A ruling from a federal judge in Texas last week could threaten nationwide access to mifepristone, the medication commonly used to end a pregnancy, leaving D.C.-area abortion providers, lawmakers, and legal minds scrambling to understand how local access will be impacted in the weeks and months to come.

The situation is changing rapidly. On Friday afternoon, the Supreme Court paused the ruling from taking effect until at least Wednesday but much remains unknown about what will happen next. Here’s what we do know about the status of mifepristone locally.

Is mifepristone still available in the D.C. region?

Yes. Advocates say the most important thing to know now is that you can still access mifepristone. People who had in-person appointments scheduled or were planning to schedule telehealth appointments so they could receive the medication by mail should keep them, said Jade Hurley, the communications manager at the D.C. Abortion Fund.

In D.C., Maryland, and Virginia, people can receive mifepristone, and misoprostol (the companion medication in the two-step regimen) by mail. Planned Parenthood of Metropolitan Washington has offered medication abortion services via telehealth to individuals in D.C., Maryland, or Virginia since 2021.

What’s happening with these federal rulings about the medication?

On Friday last week, a federal Trump-appointed judge in Texas ruled that in 2000, the FDA improperly approved the medication mifepristone, a pill that ends pregnancy by blocking a hormone called progesterone. It’s used in more than half of all abortions performed in the U.S. as part of a two-pill regimen, the other being misoprostol which is not impacted by the recent ruling. The suit was first brought in 2022 by the anti-abortion Alliance for Hippocratic Medicine. Matthew Kacsmaryk, a judge who previously worked for a conservative Christian legal organization, issued a nationwide injunction on the FDA’s approval set to go into effect on Friday. This allowed the government time to appeal.

President Joe Biden and The Department of Justice asked an appeals court to issue an emergency stay of Kacsmaryk’s decision on Monday. That same day, D.C. Attorney General Brian Schwalb joined 23 other attorneys general in filing an amicus brief asking the U.S. Court of Appeals to issue a stay pending appeal on the Texas ruling – also essentially blocking it from taking effect.

On Wednesday night, the federal appeals court ruled that mifepristone will remain partially available, but issued new restrictions on the medication as the case plays out. Mifepristone remains approved for use through seven weeks of pregnancy (as the FDA approved in 2000), but can no longer be used through 10 weeks of pregnancy, nor can it be delivered by mail.

The Biden administration appealed the ruling to the Supreme Court on Thursday. Drug manufacturer Danco Laboratories also made an appeal to the Supreme Court, asking the justices to stop the Texas ruling from taking effect.

Later on Friday afternoon, the Supreme Court granted the U.S. government’s request for a temporary stay on the Texas ruling — meaning that, for now, full access to mifepristone will continue. The stay is granted through Wednesday, while the justices study the lower court rulings in the meantime.

Then, there’s a dueling federal ruling complicating matters further.

The same day a federal judge in Texas ruled to pause the FDA’s approval of mifepristone, a federal judge in Washington state issued a contradicting decision in a case brought by the attorneys general of 17 states and D.C. In February of this year, the states sued the FDA over mifepristone, arguing the agency over-regulated the drug. In that case, federal judge Thomas O. Rice said the FDA could not do anything that would affect the availability of the medication in any of the states included in the lawsuit. Both D.C. and Maryland were included in the lawsuit but Virginia was not.

It’s still unclear how the two rulings will interact with each other, leaving states, providers, and even the FDA in a murky limbo.

What are legal scholars saying? 

No one knows exactly how this case will play out.

“There’s just so much confusion about what the law allows,” said Sonia Suter, a professor at George Washington University Law School who focuses on reproductive rights. “And so yeah, I’d say pretty uncharted territory.”

If the Supreme Court allows the appeal’s ruling on the Texas case to stay in place, mifepristone would still be available – just not by mail. Suter said this could directly impact services in the D.C.-area, where many people rely on telehealth for abortion services, as it reduces the cost of travel, time off work, and child care.

“That makes it really hard to access something because then you have to get time off of work, you have to get childcare,” Suter said. “Even in a place like Maryland or D.C., access will be limited.”

D.C. faces a unique challenge. A congressional rider on D.C.’s budget, which D.C’s hasn’t been able to overturn due to its lack of statehood, prevents the District from using local funds on abortion care. This means that Medicaid cannot be used to cover abortion. Laws passed by the mayor or D.C. Council are subject to congressional approval (an ability congress members hadn’t utilized for decades until recently when they overturned a bill revising the city’s criminal code.)

The Supreme Court could also take up the case and rule to block any changes to the FDA’s approval or, as Suter suggested, look toward a provision called the Comstock Act. The law, first passed in 1873, bans people from using the mail to spread information or “obscene” materials. It did not define what obscenity meant but it did say it included anything used to cause an abortion.

According to Suter, it may be more likely for the Supreme Court to look toward that centuries-old provision to block abortion medication from being delivered by mail, rather than making a decision undermining the FDA’s approval of a drug, which could set a broad precedent.

“I don’t think you have five votes for the Supreme Court, ultimately, to think that the FDA can’t approve [mifepristone] because I think they would just find the far-reaching implications to be problematic,” she said . “But I think [Justices] Alito, Thomas would be very happy to apply the Comstock Act.”

The Supreme Court has granted the emergency stay until Wednesday and asked for an additional information briefing by Tuesday.

What are local providers doing?

Providers say they’re figuring out how to continue serving patients and dispel misinformation caused by the cases. According to Hurley, DCAF has already been hearing from confused and fearful callers since the overturn of Roe v. Wade. She said the current legal challenge to medication abortion, regardless of outcome, could make people wary of making the decision that’s best for them out of fear of criminalization, or confusion about the pill’s safety.

“We’ve already seen since Dobbs a huge increase in the fear of especially criminalization in our callers, especially when they’re calling from out of state,” Hurley said, adding that the group has also seen an influx of donations since last week’s federal decisions. “There’s a lot of fear around ‘am I supposed to be calling you?’ ‘Am I allowed to be calling you, is this going to be tracked?’ ‘Is someone going to see this?’ Even though it’s completely within their legal right to obtain an abortion in the District of Columbia.”

Melissa Grant, the co-founder of the abortion provider Carafem (which has a brick and mortar office in Chevy Chase) said after Thursday’s appellate ruling that the organization is working in real time to determine the best way to continue providing medication abortion and serving their client base. If anything did happen to mifepristone’s approval or access in the region, Grant said Carafem would rely on the second pill of the two-step regimen, misoprostol. When both mifepristone and misoprostol are used together, they have a 98% efficacy rate. When misoprostol is used alone, it can cause more severe cramping, but still shows an efficacy rate of 95%.

“Carafem is working closely with our attorneys to determine what our next steps will be in this rapidly changing legal environment,” Grant said. “Carafem is committed to continuing to provide abortion care via telehealth in 16 states and in our health centers to the fullest extent as permitted by law.”

Providers are also trying to combat a narrative that the current legal mess has anything to do with the safety of mifepristone, a drug that’s been FDA-approved for more than two decades.

In Kacsmaryk’s ruling, in which he argued the FDA did not adequately review the evidence when it approved mifepristone over 20 years ago, the Texas judge used common anti-abortion parlance, referring to abortion providers as “abortionists” and a fetus as an “unborn human.”

“There’s a great wash of fear and misinformation that’s been put out there – often by opponents of abortion – that says ‘you are at a huge risk if you use these medications, they are harmful, that’s why they’re illegal,” Grant said. “Messages like that are permeating a lot of the sphere of public discourse, and frankly it’s not true.”

A New York Times review of more than 100 studies, including more than 124,000 abortions across 26 countries, all concluded that the pills were safe and effective. More than half of all abortions in the U.S. are medication abortions, according to the Guttmacher Institute.

How are localities responding?

In the week since his ruling, some states have tried to stockpile mifepristone and misoprostol in the event that access is somehow restricted. While the congressional rider on D.C.’s budget prevents this in the District, that’s not the case in Maryland.

“As other states work to tear down reproductive protections and attack access to care and medication, the [Moore] administration is exploring options to implement more safeguards for all Marylanders—including working with the Department of Health to explore stockpiling mifepristone,” Moore said in a statement.

In Virginia, while Republican and anti-abortion Governor Glenn Youngkin has not taken steps to stockpile the medication or its companion, local providers have. Va. Sens. Tim Kaine and Mark Warner joined an amicus brief with more than 200 congressional colleagues last week, asking the appeals court to stay the Texas ruling.

Despite each locality having unique abortion laws, Grant said the provider network in the region is interconnected, as are abortion funds. In Virginia, the only jurisdiction in the region that did not join the Washington State lawsuit protecting FDA approval, abortion is legal through the second trimester of pregnancy. Low-income patients can only use public funding for the procedure if the patient’s life or health is at serious risk, if the pregnancy is a result of rape or incest and they report it, or if the fetus has “a documented incapacitating abnormality.” Medication abortion has been available via mail in the commonwealth since 2021.

“The only good news about this is that the DMV actually has providers in Virginia, Maryland, and in D.C. proper that all work together pretty well, along with abortion funds, to try to make sure that the gaps are eliminated as much as possible, and that people in the District can receive care at a reasonable cost,” Grant said.

Earlier this month, the Maryland General Assembly passed a law that would shield people from any legal repercussions if they travel to Maryland for abortion care from a state with stricter abortion access laws. Earlier this year, Gov. Moore also released millions of dollars in state funds to expand the state’s network of abortion providers, following a General Assembly bill in 2022 that allows nurses and physicians assistants — not just physicians — to perform the procedure. The D.C. Council passed a bill in 2022 that protects anyone who is self-managing an abortion from being penalized, and also prevents anyone from being penalized for providing a product for self-managed abortion.

D.C. Mayor Muriel Bowser did not respond to DCist/WAMU’s request for comment on the threats to medication abortion. In Northern Virginia, some state lawmakers have also spoken out against the attempted restrictions to access. State Delegate Candi Mundon King, who represents Prince William County in the state legislature, hosted a discussion last weekend with Planned Parenthood Advocates for Virginia about the recent legal challenges. Florida’s recent six-week abortion ban leaves Virginia as the southern state with the least restrictive abortion laws. Democrats in the General Assembly defeated Glenn Youngkin’s attempts to further restrict abortion access earlier this year, but with all seats in both chambers up for election this November, a Republican takeover would pave the way to further abortion restrictions in the commonwealth.

This article is part of Health Hub, DCist/WAMU’s weekly segment on health in the D.C. region. Tune in to WAMU 88.5 every Tuesday or on the NPR One app for a conversation with reporters and newsmakers about local health news.