Reproductive Rights in a Bottle
Air Date: October 10, 2022
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HEFFNER: I’m Alexander Heffner, your host on The Open Mind. I’m delighted to welcome Kiki Freedman to our program today. She is the founder of “Hey Jane” and a former Uber technologist, and also a classmate of mine. Long time no see, Kiki.
FREEDMAN: Very good to see you, Alex.
HEFFNER: It’s been about 15 years, sadly, since we’ve seen each other. We might have connected in other modes, but it’s really a pleasure to see you. And it’s an honor to invite someone who’s innovating in the space of reproductive healthcare, especially amid these turbulent times after the overturning of Roe. Let me give you a platform just to tell our viewers, what is “Hey Jane,” and how you came to start it.
FREEDMAN: Absolutely. Thank you, Alex. “Hey Jane” is a digital clinic for medication abortion access. So I’ll start by introducing the concept of medication abortion access. There’s a clinical protocol often called the abortion pill. It’s a bit of a misnomer. It’s actually two different medications. It’s been around since 2000 in the United States, very safe, very effective at any unattended pregnancies up to 11 weeks, is the approval here in the U.S. We make it possible for patients to get access to this medication from the comfort of their home or location of their choosing, through telemedicine. So they could chat with the clinician via our platform at the tap of a button 24/7, as well as well as get access to On Demand emotional support or online community with other folks going through the same thing at the same time, should they want it. We launched last year. We’re now in seven states and expanding rapidly. We’ve served over 10,000 patients and look forward to really doubling down on these efforts in the times that we’re in now.
HEFFNER: And you started this organization prior to Roe being overturned. Did you anticipate Roe being overturned prior to starting it and what led to the transition from your work at Uber to “Hey Jane”?
FREEDMAN: Yeah. So the idea for “Hey Jane” sort of came about while I was in between my first and second year at Harvard Business School. I was chatting with some of my friends from undergrad. I’d gone to school in St. Louis, Missouri. Missouri at the time was one of six states that had a single abortion clinic left in the entire state. And that summer it was nearly shut down. It felt like this almost impossible dystopian event that there could be a state in the United States with no abortion access at all in the year 2019. Of course, in retrospect, it’s a bit quaint to think of only one state having no access, but at the time it felt like this really screaming problem in need of a solution. Telemedicine was becoming much more popular at the time. And so I started thinking, is that a model that could be applied for safe, discrete, affordable care access here?
I think we certainly saw where the puck was moving in terms of increasingly restricted access in ways that are totally out of line with science and patient need. Did I think Roe would be overturned? No, (laugh) I think it’s been, you know, a surprising disappointment to many of us. Since the Dobbs case has been progressing, there’s, you know, the writing has certainly been on the wall. But nevertheless, we’ve seen the slow degradation of access over the last several decades. And so regardless of Dobbs or not, there just needed to be more solutions for access in any case.
HEFFNER: So a surprise, not a shock, especially understanding President Trump’s impact on the Supreme Court and the composition of the court today, and once they took the Dobbs case. So just to be clear for those who are not familiar with “Hey Jane,” it is in effect reproductive access. You’re not based in one location, you’re based all over the country and the states you operate in, including New York, New Mexico, some other states as well. You can tell our viewers. But in effect it is like a Grub Hub or an Uber Eats or Uber-like platform for reproductive healthcare.
FREEDMAN: That’s a really interesting way to put it. I think that that’s absolutely right in terms of the convenience of being able to get access to this much-needed service from the comfort of your home, through a digital device, on your own terms, on your own time. I think where it differs slightly from some more traditional e-commerce models is the layers of additional support that we’re able to offer our patients. We call it our complete care model. So yes, patients can get medications delivered directly to their doorstep without ever needing to visit a clinic or a pharmacy in real life. That’s really fantastic for accessibility for our patients, but we view it as sort of just the beginning. We want it to be a non-transactional experience where patients can really connect with our team for other forms of emotional support, or with other peers for social support, should they, should they like to. And so we’ve been able to integrate those three elements of the experience into one single application.
HEFFNER: And what differentiates you from, I know that there are some telehealth models appealing to millennials. You can’t watch a Hulu show without getting an ad for Hers or Hims or one of the above. There, there are some things that do what you’re aspiring to do more broadly, but you’re doing it specifically for reproductive care.
HEFFNER: Besides the fact that you’re offering something that is restricted and limited in a lot of places now, what else is different about your model relative to these other folks?
FREEDMAN: Yeah, it’s a great question. And I would again say the robustness of our model is really differentiated from what we see in other competitors in the space. Many of them have leaned really heavily into convenience, which is great. It’s frictionless, but often makes it quite transactional, but crucial medical moments have a high degree of emotional complexity that really deserves this much more wholesome support that includes clinical as well as emotional and social.
HEFFNER: Kiki, what states are you operating in, and how did you achieve that operational status in those states, because there are hurdles to overcome even in states that don’t restrict reproductive access.
FREEDMAN: Absolutely. So we are currently in seven states. We’re in New York, Washington, Illinois, California, Colorado, New Mexico, and most recently New Jersey. We do have several more launches coming up soon. We’ve prioritized our launches based off states where we’re able to serve the most patients that have the highest volume, of course, that have regulations that are amenable to the model. And then also those that are likely to get the highest degree of cross-state volume in this new post Dobbs world, where many people do need to travel out of their home state in order to seek treatment. In order to launch in those states, we have to go through a number of sort of regulatory efforts including getting providers licensed in those states, making sure our entity is qualified to operate there. But really importantly, also getting to know the community groups that exist in those states so that we can be sure we’re offering culturally sensitive care within those markets and also that folks are aware of what we’re doing so that they know we are an option for them.
HEFFNER: So those are states primarily with folks in the legislature or governor’s office that support reproductive rights, that support abortion access for women, view it as a human right of that woman to determine the trajectory of the pregnancy. You are wanting to be able to mail these abortion pills, medicines, to women in states that are more purple, or red, to use the purple associated with kind of middle of the road politics, or red conservative politics. Your home state that I know is Florida, this is a place where abortion is not totally banned, and you can have access to reproductive care at this very moment. That may change. But is your aspiration to be able to offer this in and be able to mail the abortion medicine to women in states like Florida, Louisiana, Mississippi? And if so, how are you going to accomplish that?
FREEDMAN: What I would say on that is that the science is clear. These medications have a lower serious adverse reaction rate than Tylenol. They are incredibly safe and they are 98 to 99 percent effective. Moreover, there’s ample research now showing that patients prefer to get this treatment in many cases via telemedicine. I certainly feel strongly that it should be an available option for patients in any of the 50 states of this country. Significant regulatory change would need to take place in order for that to be an option. “Hey Jane” is committed to operating within full compliance of the law. And so we will continue to focus on those states that welcome these types of services. That said states depriving their populations from this access are very much again in violation of sort of common-sense science, which is very well understood at this point.
HEFFNER: Now, when you think of the obstacles to receiving the mail, we do know that the mail is not foolproof and therefore packages can go missing. But also in this particularly fraught political climate there are people from the families of potential healthcare recipients and people, even in the mail services, who might not like these outcomes and therefore try to stop it in its tracks. Have you become aware of any efforts to try to confiscate mail that’s being delivered to your patients?
FREEDMAN: Not in any significant way. That said, we do very much value the privacy of our patients and focus on discrete packaging. We do know that patients want to make sure that when they receive their package, they are the only ones who know the contents of it. Everything arrives and fully unmarked boxes with even discrete return shipping addresses. We can also ship to a post office if patients are not comfortable receiving it at their home. The post office route is also quite interesting because should a patient need to travel from another state, in order to a friendly state where “Hey Jane” offers services to receive care, they don’t even need to set up a PO box. They can just have it sent directly to a post office counter for pickup. Similarly, folks who live nearby can use that as a means of adding additional layer of privacy to their shipment, should they choose to do so.
HEFFNER: And you pointed out to me when we spoke recently that most primary care providers and internists, even if you go to an emergency care clinic, may not have access to, or may not want to prescribe abortion pills or engage a patient in a potential surgical procedure. That is your, your pitch is saying you are a one-stop-shop for this. And as a result you are able to provide competitive rates to folks and even folks who are eligible recipients can receive reimbursements or rebates on your products, because we do know that reproductive care is sought, in particular, often by underserved communities, more than affluent communities.
FREEDMAN: Yes. So financial accessibility is absolutely paramount to our team. We’re able to charge $249 dollars for our treatment, which is less than half of the national average of $550 dollars. Patients are also,
HEFFNER: And, and that is half of the two-medicine cocktail that you’re referring to?
FREEDMAN: That 249, exactly. And it includes the medication itself, of course, all of the shipping and fulfillment, as well as all of those complete care services, including the emotional support and community and plus follow up clinical care as well.
HEFFNER: And to your knowledge, studying this quite in depth, for how long has it been the case that women could not get this from their primary care physician, they couldn’t have access to. And, and what about these clinics? You know, sort of easy MD type, local care clinics?
FREEDMAN: Yeah. So this is pretty interesting. So since the medication was approved by the FDA in 2000, all of the prescribers needed to specifically register with the prescriber, essentially going through additional bureaucratic hoops in order to be able to prescribe as part of the FDA REMS program for this medication. That’s just created a lot of additional barriers to providing access to the medication that don’t exist for other drugs that have similar safety profiles. There is of course, the inevitable political controversy that comes with prescribing these medications and some providers, especially those in larger hospital systems, et cetera, may be unable to engage in this type of care simply because of the potential backlash that that may come.
HEFFNER: But you’re saying that for the past 10 years on an ongoing basis to this day in 2022, you can’t go to your City MD and receive this type of care?
FREEDMAN: It depends. You may be able to. In some instances, the clinicians will have taken the efforts to do that. But for the vast majority of cases, no. I believe it’s only about 5 percent of abortion care takes place outside of specialized abortion clinics because of these barriers to providing access.
HEFFNER: We talked about the model here being revolutionary and necessary in the post-Roe climate. But you are very tactful in the way you talk about your approach for these states where reproductive access is not possible. And I know you established your position as an advocate of reproductive care, obviously. But don’t you think it’s going to take some lobbying efforts and education to chip away at what now seems like a fortress in states like the ones I mentioned after Florida: Mississippi, Louisiana, Arkansas. We know now because there’s enough public opinion that in fact there are only a handful of states where if you took a vote of a national opinion in those states, abortion would be outlawed. And you know that hasn’t even been proven in places as deep red as Oklahoma. We know from the results of the Kansas referendum, for example, there’s absolutely no reason why “Hey Jane” shouldn’t or couldn’t operate there.
FREEDMAN: Absolutely. We know that the recent Dobbs ruling was in total opposition to the will of the people overall. We know that at least 70 percent of the population of voters does support access to safe and legal abortion. We think that there is excessive activism being taken place on the courts in making these decisions. We will need to see lobbying occur. I don’t know, within the capacity of “Hey Jane,” but certainly more generally as well as awareness efforts. One thing that we are really trying to get the word out is that even though half of abortions are now done with the abortion pill, less than one in four people even know that it’s an option, that it’s an available medical solution out there for them. And we know that.
HEFFNER: Why do you, why do you think that is? I can’t let you not explain why you think that is?
FREEDMAN: That’s a very good question. I mean, listen, it is relatively newer. It’s still been around over 20 years. And unfortunately abortion is a topic that people aren’t often discussing. It’s entered the media cycle in a much more visible way recently. But we know that two thirds of abortion patients would not talk to their closest friends or family members about their experience. One in four women similarly will have an abortion. And I think that statistic surprises people for the same reason. They’re just not hearing about it from their friends. It’s not something that necessarily lends itself to a lot of social discussion and discovery in terms of some of these new options that are out there.
HEFFNER: And what was your reaction in terms of your business, to the Kansas vote? Was it, we have to bolster up our lobbying efforts because this is not just a phenomenally novel social enterprise, but it really is serving a public good? And so my, question is what are the steps that you learned in these first states that you are operating in now that that could be beneficial in thinking about the new states and, how to approach them? You know, I, let me give you an opportunity to answer that first.
FREEDMAN: Yeah, it’s a very interesting question. I think that the Kansas referendum was hugely energizing in reaffirming what we already knew about the public sentiment related to abortion care. I think that the way messaging was approached in that state was innovative and inclusive. And I think that that’s something that we’ve really learned from is we need to continue to reiterate this is not a political issue. This is not a left-right cause. It’s a medical issue that affects one in four people with uterus. And so to describe it at set as such, I think does really lock into the fundamental issue at hand related to a person’s freedom to make decisions around their own body, with their, with their healthcare provider. We do view ourselves largely sort of on that same vein as a technical and clinical organization. Our expertise is not in lobbying, but we do believe those efforts are essential. At least if not lobbying specifically advocacy more generally, and we’ve been able to have some incredible partnerships with universities, including UCSF to participate in research efforts to again validate the safety and effectiveness of telemedicine abortion as well as medication abortion largely. That data has been very effectively used in guiding recent FDA decisions, confirmation hearings, et cetera, that we do think will ultimately lead to the changes that we, that we need to see for this to be more widespread.
HEFFNER: I’d imagine you’re first trying to target the states where it’s legally possible to operate. How are you determining where it’s legally possible to operate?
FREEDMAN: Yes. So there are a few different levels here. Number one is that the state needs to support telemedicine access broadly, which for the most part, there has been progress towards, but there are still some holdouts. And then they need to support telemedicine abortion access. We now see that up to 26 states will be eliminating access to abortion in general, but there are one or two more that have laws on their books from the pre-Dobbs era that restrict access to telemedicine abortion specifically. As we see more volume from hostile states, sort of surge into the states that are still protecting access what we’re going to see is clinics in those states being very burdened by the amount of demand they’re seeing. We’re going to see extended wait times, and we may even see clinics need to turn folks away. Let’s hope that doesn’t happen. But just given the numbers, it seems like we may end up looking at that reality. If that occurs we’re hoping that some of these states that are still standing up to protect abortion access, reevaluate the huge role that telemedicine will need to play within this access landscape, given that it just can create significantly more capacity. It’s tech enabled. We can pull in providers from across the country in order to support patients who need it within a given location.
HEFFNER: So there you’re saying there are two groups that, that disqualify themselves or are not fertile ground for you all. One group is where there are restrictions broadly on telemedicine and one group because of the trigger laws or new anti-abortion laws that restrict women’s’ access to reproductive care. So the first group is potentially more persuadable, right? You’re talking about modernizing their regulatory states, so telemedicine is incorporated into the rights and access of, of their citizens. The second group of holdouts would be much more challenging because those are laws that either were triggered in effect after Roe overturned was overturned or are, are new laws. And they’re basically saying no abortion. But are there any states where in that second group where the door is left open a little bit because of telemedicine and because of the way it was written, it’s not clear that whether they’re referring to surgical procedure or pills?
FREEDMAN: I think there are and in particular and via some of the mechanisms that would sort of functionally block telemedicine as an option without stating it explicitly. So you may be aware that many states have an ultrasound requirement where patients are forced to view an ultrasound of a pregnancy that they’re not interested in continuing. We know that those laws create significant emotional trauma for the patient oftentimes that’s completely avoidable and really does nothing to achieve healthcare outcomes. They also, of course, logistically make it very difficult for a patient to receive abortion tele medically because it requires an in person visit. I think reevaluating some of those laws could really go a long way in both improving patient care outcomes, as well as access in, again, this new world where we just need as few boundaries to care, so we could operate with efficiency in the states that do still support access.
HEFFNER: Right. And, and the ban is only a ban on your work if it really is explicit in saying you can’t have reproductive care through these pills, right? I mean, there, there is a way to analyze the law. And if it’s not explicit, is there potentially room for negotiation there?
FREEDMAN: I always think there’s room for negotiation. Absolutely.
HEFFNER: As we close, let me again, I think it’s just important for our viewers who learn about your service to see, here, here’s where you are and here’s where you want to be. And here are the, the sort of two buckets where you fall where you’re going to make inroads. So we established that. But just to close, when you’ve heard the stories that were inevitable about women, young women, older women, who could not have an abortion and therefore, you know, the alternative was inducing labor. And, you know, I’m sure that some of those women will have lifelong medical issues as a result of that. And some of those women will die and there already have been stories like that in states where all reproductive health is banned. Knowing that that’s the reality and that now those who might have supported restrictions on abortion are seeing that as the consequence, the blowback, have any minds changed in your neck of the woods on the issue, seeing what the lack of abortion access can mean, you know, when women are their deathbeds and losing pints and pints of blood, simply because they can’t have the medical procedure that’s going to more likely save their life?
FREEDMAN: It is a horrible thing that we’re, that we’re reckoning with. In terms of minds change, I have to believe, unfortunately, that the majority of politicians making decisions in this case know the history that we have witnessed in this country and elsewhere and that these are the inevitable outcomes of making these types of policies. The way that we’ve seen the laws written are apparently ambiguous in a way that is intentional, that is meant to confuse physicians who are providing care related to only adjacent treatments like naturally occurring miscarriage. I hope that we see minds change as it plays out in this more visceral way. Let’s only hope that that empathy exists.
HEFFNER: Kiki Freedman, a pleasure to see you an old classmate. Who’s doing tremendous work at “Hey Jane.” Please look it up, especially if you know young women who are vulnerable at this precarious time. Kiki Freeman. Thank you for your time today.
FREEDMAN: Thank you so much, Alex. I really appreciate it.
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