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, but just 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; which covers individuals aged 18 and younger).
The Hyde Amendment’s restrictions leave millions of women without abortion coverage. In 2015, 54% of women aged 15–44 who were enrolled in Medicaid or CHIP lived in the 34 states and the District of Columbia where abortion was not covered under the programs, except in very limited circumstances. This amounted to roughly 7.15 million women of reproductive age. Low-income women and women of color—groups that already experience elevated risk for 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, disparities still remain. Poor women and women of color are more likely than other groups to experience unintended pregnancy and abortion and to rely on Medicaid.
- 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 20111) was more than five times the rate among women with an income at or above 200% of the poverty level.2
- In addition to having elevated rates of unintended pregnancy,2 poor and low-income women accounted for 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.3
- 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 33 per 1,000 among white women.2
- Medicaid provides critical access to health care for low-income women. In 2016, 13.2 million women of reproductive age were enrolled in Medicaid.4
- Women of color are more likely than white women to be low-income and to be enrolled in Medicaid. In 2015, 31% of black women and 27% of Hispanic women aged 15–44 were enrolled in Medicaid, compared with 16% of white women. 5
Variation Among States in Insurance Coverage
Due to differing federal and state restrictions, coverage of abortion under Medicaid 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; however, states have the option to cover other abortions using their own funds.
- Thirty-four 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.6
- These 34 states and the District of Columbia that restrict public abortion coverage are home to 54% of Medicaid-enrolled women aged 15–44—more than seven million women.7
- The remaining 16 states use their own Medicaid funds to provide coverage that extends beyond what the Hyde amendment requires and applies to most or all medically necessary abortions.6
- Even though more than a third of abortion patients nationwide are enrolled in Medicaid, most are unable to use that coverage to pay for a termination because of Hyde Amendment restrictions. In states that follow the Hyde standard, Medicaid paid for only 1.5% of abortions in 2014.3
- In 2014, most abortion patients—53%—paid out of pocket; Medicaid was the second most common payment method (used by 24% of patients).3 However, 96% of patients who were able to use their Medicaid coverage lived in the 15 states then providing coverage in circumstances beyond the restrictive ones outlined in the Hyde Amendment.
- In those 15 states that, in 2014, provided coverage 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 used their insurance coverage to pay for an abortion.3
- Medicaid paid for just over 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.8
- 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.9
Costs Associated with Abortion
Abortion can represent a heavy financial burden for poor and low-income women.
- The cost of an abortion without insurance coverage is substantial: In 2014, the mean cost of an abortion—either surgical or medical—at 10 weeks of pregnancy was just over $500. The median cost at 20 weeks was $1,195.10 In addition, patients typically incur nonmedical costs, including for transportation, child care, lodging and lost wages.
- For a woman whose income is at the higher end of Medicaid eligibility in the states that only allow Medicaid funds to be used for abortion in the limited circumstances specified by the Hyde Amendment, paying for an abortion at 10 weeks of pregnancy would take nearly a third of her entire family income for a month. An abortion at 20 weeks would take almost 90% of her monthly income. (The average Medicaid income ceiling for a family of three for a month in these states, or in the District of Columbia, is $1,566.11)
- Many women and families are unprepared to handle an emergency expense of this size. When asked how they would pay for a $400 emergency expense, more than 40% of respondents in a 2016 nationally representative survey of U.S. adults said they would be unable to find the money or that they would only be able to cover the sudden cost by borrowing money or selling something. One-quarter of adults reported having forgone health care in the previous year due to unaffordable costs.12
- Forty-one percent of abortion patients surveyed in six states in 2011 said it was somewhat or very difficult to pay for their abortion.13
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 the termination. 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.14
- The risk of complications from abortion—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.15
- 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.10
- Although many low-income women who want an abortion are able to obtain one, some are not, 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.17 It concluded that among women seeking an abortion who have Medicaid coverage that follows Hyde Amendment restrictions, one in four are 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. Surveyed providers said that in the previous year, they received Medicaid reimbursement in only 58% of cases that should have been covered per the Hyde Amendment.17 As a result, some providers decided that it is not worthwhile to seek reimbursement and reported that the inability to use Medicaid coverage forced some of their patients to delay the procedure while searching for other sources of funding.
Financial Assistance Through Private Abortion Funds
Because the government has abdicated its responsibility by not providing coverage for abortion, private abortion funds have emerged to help patients obtain services. However, these organizations cannot fully meet women’s need for assistance.
- In 2014, 14% of abortion patients relied on some form of financial assistance from an organization.3 Regardless, 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 source of financial assistance, typically obtained second-trimester abortions costing an average of $2,000, reflecting the elevated cost of abortions after the first trimester.18 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 twice as high among second-trimester patients as first-trimester patients (19% vs. 8%).13
- The Tiller Fund saw an increase in assistance requests for second-trimester abortions between 2010 and 2015, suggesting that as abortion costs rise and legal restrictions intensify, abortion becomes increasingly unaffordable for poor and low-income women.18
- Regardless of their insurance status, women obtaining an abortion are more likely to rely on 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 2014.3 The Tiller Fund makes the majority of its pledges to residents of states without expanded Medicaid access to abortion.18
- While reliance on financial assistance 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.19 Such delays may be due to eligibility screening and other administration related to seeking financial assistance from an abortion fund or other 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
1. 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.
2. 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.
3. 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.
4. Guttmacher Institute, Dramatic gains in insurance coverage for women of reproductive age are now in jeopardy, News in Context, 2018, https://www.guttmacher.org/article/2018/01/dramatic-gains-insurance-coverage-women-reproductive-age-are-now-jeopardy
5. Frohwirth LF, Guttmacher Institute, special tabulations of data from the 2015 American Community Survey.
6. Guttmacher Institute, State funding of abortion under Medicaid, State Policies in Brief (as of January 1, 2018), 2018, https://www.guttmacher.org/state-policy/explore/state-funding-abortion-under-medicaid.
7. Sonfield AJ, Guttmacher Institute, special tabulations of data from the 2016 American Community Survey.
8. 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-abortion-services-fy-1980-2015.
9. 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.
10. Jones RK, Meghan Ingerick 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.
11. Special calculations of data from the 2011 HHS poverty guidelines.
12. 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-well-being-us-households-201705.pdf.
13. 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.2013.03.001.pdf.
14. 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.
15. Zane S et al., Abortion-related mortality in the United States: 1998–2010, Obstetrics & Gynecology, 2015, 126(2):258–265.
16. 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-abortions-literature-review.
17. 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.
18. 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/.
19. 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-abortion-patients.