Coverage for Abortion Services and the ACA
The Availability of Abortion Coverage to Women Newly Eligible Under the ACA
There are 11.8 million uninsured women of reproductive age (ages 19 to 49) legally residing in the United States. Of these uninsured women, an estimated 3.4 million (29%) now qualify for Medicaid or have been eligible, but had not previously enrolled in the program (Figure 2). About 4.8 million women (40%) have incomes between 100 – 400% of the Federal Poverty Level (FPL) and now qualify for subsidies in the form of tax credits if they obtain coverage through their state Marketplace. There are about 1.8 million uninsured women with incomes at or above 400% of FPL who can now obtain coverage on the state Marketplace or through the individual market, but do not qualify for subsidies because their income is too high. Finally, an estimated 1.8 million uninsured women fall into the so-called “coverage gap” because they live in one of the 25 states that is not expanding Medicaid and their income is below 100% FPL, leaving them ineligible for subsidies to purchase coverage on the health care Marketplace under the law.1
Because of the Hyde Amendment rules and the state laws that govern coverage of abortion services in private plans, the availability of abortion coverage is uneven across the states among the women who are newly eligible for Medicaid and private coverage. Of the estimated 11.8 million women who are uninsured and legally present in the United States, about half (52%) will be able to enroll in a Medicaid plan or private insurance plan that does not limit the scope of coverage for abortion services if they wish (Figure 3). One third, 3.9 million women, live in a state where they can only enroll in a private or Medicaid plan that limits abortion coverage either to pregnancy that result from rape or incest or a medical threat to a women’s life as in the Hyde Amendment or in some states even more limited circumstances. About 1.8 million women (15%) are in the coverage gap and do not have access to affordable coverage, either to Medicaid or subsidies, because their state did not expand Medicaid and their incomes are too low to qualify for tax credits under the law. Twenty-three of the twenty-five states that are not expanding Medicaid are states that follow the Hyde Amendment. Two states, Montana and Alaska, use state-only funds to cover abortions beyond the Hyde limits but are not expanding Medicaid eligibility. As a result, nearly all of the women in the coverage gap states (99%) would still have restricted availability of abortion coverage under Medicaid even if their state were to broaden eligibility.
The availability of abortion coverage varies considerably by state due to differences in state policies that limit abortion in Medicaid, on state Marketplaces, and/or in the private sector. In 9 states, uninsured women will only be able to obtain coverage in Medicaid or private plans that place limits on the circumstances in which they can use the insurance to pay for the abortion or will not gain coverage because their state is not expanding Medicaid (Appendix 1). This is because the state in which they reside has passed laws that limit coverage in both private plans and those available on the Marketplace and, in the case of those that are expanding Medicaid, also do not use state dollars to pay for abortions in their Medicaid programs beyond Hyde rules, or are not expanding Medicaid. In contrast, in 14 states, uninsured women who will be newly eligible for Medicaid, tax credits, or unsubsidized coverage will all have the option of enrolling in a plan that offers coverage for abortion without limitations.
Women who seek an abortion but do not have coverage for the service will need to shoulder the out-of-pocket costs of the services. The cost of an abortion varies depending on factors such as location, facility, timing, and type of procedure. A clinic-based abortion at 10 weeks’ gestation is estimated to cost between $400 and $550, whereas an abortion at 20-21 weeks’ gestation is estimated to cost $1,100-$1,650 or more.2 Though the vast majority (~90%) of abortions are performed early in pregnancy, the costs could still be economically challenging for many low-income women.3 Approximately 5% of abortions are performed at 16 weeks or later in the pregnancy.4 For women with medically-complicated health situations or who need a second-trimester abortion, the costs could be prohibitive. In some cases, women may have to delay their abortion while they have time to raise funds5, or women may only learn of a fetal anomaly in the second trimester when the costs are considerably higher.6Federal and State Laws Regarding Coverage of Abortion Services Coverage for Abortion Services and the ACA - Conclusion