(The Hill) — Anti-abortion groups celebrated warehouse club Costco’s decision not to dispense abortion medication at its pharmacies, but they face an uphill battle in the wider fight to restrict the drug.  

“There’s no question this is a win for Costco shareholders,” Michael Ross, legal counsel for Alliance Defending Freedom (ADF), told The Hill. “Retail pharmacies have little to gain and much to lose by turning themselves into abortion dispensaries.”  

In 2024, ADF, along with other anti-abortion groups, sent letters to Costco, Walmart, Kroger, Albertsons and McKesson urging them to “resist politicized calls” to start dispensing mifepristone. 

Most pharmacy chains have been unconvinced by the plea. 

CVS and Walgreens, two of the country’s largest brick-and-mortar pharmacies, have continued to dispense the drugs in states where abortion is legal. And most abortion pills in the U.S. are distributed via mail-order pharmacies, which remain free to distribute the medication across state lines. 

Crucially, the Food and Drug Administration (FDA) has not taken steps to change how the drug can be accessed under its Risk Evaluation and Mitigation Strategies (REMS), a safety program for certain drugs to monitor and manage adverse health events.

Health care policy experts told The Hill that the most effective way for anti-abortion advocates to restrict mifepristone is to change the REMS on the drug back to what they looked like a few years ago, before being temporarily scrapped during the COVID-19 pandemic.  

During President Trump’s first term, these REMS required the drug to be dispensed in person at a clinic. These rules were permanently changed in 2023, allowing certified retail pharmacies and mail-order pharmacies to dispense the drug without an in-person visit. 

“We’d love to see the original REMS put back on so women, at least, are told what could happen to them if they take the pills,” said Carol Tobias, president of the National Right to Life Committee. “But, you know, no surprise, we would love to just see the administration stop the pill altogether.”

Anti-abortion groups have pushed the issue with citizen petitions and lawsuits.  

The FDA first approved mifepristone to terminate early pregnancies in 2000. Serious health complications are rare but do occasionally occur after taking the medication. There have been five deaths associated with mifepristone for every 1 million people who have used the drug since 2000, according to the FDA. 

Kirsten Moore, director of the EMAA Project, said the focus on retailers like Costco is misplaced “There’s no there, there,” she said of last week’s announcement given the vast majority of abortion pills in the U.S. are now distributed via mail-order pharmacies such as Honeybee Health and American Mail Order Pharmacy. 

These pharmacies have a list of certified prescribers, which employees can cross-reference quickly, she said. The turnaround time for patients at some of the pharmacies can be 36 hours from the time they request the drug to the moment they receive it, she added. 

As anti-abortion groups have lobbied retailers to commit to not distributing abortion pills, some Democratic lawmakers have pushed in the other direction, urging large retail pharmacies to begin dispensing mifepristone following the 2022 overturning of Roe v. Wade.

The FDA first allowed mifepristone to be sent in the mail during the COVID-19 pandemic to protect patients and providers from exposure to the virus. Honeybee Health was the first mail-order pharmacy to ship the drug directly to patients after the agency relaxed some of its restrictions in 2020.  

Even though 12 states currently ban abortion and half a dozen others have harsher restrictions on the procedure than when Roe v. Wade was still in place, the number of abortions performed with medication via telehealth with the help of pharmacies has gone up in recent years. 

In 2023, abortions undergone using medication made up 63 percent of all abortions in the country, up from 53 percent in 2020, according to the Guttmacher Institute.  

This is in part due to state abortion shield laws, which protect providers and patients from civil and criminal actions originating in states that ban the procedure. There are 18 states plus the District of Columbia that have an abortion shield law in place, according to Rachel Rebouché, dean of Temple University’s Beasley School of Law.  

Anti-abortion activists and lawmakers have waged a legal battle against these laws, so far without success.

Texas lawmakers have introduced several bills to try to curb the flow of abortion medication into the state, including one bill that aimed to subject anyone who manufactures, distributes or prescribes the pills to a $100,000 fine, but it died in May.  

These efforts to restrict mifepristone are “needed and necessary,” said Tobias of the National Right to Life Committee. Still, the actual restricting of the drug is “not happening fast enough,” she said.   

James Bopp, general counsel for the National Right to Life Committee, and Emily Erin Davis, vice president of communications at Susan B. Anthony Pro-Life America, both feel “hopeful” that the Trump administration will reinstate previous REMS on mifepristone.  

Changing the REMS on a medication is not an easy or quick task, though. 

Changes to REMS are often requested by the drug manufacturer, but the FDA can independently determine if they need to be changed. The agency would need to provide evidence that the current REMS do not sufficiently protect consumers from the dangers associated with the drug. 

Health and Human Services Secretary Robert F. Kennedy Jr. suggested earlier this year that he was open to restricting access to abortion medication, while FDA Commissioner Marty Makary promised to review data on the drug’s safety.  

But the FDA, which the Department of Health and Human Services (HHS) oversees, has not taken any steps to change access to the drug.  

“I think there were some people who expected that to be a day one thing,” said a source familiar with the FDA’s REMS process.  

A spokesperson for HHS said the FDA could not comment on future actions or decisions related to the drug.  

Tobias told The Hill that her group would keep applying pressure. 

“Certainly, we are going to keep working on it,” she said. “We don’t have anything specific, any major plan that we’re looking at other than we’re looking at everything.”