Notwithstanding a widespread misinformation campaign, the health care reform law passed by Congress in 2010—the Affordable Care Act (ACA)—does not mandate abortion coverage, either now or in the future. Rather, it maintains the legal status quo, under which insurance companies decide whether abortion will be covered in the plans they offer. In practice, however, the ACA includes substantial disincentives for insurers to include abortion coverage in the plans they market to individuals and small employers on health insurance exchanges that will become operational in 2014, and for consumers shopping on those exchanges to purchase a plan with abortion coverage.
All of this raises the question of how extensively abortion is currently covered.
Several major studies have been conducted on this issue
The best available evidence—from studies conducted by the Guttmacher Institute and the Kaiser Family Foundation—suggests that most Americans with employer-based insurance currently have coverage for abortion.
- The Guttmacher Institute’s federally supported study, which assessed levels of insurance coverage for a wide range of reproductive health services, found that 87% of typical employer-based insurance policies in 2002 covered medically necessary or appropriate abortions; the data can be found in Table 1 here.
- The Kaiser Family Foundation found that 46% of covered workers had coverage for abortion; the data were released as part of Kaiser’s 2003 Annual Employer Health Benefits Survey. Another iteration of that survey, from 2010, found that three in 10 employers said they covered elective abortion, but the 2010 survey had a far higher rate of employers who could not or would not answer the question (71% in 2010 vs. 26% in 2003).
- Importantly, the 87% of plans that covered abortions did not include plans that offered abortion coverage only in very limited circumstances (such as rape and incest, or to protect the woman’s life). Only a very small number of respondents offered such limited coverage, and they were not included in the study’s findings.
- The study queried all large insurers (those with at least 100,000 enrollees) and a random, nationally representative sample of small insurers.
Differences between the Guttmacher and Kaiser studies
- The Guttmacher study queried the medical directors of insurance companies and asked them about the typical insurance policy they wrote for employers. It might not account for the fact that some employers may purchase atypical plans, such as plans with high deductibles that may not cover a range of services, including abortion.
- Kaiser directly queried employers’ human resources staff about their firm’s coverage, but many of them either could not or would not answer the question.
- Guttmacher’s study asked about medically necessary or appropriate abortions. The 2003 Kaiser study asked about abortion coverage, unspecified, and the 2010 iteration asked about “elective” abortion; in either case, some employers may have answered “no” even if coverage were available for abortions in some circumstances.
The actual level of coverage is probably somewhere between the estimates made by Guttmacher and Kaiser, meaning that most Americans with employer-based insurance currently have coverage for abortion.
Abortions paid for with private insurance
A Guttmacher Institute study found that, in 2008, only 30% of abortion patients had private insurance. Among those who did have private insurance, about one-third used their insurance (see page 11 here) and nearly two-thirds (63%) paid out of pocket. In all, 12% of abortions were paid for with private insurance.
Several factors likely contributed to the lack of reliance on private insurance among women who had it:
- Some may have had health care plans that did not cover abortion (especially given the concentration of abortion among lower-income women, whose private plans are likely to be less generous), or they may have been unaware if their plan did cover the procedure.
- Many women with private health insur¬ance have deductibles of several hundred—or even several thousand—dollars that have to be met before they can be reimbursed and thus may have paid for an abortion out of pocket.
- Finally, given the stigma that still surrounds abortion, some women may not use insurance coverage because they do not want their insurer, employer or primary policy holder (such as a spouse or parent) to find out about the abortion.
Abortion coverage and abortion rates
Because private insurance coverage of abortion is already common, there is no evidence to support the claim that continuing to allow insurers to cover abortion under health care reform would somehow lead to a significant increase in the abortion rate. In fact, to the extent that the ACA increases access to contraceptive services, health care reform could end up helping many women avoid unintended pregnancies and thus the need for abortion.
Meanwhile, according to an analysis published in the March 2010 issue of the New England Journal of Medicine, the number of abortions and the abortion rate dropped in Massachusetts after the state adopted its own health reform law. In stark contrast to the ACA, publicly subsidized health insurance plans in Massachusetts must cover abortion. The number of abortions dropped 1.5% from 2006 to 2008, with the number of abortions obtained by teens decreasing by 7.4%. These declines occurred at the same time as the birthrate increased and the population grew. Numbers of abortions are now at the lowest level since the 1970s, continuing a long-term trend.