Inequity in US Abortion Rights and Access: The End of Roe Is Deepening Existing Divides
Anti-abortion policymakers in the United States have continually crafted legal restrictions to ensure that abortion care is burdensome or impossible to obtain. This strategy has led to more than 1,300 abortion restrictions having been enacted since Roe v. Wade was decided in 1973, and is layered on top of failures of the health care and economic systems to provide Black, Indigenous and Latino* communities and communities living with low incomes access to high-quality, affordable health care, and safe and sustainable communities. Thus, while abortion bans and other legal restrictions harm all people who are or may become pregnant, they cause even greater harm to those already subject to systemic racism and economic injustice.
An already bad situation has become far worse. In the half-year since the US Supreme Court eliminated the constitutional right to abortion established by Roe, many states have responded by banning the provision of abortion care at some point in pregnancy or altogether. As of January 12, 2023, abortion is banned in 12 states with very limited exceptions and is unavailable in an additional two. Further, in the first 100 days since Roe was overturned, at least 66 clinics in 15 states stopped providing abortion care, many closing down altogether. That means 29% of the total US population of women of reproductive age are living in states where abortion is either unavailable or severely restricted. And more than 10,000 people were unable to access abortion care at a facility in just the first two months after the decision. Half of states are certain or likely to eventually enact abortion bans now that Roe v. Wade has been overturned.
Existing Inequities in Abortion Access
New and impending abortion restrictions and bans will undoubtedly deepen the profound inequities in abortion access that have long marked the reproductive health and well-being of pregnant people and their families. Not only Black, Latino and Indigenous people and people living with low incomes, but transmen and nonbinary people, immigrants, adolescents and people living with disabilities are all particularly likely to encounter compounding obstacles to abortion care and be harmed as a result.
Drivers of inequity such as income and health insurance disparities and health provider bias (including a history of racist attempts to limit childbearing among Black and Indigenous women) are not simply the result of individual acts of discrimination but rather the result of how institutions and public infrastructures function. As a result, people in these groups are systematically denied access to quality health care and safe communities that would help them determine whether and when to become pregnant and to parent children.
Just looking at health insurance by race/ethnicity and income, for example, 23% of Latinas and 13% of Black women aged 15–49 have no health insurance, compared with 8% of White women in the same age-group. Similarly, 22% of women aged 15–49 with incomes below the federal poverty threshold have no health insurance, compared with 11% of those living with incomes above poverty.
Policy choices contribute to these and other health insurance–related disparities. For example:
Among reproductive-age women who are ineligible for Medicaid because their state has refused to expand the program, nearly two-thirds are women of color.
Noncitizen US residents are barred by federal law from Medicaid eligibility for their first five years in the United States.
Similarly, immigrants living without documentation are restricted from purchasing health insurance with their own money on the exchanges established by the Affordable Care Act.
Similar disparities by race/ethnicity and income level are evident in contraceptive care:
Black women living with low incomes are more likely than White women living with low incomes to report ever having been pressured by a clinician to use a contraceptive. Other studies have documented Latinas’ and Black women’s experiences of race-based discrimination and pressure to use methods that do not align with their preferences during contraceptive counseling.
Latina and Black women living with low incomes are more likely than middle-class White women to report both that health care professionals advised them to limit their childbearing and that health care professionals discouraged them from having children.
Among women at risk for unintended pregnancy, Black women are less likely than White women to use any contraceptive method—and Latinas and Black women are less likely to use a highly or moderately effective contraceptive method.
Latinas and Black women may also be more likely than White women to experience contraceptive failure.
Once again, these inequities reflect systemic exclusion of people racialized as non-White and people living with low incomes from economic and social opportunity and resources and high-quality health care, contributing to why Latinas and Black women are more likely than White women to experience an unintended pregnancy.
Health insurance and family planning care are key examples, but inequitable, stark and avoidable differences exist across the spectrum of sexual and reproductive health care. Another example is that Black and Native American women experience pregnancy-related deaths at rates three and two times that of White women, respectively.
Discrimination and denial of resources, rights and information on the basis of sexuality, race/ethnicity, gender, age, citizenship status and disability uniquely shape abortion access for people subject to intersecting forms of discrimination. For example, Latina, Black and Indigenous women are at the lowest end of the wage gap, earning about half the wages of White men, on average. They are therefore less likely than other groups to be able to overcome the egregious, unnecessary web of barriers to abortion care, both because they are less likely to have the money to do so and because they are more likely to experience racism in health care. Indeed, the effects of these interlocking systems of oppression—in which social and economic resources, safety and opportunity are distributed along lines of gender and race simultaneously—on access to contraception and abortion are compounding, not simply additive.
The overturn of Roe has also exacerbated inequities in abortion access at the intersection of race and geography because the South and Midwest have the largest proportions of Black people and also the most states that have banned abortion or are expected to do so. States in these regions are also more likely to lack geographic access to maternity care, have worse maternal and infant health outcomes, and lack basic social family policies, such as paid family leave—making the cost of being denied abortion care very, very high.
These inequities are the foundation for differences in abortion rates by race and income. Communities subject to health care discrimination, that lack of high-quality health care and are denied the resources to raise children in safety and dignity have the fewest resources to navigate the burdens of restrictive abortion laws, and for the same reasons are more likely to need abortion care:
Half of US abortion patients live with incomes below the federal poverty threshold, compared with only 14% of the full population of US women aged 15–44.
Black women account for more than one-quarter (28%) of abortion patients but only 14% of all US women aged 15–44.
Latinas account for one-quarter (25%) of abortion patients but 21% of US women aged 15–44.
Asian and Pacific Islander women are more proportionately represented, making up 6% of abortion patients and 7% of US women aged 15–44.
White women, on the other hand, account for 39% of abortions but make up 54% of US women aged 15–44.
The very fact of who needs abortion care in the United States reflects compounding sources of unjust and avoidable inequity because while laws that restrict or deny abortion harm anyone who needs abortion care, those profound harms fall more heavily on people living with low incomes and people of color.
Abortion Restrictions’ Inequitable Effects
Many laws restricting abortion care target certain groups of abortion patients based on their circumstances, resources or health, thereby creating unnecessary and harmful additional obstacles to obtaining abortion. For example:
The Hyde Amendment bans people covered by Medicaid health insurance from using it for abortion care.
Gestational age bans that arbitrarily cut off abortion access once the a person’s pregnancy has progressed beyond a certain number of weeks result in delayed or denied care. People particularly likely to be affected by these bans include those who recognize their pregnancy near or past the ban’s limit (which is as early as six weeks in some states, before many people even know they are pregnant), those who discover a need for abortion care later in pregnancy and those who need time to raise the money for an abortion (including because of restrictions like Hyde).
All this is made worse by the fact that the effect of restrictions is cumulative. As states enact more and more restrictions and outright bans, people increasingly need to navigate multiple barriers at once and the hardship they experience escalates. For example, parental involvement laws in 22 states where abortion is still available create a barrier to abortion for pregnant people younger than 18—one that may be insurmountable for adolescents for whom obtaining their parents’ permission for abortion care is unsafe or logistically impossible. Latino adolescents may face additional difficulty because they may be more likely than White adolescents to need to seek judicial bypass of parental involvement requirements. Adolescents are also more likely than older women to recognize their pregnancy later, so are also more likely to be negatively affected by gestational age bans. These barriers are compounded with the obstacles all people needing abortion face, potentially including the need to travel to another state to find care because outright bans or other restrictions have made it inaccessible in their community. Navigating this thicket of restrictions to successfully obtain timely abortion care requires considerable social and economic resources.
Legal Enforcement of Abortion Bans
Another consequence of eliminating the protections of Roe is that people who provide abortions—and potentially those who self-manage an abortion or are suspected of doing so—will be criminalized. In states where abortion care is difficult or even impossible to obtain, people must travel for clinic-based care. Those who do not have the resources to travel may be more likely to choose to self-manage their abortion and for the same reason be targeted by law enforcement.
Law enforcement activities against pregnant people post-Roe are most likely to be against Black and Indigenous people, immigrants and people with the fewest resources. We know this because the criminalization of pregnant people already targets these groups. In a study reviewing cases of pregnant women whose arrest or detainment was at least in part related to their pregnancy outcome, 59% were Black, Latina, Indigenous or Asian, and 71% were represented by public criminal defense designated for those who cannot afford to pay for their own lawyer.
Protecting Abortion Access and Reproductive Justice After Roe
Now that Roe v. Wade has been overturned, resulting in more abortion restrictions and outright bans, more people have experienced delayed and denied abortion care, and existing inequities in abortion access have been cruelly and needlessly exacerbated. The cost of finding, arranging and traveling for abortion care has risen substantially, even in communities that already faced tremendous barriers.
Moreover, even people who can find the means to travel to another state for care may still have to contend with restrictions. For example, although abortion remains legal in Pennsylvania, the state is nonetheless considered hostile to abortion rights because it enforces at least eight major abortion restrictions, including a 24-hour waiting period and parental consent. Similarly, in border states, immigrant communities are subject to immigration checkpoints that compound the harm of abortion restrictions that force people to travel to obtain care. Immigrants living without documentation, in particular, may have no way of obtaining an abortion when immigration enforcement and abortion restrictions combine to prevent them from traveling out of state to a provider.
While the Supreme Court’s elimination of federal protections for abortion has spurred anti-abortion politicians to double down on eroding abortion access, efforts to protect it have also made progress. Several states have enshrined reproductive rights into state law, including by protecting abortion providers and providing funding for abortion care. Legal challenges to state abortion restrictions and bans are in play, and some states’ laws are enjoined while court cases proceed. In one profound victory, all Minnesota abortion restrictions were overturned because they were ruled unconstitutional. Federal solutions are also being advanced, including bills to eliminate the Hyde Amendment, establish a federal fund for abortion care and eliminate abortion restrictions nationally.
In addition, some cities have sought to protect abortion access, including by dedicating a portion of their budget to nonprofit abortion funds that help cover the cost and travel for abortion care. For instance, the New York City Department of Health and Mental Hygiene will offer medication abortion free at its sexual health clinics.
The private sector has also responded. A number of major corporations have announced efforts to ameliorate the impact of abortion bans by covering employees’ travel for abortion care. While beneficial to a fortunate minority, these policies increase inequity in abortion access by facilitating care for those who already have health care access through employer-based insurance. Meanwhile, people needing abortion care who were already denied the resources to obtain it when abortion was federally protected will experience even greater delays and be denied care more often now that Roe has been overturned. Ensuring that both the right to abortion and the ability to cover the cost of abortion care are not based on one’s income or state of residence is key to eliminating inequities in abortion access.
As we continue to navigate this severe rollback of abortion rights—one that is unprecedented in US history and out of step with global trends—attention to how policies may create or exacerbate inequities, and thereby leave behind communities most harmed by abortion restrictions and bans, will be critical to efforts to advance and protect abortion access now that Roe has been overturned.
Supported by The Commonwealth Fund, a national, private foundation based in New York City that supports independent research on health care issues and makes grants to improve health care practice and policy. The views presented here are those of the author and not necessarily those of The Commonwealth Fund, its directors, officers or staff.