Control the Bullets

The courts spent four days taking away mifepristone access and giving it back. Your Hims subscription shipped on time either way.

If a loaded gun is the problem, eventually someone has to talk about the bullets.

Here is what happened in the span of four days.

On May 1, 2026, the U.S. Court of Appeals for the Fifth Circuit issued a stay in State of Louisiana v. FDA, blocking the FDA’s 2023 rule that permitted telehealth prescriptions and mail delivery of mifepristone — the medication used in roughly two-thirds of all abortions in the United States, and routinely prescribed for miscarriage management. The ruling had nationwide effect. Patients across the country, including in states where abortion remains fully legal, were told they must now obtain mifepristone in person at a clinic, hospital, or medical office.

The court found Louisiana “likely to succeed on the merits” and cited approximately $92,000 in Medicaid costs attributed to emergency care for two women as evidence of “irreparable harm.”

Two patients. Ninety-two thousand dollars. Nationwide effect.

On May 4 — this morning — the Supreme Court issued a temporary administrative stay, signed by Justice Samuel Alito, restoring telehealth and mail access through May 11. Louisiana must respond by Thursday. The full court will then decide whether to extend the stay while the underlying case proceeds.

So as of today, access is restored. For a week.

Here is what that week means in practice. Consider a woman in rural Idaho — one of the 37 counties outside the state’s seven most populated, where a peer-reviewed study published last year in JAMA Network Open found just 23 OB-GYNs serving a population of over half a million people. She sees a telehealth provider because there is no other option. She learned last Friday that her pregnancy had a fetal abnormality. The Fifth Circuit ruling, issued that same day, meant her telehealth provider could no longer prescribe mifepristone by mail. In-person care was already hours away and weeks out. She spent the weekend making calls, doing math, trying to understand what her options still were. This morning’s Supreme Court stay restored her access — for now, for a week, contingent on what happens Thursday when Louisiana files its response.

She is still waiting for an answer the courts have not yet given her. The legal back-and-forth did not pause her pregnancy while the courts deliberated. Every day of uncertainty is a day of gestation. Every delay in access is a delay that, at a certain point, becomes a closed door. The courts can issue stays and lift them and issue them again, and the briefing schedules will proceed at the pace of litigation. The pregnancies will not.

Idaho has lost more than a third of its OB-GYNs since its abortion ban took effect in 2022. It now sits in the 10th percentile of maternal pregnancy outcomes nationally — meaning 90 percent of the country has better maternal outcomes than the state that just lost a third of its obstetric workforce. This is not a failure of coincidence. This is what the policy produces.

This is the part that gets lost in the coverage of what a stay is and what it isn’t, what’s temporary and what’s final, who filed what and when responses are due. Mifepristone is most effective in the first several weeks of pregnancy. Its availability is not an abstract legal question with an abstract legal timeline. It is a medication with a clock attached. And the clock does not stop for oral argument.

The Fifth Circuit ruling is still on the books. The case is still moving. The FDA review being used to manufacture justification for future restrictions is still underway. The administrative stay expires May 11, and nothing decided in the intervening week will permanently resolve the question of whether a woman in a legal state can access this medication through the same telehealth-and-mail model that delivers Viagra to every zip code in America.

That question — why one of those systems is protected and the other is not — is what this piece is about. And the answer tells you everything you need to know about what this has always been.

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This Is Not About Medicine

The FDA approved mifepristone in 2000. The 2023 rule at the center of this case was the result of an evidence-based review concluding that in-person dispensing restrictions were not medically necessary. That finding was not made by advocates or activists. It was made by the agency whose job it is to evaluate exactly this kind of evidence. Courts, not clinicians, are now overriding it.

Meanwhile, sildenafil and tadalafil — medications that carry their own risk profiles, including cardiovascular contraindications — flow freely through the mail. No court has moved to pause that. No attorney general has argued that the telehealth consultation model creates irreparable harm when the prescription ends up in a man’s medicine cabinet. The regulatory concern, it turns out, has a remarkably specific address.

This is not a coincidence of timing or regulation. It is a mirror of design. The founders of Ro and Hims have said openly that they built their companies around a single insight: men were too embarrassed to discuss erectile dysfunction face to face, and that embarrassment was keeping them from treatment. The clinical literature agrees — studies consistently find that the primary reason men don’t seek care for ED is stigma and social discomfort, not cost, not geography, not a closing biological window. The telehealth-and-mail model that now ships sildenafil to every zip code in America was purpose-built to solve male embarrassment.

That is a real problem. Embarrassment that prevents medical care is worth addressing. But let’s be precise about what it is: it is not urgency. It is not a condition where a two-month wait produces an irreversible outcome. It is not a medication where efficacy falls with every week that passes. The infrastructure that protects men’s access to a lifestyle medication was built around their comfort. The infrastructure that governed women’s access to a time-sensitive medication in a medical crisis was built around their control. One of those frameworks just got a stay from the Fifth Circuit. The other ships on time.

Sixty-five percent of abortions take place in the first eight weeks of pregnancy. Ninety-one percent occur in the first thirteen weeks. Abortions after 21 weeks represent barely one percent of cases, and they involve wanted pregnancies, extensive medical testing, and circumstances medicine could not prevent. These are not casual decisions. They are made with physicians, not instead of them. And in rural communities, in person means a drive that can take hours, a day off work, childcare arranged, and in many cases a wait of weeks or months for an appointment in counties where OB-GYNs are already scarce and getting scarcer. A months-long wait for a time-sensitive medication is not an inconvenience. It is a forced outcome.

Strip away religion. Strip away the language of protection. Strip away the science that doesn’t support the legal argument being made. What you are left with is control — extended or revoked not on the basis of evidence, or precedent, or constitutional principle, but on whose body is under consideration.

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The Standard That Only Applies to Women

The double standard is not only about which medications ship. It is about whose health risks the regulatory system is willing to accept — and whose it isn’t.

The medication that moves freely through the mail is the one with a documented cardiovascular risk profile, prescribed through a brief online consultation without an in-person visit. The medication hauled into the Fifth Circuit is the one the FDA reviewed and cleared — taken safely by millions of patients over 25 years, with a safety record strong enough that the agency dropped the in-person requirement entirely. No court paused the first to weigh the consequences. Courts are actively dismantling the infrastructure for the second.

And then consider what that system accepts as a baseline. The United States has the highest maternal mortality rate of any high-income nation — nearly 18 deaths per 100,000 live births, higher than the UK, France, Germany, Japan, and Norway. More than 80 percent of those deaths are considered preventable. This is the risk profile the system has decided is acceptable for women. The same system that finds that risk tolerable is the one treating a 25-year safety record on mifepristone as insufficient grounds for mail delivery.

The inconsistency is not incidental. It is structural. Different standards, applied systematically, in the same direction, every time.

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What This Is Actually About

The argument for these restrictions cannot rest on medicine — the FDA’s evidence-based review says otherwise. It cannot rest on legal precedent — decades of case law cuts directly against it. It cannot rest on constitutional principle — the First Amendment exists precisely to prevent one religious tradition’s definition of when life begins from being imposed on those of another faith.

Many abortion restrictions include exceptions for rape or incest. Their presence reveals the game: if the position is that abortion ends a life, the circumstances of conception are irrelevant to that calculus. The moment the law says except in these circumstances, it has conceded that the reasons behind a woman’s decision matter — that someone in a position of legal authority gets to evaluate those reasons and decide whether they are sufficient to restore her bodily autonomy. That is not a legal standard. That is a moral tribunal.

It cannot rest on states’ rights either — though that has been the loudest promise. The Fifth Circuit opened its opinion in this case by quoting Dobbs for the proposition that the Supreme Court had “returned the regulation of abortion to the states.” It then spent 18 pages imposing a nationwide rule that overrides the abortion policies of every state in the country, including those where abortion is fully legal. The panel’s jurisdiction covers Texas, Louisiana, and Mississippi. California’s laws on the subject are beside the point, as are New York’s. As Jay Kuo detailed this morning, this is the clearest illustration yet of the distance between that promise and the current reality — a three-judge panel, two of them Trump appointees, one of whom was previously general counsel for a conservative religious liberty organization, setting national abortion policy from a circuit that covers three states.

And the injury claim that produced the ruling may not survive legal scrutiny. Louisiana grounded its standing partly in $92,000 in Medicaid costs attributed to emergency care for two women. Mifepristone manufacturer Danco, in its emergency filing to the Supreme Court, argued this is the same chain-of-causation reasoning the Court unanimously rejected when it threw out the last mifepristone challenge in 2024. Louisiana is not required to prescribe mifepristone or do anything differently because of the FDA’s rule. It simply doesn’t like it — which the Court has already found is not enough. Whether the current Court agrees will determine whether this case survives at all.

No court applying its standards consistently would allow one class of telehealth prescription to flow freely while blocking another. No policy applying its standards consistently would accept an 18-per-100,000 maternal mortality rate as tolerable while treating a 25-year FDA safety record as insufficient grounds for mail delivery. No framework applying its standards consistently would be cutting rural hospitals while requiring rural women to travel hours for an in-person appointment.

The inconsistency is not an accident. It is the architecture. And in this case, the blueprints are public.

Project 2025 — the 900-page governing document authored by former Trump administration officials and already being implemented across federal agencies — explicitly calls for reinstating in-person dispensing requirements for mifepristone, revoking its FDA approval entirely, and enforcing the 1873 Comstock Act to ban mailing anything “intended for producing abortion.” That last provision, applied broadly, would constitute a nationwide abortion ban without requiring a single vote in Congress. The document also labels certain contraceptives as potential abortifacients and calls for stripping them from no-cost insurance coverage — not by banning birth control outright, but by reclassifying it.

That reclassification is not theoretical. I wrote about this in November, when the Trump State Department labeled $9.7 million in USAID-purchased contraceptives — standard IUDs, hormonal implants, and birth control pills stored in a warehouse in Geel, Belgium — as “abortifacient birth control commodities” and moved to destroy them rather than allow international health organizations to purchase and distribute them. ACOG stated flatly there is no such thing as an abortifacient contraceptive. State Department officials had been informed the products were not abortifacients per their own inventory lists. The administration applied the label anyway. The full piece is here — and if you’re a newer reader, it’s worth understanding how this strategy works, because what happened in Belgium was not a foreign policy footnote. It was a field test. The mechanism being used against mifepristone — reclassify the medication, manufacture a legal justification, remove it from the access model that makes it reach people — has already been applied to standard contraception. Women currently access oral contraceptives through the same telehealth-and-mail infrastructure the Fifth Circuit just tried to shut down. The pipeline for challenging that access exists. The definitional framework for doing so is already in use.

If you want to understand what this is about, don’t look at the medical arguments — they don’t hold. Don’t look at the legal arguments — the precedent runs the other way. Look at who has full control over their own medical decisions, and who doesn’t. Look at whose telehealth prescriptions are protected, and whose are paused. Look at who can make a phone call tonight and have a prescription delivered by Thursday, and who has to drive two hours to a clinic that may not have an appointment available for months.

That’s your answer.

A loaded gun is a problem. But the bullets are what does the damage. And right now, only one side of this equation is being asked to put them down.

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Postscript, May 4, 2026: The administrative stay restoring mifepristone access was signed by Justice Samuel Alito — the author of Dobbs. It is worth sitting with that for a moment. The justice who wrote the opinion ending the federal right to abortion is the one who signed the order giving women one more week. The architecture described in this piece was not dismantled this morning. It was paused — temporarily, provisionally, by a single justice, for seven days.

Watch what happens on May 12.

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References & Further Reading

Legal Analysis

“Let the States Decide Abortion!” My Ass

SCOTUSblog. “Abortion Pill Dispute Returns to Supreme Court.” May 4, 2026. Primary source coverage of the administrative stay issued by Justice Alito, the Danco and GenBioPro emergency applications, and the standing arguments.

Danco Laboratories. Emergency Application for Stay, Danco Laboratories v. Louisiana, Supreme Court of the United States. May 2, 2026. The full text of Danco’s Supreme Court filing, including the standing argument drawing on Alliance for Hippocratic Medicine v. FDA (2024).

The Case

American Civil Liberties Union. State of Louisiana v. U.S. Food and Drug Administration — Case Page. Updated continuously. Full case history, legal documents, and press releases.

Center for Reproductive Rights. “Louisiana v. FDA: Abortion Pill Access Under Fire.” Updated continuously. Case timeline and analysis including the district court’s April 2026 stay of litigation and Louisiana’s Fifth Circuit appeal.

Guttmacher Institute. “Fifth Circuit Decision Directs FDA to Restrict Mifepristone Access.” May 1, 2026. Data on medication abortion use and the scope of impact of reinstating in-person dispensing requirements.

CNN. “Appeals Court Blocks Access to Abortion Pills via Telehealth and Mail Nationwide.” May 1, 2026.

Idaho & Rural Access

McEachern, Edward, et al. “Obstetric Physician Workforce Changes in Idaho Following Abortion Restrictions.” JAMA Network Open, July 31, 2025. Peer-reviewed study finding Idaho lost 35% of its OB-GYN physicians — 94 of 268 — between August 2022 and December 2024, with remaining physicians concentrated in the state’s seven most populated counties. Reported widely including by the Idaho Capital Sun, Washington State Standard, and ABC News.

Maternal Mortality

The Commonwealth Fund. “Insights into the U.S. Maternal Mortality Crisis: An International Comparison.” June 2024. Primary source for the finding that the U.S. has the highest maternal mortality rate of any high-income nation, with over 80 percent of deaths considered preventable. The 2023 U.S. maternal mortality rate of 18.6 deaths per 100,000 live births is from AJMC’s reporting on updated CDC data.

Abortion Statistics

Guttmacher Institute. “Induced Abortion in the United States.” Updated March 2026. Source for the 65% medication abortion figure (share of all clinician-provided abortions in 2023). Note: the 65% gestational timing figure in the piece (abortions at or before 8 weeks) is from CDC Abortion Surveillance data, consistently reported across years at approximately 65%.

CDC Abortion Surveillance. “Abortion Surveillance — United States.” Published annually. Source for gestational timing data: approximately 65% of abortions at ≤8 weeks, 91% at ≤13 weeks, and 1.3% at ≥21 weeks.

Project 2025

Heritage Foundation. Mandate for Leadership: The Conservative Promise (Project 2025). 2023. 900-page governing document. Relevant sections include Chapter 14 (HHS, pp. 449–502, authored by Roger Severino) on revoking mifepristone’s FDA approval and reinstating in-person dispensing requirements; Chapter 17 (DOJ, p. 562) on enforcing the Comstock Act against abortion pill distributors; and provisions on contraceptive mandate exemptions including the classification of Ella as a “potential abortifacient.”

Guttmacher Institute. “How Project 2025 Seeks to Obliterate Sexual and Reproductive Health and Rights.” September 2025. Comprehensive analysis of the document’s reproductive health provisions.

Rolling Stone. “GOP’s 2025 Plan: Attack Birth Control, Surveil Women and Ban Abortion.” December 2023. Detailed reporting on Project 2025’s mifepristone and Comstock provisions.