“Our highest priority is ensuring safe and timely access to medications for our patients, and we understand the important role pharmacies serve in support of women’s health care. We have policies in place to ensure no patient is ever denied access to medication prescribed by a physician based on a pharmacist’s individual religious or moral beliefs,” Thibault said.
More broadly, reproductive rights advocates say the alleged incident is a jarring reminder of how the national fight over abortion can spill over into deeply blue California, affecting patient care. In the two years since the U.S. Supreme Court eliminated federal abortion protections, California lawmakers have gone to great lengths 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 can affect reproductive health access everywhere — even when abortion is not involved.
“This prescription was to manage continued miscarriage, and yet employees at CVS, their stigma against anything that looks like abortion or sounds like abortion, interfered with their legal obligation to provide (Costales) with her medication,” said Clara Spera, senior counsel for the National Women’s Law Center, and Costales’ attorney.
California law requires pharmacies to dispense legally prescribed medications to patients and make accommodations for both the patient and employee if an individual employee registers a sincerely held objection to providing the medication. Costales’ attorney said CVS violated that law — as well as the state’s Unruh Civil Rights Act prohibiting discrimination based on sex or pregnancy-related conditions — when it denied her misoprostol.
CVS and its national competitor Walgreens have previously faced scrutiny from federal regulators over similar complaints from patients around the country. Last year, the U.S. Department of Health and Human Services Office for Civil Rights published an agreement the companies made after numerous discrimination complaints of medication denial from women experiencing miscarriages and people with disabilities. The companies agreed to train pharmacy staff on reproductive health rights and monitor medication denials to ensure patients receive prescriptions in a timely manner.
Thibault did not answer questions about when the last time employees at Costales’ local pharmacy had been trained on reproductive health rights or what specific company policies are in place to ensure patients get medications in a timely manner.
A rare pregnancy complication
Costales’ said her ultrasound and other tests led doctors to suspect she might have a molar pregnancy, a rare complication that can form cancer if untreated, and recommended surgery to find out.
Surgery is the only way to remove the tissue and confirm a molar pregnancy diagnosis, said Dr. Aparna Sridhar, an obstetrician and associate clinical 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 heavily and in severe pain. In the emergency room, a doctor recommended misoprostol to help her body finish expelling any remaining pregnancy tissue or uterine lining.
“I wanted to get my medication as soon as I could. And I wanted to get home and administer it so that we could feel at ease and at peace with, you know, the rest of our care plan,” Costales said.
For most miscarriages and early pregnancy loss, Sridhar said the three management options are surgical intervention, medication and waiting to see if the body successfully empties the uterus by itself. Determining the course of treatment should be a joint decision between the patient and doctor, and all three options have been shown to be safe, Sridhar said.
But at her CVS pharmacy, the first employee told Costales there was no prescription for her on file, the National Women’s Law Center letter alleges. The second employee told her, “I don’t know if we can fill this,” according to the letter. And after asking to speak with the pharmacist for an explanation, Costales alleges in the letter that the pharmacist said, “It doesn’t matter if I have it, I am not comfortable dispensing it to you,” and walked away.
The experience was humiliating, Costales said, adding that the shame and anger have lasted for months.
“The hardest part is I feel like CVS robbed me of my ability to mourn my pregnancy loss,” she said.
Abortion challenges continue
The CVS employees did not tell Costales why they objected to providing her with the medication prescribed to her, she said. Nonetheless, California health experts say that since the U.S. Supreme Court overturned Roe v. Wade two years ago, ending the constitutional right to an abortion, there has been confusion among providers about what is required under the law.
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 medication, mifepristone, used both for abortion and miscarriage management. The plaintiffs were doctors opposed to abortion who argued that they could be required to treat someone in the emergency room with a complication related to abortion.
In that ruling, Justice Brett Kavanaugh wrote that federal law guarantees “broad and comprehensive conscience protections” for doctors who object to abortion and that the plaintiffs had no examples of being forced to treat a patient who had an abortion. The anti-abortion legal group leading the case against the FDA has already pledged to continue its legal battle.
Experts say religious and moral objections have been protected for decades.
“That’s the status quo. We have decided that we are going to allow people to opt out of care that they don’t want to perform,” said Cathren Cohen, a staff attorney with the UCLA Center on Reproductive Health, Law and Policy.
Despite laws protecting a patient’s right to medical care, individuals can struggle to defend or advocate for themselves.
“This flip-flopping of changing of laws from day to day does have a detrimental and chilling effect on care people are getting,” Cohen said.
Even in California, the constantly changing landscape causes uncertainty, said Dr. Josie Urbina, an obstetrician at Zuckerberg San Francisco General Hospital. Doctors like herself have difficulty keeping up with the ripple effects of national decision-making, and patients find it especially hard to know what is available to them and what they have a right to, she said.
“It still causes confusion; it still causes people to think, ‘This may affect me,’” Urbina said.
Costales said she wants Californians who identify with her story to know that they have legal protections.
“One of the reasons why I live in California is to make sure I will be protected, and I don’t have to worry about planning for my family,” Costales said. “How many other people are being impacted by this and are getting their rights neglected or just stomped on?”
