What do the recent rulings on medication abortion mean for access in Minnesota?

Minnesota's abortion providers had been bracing for weeks for a ruling expected to complicate the future of one of the drugs used in medication abortions.

That ruling landed in early April, when U.S. District Court Judge Matthew Kacsmaryk in Texas ordered a hold on federal approval of mifepristone, a decision that overruled more than two decades of authorization of the drug.

While abortion is still legal in Minnesota, abortion rights advocates say the ruling has the potential to be even more consequential in the state than the overturning of Roe v. Wade last summer. More than half of abortions in the state are done through the use of a medication regimen that includes mifepristone.

"This judge has reached across state lines and brought the abortion crisis to Minnesota and every other state that still protects abortion rights," Megan Peterson, executive director of Gender Justice, an abortion rights legal nonprofit, said after the ruling.

Abortion opponents in Minnesota celebrated the Texas ruling, arguing the U.S. Food and Drug Administration (FDA) improperly approved the drug more than 20 years ago and then expanded access to the medication by mail and in pharmacies.

"Judge Kacsmaryk is right to recognize the major flaws in mifepristone's approval process," Minnesota Citizens Concerned for Life Co-Executive Director Cathy Blaeser said in a statement.

But the ruling doesn't mean access to mifepristone will end immediately, and a conflicting order issued by a different judge in Washington could affect the availability of the drug in Minnesota. State abortion providers also say they're prepared with an alternative for Minnesotans seeking medication abortion.

Here are some answers about what's next in Minnesota following the dueling court rulings.

What is mifepristone?

Mifepristone is a drug that was approved by the FDA in 2000 and is used in Minnesota and other states with abortion access as part of multi-pill regimen to end pregnancies before 10 weeks. Mifepristone is a hormone blocker that stops the growth of the pregnancy. A second pill, known as misoprostol, effectively induces a miscarriage. The mifepristone pill is taken first, followed by misoprostol pills.

Did the ruling out of Texas immediately stop the use of mifepristone in Minnesota and other states?

The judge in Texas granted a preliminary injunction stopping the FDA's approval of mifepristone, allowing the federal government to file an appeal. Less than a week after the initial ruling, the 5th Circuit Court of Appeals allowed allowed mifepristone to remain on the market as the case continues in court, but with severe restrictions.

The court ruled mifepristone can only be used up to seven weeks of pregnancy, instead of 10, and can only be dispensed by a physician. The federal court also blocked the ability to send the drug via the mail.

The Biden administration filed an emergency request with the Supreme Court to preserve access to the drug — free from restrictions — while the legal fight continues. The court agreed with that request, allowing mifepristone to be used without restrictions while the legal case continues.

What does the other ruling out of Washington mean for Minnesota?

About an hour after the Texas ruling was issued, U.S. District Court Judge Thomas O. Rice in Washington blocked the FDA from restricting availability of mifepristone in 17 states that filed a lawsuit aimed at protecting access to the drug. Minnesota Attorney General Keith Ellison joined that lawsuit with other Democratic attorneys general.

Ellison said he expects no change in use of mifepristone for Minnesota given its role in the Washington case, meaning the drug should continue to be available in Minnesota without restrictions while legal challenges continues.

"Mifepristone remains an approved drug for abortion," said Ellison. "I want to remind everyone, this is an evolving situation, things are changing rapidly. Nobody can honestly say they know exactly what is going to happen, but we are committed to making sure people have the right to make their own reproductive choices."

What do Minnesota abortion providers say?

Planned Parenthood North Central States Chief Medical Officer Sarah Traxler said that the state will continue to provide the current two-pill regimen in Minnesota because of the state's role in the Washington lawsuit.

"We're lucky to live in Minnesota," she said. "We will be practicing evidence-based standard of care in Minnesota."

Amy Hagstrom Miller, founder and CEO of Whole Women's Health, which operates six clinics in five states, including Minnesota, said shortly after the Texas ruling that their clinics will continue to dispense mifepristone in person and by mail unless the FDA tells them to do otherwise.

"It means that the ball is in the FDA's court. Judge Kacsmaryk — or any other judges — can't give our doctors orders," she said. "It's my understanding that the FDA and the Department of Justice have a lot of options that wouldn't necessarily be immediately removing that drug from the market."

What happens if mifepristone is eventually taken off the market?

Abortion providers in Minnesota have said they will switch to a medication abortion regimen that uses only the second drug, misoprostol, which is used in countries where mifepristone is unavailable.

"We are waiting to see when that appeal hearing will be set and we'll go from there," said Dr. Julie Amaon, medical director with the Minnesota-based telehealth clinic Just the Pill. "We are prepared to offer the safe and effective misoprostol-only regimen to patients if needed."

Is misoprostol as effective as the combined medication approach?

Studies have shown that the single-drug approach has a slightly lower rate of effectiveness in ending pregnancies, and it can cause more side effects for the patient, such as nausea. But the World Health Organization has endorsed the use of misoprostol alone as safe for early abortion in cases where the other drug is not available.

Could misoprostol lose its FDA approval too?

That's less likely. Misoprostol has been available for decades and is also used to induce labor and for miscarriages where the fetus has stopped developing but is still in utero. It's also used to treat medical conditions such as ulcers.

How common is medication abortion in Minnesota?

Sixty percent of abortions in Minnesota were performed through medication in 2021, increasing from 3,522 in 2016 to 6,157 in 2021, according to an annual report released in July. That report came out one week after Roe was overturned by the Supreme Court.

What's next?

It's widely expected that the case will end up before the U.S. Supreme Court, which will determine if the judge's order blocking the approval of mifepristone will continue. The Supreme Court could also weigh the dueling ruling in Washington.

Does this change the debate at the Minnesota Capitol?

Minnesota lawmakers codified abortion rights in a proposal signed into law at the end of January. No legislation being debated at the Capitol would safeguard the use of mifepristone in Minnesota, but several Democratic legislators said Monday that the ruling underscored the need to pass a proposal to protect patients and providers traveling to Minnesota for abortions and another to repeal statutes on the lawbooks that restrict access to abortion.

"We were told that the work didn't need to be done in Minnesota because we were a state that already protected reproductive rights," said Rep. Kaohly Vang Her, DFL-St Paul. "But [what] we are seeing now is the overreach from other states, continuing to limit individual liberty to choose."

Those bills are moving both separately and as part of a broader Human Services budget package.

Staff writers Jeremy Olson and Emma Nelson contributed to this report.