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Reproductive Health and Shield Laws: Latest Developments

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Texas’ attorney general recently filed a civil lawsuit against a New York physician for prescribing medication abortion pills via telehealth to a woman in Texas. Natalie Birnbaum, State Legal and Policy Director, RHITES, and Krusheeta Patel, Associate, Manatt Phelps & Phillips LLP, discuss this first open challenge to abortion shield laws and the intersection of telehealth, abortion access, and interstate licensure pathways for U.S. providers.

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Speaker 1:

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Speaker 2:

Hi, A HLA listeners, my name is Natalie Birnbaum and I am joined by Khi Patel . And we are here to discuss the intersection of telehealth, abortion access, and interstate licensure pathways for US providers. Our conversation will center around a civil lawsuit filed by Texas Attorney General Ken Paxton. Um, he filed this lawsuit against a New York physician who provides telemedicine for medication abortion care out of New York State. But before we get into all of that, we will start off with some intros. So my name is Natalie Burnbaum . I use she her pronouns. I am a healthcare regulatory attorney and the state legal and policy director at rights. Rights stands for the Reproductive Healthcare Initiative for Telehealth Equity and Solutions. And we are the only organization driving change at the intersection of telehealth and reproductive health rights and justice communities. We equip telehealth for medication abortion providers, repro advocates, and the telehealth industry with strategic resources to make well-informed, sustainable and long lasting change. I'm also the founder of Repro Solutions Law, which specializes in advising telehealth providers and companies in the reproductive healthcare space .

Speaker 3:

I'm so happy to be here with you, Natalie. I am Khi Patel. Uh , I use she her pronouns, and I am a healthcare compliance and regulatory attorney , um, working as an associate at the New York office of Manat Phelps and Phillips . I have a particular, particular interest in focus on supporting women's healthcare providers navigate these complex regulatory issues, especially in the Postops era we find ourselves in now. And I also advise providers in emerging health tech and service companies working in the telehealth space.

Speaker 2:

Thanks, cci . I'm so excited to have this conversation with you . Um, for our listeners, Chrisie and I had a great chat about, about what we're gonna get into yesterday and , um, we hope that we'll be able to shed some light on on the Texas lawsuit and the related issues at hand. So in a landmark piece of litigation, Texas AG Ken Paxton filed the civil lawsuit against a New York doctor for prescribing medication abortion pills to a woman in Texas using telehealth. Now most of us know that medication abortion is safe and effective and has been on the market for over 20 years. When it was initially approved by the FDA today medication, abortion accounts for 60% of all abortion care. Still, this lawsuit seeks up to $250,000 in civil damages and marks the first open challenge to the abortion shield laws , which we'll explain and , and get into shortly. So , um, the use of telehealth for medication abortion as, as we all know , um, has been real lifeline for many pregnant people in states with restrictions in place. And regardless of the final holding of this lawsuit, it is already having a chilling effect on who, who would be a potential prescriber institutes that were considering having telehealth for medication abortion practices, whether just within their state or outside of their state. And the confusion is definitely already trickling in, in both of our circles and, and the broader public. So we are, we are excited to hopefully dispel some of that today. Ultimately, this lawsuit will also strip test the strength of shield laws in court for the first time pitting New York's protections against the Texas restrictions. It is unclear what the outcome will be, but Texas will argue that providers not licensed in Texas are facilitating illegal care within its borders. And New York will argue that its state law permits the provision of care, or at least protects from the provision of care , um, by providers within its state's borders. So we will get into that shortly. And just as a reminder, while 60% of all medication of all abortion is done through medication abortion, the most recent data shows us that in October, out of , from October, 2024, that telehealth itself accounts for 20% of all medication abortion care, and about half of this care comes from providers who are licensed in states with , um, with shield bots. So yeah, I'll pass it over to you. Cida , add anything I may have missed?

Speaker 3:

No, you said it best, Natalie, this is really a landmark sort of first of its kind case, and I haven't seen anything , um, like about a case against a provider that's quite like this one. Um, the, the petition asks Texas Court to impose , uh, quite a few really impactful , um, violations against , uh, the New York provider. And so some of that relief would be a temporary and permanent injunction that would enjoin the provider violating Texas laws that require a Texas license to practice medicine in the state, as well as the Texas abortion ban. Um, and then also civil penalties of a hundred thousand dollars per violation , um, of the state's abortion ban. And it's really unclear sort of what, what that per violation even means. This could really , uh, snowball into something that , um, affects every single prescription that's been written, every single patient that's been seen. Um, and as you said, telehealth is really the way that we're seeing access to abortion care get stay protected in the nation. And so , um, it's really concerning that these might be some of the things that are at stake in this lawsuit. Um, interestingly, the complaint doesn't even actually allege that either the provider or the patient were physically located in the state where the abortion medications were prescribed. So it's , um, to your point, there's what matters most is really the impact of the litigation. And litigation doesn't have to be successful, quote unquote , um, to be impactful. And I'm really worried about what a ruling in favor of the Texas Ag could do in terms of a chilling effect on providers who are working in the telehealth space broadly. Um, and unfortunately it's underserved communities that bear the brunt of that impact.

Speaker 2:

Yeah, yeah, absolutely. And I think, like, I just wanna highlight the last thing you said that this really impacts the telehealth community broadly and telehealth providers broadly. Why? Because as you mentioned, two of these claims have absolutely nothing to do with abortion. They're just, it's practicing medicine without a Texas license and providing telemedicine in the state of Texas without a license. And it's pretty unusual. I mean, I don't know this, so , um, perhaps somebody else does, but to my knowledge, there have not been any cases brought by a state attorney general specifically by towards a telemedicine provider who's offering care into their state without that specific state license. I know this has been a big conversation , um, during COVID and after Covid and, you know, in, in both of our healthcare regulatory practices have seen an uptick in doing this kind of research and advising for telehealth providers to make sure that, you know, they're complying with state , um, licensing requirements and all of the laws around telehealth. But I don't know , could you , have you seen any other lawsuits of this nature or medical board investigations that have specifically to do with telehealth, perhaps in another area of care? Or is this coming through the abortion pipeline really the first time?

Speaker 3:

Uh , no, I agree with you. I think this is sort of coming through the abortion pipeline for the first time. And , um, although I, I can't promise I have a , a total compendium of all cases <laugh> and , um, and complaints brought against telemedicine providers, I think I, I I think that we would have heard of things that were coming up and , uh, in fact, what we've seen more of in the past few years in a covid and post covid era is a lot of flexibility and , um, a lot of grace given to telehealth providers who are expanding access to care during a time when that was not available sort of in a physical realm. And so at brick and mortar , um, facilities. And so we've seen the opposite, in fact, in other areas where a lot of telehealth providers are sort of getting a lot of leeway, a lot of flexibility, a lot of , um, cooperation from regulators.

Speaker 2:

Yeah. You know, that the, the pandemic really opened up this idea, or at least brought to the forefront in the legal and regulatory world of what do you do when there is an emergency situation or there it is impractical for a patient to get care in any other way , um, in their physical proximity, and how can we leverage this new technology to do so? And we saw, to your point, a lot of opening , um, and flexibility around that because it meets patient need. Um, utilizing telehealth in a situation where you cannot get care in any other way, of course, is centering the patient. Um, and that's particularly true for in, in broader healthcare settings for rural patients, for patients that want to have culturally competent care that isn't available in their location or have disabilities or have experienced biases by healthcare providers in physical settings. Um, and, and in other ways. And, and the same thing applies in the abortion space. And, you know, it's kind of when you boil it down, why is it any different if somebody can't get abortion care in their state, why would it be any different for them to receive , um, care from a provider out of state for telehealth, for medication abortion than somebody during the pandemic who cannot access care or somebody currently who cannot access care from a specialty provider in their state? So yeah, I I, it's really interesting to boil down and , and just think about the, the logic of it.

Speaker 3:

Yeah. And something you said during our conversation yesterday that I thought was really interesting, and I wanna highlight here for our listeners, is that it's not one of the biggest concerns is really what, what, what impact does this have on the care that patients are receiving, and what is the impact on how providers are going to be acting? So , um, I , and I completely understand from the provider's perspective why they would be concerned and afraid to continue providing care across state lines to patients when this is, you know, the , the threat of this litigation sort of looms so large. Um, but we've seen the ways in which the threat of too much regulation or too much , um, too much , uh, restriction on providers sort of impacts the provision of care for the worse. So I'm thinking of malpractice as a example. We've seen how these limits and changes that the threat of malpractice litigation makes it so that providers are providing care not so much in a patient oriented way at all times, but also because they feel understandably the sort of threat of litigation , um, and the threat of, of other sort of regulatory , um, implications on their shoulders. And I, I think we wanna try and avoid that to the extent possible , um, in another sort of avenue. And so putting more restriction on telehealth providers, making them sort of more afraid of providing care is really ultimately, I think, gonna do a vast injustice to patients who really benefit from this type of care.

Speaker 2:

Yeah, yeah, absolutely. And okay, we didn't talk about this yesterday, so I'm gonna go a little off script for a second, but after we spoke yesterday, I came across an article , um, that talked about how PornHub is no longer going to be , um, like keeping their website available in the state of Florida because the state of Florida is now requiring , um, any user to upload their id. And PornHub is like, no, that is too much of a privacy risk to people that are accessing our website. So we're just stopping services here. Why am I bringing this up in this context? Because this is also something we're seeing in the healthcare context. Providers are so concerned that they're going to be held accountable for serving patients across state lines, both in the abortion context and, and really specifically in the abortion context because there are criminal risks associated as well, but also in other healthcare contexts like just providing care across state lines, which I'll retract what I just said. There also are criminal , um, penalties for practicing medicine without a license in a number of states. Um, that can equally be as , um, utilized , uh, for this as it could be for any type of healthcare , as it could be for abortion care. So what we see providers doing is going through , um, more diligent and sometimes overly cautious measures of getting their patients identification and not always in manners that are HIPAA protected if we're talking about cash pay , uh, telehealth providers, and, you know, if PornHub is concerned about the privacy of their users, we can also imagine that the providers, especially when we're talking about legally protected healthcare services, are concerned about the privacy of their users. And I don't know, I was just reading this article and I was in this other realm of, of the world and was just like, wow, this is so interesting because this is the real impact of these different state by state , both, you know, internet surveillance communications, and also in our case healthcare licensing regimes.

Speaker 3:

Yeah, that is so interesting, and I'm glad you went off script and brought that <laugh> brought that into the conversation <laugh> , because it really is, it really is just such a , um, a striking example of a situation where people are reacting to what's going on around them. And that , that sounds pretty obvious, but it's , um, it's scary to be a telehealth provider and sort of not know what restrictions might , um, what impact the restrictions might have. Um, but at the same time that sort of shifts them away from a user-centric, a patient-centric model. Um, and we were talking about, you know, how it's not, there are a number of states that don't have any requirements that would, you know , uh, require them to take a patient's ID or to , uh, verify their location by collecting their, their full street address, for example. Um, but a lot of providers are have , are doing that because they just don't wanna be caught in a situation where they didn't, they can't prove that they , um, did the due diligence that was necessary to sort of ensure that they were only providing PA care to patients within their state lines. And obviously in the abortion context, that gets really tricky and even dangerous for some patients.

Speaker 2:

Yeah, yeah, absolutely. And you know, I know we are lawyers talking to an audience of lawyers and <laugh> oftentimes it is the lawyers of the telehealth providers and of the abortion providers that are like, you need that because we as lawyers are not trained to be patient centered. We are trained to be client centered. Oftentimes, we are also the ones instituting these like over regulatory policies , um, that really move away from the patient's best interest. So yeah, this is a call and encouragement for myself included and all of us to really remember when we are doing advising, particularly in the telehealth for medication abortion space. Like how can we really center these patients so like , um, like the patient at hand in, in the lawsuit, you know, their story does not become publicly available against their will.

Speaker 3:

Yeah. That is such a great, a great reminder. And we have clients who are so good in this space who sort of remind us to be, to be this way because of how user-centric they are. And so we really have to sort of meet them in the middle and, and think about how our advice implicates the patient as well.

Speaker 2:

Yeah, yeah, absolutely. Yeah, on one hand it's the increased confusion and regulation is one thing for providers, but it obviously also has an impact on the way that we as lawyers advising these providers and telehealth companies and abortion clinics are, are really thinking about these issues. So speaking of, you know, new exciting laws that we get to interpret as lawyers, maybe we can can move to talking about shield laws.

Speaker 3:

That was a great segue. Yes, <laugh> . Um , do you , do you wanna give us a little, a little bit of background and sort of what, what our nationwide landscape sort of looks like in terms of shield laws and, and then let's talk about how this impacts the case , um, in Texas.

Speaker 2:

Yeah, absolutely. Okay. So shield laws are designed to protect providers, healthcare facilitators, supporters. They, they vary based on the state that , um, they, they vary state by state , but about 22 states and , um, Washington DC have some sort of shield law protection. So they're designed to protect the providers, facilitators, supporters who offer abortion care to patients that are living in states with abortion bans. And what they do is they protect these providers against actions from hostile out-of-state prosecutors, actors or licensure boards who seek to restrict abortion in their own state, and then thereby penalize a provider. And some of these in the different shield laws, there are different levels of data privacy protections. Some of them also include gender affirming care , um, in what they define as legally protected healthcare . And also some of them have protections to prevent against malpractice insurance , um, from raising their rates because their provi , because of the nature of the care that these providers are offering. And like I said, each state is different. And there are eight states that specifically enacted an interstate shield law , and that's California, Colorado, Massachusetts, Maine, Rhode Island, Washington, Vermont, and New York, which is, you know, relevant to what we're talking about today, that their shield loss specifically states that protections will be extended even when the patient is located outside of the shielding states borders at the time of care. Now, importantly, these shield laws do not change the laws in the state where the patient is located. Instead, they provide legal remedies and protections for the providers operating within their own state's orders and within their own states' scope of licensure.

Speaker 3:

Yeah, that's a great point, Natalie. And one that I really wanna focus in on a little bit, especially for this case in Texas , um, where we're gonna see, I think , um, SHIELD law, the New York Shield law, because we're looking at a case against a New York provider , um, and the tension that that has against the, the Texas state laws that are implicated in the case. Um, the shield laws, as you said, serve as a really important protection for abortion providers , um, and other reproductive healthcare providers , um, but especially for tele medication abortion providers located in access states and then attempting to protect access for abortion seekers in restricted states. Um, but it's important to remember what the shield laws do versus what they don't do. And that's what you highlighted for us. Unfortunately, the shield laws don't change the fact that certain states like Texas make it illegal to provide abortions within their state lines. And the SHIELD law doesn't change the Texas abortion ban, eliminate its unlicensed practice of medicine law or attempt to limit a Texas's ability to enforce its own laws within the state of Texas. I think the way that our federalist , um, system is set up, that would be sort of impossible to , um, effectuate. And so because of that, even though New York has one of the mo the more comprehensive shield laws, it's one of those eight , eight states you mentioned that tries to protect some sort of interstate legal, it tries to enact some sort of interstate legal protection. Um, the New York Shield law is not necessarily going to be immediately implicated or immediately protective of the New York provider in this case. What it does do is protect the New York provider from the effects of litigation that originate , um, that originates in Texas or, you know, in other states. But New York Shield law, ultimately, it makes it harder to get the Texas judgment enforced in New York. It makes it harder to get a subpoena or a summons from a New York Court to support the Texas ags case. It'll help protect the New York provider's medical license in the state of New York. But I don't think it's going to stop the provider from feeling the effects of that litigation altogether. Um, and that's really what I'm worried about here, the litigation. Like we, we started this conversation by saying the litigation doesn't have to be quote unquote successful to be impactful. And , um, it may be the case that the SHIELD law ends up being less protective against that chilling effect that we're talking about. Then , you know, we had hoped

Speaker 2:

Yeah, absolutely. That was really well said and informative and yeah. I'm curious what, like, if , um, if other providers are out there and they are, you know, we've heard a lot SHIELD law provider, I I often think that, you know, there's no such thing as a SHIELD law provider. There is a physician, a PRN clinician who does, who takes a risk calculus and understands like their personal set of circumstances, what's at stake for them and what the shield law protections are in their state and who they seek to serve. And you know, where, where they , um, where they wanna fall in line with all of this and then decide whether or not they wanna offer this type of care. Um, but I'm curious, like what are some of the risks in addition to, you know, a civil lawsuit that a provider who chooses to offer care across state lines under a SHIELD law, and of course, like just broadly because we're not, you know, doing a state by state deep dive right now, but that this provider may, may face.

Speaker 3:

Yeah, that's such a great point that you made about how there's, there's potentially no such thing as a shield law provider, just a provider who sits in a shield law state. Right. And , um, I, I think the risk is that this , you still have the risk of litigation, the risk of prosecution, because we can't forget, as you mentioned earlier on in our conversation, we can't forget that the risk of criminal liability exists in the abortion context. And so, you know, I never thought as a healthcare attorney that I'd be working in the criminal law space, but here we are , um, <laugh> One of <laugh> Yeah, absolutely. Had to sort of give myself a refresher. Um, but I, it's really, I think, difficult to imagine , um, how a shield law would protect a provider from ever being prosecuted or ever being sued in a civil case. Um, really what the SHIELD law is going to do is help them avoid subpoenas, help them avoid extradition , um, help them avoid sort of feeling the effects of that litigation in the state of New York. But as, or in the state, you know, where the SHIELD law is enacted, but as soon as that provider sort of steps foot outside of the shield law state , um, or steps into a , even if they're not going into the state that originated the lawsuit, they could be stepping into another state that doesn't have a shield law. I think they're, they're sort of putting, they're creating additional risk , um, for themselves. Um, and that's, you know, I don't mean to be sort of doom and gloom about it, unfortunately, that I feel that I'm the doom and gloom attorney these days when I work in this space. But , um, yeah, it's, I think it's really scary. Do you have any other thoughts on some of the other risks we might be looking at here ?

Speaker 2:

Yeah , you know, the , the, what, what stuck in my head was just talking about , uh, the criminal risk and how yes, of course this is unique to the abortion space. I mean, we don't see any other area of healthcare so highly scrutinized, criminalized, and just like downright made to, made to be done in an impossible ways that really fall below the medical standard because of laws that are totally out of touch with, with the healthcare system , um, and, and how a medication abortion actually works. We, we don't really see this in other areas of healthcare specifically per , per procedure or per drug, but what we do see is other states and other areas where the practice of medicine , um, we're practicing medicine without a license in a certain state does have criminal penalties. Mm-hmm <affirmative> . And this is something that, you know, is not just concerning in, in the abortion space. It's also concerning for, you know, there, there's a lawsuit . There are two lawsuits ongoing right now about , um, interstate licensure, one in Texas and one in California, sorry, not in Texas, that's what we're talking about. One in California and one in New Jersey. Um, and essentially the basis of these lawsuits state that the, in the, the state by state licensure regime , um, prevents, prevents patient centered care and prevents these providers from practicing to the full extent of their license . And in New Jersey, they are , um, the, they're arguing that, you know, interstate licensure model, or sorry, the state by state licensure model is actually not constitutional. And to my understanding, the reason why these cases were, were , um, brought in New Jersey and California specifically is because they both have criminal penalties for , um, for providing medicine in their state without a state-based license. So again, speaking to the broader issue here of we are living in a legal system that is criminalizing healthcare and , um, and is criminalizing providers for, for providing the healthcare that their patients need , um, in situations that their patients shouldn't have to be in, in some of their most vulnerable moments. And we have the technology to do it right, like we have the ability, the, the expertise to provide patients care, whether it's in the abortion context or outside of the abortion context. And , um, in, in both of these scenarios, what we're really seeing is the impact of overly restrictive laws on providing good care to good people.

Speaker 3:

Yeah, absolutely. I'm so glad you brought up those two cases. That's really striking. And , um, you know, it's, it's interesting when we talk about advising telehealth clients, it's often, I don't know about you, you, I often get sort of , um, a furrowed browse when I try to explain the, the healthcare sort of legal construct that seems almost made up that the, it's where the patient is located, that that determines what law applies, and , um, sort of the provider's location has, has no impact on, on what law applies, and the provider has to be licensed in the state where , um, the patient is located. And, and that takes us back to, again, trying to determine where is the patient located and, and all that. And , um, it's, it's hard to imagine that a provider could be criminalized for sort of getting that wrong.

Speaker 2:

Yeah, yeah, totally. And you know, it just, just the speaking to like the legal fiction part of it, we, we know that there are situations where this , um, these laws have been, you know, maybe pushed aside temporarily, such as during the pandemic , um, when states lifted , um, licensure exceptions or created expedited pathways or in situations like sports medicine when you have , um, physicians traveling with their team and they don't need to be licensed in every single state. So there, there's like little hints in our system as to the knowledge that, hey, maybe this isn't working anymore. Um, and really isn't helping to support the proliferation of telehealth and reach as many patients as possible, particularly in a nation that is in a healthcare crisis and is in an abortion healthcare crisis as well.

Speaker 3:

Yeah. I really appreciate you keeping us sort of focused on ways that we might be able to sort of see glimmers of hope. Um, <laugh> you're not, you're not the doom and gloom attorney clearly, so I really appreciate that <laugh> . Um ,

Speaker 2:

Yeah, I,

Speaker 3:

And

Speaker 2:

I was once told I have a disturbing sense of optimism, but you know what, I will take it <laugh>.

Speaker 3:

No, right now. I think that's exactly what, what we need, what our clients need. I'm sure our listeners really appreciate that. Um, something you said just made me think of, you know, the fact that what types of restrictions are being placed on providers right now? And , um, there's this really important slippery slope that concerns me, and that's, I've never seen a state attempt to ban an FDA approved medication before. Right . Um, and the, the conversation about states banning mione is one that , um, you know, is really concerning. There's a developing argument that the FDA's judgment on safety and efficacy should preempt any state's individual disagreement with the FDA's opinion. But , uh, you know, this is pretty untested, and so it remains to be seen how, how this will go. I wonder if it'll come up in this Texas lawsuit too.

Speaker 2:

Yeah, yeah, that's a great point. Thanks for bringing that in. It, it really is introducing a whole new world of states regulating drugs. Um, right. And it'll be really interesting to see in the new administration what the interplay is going to be between, you know, the federal authorities, including the FDA and state's regulatory powers. Because on one hand, we're moving more and more towards state by state , um, regulations just generally. And, you know, on the other hand, particularly in the abortion context, it seems that, you know, there's some concerns over, maybe there will be federal actions taken that would, that would prevent abortion from being accessible or medication abortion, at least from being accessible altogether. But then, you know , a conversation I have with my colleagues often is like, well, we don't, there's no like a national ban. Okay. That's, that's one way of going about it. But bringing it back to the states is effectively creating a national ban. Because to your point now you have states for the first time ever saying that an FDA approved drug is not legal in their state. I mean, what if people, what if, what if legislators start doing this for other drugs? Like, what if this happens for ozempic? How, how are people gonna react?

Speaker 3:

Yeah, absolutely. And this, that takes us back, you know, all the way back to your very first point, I think about how this is not just an abortion issue, this is a telehealth issue more broadly, this is a healthcare issue more broadly. Um, this is an issue that affects all stakeholders in healthcare, I think. And, you know, pharmaceutical companies will be, will be interested in what , um, this, this type of ar how, where this argument leads and how drugs are being enforced. I think researchers, developers are gonna be starting to think about it. And so , um, i I hope that people start to really think about what the impact of this is beyond the abortion and repro setting. Um, it's, it's a healthcare issue. Yeah,

Speaker 2:

Absolutely. That was, that was beautifully said. Um, yeah, thank you so much for, for joining today. I'm so glad we got to, to talk about this. And for any of the listeners, feel free to reach out to me at , um, natalie@wrights.org to continue this conversation. I'd be happy to do so. And, and yeah, thank , thank you all for listening. Um, I'll, I'll pass it to you to, to close us out.

Speaker 3:

Thank you, Natalie. It was such an honor and pleasure to have this conversation with you. You have such interesting insight , um, and all your great work. So thank you so much for the work that you do in this space and for sitting down with me this afternoon. Um , if any of our listeners have any questions for me, I'm at katePatel@manat.com and I'd love to continue this conversation. Thanks everybody so much. Thanks everyone.

Speaker 1:

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