Barriers to later abortion access

Since the legalization of abortion in 1973 following the Roe v. Wade decision, restrictive legislation and policies have been enacted that significantly limit the availability of abortion in the US. Restrictions based on funding and gestational age and allowing for provider refusal disproportionately impact women who need a later abortion.[1] [2]

The Hyde Amendment

The Hyde Amendment, enacted in 1976, prohibits federal funds from being used to cover the cost of an abortion. This effectively means that women who are covered by public health insurance are no longer able to use their own health insurance to pay for an abortion unless the pregnancy poses a risk to the woman’s life or resulted from rape or incest.[3] Similar policies restricting the use of federal funds to pay for abortion were subsequently enacted for federal employees and their dependents, military personnel, Native American women who access care through the Indian Health Service, women incarcerated in federal facilities, and Peace Corps volunteers.[4] Currently, only 16 US states use their own funds to cover abortion for public health insurance enrollees beyomd what the Hyde Amendment requires.[5] Women that qualify for public health insurance but live in one of the 34 states that do not cover abortion may be forced to carry an unintended pregnancy to term if they are unable to independently raise the money to cover the cost of their abortion.[5] A 2009 review of the literature estimates that when state funding is not allocated for abortion coverage, nearly one-quarter of women with public health insurance may carry a pregnancy to term when they would otherwise choose to obtain an abortion.[3] In states that adhere to the Hyde Amendment, Medicaid paid for only 1.5% of abortions in 2014 [5].

Impact of the Affordable Care Act

With the implementation of the Affordable Care Act (ACA) in 2014, the restriction on the use of federal funds to pay for abortion was applied to plans offered through the healthcare exchange.[6] The ACA requires only that states separate federal funding in their accounting to ensure it is not allocated for abortion, but it does not otherwise prohibit abortion coverage.[7] However, 26 US states independently enacted bans preventing plans sold through the state marketplace from covering abortion care [8]. 22 states also ban abortion coverage for public employees, and 10 states ban abortion coverage in private “plans written in the state" [8]. In addition, in 2018, the Trump adiministration proposed new regulations that would require issuers to send two sperarate monthly bills to each policyholder; one bill for the non-Hyde abortion coverage and another for the premium fo rthe coverage of Essential Health Benefits.[9] Policyholders would also need to return payment in two separate transactions. This proposed rule would disrupt coverage for many policyholders, and place additional logical obstacles on issuers[9].

Impact of gestational age bans

The cost of an abortion increases rapidly as a woman’s pregnancy advances. Women who discover they are pregnant during the first trimester but are unable to afford the cost of an abortion, may have to delay their appointment until the second trimester in order to raise sufficient funds. The median cost of a procedure rises from approximately $460 in the first trimester to $750 between 14 and 20 weeks and $1,750 after 20 weeks [2] This cost can be almost two-thirds of a woman’s monthly income, significantly higher than the average cost of a first-trimester abortion.[2] In a study of women who were denied an abortion because of gestational age limits, delays were reported primarily because women needed time to raise funds for the procedure and for the cost of travel to the appointment.[1]

By the time that some women are able to raise sufficient funds for their appointment, their pregnancy may have progressed such that there is no nearby provider that offers abortions at that gestational age. In the last decade, a number of states have enacted legislation banning abortion past a certain point in pregnancy based primarily on gestational age, thus further restricting the availability of legal abortion. Currently, 24 states have active policies banning abortion after a particular point in the second trimester, with 17 of those bans beginning at 20 weeks post-fertilization or 22 weeks LMP; one additional state has a ban beginning at the third trimester [10]. Women in need of a later term abortion are more likely to have to travel long distances or out-of-state to find a provider that offers abortions at the appropriate gestational age [11]. Later abortions can require a multi-day procedure, thus requiring a woman to arrange not only for transportation, but for several days of food, lodging, and childcare in addition to the cost of the abortion itself. Whether women are denied coverage for abortion by their state-sponsored insurance, private ACA insurance plan, or by their federal employee plan, the financial barriers to obtaining a later abortion can effectively make it out of reach.

Limited access to providers

Between 2008 and 2014, the number of clinicians providing abortion dropped by 7% in the United States [12] Even for women that are able to overcome financial barriers to obtaining a later abortion, they may have difficulty finding a clinician that offers later abortion services. In a 2012-2013 survey of US abortion providers, only 34% reported that they provide abortions after 20 weeks and only 16% do so at 24 weeks [13]. Further compounding this limited access are the state and federal laws that allow providers and entire health care institutions to refuse to provide abortion care because of a moral or religious objection. As of April, 2019 laws in 46 states allow individual providers, including doctors and nurses, to refuse to participate in abortion provision, 4 states allow health care institutions to do the same [14]. Providers who are willing to offer a later term procedure but work in a department where other providers refuse, or in an institution whose policies prohibit abortion provision, are effectively prevented from making their care available to women who need it. Because of these refusal laws, women who need abortions at a later stage in pregnancy may be forced to travel long distances to reach a later term abortion provider even if they live in a state whose regulations do not restrict the procedure itself.

For more information about barriers to later abortion access see the Related Research in our archives.

References

1. Upadhyay UD, Weitz TA, Jones RK, Barar RE, Foster DG. Denial of abortion because of provider gestational age limits in the United States. American Journal of Public Health. 2014; 104(9): 1687-1694

2. Roberts SC, Gould H, Kimport K, Weitz TA, Foster DG. Out-of-pocket costs and insurance coverage for abortion in the United States.Women's Health Issues. 2014; 24(2): e211-e218

3. Henshaw SK, Joyce TJ, Dennis A, Finer LB, Blanchard K. Restrictions on Medicaid funding for abortions: A literature review. Guttmacher Institute. 2009

4. Boonstra HD. The heart of the matter: public funding of abortion for poor women in the United States. Guttmacher Policy Review. 2007; 10(1): 12-16

5. Guttmacher Institute. Medicaid Funding of Abortion.February 2018. Accessed: April 10, 2019.

6.Salganicoff A, Sobel L, Kurani N, Gomez I. Coverage for abortion severices in Medicaid, Marketplace plans, and private plans. Kaiser Family Foundation. Jan 2016. Available from: https://www.kff.org/womens-health-policy/issue-brief/coverage-for-abortion-services-in-medicaid-marketplace-plans-and-private-plans/Accessed: April 10, 2019.

7. Hasstedt K. Abortion Coverage Under the Affordable Care Act: Advancing Transparency, Ensuring Choice and Facilitating Access. Guttmacher Policy Review. 2015; 18(1)

8. Guttmacher Institute. Restricting insurance coverage of abortion. State Policies in Brief. August 1, 2015

9. Salganicoff A, Sobel L. Abortion coverage in the ACA marketplace plans: The impact of proposed rules for consumers, insurers and regulators. Kaiser Family Foundation. 2018. https://www.kff.org/womens-health-policy/issue-brief/abortion-coverage-in-the-aca-marketplace-plans-the-impact-of-proposed-rules-for-consumers-insurers-and-regulators/. Accessed: April 10, 2019.

10.Jatlaoui TC, Shah J, Mandel MG, et al. Abortion Surveillance — United States, 2014. Morbidity and Mortality Weekly Report Surveillance Summaries. 2017; 66(-24):1–48. DOI: http://dx.doi.org/10.15585/mmwr.ss6624a1 .