In the decades since Roe v. Wade, federal and state lawmakers have found ways to make abortion more difficult to obtain by restricting insurance coverage for the procedure, leaving many people without coverage for a critical reproductive health service. The most notable of these restrictions is the Hyde Amendment. Named for the late Rep. Henry Hyde (R-IL) and first implemented in 1977, the amendment bans the use of federal funds for abortion coverage through the Medicaid program, except in cases of rape, incest or life endangerment. Some 17 states have a policy to use their own Medicaid funds to pay for medically necessary abortion care beyond what the Hyde amendment requires; 16 appear to be doing so in practice. The result is a nationally fragmented approach to coverage in which access to affordable abortion care varies by state for enrollees in Medicaid or the Children’s Health Insurance Program (CHIP) for individuals aged 18 and younger.
The Hyde Amendment’s restrictions leave millions of women without abortion coverage. As of 2018, more than seven million Medicaid-enrolled women of reproductive age (aged 15–44) lived in the 34 states and the District of Columbia where abortion was not covered under the programs, except in very limited circumstances. As a result of the United States’s systemic racism and inequality, people of color are more likely to be low income and enrolled in Medicaid—and thus subject to the Hyde Amendment’s cruel restrictions. Low-income women and women of color—groups that already experience elevated risk of unintended pregnancy—may be especially affected by the lack of abortion coverage and the substantial cost of a procedure without it.
STATE LAWS AND POLICIES
For a chart of current laws and policies in each state related to Medicaid coverage of abortion, see State Funding of Abortion Under Medicaid.
For information on state laws and policies related to other sexual and reproductive health and rights issues, see State Laws and Policies, issue-by-issue fact sheets updated monthly by the Guttmacher Institute’s policy analysts to reflect the most recent legislative, administrative and judicial actions.
RELEVANT DATA AND ANALYSIS
Disparities in Unintended Pregnancy and Medicaid Coverage
Despite recent declines in unintended pregnancy across all groups, disparities still remain, in part as a result of long-standing systemic oppression and racial inequality. Low-income women and women of color are more likely than other groups to experience unintended pregnancy and abortion—and women of color are more likely to rely on Medicaid.
- Women of color are more likely than white women to be low income and enrolled in Medicaid. In 2018, 31% of Black women and 27% of Hispanic women aged 15–44 were enrolled in Medicaid, compared with 16% of white women.1
- Low-income women are more likely than more affluent women to have an unintended pregnancy. In 2011, the unintended pregnancy rate among women with an income below the federal poverty level ($18,530 for a family of three in 20112) was more than five times the rate among women with an income at or above 200% of the poverty level.3
- In addition to having elevated rates of unintended pregnancy, low-income women had 75% of U.S. abortions in 2014; 49% of abortion patients that year had a family income less than 100% of the federal poverty level.4
- Women of color are much more likely than white women to experience unintended pregnancy. In 2011, Black and Hispanic women had an unintended pregnancy rate of 79 and 58 per 1,000 women, respectively, compared with a rate of 33 per 1,000 among white women.3
- Medicaid provides critical access to health care for low-income women. In 2018, 13 million women of reproductive age were enrolled in the program.1
Variation Among States in Insurance Coverage
Due to different federal and state restrictions, Medicaid coverage of abortion depends on where enrollees live.
- Medicaid is a federal-state partnership. Under the Hyde Amendment, federal Medicaid funds cannot be used for abortion except in cases of rape, incest or life endangerment. All state Medicaid programs must cover abortions under these circumstances; states have the option to cover other abortions using their own funds.
- Thirty-three states and the District of Columbia follow the federal standard and only cover abortions in their Medicaid program in cases of rape, incest or life endangerment. One additional state, South Dakota, violates federal law by limiting public abortion coverage to cases of life endangerment.5
- As a result of these states’ policies, half of Medicaid-enrolled women of reproductive age—seven million women—are subject to the Hyde Amendment’s ban on abortion coverage.6
- The remaining 16 states use their own Medicaid funds to provide coverage that applies to most or all medically necessary abortions.7
- Even though more than a third of abortion patients nationwide are enrolled in Medicaid, most are unable to use that coverage to pay for abortion care because of Hyde Amendment restrictions. In states that follow the Hyde standard, Medicaid paid for only 1.5% of abortions in 2014.4
- In 2014, most abortion patients—53%—paid out of pocket; Medicaid was the second most common national payment method (used by 24% of patients).4 The overwhelming majority of those who used Medicaid to pay for abortion care lived in the 15 states that, at that time, provided coverage beyond the limits of the Hyde Amendment.
- In the 15 states that provided coverage in 2014 beyond what Hyde required, Medicaid was the most common payment method and was used by 52% of abortion patients. In 2014, 89% of Medicaid-enrolled abortion patients in those states had their abortion covered by their insurance.4
- Medicaid covered slightly more than 157,000 abortions nationwide in federal fiscal year 2015, and almost all were in states that use their own funds to cover the cost. The federal government contributed funds to only 160 of those abortions.7
- According to a 2015–2016 study, in states that do not use their own Medicaid funds to cover abortions beyond those required under the Hyde Amendment, most providers declined to accept patients’ Medicaid coverage—even for abortions that met Hyde requirements—citing spotty reimbursement and complicated billing. As a result, some patients enrolled in Medicaid are forced to pay out of pocket or rely on financial assistance to obtain abortion care that is legally covered under the federal Medicaid program.8
Costs Associated with Abortion
Abortion can pose a heavy financial burden for low-income women.
- The cost of an abortion without insurance coverage is substantial: In 2014, the average cost of an abortion—whether surgical or medical—at 10 weeks of pregnancy was slightly more than $500. The median cost at 20 weeks was $1,195.9 In addition, patients often must pay out of pocket for additional nonmedical costs, such as transportation, child care and lodging.
- For a woman whose income is at the higher end of Medicaid eligibility in the states that adhere to the Hyde Amendment requirements, paying for an abortion at 10 weeks of pregnancy would take nearly a third of her monthly family income. An abortion at 20 weeks would take almost 90% of her monthly income. (The average Medicaid monthly income ceiling for a family of three in these states, or in the District of Columbia, is $1,566.10)
- Many women and families are unable to handle an emergency expense of $500 or more. When U.S. adults were asked in a 2016 nationally representative survey how they would pay for a $400 emergency expense, more than 40% of respondents said that they would be unable to find the money or that they would only be able to cover the unexpected cost by borrowing money or selling something. One-quarter of adults reported having forgone health care in the previous year because of high cost.11
- Forty-one percent of abortion patients surveyed in six states in 2011 said it was somewhat or very difficult to pay for their care.12
Cost-Related Delays, Increases in Risk
Difficulties securing funds for an abortion can force a patient to delay the procedure, increasing both the cost and the risk associated with abortion. Some women may be unable to obtain the procedure altogether.
- About half (54%) of abortion patients surveyed between 2008 and 2010 said that having to raise funds delayed their care.13
- The risk of abortion complications—although exceedingly small at any point—increases later in pregnancy. The risk of death associated with abortion rises from 0.3 for every 100,000 abortions at or before eight weeks to 6.7 per 100,000 abortions at 18 weeks or later.14
- The cost of an abortion increases sharply as a pregnancy progresses. An abortion at 20 weeks’ gestation is likely to cost nearly 2.5 times as much as an abortion at 10 weeks.9
- Some low-income women who want to obtain an abortion are unable to do so, and the result is an unplanned and often unwanted birth. A 2009 literature review identified studies in five states that compared the ratio of abortions to births before and after Medicaid coverage of abortion was restricted.16 It concluded that one in four women seeking an abortion who had Medicaid coverage that adhered to the Hyde Amendment restrictions were unable to obtain an abortion because they lack insurance coverage for the procedure.
- A qualitative survey of abortion providers in 15 states conducted in 2007–2010 showed that inconsistent Medicaid reimbursement makes it more difficult for patients to access services and contributes to delays in obtaining care. Providers said that in the previous year, they received Medicaid reimbursement in only 58% of cases that should have been covered according to the Hyde Amendment.16 As a result, some providers decided that it was not worthwhile to seek reimbursement; they reported that the inability to use Medicaid coverage forced some of their patients to delay the procedure while they searched for other sources of funding.
Financial Assistance Through Private Abortion Funds
Because the government has abdicated its responsibility by not providing abortion coverage, private abortion funds help patients obtain services. However, these organizations cannot fully meet patients’ financial needs.
- In 2014, 14% of abortion patients relied on some form of financial assistance from an organization.4 However, abortion funds cannot cover the full funding need for all—or even most—of the people they assist.
- Women who received funding between 2010 and 2015 from the George Tiller Memorial Abortion Fund, a national fund, typically obtained second-trimester abortions costing an average of $2,000, reflecting the elevated cost of abortions after the first trimester.17 Women receiving assistance contributed an average of $500 toward the total cost of their abortion.
- A 2011 national survey of 639 abortion patients found that the proportion receiving financial assistance from an abortion fund was more than twice as high among second-trimester patients as among first-trimester patients (19% vs. 8%).12
- The Tiller Fund saw an increase in assistance requests for second-trimester abortions between 2010 and 2015; this suggests that as abortion costs rise and legal restrictions intensify, abortion becomes increasingly unaffordable for low-income women.17
- Regardless of their insurance status, women obtaining an abortion are more likely to rely on external financial assistance to pay for abortion care in states without Medicaid coverage of abortion than in the 15 states that do have such coverage: 22% vs. 4% in 2014.4 The Tiller Fund makes the majority of its pledges to residents of states without expanded Medicaid coverage to abortion.17
- While financial assistance from these funds helps make abortion accessible for many women, it may also result in delays in care. Compared with women who pay out of pocket, those who use financial assistance reported in a 2014 survey having a longer wait between making an appointment and seeing a provider: They were more likely to have made their appointment more than two weeks ahead of time.18 Such delays may be due to eligibility screening and other administrative delays related to seeking financial assistance from an abortion fund, insurance, or other personal and community sources.
RECENT STATE ACTION ON THIS ISSUE
States that have addressed this issue over the past three years are listed below.
E: State enacted a relevant measure
V: State vetoed measure
A: State adopted measure in at least one chamber
States that require Medicaid to cover medically necessary abortions
States that prohibit use of public funds for abortion
West Virginia (2018)
1. Sonfield A, U.S. insurance coverage, 2018: The Affordable Care Act is still under threat and still vital for reproductive-age women, New York: Guttmacher Institute, 2020, https://www.guttmacher.org/article/2020/01/us-insurance-coverage-2018-af....
2. Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services (HHS), 2011 HHS poverty guidelines, 2011, https://aspe.hhs.gov/2011-hhs-poverty-guidelines.
3. Finer LB and Zolna MR, Declines in unintended pregnancy in the United States, 2008–2011, New England Journal of Medicine, 2016, 374(9):843–852.
4. Jerman J, Jones RK and Onda T, Characteristics of U.S. Abortion Patients in 2014 and Changes Since 2008, New York: Guttmacher Institute, 2016, https://www.guttmacher.org/report/characteristics-us-abortion-patients-2014.
5. Guttmacher Institute, State funding of abortion under Medicaid, State Policies in Brief (as of February 1, 2021), 2021, https://www.guttmacher.org/state-policy/explore/state-funding-abortion-u....
6. Donovan MK, EACH woman act offers bold path toward equitable abortion coverage, New York: Guttmacher Institute, 2019, https://www.guttmacher.org/article/2019/03/each-woman-act-offers-bold-pa....
7. Hasstedt K, Sonfield A and Gold RB, Public Funding for Family Planning and Abortion Services, FY 1980–2015, New York: Guttmacher Institute, 2017, https://www.guttmacher.org/report/public-funding-family-planning-abortio....
8. Kimport K and Rowland B, Taking insurance in abortion care: policy, practices, and the role of poverty, in: Jacobs Kronenfeld J, Health and Health Care Concerns Among Women and Racial and Ethnic Minorities, Research in the Sociology of Health Care, Vol. 35, Bingley, UK: Emerald Publishing, 2017, pp. 39–57.
9. Jones RK, Ingerick M and Jerman J, Differences in abortion service delivery in hostile, middle-ground and supportive states in 2014, Women’s Health Issues, 2018, doi:10.1016/j.whi.2017.12.003.
10. Special calculations of data from the 2011 HHS poverty guidelines.
11. Division of Consumer and Community Affairs, Federal Reserve Board, Report on the Economic Well-Being of U.S. Households in 2016, Washington, DC: Board of Governors of the Federal Reserve System, 2017, https://www.federalreserve.gov/publications/files/2016-report-economic-w....
12. Jones RK, Upadhyay UD and Weitz TA, At what cost? Payment for abortion care by U.S. women, Women’s Health Issues, 2013, 23(3):e173–e178, http://www.guttmacher.org/sites/default/files/pdfs/pubs/journals/j.whi.2....
13. Roberts SCM et al., Out-of-pocket costs and insurance coverage for abortion in the United States, Women’s Health Issues, 2014, 24(2):e211–e218, doi:10.1016/j.whi.2014.01.003.
14. Zane S et al., Abortion-related mortality in the United States: 1998–2010, Obstetrics & Gynecology, 2015, 126(2):258–265.
15. Henshaw SK et al., Restrictions on Medicaid Funding for Abortions: A Literature Review, New York: Guttmacher Institute, 2009, https://www.guttmacher.org/report/restrictions-medicaid-funding-abortion....
16. Dennis A and Blanchard K, Abortion providers’ experiences with Medicaid abortion coverage policies: a qualitative multistate study, Health Services Research, 2013, 48(1):236–252.
17. Kotting J and Ely GE, The Undue Burden of Paying for Abortion: An Exploration of Abortion Fund Cases—Data from the National Network of Abortion Funds’ George Tiller Memorial Abortion Fund, 2010–2015, Chicago: National Network of Abortion Funds, 2017, https://abortionfunds.org/tiller-fund-2017/.
18. Jones RK and Jerman J, Time to Appointment and Delays in Accessing Care Among U.S. Abortion Patients, New York: Guttmacher Institute, 2016, https://www.guttmacher.org/report/delays-in-accessing-care-among-us-abor....