Cindy Adam, Choix, on increasing medication abortion through telehealth

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In this episode, we sat down with Cindy Adam, Co-Founder & CEO of Choix and a nurse practitioner. Choix is a telehealth clinic offering abortion care and sexual and reproductive health care to patients in their homes. Choix recently raised $1M in seed funding in a round led by Elevate Capital.

Cindy completed her master's degree in Nursing at the University of California in San Francisco. She started her nursing career in primary care with the Santa Rosa and Santa Cruz community clinics specializing in sexual and reproductive health care with the SF Department of Public Health, private practice and an early stage contraceptive care telehealth provider.

We discussed:

• The recent history of abortion care in the U.S. and the legal implications of the Dobbs v. Jackson decision eliminating the federal constitutional right to abortion.
• The clinical background of medicated abortion care and how permanent FDA authorization for providers to mail mifepristone, the pill used in medicated abortions, enabled abortion care to be practiced through telehealth.
• The importance of the November midterms and potential regulatory shifts after voters express their views on abortion at the polls.

Start to 10:19: Background on abortion in the U.S.

• An early interest in helping others: Cindy initially aspired to be a human rights lawyer, but revaluated and decided to pursue a career in healthcare. As a nurse practitioner, Cindy provides direct care to patients and helps spearhead public health initiatives that benefit people in her community. Specifically, Cindy’s clinical training included abortion care, and abortion care has been a core part of Cindy’s practice. This exposure to abortion care initiated Cindy’s early interest in abortion services.
• On the recent landscape of abortion care in the U.S.: In 1973, the landmark Roe v. Wade case passed in the Supreme Court, stating that the U.S. government cannot interfere excessively with decisions about pregnancy under the individual’s right to privacy. In response to Roe v. Wade, various states started adding more restrictions to abortion care, often by holding abortion providers criminally liable for performing abortions and limiting public funding for clinics that perform abortions. The recent Dobbs v. Jackson case overturned the legal precedent set in Roe that protected the federal right to abortions. The implication of this ruling is each state now has the jurisdiction to decide abortion laws within their state lines.
• Yet most Americans support abortion: A recent Pew research poll indicates 61% of Americans support legalizing abortion in all or most cases. In addition, most Americans disapprove of the Dobbs v. Jackson decision. Cindy explains part of the way the Supreme Court and state legislatures can restrict and limit the federal right to abortion despite public opinion supporting abortion is due to gerrymandering and the appointment of pro-life Supreme Court candidates.
• On medical methods of carrying out abortions: There are two general types of medical abortions: medication and surgical. Choix provides medication abortions. The FDA’s recommended medication abortion regimen involves two pills. Mifepristone is the first pill and blocks progesterone. This terminates the progression of the pregnancy. The second pill is misoprostol, which leads the uterus to cramp and pass the pregnancy. Prior to 2020, patients seeking a medication abortion could only access the pills after an in-person appointment at the clinic. During COVID, a federal district court rule allowed for abortion pills to be mailed. In December of 2021, the FDA authorized the mailing of mifepristone to make medication abortions more accessible.
• On the impact of telemedicine on abortion access: The FDA’s permanent authorization for patients to receive mifepristone by mail has enabled telehealth providers to dispense medicated abortions to patients without an in-person evaluation. Providers such as Choix conduct online appointments with patients to determine the patient’s safety and eligibility for receiving a medication abortion. This assessment can be done without the ultrasound or other lab work otherwise completed during an in-person visit. Once approved, the patient can receive abortion pills mailed directly to them.
• Mailed medical abortions from Europe: Before the FDA allowed abortion pills to be mailed, Dutch doctor Rebecca Gomperts and her organization Aid Access were mailing abortion pills to Americans who otherwise would not have been able to access medical abortions. Because Dr. Gomperts and her team operate outside of the U.S. and mail pills sourced from a pharmacy in India, American authorities currently have limited means to stop Dr. Gomperts and Aid Access from mailing abortion pills to Americans. In fact, Aid Access is the only way many Americans living in states that have banned abortion can access a medical abortion.

10:19 to 32:45: Deep dive on Choix

• On the motivation for starting Choix: Choix was co-founded by a group of practitioners who observed a gap in abortion care access amongst their patients. The founding team aimed to develop a solution that would expand access while providing a full range of sexual reproductive care to patients. This practitioner-led founding team is unique amongst healthcare startups, and has helped Choix identify what is missing in the abortion care experience for patients, family members, and providers.
• On the name “Choix”: Choix comes from the French word for “choice.” The French influence behind Choix’ name is an homage to mifepristone, the first drug used in the medicated abortion process, which was developed in France. The “x” in “Choix” brings awareness to gender neutrality as Choix serves all people who can become pregnant.
• Overview of Choix: Choix is a sexual and reproductive health telehealth provider focused on reducing barriers to safe and accessible healthcare in the home. While perhaps best known for their medicated abortion care services, Choix also offers birth control and STI treatment. Choix is planning on expanding its services to offer STI testing and vaginitis treatment. Choix’ services are fully virtual. Choix’ practitioners are all employed in-house, which allows the company to ensure a consistent standard of care and create a more positive employment experience for clinicians.
• On the decision to focus on telehealth: Part of Choix’ mission is to decrease accessibility barriers for patients. Incorporating a telehealth model lowers the cost of care by eliminating the investment cost of building a brick and mortar presence as well as transportation challenges patients may face if they have to commute to an in-person clinic. While telehealth may not be the preferred mode of engagement for every patient, telehealth is helpful for those who may face cost and transportation difficulties.

“The idea is that we can really meet patients where they're at and offer them care in a way that's really patient centered and fits what they need.”

• Expanding in the face of legal shifts: Choix currently operates in California, Colorado, Illinois, and New Mexico. Choix aims to be in 10 states by the end of the year and 20-25 states by the end of 2023. The evolving state regulations on where forms of abortion care are legal impacts Choix’ decision to begin operating in that state. The Choix team is also targeting places where abortion may be legal but patients still experience a gap in care, such as in rural areas.
• Potential implications for contraception: Riding the wave of legal maneuvers restricting or banning abortion are groups working to roll back access to contraception, including emergency contraception such as the Plan B pill. These efforts have been met with some counter resistance, such as the introduction of a bill in the Senate to codify the legal right to contraception.
• The true cost of abortion pills: Affordability is a key component of accessibility. Mifepristone is the generic version of Mifeprex, and this pill costs around $50. Misoprostol is the second pill used as part of a medication abortion and costs only a few dollars. The large difference in pricing for the two pills has led some patients to only use misoprostol to facilitate their abortions even though official FDA guidance is to use the combination of mifepristone and misoprostol. Choix offers transparent pricing through their direct-to-consumer model. Choix charges $88 to deliver the mifepristone, misoprostol, a high dose ibuprofen, and ondansetron (Zofran), an anti-nausea medication.
• Near-term priorities post closing seed round: The co–founders of Choix decided to pursue external fundraising to scale the company more quickly. One of Choix’ priorities with this funding is to expand its operations to other states. Choix will also explore how they may partner with employers and payers to offer its services to more patients, starting with assessing the viability of accepting Medicaid.
• Offering advanced provision of medication abortion: Choix recently launched an offering for the advanced provision of medication abortion. This allows patients to receive abortion pills before getting pregnant, enabling patients to use the pills in the future as needed. This offering is intended to expand access to safe abortions for more patients especially in light of the Dobbs decision and subsequent bans and other restrictions on abortion care. The ability to access abortion care before a pregnancy helps reduce the stress patients may face in the time-sensitive period between discovering they are pregnant to sorting out the logistics needed to receive quality abortion care.

“Everyone should be able to access supportive, nonjudgmental and trusted abortion care. And unfortunately, we know that this isn't the case for the countless people who increasingly face barriers to access abortion here in the U.S. We hope that with the advanced provision of abortion pills, people can take back some of that power and control from the system that is intent on taking it away from them.”

32:45 to 41:40: On the broader abortion landscape in the U.S.

• The importance of November elections: A study from the Kaiser Family Foundation indicates abortion access has become a bigger issue motivating voter engagement particularly amongst Democrats and reproductive-age women. While there are some states where restrictions on abortion have already been decided, voters in many other states will have the opportunity to indicate their views on abortion in upcoming midterm elections.
• Results from the Kansas public referendum, where voters rejected an amendment to the Kansas state constitution that would have banned abortion, indicate abortion is a complicated issue even in conservative states. Meanwhile, the Indiana state legislature passed a law that bans abortion with few exceptions. Democrats are positioning abortion as a key voting issue for the November midterms in an effort to galvanize turnout and engagement despite other pressing concerns such as inflation. The results of the November midterms will be an important litmus test on how Americans perceive and prioritize abortion access.
• States proactively protecting abortion rights: While some states with trigger laws effectively banned abortion after the Dobbs decision, other states have rushed to extend protections for abortion. These states, termed “haven states”, have adopted a range of actions from codifying abortion rights in their state laws to expanding insurance coverage for abortion care and even facilitating abortions for patients traveling from states that have banned abortion access.

“Politicians are creating medical protocols with the way they create restrictions and laws, and instead it should be up to the patient and the medical provider to make the best decision for them within what we consider to be safe and appropriate medical care.”

• The rise of partnerships to protect abortion access: Abortion-rights proponents have mobilized around ensuring abortion access. Groups such as the Abortion Care Network, a collection of independent abortion providers, and the National Abortion Federation, a professional organization for abortion providers, have been and continue to push for legal pathways to abortion. Collaboration between practitioners as well as organizing efforts for private citizens, corporations and politicians to do their part to bring greater access to abortion all help to bring this critical medical care to more patients.
• The importance of practical care for abortion: One critical aspect of abortion care that is often overlooked is practical care. Practical care includes everything that enables a patient to receive abortion care. This may include transportation to the abortion clinic, childcare, and other logistical components. Organizations such as the Brigid Alliance and the Apiary Collective are among those groups that have been coordinating efforts to provide practical care to patients.

“The goal of being more innovative and less reactionary is really important in this space. We receive calls every day from people who just don't know what to do, and don't know what the best next step is to take. And so I think it's important for all of us as a community to come together to support them.”

41:40 to End: Entrepreneurship advice

• Trust as a critical ingredient of startup success: Given the importance of its mission, investors and employees at Choix must trust in its goals and vision. Building trust has been a critical part of curating the Choix team as well as assembling its investors. Cindy explains Elevate Capital, the venture capital firm leading Choix’ seed round, shared a similar ethos with Choix. Elevate focuses on working with minority founders and provides mentorship to founding teams. This mission alignment has helped Choix succeed and position itself for future growth.
• Starting a telehealth company during COVID: Choix was uniquely positioned to dispense care through telemedicine during COVID as more patients and clinicians moved to a health-at-home model of care. Cindy recalls working with patients at the height of the pandemic who were terrified of leaving their homes for fear of exposing themselves or immunocompromised family members to COVID. The FDA authorization to mail mifepristone also enabled Choix to operate as a virtual medicated abortion pill service. Moving forward, Choix will continue to leverage its strengths as a startup born during the COVID epidemic to transition into the next phase of its growth journey.