Abortion Out of Reach: The Exacerbation of Wealth Disparities After Dobbs v. Jackson Women's Health Organization
Originally published in the American’s Bar Association’s Human Rights Magazine.
“Above all others, women lacking financial resources will suffer from today’s decision,” wrote Justice Elena Kagan in her dissent, joined by Justices Sonia Sotomayor and Stephen Breyer, in the June 24, 2022, U.S. Supreme Court case of Dobbs v. Jackson Women’s Health Organization. Dobbs overturned nearly 50 years of precedent protecting the right to abortion.
Since Dobbs was decided, the landscape for legal abortion has immediately and rapidly deteriorated, shifting constantly across the country. As of October 2022, 12 total bans on abortion and one ban on abortion at six weeks are in effect—along with myriad other restrictions resulting in abortion being essentially unavailable in 15 states. A total of 26 states are expected to ban abortion in the near term, directly impacting 36 million people of reproductive age nationwide who could become pregnant. But since long before the protections of Roe v. Wade, wealth disparities have meant that access to abortion in the United States has been bleak for millions of Americans. Dobbs has and will continue to profoundly worsen this impact.
Key Ways Wealth Inequity Shapes Abortion Access
Wealth inequity shapes every feature of the landscape of abortion in the United States, starting with the chasm between those who have the resources to plan for if, when, and how to become pregnant and those who do not.
Take health insurance, for example, which is associated with a greater likelihood of contraceptive use among women. (A note from the authors: We deeply value gender inclusivity. The term “women” is used herein where required to reflect underlying supportive research.) Despite the gains made since the Affordable Care Act’s passage over a decade ago, the proportion of women who do not have health insurance is two times higher among those living with low incomes compared to those with higher incomes.
A multitude of additional intersecting factors are also at play: poor access to medically accurate sexuality education, biased treatment in the health care system, and divestment from communities and social supports that would allow people to raise children in healthy, sustainable environments—all fueled and compounded by the full spectrum of social drivers of health and systemic racism. These factors contribute to the unintended pregnancy rate among women with incomes below the federal poverty threshold being more than five times higher than those with incomes at or above 200 percent of poverty. These dynamics also underpin that people with lower incomes are more likely to need abortions: Women with incomes less than 200 percent poverty experience an abortion rate six times that of women with incomes more than 200 percent above poverty.
Insurance Coverage Bans
Once someone needs an abortion, the means to cover the cost is a key determinant of whether they will be able to obtain that care without delays, or at all. The average cost of a first-trimester abortion in the United States is $550—nearly 50 percent of the monthly income for people living with incomes below the federal poverty threshold. The cost of obtaining an abortion, however, is prohibitive for far more Americans than just those with the fewest financial resources. A recent Kaiser Family Foundation poll found that “half of U.S. adults don’t have the cash to cover an unexpected $500 health care bill.”
Even among those with health insurance, the cost of abortion care could be out of reach. Despite abortion being basic health care and one in four U.S. women having an abortion in her lifetime, millions of Americans live in states that have long banned private health insurance plans from covering abortion care. Post Dobbs, many of those states have banned abortion altogether, forcing their residents to find the cash to cover the procedure and travel out of state.
Further, half of women with incomes at or below the federal poverty threshold have health coverage through Medicaid, yet federal funds have been prohibited from being spent on abortion since 1977 due to the annual “Hyde Amendment.” Famously, absolutely no regard was paid to the disproportionate impact on people living in poverty when the amendment was first introduced—in fact, to the contrary. As the late Congressman Henry Hyde (R-IL) stated during a debate, “I certainly would like to prevent, if I could legally, anybody having an abortion, a rich woman, a middle-class woman, or a poor woman. Unfortunately, the only vehicle available is the . . . Medicaid bill.”
Because Medicaid is funded by a combination of federal and state dollars, states have the option to cover abortions in their Medicaid programs—yet only 16 states do so. The burden of the Hyde Amendment falls disproportionately on Black, Latine/x, and Indigenous communities due to their systematic exclusion from economic opportunity, making them more likely to be eligible for Medicaid.
Travel, Childcare, and Other Related Expenses
Of course, the expense of the abortion itself is just one part of the cost of obtaining abortion care. This has been true since well before Dobbs. In the decades since Roe, states passed extensive restrictions (about 1,400 to date) that disproportionately disadvantage those with fewer resources and take advantage of the fact that people with low incomes are largely disenfranchised from the legislative process in the first place. Only people with the resources to take off work, arrange transportation, secure childcare, and navigate abortion restrictions can access care. All in an environment where, for example, 95 percent of the highest wage workers have access to paid sick days, but only 33 percent of the lowest paid workers do. The restrictions have resulted in far fewer providers, and, by 2017, nearly 90 percent of all U.S. counties had no health center providing abortion—now exponentially exacerbated by Dobbs.
Consider Alabama, where abortion is now banned (with no exceptions for rape or incest), forcing people to cross state lines for care. Yet, Alabama is surrounded by states that also have bans in effect. For some Alabamians, the closest option for an abortion is Georgia, which has a ban at six weeks—before many people would even know that they are pregnant. For Alabamians needing an abortion up to 14 weeks, the closest provider could be hundreds of miles away in Florida. For those who can afford to make it to Florida, they also must come up with lodging costs or make two trips: first for the state’s mandatory in-person “counseling” (including information designed to discourage the patient from having an abortion) and second for the actual abortion, following a medically unnecessary required 24-hour waiting period. And they must do so on a tight timeline, as Florida now has banned abortion at 15 weeks.
The unnecessary and cruel obstacles to accessing abortion care that Alabamians face are not anomalous but rather the new norm. Dr. Serina Floyd, medical director at Planned Parenthood of Metropolitan Washington, D.C., describes the impact from the front lines. “We recently had a patient fly to D.C. from Texas in the morning, have an abortion, and fly home that night. No one should have to do that. Yet, that patient’s ability to have an abortion is phenomenally different from thousands of others who do not have the resources or ability to travel in the same way.”
Fear, Confusion, and Legal Risk
Even for patients who could navigate going out of state for an abortion, the constantly shifting legal landscape has created debilitating fear and confusion because it is unclear what is legal where and when, including whether patients themselves or anyone who helps them might be civilly or criminally penalized.
Long before Dobbs, pregnant people, especially those without access to financial and legal resources, faced criminal repercussions for the outcome of their pregnancies, including for self-managing their abortions. All pregnant people are at risk where abortion is banned; anyone experiencing pregnancy loss may be placed under scrutiny if they are suspected of self-managing an abortion. Self-managed abortion with appropriate medications is extremely safe, but the legal risks fall disproportionately on those with low incomes. The overturning of Roe v. Wade has made matters worse. Given the increased costs of accessing abortion through a health care provider, people with fewer resources may be more likely to choose to self-manage their abortion. And the risk of this harm is heightened for Black and Indigenous people and immigrants, who are already disproportionately impacted by the criminal justice system, yielding devastating consequences when abortion access is out of reach.
Access to abortion should not be determined by who you are or how much money you have. Even for people who can come up with the money in the short term to obtain abortion care, the costs can result in major financial setbacks, including running up credit card balances with little hope of paying them off and putting off other essential bills and basics. And for those who ultimately cannot access abortion, they are being forced to take on the medical risks and burdens, including financial consequences, of continuing a pregnancy that they have determined they cannot or do not want to continue.
Here are just a few ways that you can help:
- The ABA officially supports reproductive rights: Join a committee to help with amicus briefs, resolutions, and programming advocating to protect and expand reproductive rights.
- Get involved in your local bar associations and reproductive health organizations to help educate other lawyers and advocate to protect and expand access in local law (e.g., submitting testimony for/against pending bills).
- Give to local abortion funds that provide resources to patients who otherwise cannot afford access to care.
Originally published in the American’s Bar Association’s Human Rights Magazine.
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.