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Coverage for Abortion Services and the ACA

While millions of women stand to gain health insurance coverage as a result of the ACA insurance expansions, many will have insurance plans that restrict the circumstances in which abortion services will be covered. As a result of state actions to limit coverage of abortion in the Marketplace plans and federal law limiting abortion coverage under Medicaid, one third of women newly eligible for coverage can only enroll in a plan that restricts  abortion coverage to limited circumstances. About half of women of reproductive age who are legally residing in the U.S. qualify for coverage in plans that do not have limitations, and 15% are in the coverage gap and will not qualify for Medicaid or affordable coverage.

These coverage limitations are occurring at a time when many states are taking other actions to curtail access to abortion through multiple fronts. These efforts include state level legislation that focuses on the doctors and clinics that provide abortion services to women. Some state legislatures are enacting laws that expand the regulatory requirements on abortion clinics, place gestational limits on when women can have abortions, include new rules for women to have ultrasounds and multiple visits, and impose new regulations on clinicians such as requiring them to have hospital admitting privileges.1 In addition, legislative activity has focused on prohibiting certain providers and clinics that perform abortions from qualifying for any public financing, including Title X allotments and Medicaid funds, even when those funds are specifically required to be used for other services such as family planning and other preventive services and not abortions.

The impact of the abortion coverage restrictions will be disproportionately felt by poor and low-income women who have limited ability to pay for abortion services with out-of pocket funds. The effect of the absence of abortion coverage could be magnified by laws that have been enacted in some states requiring that additional services, such as sonograms, be performed before all abortions or by the multiple visits and waiting periods that are required in some states which will result in increased costs of abortion procedures and higher travel costs. These requirements, along with policies that increase the regulations on clinics and providers, will have the expected result of limiting access to and the availability of abortion services in some states.

At the federal level, further efforts to limit abortion coverage have recently focused on legislation that would ban the availability of federal tax credits to individuals who purchase Marketplace health plans that includes coverage of abortions.2 This bill, HR7, would also limit tax credits to small businesses that offer plans that include abortion coverage to their employees. In the coming years as the ACA is implemented, the laws that are enacted at the federal and state levels as well as the choices that are made by insurers, employers, and policy holders will ultimately determine the extent of abortion coverage that will be available to women across the nation.

The authors would like to thank Laurie Sobel and Usha Ranji for their helpful comments and Anthony D’Amico for assistance with data analysis.

The Availability of Abortion Coverage to Women Newly Eligible Under the ACA Appendix