion services; its sleek branding and meme-heavy social media presence will feel familiar to regular patrons of other direct-to-consumer brands. (“We are the first digital abortion clinic to be verified on Tiktok and Instagram,” Freedman noted.) It’s not hard to picture startups like Hey Jane becoming a destination for patients who are merely looking for a quick, convenient alternative to visiting a local abortion clinic. The patients who may be best served by telemedicine abortion are those who not only medically qualify, but also have “internet access, language competency, and a safe place to have their abortion,” according to Phifer. (Her clinical team has more than 20 years of experience working in abortion care, largely in independent clinics.) For a venture-backed company, there are also financial incentives to court patients through Google and social media to quickly increase market share.

“Since Dobbs, there have been a lot of very well-meaning startups entering an oversaturated market,” Phifer says. “We have, I think, done a great job messaging that: ‘Telehealth abortion is safe [and] easy. We’re trying to make it as accessible as possible. It’s medically uncomplicated for the vast majority of folks.’ [But] there is still some nuance. There are folks who don’t qualify for telehealth abortion or don’t want telehealth abortion. Without some really thoughtful processes in place, we might lose access for those really vulnerable people.”

While some of its competitors have also raised venture capital funding—Choix closed a $1 million seed round this year—Hey Jane has attracted far more. Until recently, founders in this space have been up against considerable challenges, including skittish investors; in some cases, funds even explicitly forbid any investments in abortion care. There are other investors—like Elizabeth Bailey and Stasia Obremskey at RH Capital, which backs companies in reproductive health—who simply aren’t convinced that the market for telemedicine abortion alone is large enough, and that abortion pills should be offered alongside other healthcare services.

The new interest in startups like Hey Jane may be driven in part by “moral imperative,” as Freedman describes it, but some investors might just see it as a good business opportunity. (Prior to the election, a coalition of more than 100 venture capital firms came together to denounce criminalizing abortion, calling it a violation of human rights and “anti-innovation.”) “I think it’s a really interesting space to raise for because it is such a clear problem, and the risk around traditional product-market fit is so limited relative to a traditional startup,” Freedman says. “We’ve gained quite a bit of traction as a business, and I think people can now see this is a safe and effective way to provide care—and it’s a way to provide care that patients really like.” (Hey Jane’s fundraising record may also have something to do with Freedman’s pedigree as an alum of Bain and Uber.)

Of course, as funding has flown into this space over the last two years, the legal landscape has dramatically changed. Even before Roe v. Wade was overturned, the states with the most restrictive laws largely prohibited telemedicine abortions. The Supreme Court’s decision cemented those restrictions and, in some cases, triggered new bans on telemedicine. Unlike organizations like Aid Access, which operates in a legal gray area by providing abortion pills in states where the procedure is banned, startups like Hey Jane are restricted to only serving patients who can legally access telemedicine abortion, which hampers their ability to scale. Hey Jane has tried to distinguish itself by offering additional support like a community forum, but the post-Roe legal reality—and investor expectations—help explain why Freedman has ambitions to diversify into, say, postpartum care and other services. By the end of next year, she says, her hope is for Hey Jane to serve patients in every state. 

Many telemedicine providers see their role as absorbing patients in states where abortion remains legal, especially as demand from out-of-state residents swells. “Telemedicine is not the panacea, [but] we do see in-person clinics operating under a lot of strain right now, because they are serving patients from across the country in ways that they haven’t had to before,” Freedman says. “So in the states that are protecting access, there just needs to be more channels and avenues to receive care.” They believe telemedicine abortion startups can not only help relieve the burden on clinics and providers, but also free them up to focus on patients that require in-person medical attention or later abortions.

Freedman and other founders are quick to describe their competitors in telemedicine as partners, arguing that augmenting abortion access is a net positive. “The same sort of problems that indie clinics face for advertising come up for us,” says Cindy Adam, a nurse practitioner and the cofounder and CEO of Choix. “Sometimes we’re seen as being in competition, but I would argue that it’s the space and the environment that kind of pits us against one another. I really caution folks against pitting abortion providers against one another because we all need to find ways to work together.” 

Many telemedicine abortion startups cite their grassroots efforts to get the word out—partnering with local abortion funds, clinics, and other organizations. Hey Jane regularly raises money for abortion funds and is currently working to set up insurance coverage, including Medicaid. Choix is building out a B2B arm to help companies coordinate abortion benefits, with plans to eventually provide practical support (which includes travel costs and logistics) for all kinds of patients, including those in states where abortion is illegal. It’s also true that many patients have responded well to telemedicine abortion care, as Carafem found when compiling patient feedback prior to launching its telemedicine product more widely. “They found it effective [and] preferable,” Grant says.

Still, while the majority of abortions do take place within the first trimester—early enough that telemedicine care could be a viable option—there are plenty of people who need in-person care or don’t qualify for a medication abortion. Since the cost of operating a telehealth-first model is lower, these startups are also able to undercut the average price of a medication abortion in a clinic setting. Grant worries that patients may not be exposed to the full spectrum of abortion care as telemedicine startups grow, or that their options aren’t being presented uniformly if at-home medication abortions are markedly cheaper.

“Telehealth cannot exist at the expense of in-person care,” she says. “The opportunity to seek new options for clients through innovation was part of what Carafem was founded on. We really wanted to be able to take advantage of newer, more efficient ways that were more client-centered. [But] there is some concern that the patient should be the ones who decide what kind of abortion is best for them—to understand the whole array of options, and to be able to choose what feels right.”

And while there’s currently a growing pool of capital in this space, it’s not clear how long the runway might be for these startups, or whether they can parlay that funding into a sustainable business. “When there’s an influx of money into various organizations, it allows them to do things that they may not be able to do long term,” Grant adds, pointing to how it may aid their initial marketing efforts. “If they’re not going to be there for the long term, then does that potentially perpetuate a problem? [Then] we haven’t really helped to inform people or gained trust—we’ve just flooded the market with brief connections that aren’t sustaining. I don’t know that answer. But it is concerning for those of us who’ve done the work for a long time.”

As more startups enter this space, there’s also the risk that they might take business away from small, independent clinics that are unable to invest resources in telehealth, inadvertently making it harder for them to stay afloat and provide other essential services. “I think that more indie clinics in the near future are going to be able to do telehealth,” Phifer says. “But it’s my colleagues who’ve been doing this for 50 years and trying to take care of some of the most vulnerable patients—often at great expense to themselves—who just don’t have the resources to start a telehealth model.” 

Some investors and startup leaders may believe this is just the cost of doing business—that innovating in this space will lead to some upheaval, especially as more patients gravitate to telemedicine abortion. Obremskey, the managing director at RH Capital, says that to stay in business, indie clinics will have to find ways to expand beyond their traditional suite of services. “It was inevitable that the market was going to move this way,” she says. “I would like to see the the abortion industry get reabsorbed into the healthcare industry. There’s going to be a lot of short-term pain and disruption, and some of those clinics are going to have to figure out whether they just want to be a specialty clinic in abortion, or whether they can, like Planned Parenthood, try to expand their breadth of services beyond just abortion care. There are going to be some winners and losers—that’s just the way it works in markets.”

But it’s patients who will bear the brunt of those losses if more clinics are forced to shutter as they face competition from telehealth companies and the continued fallout of Roe being overturned. That’s one reason Phifer donates a majority of Abortion on Demand’s profits—60%, she says, the IRS limit on charitable contributions—to independent clinics. “We are focused on doing our utmost to make sure that the presence of telehealth doesn’t dilute resources,” she says. To bring in additional revenue and help clinics streamline their operations, Abortion on Demand is also licensing its own text-based follow-up system. 

Still, as Phifer watches companies like Hey Jane attract more and more funding, she worries about the potential impact to her own company and independent clinics—and the ripple effects of scaling telemedicine abortion care. “I do push back against the term ‘increasing access,’ she says. “Are telehealth startups—especially now, it’s so oversaturated—really increasing access? And if so, for whom? As a community of telehealth abortion providers, I want to see us have an analysis of the overall ecosystem. Who are we really trying to help here?”