The doctor starts each day with a list of addresses and a label maker.
Sitting in her basement in New York's Hudson Valley, next to her grown children's old bunk beds, she reviews the list of towns and cities she'll be mailing to that day: Baton Rouge, Tucson, Houston.
A month ago, a phone call was the only thing the doctor could offer to women in states with abortion bans who faced unexpected pregnancies. Hamstrung by the laws, she could only coach them through the process of taking abortion pills they received from overseas suppliers.
Then, all of a sudden, the whole system changed. Now she can legally mail them pills herself.
A new procedure adopted in mid-June by one of the largest abortion pill suppliers, Europe-based Aid Access, now allows U.S. medical professionals in certain Democrat-led states that have passed abortion "shield" laws to prescribe and mail pills directly to patients in antiabortion states.
Previously, Aid Access allowed only Europe-based doctors to prescribe abortion pills to women in states where abortion is restricted and then shipped those pills internationally, leaving patients to wait weeks. The telemedicine shield laws, enacted over the past year in New York, Massachusetts, Washington, Vermont and Colorado, explicitly protect abortion providers who mail pills to restricted states from inside their borders.
The result is a new pipeline of legally prescribed abortion pills flowing into states with abortion bans. In less than a month, seven U.S.-based providers affiliated with Aid Access -- including the Hudson Valley doctor, who spoke on the condition of anonymity because she was concerned for her safety -- have mailed 3,500 doses of abortion pills to people in antiabortion states, according to Aid Access, putting just this small group alone on track to help facilitate at least 42,000 abortions in restricted states over the next year. If more doctors and nurses sign up, as current providers hope they will, the numbers could climb far higher.
"Everything I'm doing is completely legal," the Hudson Valley doctor said, her family's ping-pong table covered with abortion pills bound for the South and Midwest, where abortion has been largely illegal since the Supreme Court overturned Roe v. Wade in June 2022.
"Texas might say I'm breaking their laws, but I don't live in Texas."
The development tees up a complicated interstate battle where doctors on U.S. soil are empowered to legally circumvent abortion laws -- allowing blue states to potentially undermine the red state bans that many Republicans hoped would end abortion within their borders. Meanwhile, some conservative groups are angling to outlaw the abortion pill nationwide, attempting to outlaw the medication in the courts as well as calling for a national abortion ban.
The increasing flow of prescribed pills adds to an already expanding underground network for pills being imported from overseas and illegally distributed by abortion rights advocates largely without medical oversight, underscoring the prominent role pills are playing in post-Roe America.
The shield laws are "a huge breakthrough for people who need abortions in banned states," said David Cohen, a Drexel University law professor who focuses on abortion legislation. "Providers are protected in many ways as long as they remain in the state with the shield law."
Some lawyers say these doctors could face repercussions, even if they steer clear of traveling to states in which abortion bans call for prosecuting abortion providers. At a minimum, some experts said, the question of legal peril could wind up in a gray area ultimately resolved by the courts, such as whether shield-law states have the power to block other states from extraditing people charged with crimes.
Major groups that support abortion rights, including Planned Parenthood and the American College of Obstetricians and Gynecologists (ACOG), have been largely silent on the subject of mailing pills from shield law states. Several Aid Access providers say the groups have expressed concern about backing the approach, worried that providers could put themselves at risk.
Molly Meegan, ACOG's general counsel and chief legal officer, said the group is "not positioned to provide legal advice to individual members," adding that "it is wrong for a state to be able to prosecute clinicians and patients in other states where abortion remains legal and unrestricted." Planned Parenthood issued a statement saying that their advocacy arm was doing "doing everything possible, and looking into every opportunity, to ensure that patients can access care no matter where they live."
Jonathan Mitchell, the former solicitor general of Texas and architect of the state's six-week abortion ban, said it was too early to predict how these shield laws would play out, but said the providers may face consequences.
"There absolutely is a world in which they could get in trouble for it," he said. "Someone in Texas could do a sting operation and charge them with attempted murder."
In many states, including Texas, someone found guilty of distributing abortion pills could be sentenced to at least several years in prison. Current abortion bans explicitly exempt those seeking abortions from prosecution, though prosecutors have a history of charging people who have abortions with other crimes.
The Hudson Valley doctor said she's not worried about her own legal risk. When she arrives at the post office with dozens of new packages every afternoon, she said, no one ever asks any questions.
"Nobody has any idea. I could be doing so many different mailer businesses from home," she said. "It could be beaded necklaces. It could be soaps. It could be candy."
Massachusetts passed the first telemedicine abortion shield law of its kind just days after Roe v. Wade was overturned. The most recent law passed in New York in mid-June.
The New York law states that no state or local government employee "shall cooperate with or provide information to any individual or out-of-state agency or department regarding any legally protected health activity in this state."
With shield laws, abortion rights advocates have seized an opportunity to "define the landscape," said Julie F. Kay, a human rights lawyer and the legal director of the Abortion Coalition for Telemedicine Access. One key question that could emerge in the coming months is whether prosecutors in any antiabortion states would attempt to extradite medical providers from shield law states, thereby challenging the power of the new laws.
Kay said that traditional extradition laws would be difficult to apply in these circumstances.
"One state can extradite if a person commits the crime in the state, then flees," Kay said. "But no one is fleeing here. You are just sitting in your office in New York."
Aid Access started sending abortion pills to women in the United States long before the June 2022 Supreme Court ruling. The service, which costs $150 or less, is far cheaper than having a surgical abortion or obtaining medication at a clinic -- usually between $500 and $800 -- making it an appealing option even to people in states where abortion is readily accessible.
Once Roe fell, the organization operated in a legal gray area, shipping pills to antiabortion states from India. Aid Access providers mail pills sealed in clearly marked boxes, setting the organization apart from many other overseas pills suppliers, which send pills without a prescription, sometimes unmarked and unsealed.
Demand for pills from Aid Access has soared since the June 2022 Supreme Court ruling, with the organization receiving almost 60 percent more requests for pills this spring than in the months immediately following the decision, according to Abigail Aiken, lead investigator of the Self-managed Abortion Needs Assessment Project at the University of Texas at Austin. People seeking abortions often find the group online, and make their request through their website -- which then gets forwarded to one of the providers.
U.S.-based Aid Access providers were used to the process of receiving and processing requests for abortion pills, accustomed to working with patients in states where abortion is legal -- but the process of ordering the medication and mailing it out was far less familiar.
The providers order mifepristone and misoprostol -- the pills in a two-step medication abortion regimen -- from licensed pill distributors, and ship out the pills to patients fairly quickly along with detailed instructions.
Before the recent procedure change, the Aid Access providers would send all of their prescriptions to an online pharmacy in California to handle shipping, one of two online pharmacies nationwide that dispenses abortion pills. But neither of those pharmacies is located in a state with a shield law. Until California passes one, a development that is expected this fall, the doctors have to prepare and package the pills bound for restricted states themselves, creating their own labels to stick on the pill boxes they receive, providers said. (Doctors are legally permitted to order and distribute pills on their own, the providers said -- it's just not typical.)
"We're medical providers suddenly thrown into this world of shipping," said Lauren Jacobson, a nurse practitioner who operates out of Massachusetts. "Do we write labels by hand? What if we mess up an address? How on earth do we ship 50 packages a day?"
Jacobson concedes that this system is far from perfect. While medication abortion is overwhelmingly safe and effective, she said, on rare occasions her patients in restricted states require in-person care -- and they fear the legal risk that could come with a trip to the hospital. In those cases, she said she will try to help them navigate their state's health care system safely, searching online for a trustworthy provider and advising them on what to say. Sometimes, she said, she'll go on LinkedIn and scope out the local OB/GYNs, searching for someone who has posted something that supports abortion rights.
"This isn't normal health care," she said. "We don't want to have to do this."
Providers also recognize that many patients prefer or require a surgical procedure to end their pregnancies instead of pills.
One major impetus for Aid Access changing its protocol was the shipping time, said Linda Prine, an Aid Access provider and doctor based in New York. Patients would have to wait weeks for pills shipped from India, she said, often pushing their abortions well into the second trimester -- a far more difficult and complicated process. (The U.S. Food and Drug Administration endorses the use of abortion pills up to 10 weeks, though some studies show it's safe and effective to use them significantly later in pregnancy.)
"They were having a really scary miserable experience," Prine said, with some far enough along that they would pass a recognizable fetus.
Prine founded the Miscarriage and Abortion Hotline, where people often call with questions about medication abortion. Since Aid Access's protocol change, she said, she has noticed a significant decrease in calls from women who are taking pills in their second trimester.
Eventually, the Aid Access providers fully expect Republicans to take a swing at their efforts.
"We're all like, 'okay which one of us is going to be the case?'" said the doctor in the Hudson Valley. "It's not if there will be lawsuits, it's when."
Jacobson said she trusts the Massachusetts courts to protect her.
"We have seven American providers who are stepping in and saying, 'you know what, we're not going to be intimidated,'" Jacobson said.
The providers are eagerly waiting for the shield law to pass in California.
Once that passes, the Hudson Valley doctor may no longer have to run a complex shipping operation from her basement. She'll likely be able to send her prescriptions to the pharmacy, just like she used to, she said.
For now, she said, she doesn't mind staying up until 1 a.m. to finish the packing.
"It feels like I'm giving a big middle finger to that part of the country that has done this," she said.