Erika Christensen was in her third trimester in May 2016, when doctors told her the fetus wasn’t swallowing, and her baby would likely not be able to breathe outside her body.
They were also concerned for her health. Christensen had had brain surgery a year before, and going into natural labor was already a risk. The doctors agreed that the best course of care was to terminate the pregnancy.
This is part of a series of articles on the business case for abortion access. See the full package here.
Despite the risks, Christensen was past the point where abortion was legal in New York, as she was more than 24 weeks pregnant. She would have to travel to Colorado for a $10,000 procedure. On top of that, she discovered that—while she had “very good private insurance”—abortion care wasn’t covered out-of-network. “I didn’t know to ask for pre-authorization to reimburse myself,” she says. “And I am not sure it would have mattered—like most abortion seekers, I didn’t have time, I needed care.”
This issue isn’t uncommon for people who need an abortion, and it highlights the complexity of insurance in America when it comes to abortion access, much of which is intentionally complicated in order to put abortion financially out of reach, advocates say. Insurance policies are poorly defined, inconsistent, and difficult to parse, which means even those with “good” insurance can pay anywhere from five hundred to thousands of dollars out of pocket, depending on how far along they are.
“While I was dealing with this health crisis, we also had to hustle to get thousands and thousands of dollars together,” Christensen says. “I actually borrowed the money from my mom’s 401(k) to be able to pay for it.” Later, the clinic helped Christensen file for reimbursement through her insurance company, but she only got one-third back. The experience motivated Christensen to found Patient Forward, an abortion advocacy and education organization.
The convoluted relationship between insurance and abortion access exposes yet another inequity in our healthcare system, as millions of low-income Americans rely on state-sponsored insurance to cover abortion, and a number of states severely restrict abortion access for those covered by Medicare, Medicaid, or ACA plans. This is to say nothing of the estimated 10.3 million reproductive-age women in America without any insurance at all.
Abortion advocates know that navigating insurance is yet another barrier to access, and they only expect the landscape to get more challenging if Roe v. Wade is overturned, as the leaked Supreme Court draft opinion indicated it would be. Experts say that many people don’t even realize their insurance plans cover abortion, whether because of the stigma it carries or opaque language in plans. Insurance policies and laws around how they can be used for abortion vary wildly from state to state, and, on top of that, many clinics don’t even take insurance. It all adds up to a morass of regulations, red tape, and competing mandates that can make it nearly impossible for pregnant people to pay for abortion care when they need it.
“Some states already restrict private-insurance coverage of abortion care,” says Ameri Klafeta, director of the Women’s and Reproductive Rights Project at the American Civil Liberties Union of Illinois. “Unfortunately, the end of Roe could mean increasing state restrictions, including additional states prohibiting insurers from covering abortion.”
The Private Insurance Landscape
About half of Americans—more than 158 million people—are insured through an employer, according to the Kaiser Family Foundation. And while two studies have found that a majority of Americans with employer-based insurance do have coverage for abortion, research indicates that only about 4 in 10 privately insured patients actually use that insurance to pay for the abortion procedure, according to the Guttmacher Institute, a pro-choice reproductive-health research organization. (Another study found that as many as 69% of patients paid out of pocket, including those with private insurance.) This can be for a variety of reasons: People may be unsure what their plan covers, they may have high deductibles, their plan may not cover their particular abortion needs, or the clinic may not accept insurance.
The median cost for a first-trimester procedural abortion out of pocket from 2017 to 2020 was $575, while a second-trimester abortion was $895, according to a recent University of California San Francisco (UCSF) study of abortion and insurance. Later-stage second- and third-trimester abortions can top $10,000. Meanwhile, one-quarter of Americans aren’t able to pay for a $400 emergency expense solely with the money in their bank accounts.
Corporations have a responsibility to make sure their employees are fully covered for abortion healthcare, Christensen says. Through PatientForward, she’s developing resources to challenge obstacles to abortion care, including insurance barriers. “The gold standard policy would cover all abortions, ensure timely reimbursements . . . provide medical leave for recovery, and find ways to provide support for things like travel, childcare, and time off without requiring employees to disclose private information to their coworkers or employer,” she says.
But while that might be the gold standard, a number of states restrict private insurers from covering abortion at all.
Eleven states already have outright bans on abortion coverage in all private insurance plans regulated by the state (Idaho, Indiana, Kansas, Kentucky, Michigan, Missouri, Nebraska, North Dakota, Oklahoma, Texas, and Utah).
On the other hand, seven states legally require abortion coverage to be in private health insurance plans (California, Illinois, Maine, New York, Oregon, Washington, and Maryland).
“Some states ban it, and others require it,” Kaiser Family Foundation Women’s Health Policy director Alina Sal
ganicoff says. “It’s incredibly complicated . . . the states can pass these mandates, and they affect some insurance plans but not all.”
The state laws only apply to what are called “fully insured plans,” in which employers pay a premium to an insurance carrier that then covers the medical claims of its employees. Meanwhile, employers with “self-funded” plans—which are common among larger employers—pay for medical claims themselves, basically acting as their own insurers. They can “do whatever they want, for the most part,” Salganicoff says.
Nuances of Insurance
Even if you’re lucky enough to have insurance that covers abortion, some clinics don’t take it. A study published in April found that the number of clinics accepting insurance for abortion declined from 89% to 80% between 2017 and 2020.
The DuPont Clinic in Washington, D.C., is one of those. Founder Matthew Reeves says most patients who come to the clinic for later-stage abortions don’t have coverage for the procedure they need. For plans that did have abortion coverage, the reimbursement was so poor that it didn’t even cover the clinic’s cost to provide the service.
Insurance providers that do cover abortion typically don’t have a process to address its nuances, abortion advocates say. An insurance company might have one billing code for second-trimester abortions, when the cost of providing that abortion differs vastly between 14 and 27 weeks of pregnancy, as well as for the state you’re in.
“The billing code used to represent a third-trimester abortion in an independent clinic with bulletproof glass, or in a hostile state with clinic protestors, may also be used to represent an earlier second-trimester abortion in a hospital in a friendly state,” Christensen says, adding that the cost of providing these services can vary dramatically.
Even when a private insurance plan covers abortion, it may not cover your particular abortion. Christensen says that many private plans don’t cover so-called elective abortions—they only cover “therapeutic” abortions. These terms are rarely defined, nor used consistently; so in practice, it leaves the decision to the insurer’s discretion. Meanwhile, some plans only cover abortions in-network or in-state. In other cases, people may have a medical emergency that necessitates an abortion, like Christensen, and don’t have the time to determine exactly what their plan covers.
Insurance plans are confusing by design, says Megan Jeyifo, executive director of the Chicago Abortion Fund. “That is the goal: to make you call an insurance company when you’re dealing with time-sensitive healthcare.”
The vast majority of the callers to Chicago Abortion Fund are privately insured, she says. But each policy has its differences. She remembers a woman who needed an abortion in 2021 due to her fetus having a fatal heart defect. The woman was covered under a Blue Cross Blue Shield self-funded plan in Illinois. But she was told that her insurance only covered the procedure if her life was in danger, not for a fetal anomaly. “Her child has a heart defect, and she’s forced to remain pregnant,” Jeyifo says.
A lot of people don’t look to see if abortion is covered under their insurance plan until they need it, says Renee Bracey Sherman, founder and director of We Testify, an organization that elevates the stories of people who have had abortions. In states like Texas where state-regulated private insurance plans are prohibited from covering abortion, people need to purchase a separate rider—or supplemental benefit policy—each year, in order to be covered.
“You’re prepaying your abortion,” Sherman says, adding that most of the policies she has seen bury the fact that they cover abortion in complex language. She has often seen abortion care listed under “outpatient surgery.” “It plays on the fact people won’t know what that is.”
Medicaid and the Hyde Amendment
Those who rely on federal funding for their health care—some of the nation’s poorest citizens—are already in a post-Roe situation because of the Hyde Amendment, which bars federal funds from being used for abortion care, with few exceptions, the ACLU’s Klafeta says.
In 1976, realizing he couldn’t easily overturn Roe v. Wade, Illinois congressman Henry Hyde saw another way to make abortion inaccessible for millions: by putting it out of reach financially.
“He knew that he might not immediately be able to nullify the legalization of abortion through the Supreme Court decision, but he very openly said that he could make it so it wouldn’t be accessible for everyone,” says Sherman.
He proposed a federal provision that would eliminate coverage of abortion through Medicaid or Medicare. It passed, and since 1977, the Hyde Amendment has effectively banned the use of federal funds for abortion unless the pregnancy is a result of rape or incest, or will endanger the pregnant person’s life.
That impacts low-income people who rely on the federal Medicaid program for their healthcare, plus anyone for whom the government is their insurer, employer, or provider of care. It also impacts about 907,000 women, ages 15 to 44, who are insured through Medicare—including disabled women—as well as those insured through the Children’s Health Insurance Program (CHIP), which covers kids up to age 19 in families with incomes too high to qualify for Medicaid, but too low to afford private insurance.
The Hyde Amendment impacts people of color disproportionately: Of women between the ages of 15 and 44, 31% of Black women and 27% of Hispanic women were enrolled in Medicaid in 2015, compared with 15% of white women. “They pay for health insurance through their taxes, then cannot use the insurance they have because they’re poor, and can’t afford an abortion because they’re poor,” Sherman says. “It’s a really disgusting system, which punishes people for not having enough money.” UCSF researchers cited a study in Louisiana, which found that 29% of Medicaid-eligible pregnant people would have had an abortion if Medicaid covered it, but gave birth instead.
While the Hyde Amendment effectively bars federal Medicaid from being used for abortion, states can opt to use their own budgets to cover abortions for low-income residents. Still, only 16 do, including Illinois, which passed a law in 2017 allowing state Medicaid funds to cover abortions for more than 2 million eligible residents.
“It’s been transformative. No abortion funds could ever come close to supporting the amount of people Medicaid supports,” says Chicago Abortion Fund’s Jeyifo, adding that some people who contact the fund don’t real
ize they’re eligible for Medicaid, or that they can use it to cover their abortions.
According to the Guttmacher Institute, Medicaid covered slightly more than 157,000 abortions nationwide in 2015, and almost all were in states that use their own funds to cover the cost. In the other 34 states—where about 7.5 million women ages 15 to 44 rely on Medicaid or CHIP—abortion isn’t covered unless it’s rape, incest, or the mother’s life is in danger. In South Dakota, abortion isn’t even covered in cases of rape or incest.
Congress has also used the Hyde Amendment as a model to bar abortion access for those who get health coverage through the government as federal employees (335,000 women of reproductive age), military personnel (1.4 million), veterans (257,000), Peace Corps volunteers (about 4,700), American Indians and Alaska Natives covered under the Indian Health Service (345,000), and women held in federal prisons or detention centers (more than 13,000).
Meanwhile, anti-abortion politicians are using Hyde-like techniques to ban abortion from private insurance coverage, too, according to the Guttmacher Institute. Already, 25 states have enacted near-bans on abortion coverage in Affordable Care Act marketplace plans offered through state health insurance exchanges since Obamacare was passed in 2010. The plans insure more than 11 million people nationwide.
What is being done
Meanwhile, the increasingly polarized abortion landscape is forcing some companies and states to take action.
In March, Citigroup revealed in a shareholder filing that it had begun covering travel expenses for employees requiring abortions out of state. The policy reportedly works in the same way that the company plan covers those with a heart condition who might need treatment at an out-of-state hospital.
Apple confirmed that its health insurance policies cover abortions, including travel fees if needed, and Amazon and Tesla announced that they will cover travel costs for employees who need abortions in other states. Bumble and Match Group’s CEO set up relief funds for people seeking abortions in Texas. Yelp, meanwhile, will cover costs for employees and their spouses who must travel out of state to access abortion care; CEO Jeremy Stoppelman wrote an op-ed for Fast Company arguing that companies should be taking a stand on this issue.
Like corporations, states are also being pushed to decide whether they want to be an abortion desert, a haven, or somewhere in between.
California lawmakers are looking to pass bills that would create a state abortion fund to help people pay for abortions and associated travel costs, including those from out of state, and another that would help support clinics that provide abortions for people without insurance coverage.
Maryland recently passed a law expanding abortion rights, which will require most insurance providers in the state to cover the cost of an abortion, at no cost to the resident.
“Providers told us that people didn’t even realize it’s something that could be covered under insurance because it’s been so stigmatized,” says Maryland State Delegate Ariana B. Kelly, who cosponsored the bill.
She says they found that, even for the insured, deductibles could be hundreds of dollars—a major barrier for lower-income people seeking abortions.
“We had one written testimony from an abortion clinic that said one patient was so excited to discover the procedure was covered because she’d been saving money for it, and now her kids could get Christmas gifts. That makes it real,” Kelly says.
The law also requires insurers to standardize the language in policies to make it easier for consumers to find, by explicitly using the words “abortion care.”
Kelly says she hopes the political landscape will push more insurers to add abortion healthcare to their policies voluntarily. Corporations have a responsibility to take the lead on the issue, she says, especially now.
“Generally speaking, this has not been something companies are particularly comfortable talking about and don’t want to take a position one way or another,” she says. “But the national landscape is forcing people to.”