Abortion rights demonstrators protest outside the United States Supreme Court as the court rules in the Dobbs v Women's Health Organization abortion case, overturning the landmark Roe v Wade abortion decision in Washington, U.S., June 24, 2022.
Jim Bourg | Reuters
Even when Roe v. Wade was in effect and women had the legal right to an abortion no matter where they lived in the U.S., health insurance coverage of the procedure was limited.
Many states restrict what plans can cover, and a decadeslong national law bans the use of federal funds for abortions, meaning that women on Medicaid and Medicare were often not covered when it came to pregnancy terminations.
With abortion now expected to be prohibited in at least half the states after the landmark decision protecting women's right to an abortion was overturned by the Supreme Court last week, coverage will only become rarer, experts say.
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"State-regulated insurers in states where abortion is banned will have to drop coverage of abortions to stay in compliance with state criminal law," said Caitlin Donovan, a spokeswoman for the National Patient Advocate Foundation.
Still, women seeking coverage for abortion may have options available to them. Although the landscape is quickly changing, here's what we know as of now.
Medication abortions, which account for over half of all abortions, and include a two-drug regimen of mifepristone and misoprostol, can be safely used within the first 10 weeks of pregnancy, and can cost up to $750 without insurance, according to Planned Parenthood.
A surgical abortion, meanwhile, can run more than $2,000 out of pocket.
Prior to the Supreme Court's decision last week, abortion coverage was still highly dependent on where you lived and what type of plan you had, Donovan said. "Most states impose restrictions on coverage in varying degrees."
Eleven states limit the coverage of abortion in all private health insurance plans written in the state, according to The Guttmacher Institute, a pro-abortion rights research organization. They are Idaho, Indiana, Kansas, Kentucky, Michigan, Missouri, Nebraska, North Dakota, Oklahoma, Texas and Utah.
The Hyde Amendment, passed in 1976, blocked federal funding for services such as Medicaid from being used for abortions, except in limited cases including rape and incest. States can choose to use their own budgets to supplement their Medicaid coverage and extend their abortion policies, but more than 30 states have not done so, Donovan said.
As a result, "in many states, hundreds of thousands of women seeking abortion services annually are left without coverage options," according to a 2019 report by the Kaiser Family Foundation.
If you live in a state such as Louisiana or South Dakota, where abortion is now banned, "you probably don't have any insurance coverage for it at all except in the case of rape, incest or a threat to the mother's life," Donovan said.
"Some states may not even allow those exceptions," Donovan added.
However, employers that self-fund for their health insurance policy, meaning they take on most of the costs of benefit claims, may be able to maintain their abortion coverage, said Joelle Abramowitz, an assistant research scientist at the University of Michigan. Such plans tend to be subject to less regulation, giving the company more flexibility on benefits offered.
Donovan recommends calling your plan provider and asking about its abortion coverage. Of course, if abortions are banned in your state, even if you're covered, you'll likely have to travel to another state to get one.
Some companies are also covering travel expenses for employees who need to leave the state for an abortion.
Out-of-network coverage is typically less robust, and some health plans, including HMO plans, don't offer it at all. Abramowitz suggests calling your insurance plan and asking whether you have out-of-network benefits and how they work.
In some cases, people may find it's cheaper to pay a provider out of pocket than to go through their out-of-network insurance option, Abramowitz said. Many abortion providers work on a sliding scale, she added.
It's also worth asking your insurance plan if there are any in-network abortion providers in another state. There could be one right over the state line, for example, Abramowitz said.
You also may be able to see a provider in another state virtually through a telehealth visit to get a medication abortion. In these cases, your medication can be mailed to you or you'll be asked to pick it up somewhere.
However, 19 states have already made it illegal to receive medication prescribed during a telehealth visit.
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A number of Republican-led states that are moving to ban abortion are, at the same time, extending health insurance benefits to new mothers, professing to support “women in crisis”.
As the US supreme court prepares to rule on national abortion rights, many Republican states are seeking severe abortion bans that would force many women to carry pregnancies to term, likely worsening the US maternal mortality crisis.
Some of those same lawmakers are now passing bills that extend Medicaid benefits to low-income mothers, typically for one year after they give birth rather than the current two months.
Arizona, Florida, Tennessee and Texas have all extended health benefits for low-income mothers in recent months, and Alabama and Georgia have both moved to implement such extensions, according to the Kaiser Family Foundation. All have also sought to impose severe abortion restrictions or bans.
Although expanding pregnancy-related health coverage is “a win in many ways”, it does not counteract the fact that abortion bans “would certainly lead to higher risks for maternal morbidity or mortality,” said Sarah Blake, an associate professor of health policy at Emory University in Georgia.
Blake said Georgia lawmakers are in “Jekyll and Hyde mode”. Even as advocates for maternal health, herself included, are “very happy” for the extension, she said, “we know the state is very against women and their access to full scope reproductive health services”.
Changes to postpartum benefits come as the supreme court is expected to rule in the coming days on a critical abortion rights case, Dobbs v Jackson Women’s Health Organization. A leaked draft opinion showed conservative justices are on the verge of ending federal abortion protections. If that happened, 26 states would be certain or likely to ban abortion.
“It shows you how [Republicans] are not operating in good faith,” said Loretta Ross, an associate professor at Smith College in Georgia and a reproductive justice activist. “If they really cared about maternal mortality they’d reduce the causes of maternal mortality – and it goes way beyond Medicaid expansion.”
State legislators in both Democrat- and Republican-led states have made changes to Medicaid, a federal and state partnership that provides health insurance for the poor and disabled, to take advantage of a provision of federal pandemic aid which streamlined postpartum benefit changes.
However, the most dramatic effects would be in Republican-led states, where lawmakers have long refused to expand the program to more low-income people.
The refusal is a legacy of Obamacare debates. Around the time the Affordable Care Act, better known as Obamacare, Republicans sued to stop the expansion of Medicaid. They succeeded in the supreme court, and each state was forced to adopt Medicaid expansion individually.
A dozen states, mostly in the US south, still refuse to do so, even though the federal government would pay 90% of the costs of expanding the program.
Expanding Medicaid only to postpartum women appears to be a way for Republican-led states to champion their aid to a sympathetic group, even as they oppose broader Medicaid expansion and ban abortion, said Ross.
In Texas, for example – a state where one-quarter of women of reproductive age lack health insurance, the highest rate in the nation, and which is among the 10 worst states for maternal mortality – lawmakers recently expanded Medicaid to pregnant patients for six months after giving birth, instead of two.
A single adult supporting two children cannot earn more than $2,760 a year and qualify for Medicaid – unless they are pregnant, in which case they can earn up to $45,600 a year and qualify. However, the exemption previously lasted just 60 days after birth – the federal minimum – after which most people become uninsured once again.
The expansion to six months is welcome but insufficient, said Erika Ramirez, director of policy and advocacy for the Texas Women’s Healthcare Coalition: “We got six, which is better than nothing … [But] over and over, [the] top recommendation [from maternal health experts] has been for women to get postpartum care for a full 12 months.”
When the legislation was signed, Texas state senator Lois Kolkhorst, who sponsored it, described the Medicaid extension as a “bipartisan effort to help keep Texas moms healthy and provide the care needed to avoid preventable deaths and illnesses” .
Yet just two days before the bill passed in the Senate, Kolkhorst and her Republican colleagues passed a total abortion ban, which is expected to go into effect immediately if the US supreme court ends federal abortion protections. It is one of 26 abortion restrictions Kolkhorst voted for in her 11-year career as a legislator.
A similar effort to simultaneously extend Medicaid to pregnant women and ban abortion is under way in Alabama. There, one of the most vocal proponents of expansion is Republican state representative Debbie Wood, who also opposes abortion in nearly all circumstances, including rape and incest.
Kolkhorst could not be reached for comment and Wood did not respond to requests for an interview.
In Tennessee, the Republican governor, Bill Lee, directly connected the state’s postpartum Medicaid expansion and abortion. At a press conference in May, he spoke about Tennessee’s “trigger” ban, a law that will allow the state to immediately ban abortion if the supreme court ends federal protections.
“The lives of unborn children – it’s very important that we protect the lives of them,” he said, adding: “It’s also important that we recognize that women in crisis need support and assistance through this process. For example, that’s why we’ve expanded our postpartum coverage for women in TennCare.”
“This kind of strategy pits needy people against each other,” said Ross. “We’re supposed to advocate for postpartum women to get Medicaid, and screw everybody else who needs it? It’s a classic divide and conquer strategy.”