The next salvo in the crusade to ban abortion is now clear. Anti-abortion activists have launched what they’re privately calling “Rolling Thunder” — a coordinated campaign to pressure the Food and Drug Administration (FDA) to restore restrictions on mifepristone, a popular drug used in the US to end pregnancies. Under Rolling Thunder, activists also plan to bring new lawsuits against doctors who prescribe abortion medication, and continue lobbying to strip the drug from the market entirely.Their vision relies heavily on a new report claiming mifepristone causes high rates of health complications — contradicting decades of rigorous drug safety testing. Citing the report, Republican Sen. Josh Hawley introduced a bill on Tuesday to reimpose mifepristone restrictions, and to allow patients to sue telehealth abortion providers who prescribe it. This comes amid another legal attack on a New York abortion provider, who faces a first-of-its-kind criminal charge for prescribing abortion pills to the mother of a pregnant minor in Louisiana.The FDA approved mifepristone 25 years ago, and it’s used today in two-thirds of abortions in America. Abortion pills have become the most common method for ending pregnancies in the US, partly due to their safety record and lower cost, combined with diminished access to in-person care. While states have ramped up abortion restrictions since Roe v. Wade was overturned in 2022, access to abortion pills has actually significantly expanded since, helping to explain why there were more US abortions in 2023 than in any year since 2011. Reinstating federal restrictions on mifepristone could effectively end telemedicine abortion access, in which patients consult with abortion providers remotely, and which thousands of people in states with bans rely on each month for care.While activists’ current focus is on telehealth bans, physician intimidation, and shortening the legal window to use mifepristone, anti-abortion leaders were explicit on a private Zoom call that this all just represents a “first step” ahead of pushing to ban the drug entirely. Meanwhile, the Trump administration has continued to send mixed signals. In April, Marty Makary, Trump’s pick to lead the FDA, said that while he has “no plans” to restrict mifepristone, he “can’t promise” his agency won’t act on incoming safety data that “suggests something or tells us that there’s a real signal.” In his January Health and Human Services confirmation hearing, Robert F. Kennedy Jr. also said he would study the safety of mifepristone and follow whatever the president wanted to do.And earlier this week the Trump administration’s Department of Justice asked a federal court to dismiss a lawsuit from three Republican states seeking to restrict access to the medication. Yet the DOJ was not explicitly defending the safety of mifepristone; instead, it was rejecting states’ ability to challenge the FDA’s authority. Abortion rights experts see the Trump administration’s latest move as an effort to protect its ability to restrict mifepristone by making it harder for blue states to bring any court challenges. But pulling the drug or passing new limitations wouldn’t be so simple, and would require a significant amount of resources and data for the FDA to justify reversing its own earlier findings.“None of these things are happening in a vacuum,” Angela Vasquez-Giroux, vice president of communications of Planned Parenthood Action Fund, told Vox. “This junk science ‘report,’ the Rolling Thunder campaign...it’s all part of the same coordinated effort to end abortion access by any means necessary.”How anti-abortion advocates plan to use a controversial new reportIn late April, a conservative think tank, the Ethics and Public Policy Center (EPPC), published a report claiming that serious complications from abortion pills are dramatically higher than previously known. The report was not peer-reviewed and was based on an analysis of insurance claims data from medication abortions between 2017 and 2023. It alleged that nearly 11 percent of women who took mifepristone experienced “infection, hemorrhaging, or another serious or life-threatening adverse event” — which would be 22 times higher than the rate listed on the FDA-approved drug label.Reproductive health experts dismissed the findings and pointed to the large body of research affirming mifepristone’s safety. (My former colleague Keren Landman covered this literature for Vox two years ago.) “The evidence that we have for the safety of medication abortion is so robust,” Brittni Frederiksen, the associate director for women’s health policy at KFF, told me. “Additional studies are always welcome, and researchers are always looking into safety and the use of medication abortion. But it’s not going to be one [report] that’s going to change an entire body of evidence.”Legal health experts criticized the analysis, noting that insurance claims often overcount procedures for billing purposes, and can be misleading proxies when trying to figure out the true cause of a health outcome. The conservative think tank also suggested mifepristone led to dangerous events like ectopic pregnancies, which the medication cannot cause. The EEPC received so many objections that on Wednesday the co-authors released an FAQ in defense.Matthew Loftus, a physician who opposes abortion but also had concerns about the study’s methodology, said while insurance claims are imperfect proxies, that does not make them inherently invalid ones. Loftus believes the report should prompt further review, and argues that the ectopic pregnancy data could suggest potential safety concerns with telehealth, as patients don’t receive ultrasounds that could identify ectopic pregnancies. However, the FDA considered such concerns before approving mifepristone via telehealth. Ushma Upadhyay, a professor with Advancing New Standards in Reproductive Health at the University of California San Francisco, points to research showing telehealth may actually lead to earlier diagnosis and treatment for patients with ectopic pregnancies, because it’s more accessible and allows people to take their pills sooner than if they had to wait weeks for an in-person appointment.Research published since the FDA’s telehealth approval in 2021 has continued to affirm medication abortion’s safety profile, and Kirsten Moore, director of the Expanding Medication Abortion Access Project, disputes the necessity of ultrasounds for ectopic pregnancy screening. “Even if every patient were to get an ultrasound before being given mifepristone, the chance that an ectopic pregnancy is discovered so early in pregnancy is limited because there is little to nothing to see — especially at six, seven, eight weeks,” she told me. Moore notes that telehealth protocols also have screening measures, including disclosure of ectopic pregnancies, “something that can obviously be done over Zoom, phone, or even just paperwork.”The FDA, for its part, has responded cautiously. A spokesperson told Vox the agency is “committed to safeguarding public health by ensuring the safety, efficacy, and quality of the products it regulates.” They emphasized that the FDA “rigorously evaluates the latest scientific data, leveraging gold standard science to make informed decisions” and applies “a balanced, science-based approach while incorporating practical, common-sense considerations to its regulatory processes.”What the DOJ’s mifepristone case defense really meansIn the fall of last year, when attorneys general from Idaho, Kansas, and Missouri filed their lawsuit against the FDA demanding rollbacks on mifepristone access, most observers expected Trump’s DOJ to drop the Biden administration’s defense of the drugs or even side with the states, since Trump had emphasized repeatedly on the campaign trail that abortion was now a states’ issue. Instead, the DOJ this week asked to drop the case or transfer it to another court, arguing that the Republican-led states had relied on “an incorrect legal argument” to challenge the federal rules allowing the pills to be prescribed online and sent by mail.Reproductive rights advocates stress the administration’s hostility to abortion rights has not changed. “The most cynical read you could have on that situation is they’re making that move so they are free to enact whatever restrictions administratively,” said Vasquez-Giroux of Planned Parenthood. “They were making a strictly procedural argument and not saying anything about the merits” of mifepristone’s safety. It’s not yet clear what the president will decide to do. While on the campaign trail Trump claimed he would “not support a federal abortion ban, under any circumstances,” but he did vote in Florida to maintain the state’s extreme six-week ban. In December Trump told Time magazine it was “highly unlikely” he would limit access to medication abortion as president, but he also declined to rule out the possibility. He added that “somebody could come up with something that, you know, this horrible thing,” implying new information brought to his attention could change his position. Since winning, Trump and his team have aimed to keep abortion out of the news, in a way they have not for other planks of the Project 2025 agenda. While Trump did appoint Dr. Mehmet Oz , who is anti-abortion, to oversee the Centers for Medicare and Medicaid Services, Trump’s HHS secretary pick Robert F. Kennedy Jr. was on record supporting abortion rights. Trump’s team also rejected naming Roger Severino to a top HHS post, primarily because the administration thought his anti-abortion views would be too controversial. (Anti-abortion leaders lobbied heavily for Severino.) Vox has previously reported that anti-abortion advocates were preparing to be lenient with the president, meaning they would accept compromises with him to stay in his good graces.What’s at stake for abortion accessIf the anti-abortion coalition succeeds in pressuring the FDA to restrict access, several levels of regulation could be reimposed.The most likely scenario would be reinstating requirements that were relaxed during the Biden administration, like rules requiring in-person dispensing of the medication. Other potential restrictions include reducing the approved use of mifepristone from 10 weeks to 7 weeks of pregnancy, banning pharmacy dispensing (reversing the 2023 change that allowed retail pharmacies to provide the medication), or even enforcing the Comstock Act to ban mailing abortion medication entirely.Another option for restricting the drug could be for an HHS official to write a memo on behalf of Kennedy claiming mifepristone represents an “imminent harm.” Under federal law, that could empower the HHS secretary to pull the drug from the market.The impact of such changes would extend far beyond states with abortion bans. Even in states where abortion remains legal, telehealth abortion services have significantly expanded access, particularly for those in rural areas, those with limited transportation options, or those who can’t take time off work for multiple clinic visits.For now, it’s not clear how the FDA will respond. While many anti-abortion activists are feeling optimistic that the EEPC report will give the FDA reason to revisit restrictions, a push to do so would still require Trump’s approval. And while the president continues to receive intense pressure from his base to curb access to mifepristone, some advocates are skeptical that Trump will dedicate his political capital for it.“I remain skeptical that this will be the path,” Moore, of the Expanding Medication Abortion Access Project, said. “And yes, manufacturers can and will sue” the FDA, too, if it tries to roll back access to approved drugs. See More: