In summary
California has greatly expanded protections for abortion care since the Supreme Court overturned Roe v. Wade. But enforcing the laws can be complicated, and some providers are confused about what is required of them.
After months of trying, Angela Costales eagerly watched her home pregnancy test come back positive. She and her husband were so excited that they filmed a video at 3am to document the moment – but the joy they felt didn’t last.
Costales’ first ultrasound showed placental abnormalities and no fetal heartbeat. She had lost her pregnancy and her first chance to become a mother.
It was devastating, she said. What happened next made her feel even worse: The CVS Pharmacy in her San Diego neighborhood, she said, refused to fill the prescription she was given to manage her miscarriage.
The drug Costales needed was misoprostol, a pill commonly used to help with miscarriages that is also used in abortions. According to Costales and her attorney, three separate pharmacy employees refused to help her get the medication while she stood in the store bleeding and in pain on Dec. 20.
“I couldn’t believe what was happening,” Costales said. “I I really felt like I was in danger and [CVS]… denied my care without regard for my well-being.”
Costales and the nonprofit National Women’s Law Center claim the retail pharmacy chain broke federal and state laws when it fired her. They have issued a formal request to CVS in the form of a public letter outlining the CVS staff members who refuse to fill Costales’ prescriptions and the laws violated by such refusal. The letter includes a list of demands, among them that CVS improve its policies and train employees nationwide to prevent similar occurrences. It requires CVS to post a notice at each pharmacy detailing “patients’ rights to receive their prescribed medication.”
Costales has not filed a lawsuit against CVS, but is not ruling one out, her attorney said.
“If it happened to me, it’s happening to other people,” Costales said.
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Thibault said any pharmacist who has personal objections to dispensing certain medications should notify the company in advance so arrangements can be made to fill the prescription.
“Our highest priority is ensuring safe and timely access to medications for our patients, and we understand the important role that pharmacies serve in supporting women’s health care. We have policies in place to ensure that no patient is denied access to medication prescribed by a physician based on a pharmacist’s individual religious or moral beliefs,” Thibault said in an email.
More broadly, reproductive rights advocates say the alleged incident is a chilling reminder of how the national fight over abortion can spill over into deep blue California, affecting patient care. In the two years since the U.S. Supreme Court struck down federal abortion protections, California lawmakers have made major efforts to expand and protect reproductive health rights, and voters in 2022 amended the state constitution to include the right to an abortion. But enforcing the laws on the ground can be difficult, experts say.
Legal scholars, doctors and abortion rights advocates also contend ongoing court battles and laws criminalizing abortion in other states could affect access to reproductive health everywhere — even when abortion isn’t involved.
“This prescription was to manage ongoing miscarriage, and yet the employees at CVS, their stigma against anything that looks like an abortion or sounds like an abortion, interfered with their legal obligation to provide (Costales) with her medication,” said Clara Spera, senior counsel for the National Women’s Justice Center and Costales’ attorney.
California law requires pharmacies to dispense legally prescribed medications to patients and make accommodations for both the patient and the employee if an individual employee registers a bona fide objection to the dispensing of the medication. Costales’ attorney said CVS violated that law — as well as the state’s Unruh Civil Rights Act, which prohibits discrimination based on sex or pregnancy-related conditions — when it denied her misoprostol.
CVS and its national competitor Walgreens have faced scrutiny from federal regulators before over similar complaints from patients nationwide. Last year, the Office of Civil Rights of the US Department of Health and Human Services published a settlement made by the companies after numerous complaints of discrimination for refusing drugs from women experiencing abortions and people with disabilities. The agreement included training pharmacy staff on reproductive health rights and monitoring drug refusals to ensure patients received prescriptions in a timely manner.
Thibault did not respond to questions about when employees at Costales’ local pharmacy were last trained on reproductive health rights or what specific company policies are in place to ensure patients receive medications on time.
A rare complication of pregnancy
Based on Costales’ ultrasound and other tests, she said doctors suspected she might have a molar pregnancy, a rare complication that can develop into cancer if left untreated. They recommended surgery to find out, she said.
Surgery is the only way to remove the tissue and confirm a molar pregnancy diagnosis, said Dr. Aparna Sridhar, an obstetrician and clinical associate professor at UCLA’s David Geffen School of Medicine. Sridhar was not involved in Costales’ care.
After the procedure, Costales said she felt fine until a week later when she woke up bleeding profusely and in severe pain. In the emergency room, the doctor prescribed misoprostol to help her body finish expelling any remaining pregnancy tissue or uterine lining.
“I wanted to get the medication as soon as possible. And I wanted to come home and administer it so that we felt comfortable and at ease with the rest of our care plan,” Costales said.
For most miscarriages and early pregnancy loss, Sridhar said the three management options are surgery, medication and waiting to see if the body successfully empties the uterus on its own. Determining the course of treatment should be a joint decision between the patient and the doctor, and all three options have been shown to be safe, Sridhar said.
But at the CVS pharmacy at 4829 Clairemont Drive, the first employee told Costales there was no prescription for her on file, the National Women’s Law Center said in the letter. The second employee told her “I don’t know if we can fill this,” according to the letter. And after asking to speak to the pharmacist for an explanation, Costales claims in the letter that the pharmacist said “It doesn’t matter if I have it, I’m not comfortable giving it to you” and left.
The experience was humiliating, Costales said, adding that the shame and anger have lingered for months.
“The hardest part is that I feel like CVS took away my ability to mourn my pregnancy loss,” Costales said.
Abortion challenges continue
CVS employees did not tell Costales why they refused to provide her with the prescribed medications, she said. However, California health experts say there has been confusion among providers about what the law requires since the U.S. Supreme Court two years ago overturned Roe v. Wade and ended the constitutional right to abortion.
Last week, the Supreme Court rejected the latest bid by anti-abortion groups to overturn federal Food and Drug Administration regulations that expanded access to another drug, mifepristone, used for both abortion and miscarriage management. The plaintiffs were anti-abortion doctors who argued that they could be required to treat someone in the emergency room with an abortion-related complication.
In the ruling, Judge Brett Kavanaugh wrote that federal law guarantees “broad and comprehensive protection of conscience” to doctors who oppose abortion and that the plaintiffs had no examples of having to treat a patient who had an abortion. The anti-abortion legal group leading the case against the FDA has already vowed to continue its legal battle
Experts say religious and moral objections have been defended for decades.
“This is the status quo. We’ve decided that we’re going to let people opt out of care they don’t want to have,” said Cathren Cohen, a staff attorney with the UCLA Center for Reproductive Health, Law and Policy.
Despite laws also protecting the patient’s right to receive medical care, individuals may struggle to protect or defend themselves.
“This change of changing laws from day to day has a detrimental and chilling effect on the care that people are getting,” Cohen said.
Even in California, the ever-changing landscape causes uncertainty, said Dr. Josie Urbina, an obstetrician at Zuckerberg San Francisco General Hospital. Doctors like her have a hard time keeping up with the ripple effects of national decision-making, and patients have a particularly hard time knowing what’s available to them and what they’re entitled to, she said.
“It still causes confusion, it still makes people think ‘This could affect me,’” Urbina said.
Spera, Costales’ attorney, said the confusion and loss of federal abortion protections encourages people not involved in an individual’s health care to say “I know what’s best.” Costales said she wants Californians who identify with her story to know they have legal protection.
“One of the reasons I live in California is to make sure I’m going to be protected and not have to worry about planning for my family,” Costales said. “How many other people are being affected by this and having their rights ignored or violated?”
Supported by the California Healthcare Foundation (CHCF), which works to ensure this people have access to the care they need, when they need it, at a price they can afford. Visit www.chcf.org to learn more.
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