Start-Up Provides Reproductive Care for Underserved Communities

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Eduardo Garcia, MD, a California-based medical adviser to staff physicians at Twentyeight Health, consults online with staff member Karla Robinson, MD, a family practitioner in North Carolina. Photo: Nancy Newman

When the Supreme Court overturned the constitutional right to abortion in Dobbs v. Jackson Women’s Health Organization last summer, the founders of start-up Twentyeight Health, which provides virtual health services to women and other birthing people, began figuring out how to launch nonsurgical abortion services in the face of rapidly changing policies.

Bruno Van Tuykom and Amy Fan co-founded Twentyeight Health in 2018 to increase access to reproductive and sexual health services in underserved communities. They were already using a telehealth platform and home medication delivery to offer birth control, prenatal vitamins, and treatment for sexually transmitted infections. Offering medication abortion seemed like the logical next step in their quest to support equitable access to health care.

“Since abortion restrictions disproportionately impact low-income women and women of color, it became even more important for us to really think about how we can offer these services to our users,” said Fan, the company’s president and chief product officer.

While the Dobbs v. Jackson ruling was a backward slide for women’s reproductive rights, it solidified state authority over reproductive health care, including medication abortion in states where abortion continues to be unrestricted.

In February, Twentyeight Health successfully launched medication abortion services in California and New York. “It couldn’t be closer to our mission of improving reproductive and sexual health,” said Van Tuykom, Twentyeight Health’s CEO.

“Twentyeight Health is designing health care services to be accessible to underserved communities and providing a dignified and welcoming experience in Spanish and English.“

—Medical adviser Eduardo Garcia, MD

Among start-ups that use technology to address women’s health issues, Twentyeight Health is unique because it was built to provide reproductive and sexual health care to women and birthing people of color and those with low incomes, said Fan. Slightly more than half its users are Medicaid enrollees; 58% identify as a person of color; and nearly 60% of Twentyeight Health clients live in nonurban settings, she said. Twentyeight Health is available to patients in 34 states and Washington, DC.

Its services are available in California to women between 13 and 49 years old, and the company plans to launch related perinatal services in the state this year. The company focuses on the needs of individuals assigned female at birth. “If you are nonbinary or transgender and need access to birth control because you have an intact uterus, we welcome you to use our services,” the company says on its website. A majority of Twentyeight Health’s direct medical providers are women; 80% of medical staff identify as a person of color; and half of the staff speak Spanish, Fan added.

“What Twentyeight Health has done is phenomenal,” said Melissa Buckley, director of the Innovation Fund at CHCF. “They’ve built everything for Medicaid and women of color from the ground up. None of it was an afterthought.”

Eduardo Garcia, MD, a California OB/GYN who advises the start-up’s frontline providers, said he is proud to support the company’s “inclusive approach to health care.”

“Twentyeight Health is designing health care services to be accessible to underserved communities and providing a dignified and welcoming experience in Spanish and English,” he said.

While CHCF recognizes that community clinics are the primary providers of health services to women with low incomes and to communities of color, the foundation decided to support the expansion of alternative reproductive health options for women. The Innovation Fund invested $250,000 in Twentyeight Health to increase access to health services for Spanish-speaking and rural women.

Even When Enrolled in Medicaid, Women Struggle to Access Care

Twentyeight Health is accessible online via computer, tablet, or smartphone. No app is needed to reach its website. For clients, the process begins with an asynchronous medical questionnaire that includes information to determine Medicaid eligibility. Then an audio consultation can be scheduled, although that’s optional in California and some other states. Thereafter, a wide array of medications, including contraceptives, herpes medications, morning-after pills, and abortion pills, can be delivered to patients’ homes or to a nearby pharmacy. Patients can also message a provider at any time.

Medicaid programs typically cover users’ medications with no copay, though they must pay a $26 annual doctor evaluation fee for each medication they’re prescribed. If someone doesn’t have insurance, medications can be obtained at reduced costs. For example, a birth control pack can be purchased for as little as $18 a month. Twentyeight Health partners with nonprofit organizations to provide free birth control for uninsured individuals with financial need. The company generates revenue through Medicaid billable services, annual fees, cash-pay users, and fulfillment of prescriptions.

“Everyone now has an opportunity to experience what once was limited to those who either had transportation to a clinic or insurance in order to be able to afford to see the doctor.“

—Karla Robinson, MD

Even in California, where abortion and contraception have been enshrined in the state constitution, not all women have equal access to abortion services. There are abortion deserts in rural parts of the state. In 2017, roughly 40% of California counties had no clinics that provided abortions to women, according to a study by the Guttmacher Institute. The state is also home to 179 crisis pregnancy centers (PDF), which advocates warn make deceptive medical claims about pregnancy and abortion in an effort to dissuade people from undergoing an abortion. In California in 2019, there were 20% more crisis pregnancy centers than abortion clinics.

Another study found that 12% of women with Medi-Cal who had abortions in 2011 and 2012 —  half of whom lived in rural areas — had to drive at least 50 miles for that care. The researchers reported that “28 counties, home to 10% of eligible women, did not have a facility routinely providing Medi-Cal-covered abortions.”

“Someone might have insurance, but it doesn’t necessarily mean they can actually access health care services that can be covered. That’s why home-delivery abortion medication and online women’s health services are lifelines to women who live in places not served by abortion clinics,” Fan said.

All That’s Needed Is an Internet Connection

Communities of color have long experienced that non-Black doctors perpetuate systemic inequities. That’s another issue addressed by Twentyeight Health.

“Mistrust, that’s a big issue — certainly in marginalized communities that have been taken advantage of for many, many years,” said Karla Robinson, MD, a Charlotte, North Carolina, board-certified family physician with Twentyeight Health who is licensed to care for patients in California and 27 other states.

The company’s providers are mostly women of color who have experience working with patients from underserved communities. Prospective patients can visit the company’s website and see “providers who look like they do, who are relatable,” said Robinson. “I think that goes a long way.”

One of Robinson’s favorite features of Twentyeight Health is that racial, ethnic, and other demographic characteristics of patients are not flagged in the records. This helps reduce provider bias, she said.

“We are blinded, so to speak, to the particular demographics of our users, and that really helps to take out the unconscious bias we may hold for whatever reason,” Robinson said.

Twentyeight Health also builds trust by partnering with nonprofit organizations like Bay Area-based Access Reproductive Justice. Three-quarters of the company’s referrals come from these partnerships, according to the start-up. With a high rating of customer loyalty and satisfaction, Twentyeight Health sees its efforts paying off for customers.

By harnessing the convenience and benefits of telehealth, Robinson said, the company appeals to women and other birthing people who previously faced barriers to accessing brick-and-mortar clinics because many can’t take time off work or afford child-care costs or reliable transportation.

“With a click of a button on your phone or on your computer, you now have an opportunity to experience what once was limited to those who either had transportation to a clinic or insurance in order to be able to afford to see the doctor,” Robinson said. “As long as you’ve got access to the internet, we can provide you the reproductive services that you need.”

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