Trends In Self-Pay Charges And Insurance Acceptance For Abortion In The United States, 2017–20 – healthaffairs.org
Abortion is an essential health service and a critical component of primary health care.1,2 Abortion care in the US is delivered primarily through dedicated facilities that are often miles from the patient’s home.3,4 The US has twenty-seven abortion deserts—major cities where people must travel 100 miles or more to obtain abortion care.3 For people seeking abortion, obtaining care as soon as desired is central to patient autonomy and satisfaction, and it generally results in improved abortion outcomes. Medication abortion, which involves taking two medications—mifepristone, which blocks the progesterone needed to maintain a pregnancy, followed by misoprostol, which causes the uterus to contract and empty5—can be provided remotely through telehealth.6 However, gestational limitations on this method make people ineligible for it after about ten to twelve weeks of pregnancy. Both first-trimester procedural and second-trimester abortions require a clinic visit, during which the provider uses suction or instruments to evacuate the pregnancy.7 (Sometimes these procedures are inaccurately called surgical abortions, but no incisions are actually made.) Efforts to obtain an abortion also are often delayed or stopped altogether because the patient must first gather the funds to pay for the abortion. In one study of people denied an abortion because of provider gestational limits, the most common reason for delay in obtaining the service was having to raise money for travel and procedure costs.8
Most patients pay out of pocket for abortion.9,10 In one study that surveyed patients at six abortion-providing facilities nationwide, as many as 69 percent did so, including patients with private health insurance.11 The most common reason reported for not using insurance was that abortion was not covered. Eleven states restrict the type of abortion coverage that private health insurance plans can offer, and twenty-six states have laws that bar all plans participating in their state’s health insurance exchange from covering abortion.12
In addition, in thirty-two states and Washington, D.C., low-income people with Medicaid cannot use their health insurance for abortion in most cases. Since 1977 a federal law known as the Hyde Amendment has banned the use of any federal funds for abortion unless the pregnancy is a result of rape or incest or is determined to endanger the pregnant person’s life. (South Dakota does not cover cases of rape or incest, in violation of federal law.)12,13 This policy also prevents all health insurance available to federal employees and military personnel from covering abortion. These restrictions have been demonstrated to have life-altering consequences. One study conducted at three prenatal clinics in Louisiana estimated that 29 percent of Medicaid-eligible pregnant women who would have an abortion if Medicaid covered it instead give birth.14 Another study found that living in a state that does not provide coverage of abortion for people with Medicaid was associated with prolonged abortion seeking—people living in such states had twice the odds of still seeking an abortion four weeks after initially searching for an abortion provider.15 In general, the earlier in pregnancy an abortion is obtained, the more likely it is to be successful without complications.16 Being able to obtain an abortion as soon as one is wanted is critical for patient-centered care.
Lack of financial resources can create an insurmountable barrier to abortion. For many people, the cost of an abortion can exceed the capacity to pay.17 One analysis found that the out-of-pocket expenditure for a first-trimester procedural abortion in 2016, $397, would have been financially catastrophic for households earning their state’s median monthly income in thirty-nine states.18 The out-of-pocket expense for a second-trimester abortion, $854, would have been financially catastrophic for households earning their state’s median monthly income in all fifty states and Washington, D.C. This analysis however, used data from a single study11 performed in six clinics in 2011 and assumed the same average cost of first-trimester and second-trimester abortions for all states, when in reality, average prices differ by type of abortion (medication versus procedural) and by state.
At this time, limited national, regional, and state-level data are available on self-pay charges for abortion—that is, the total out-of-pocket amount one would have to pay without insurance coverage or other funding. A study that surveyed abortion facilities throughout the US in 2017 found that the national mean cost of medication abortion was $551, the mean cost of first-trimester procedural abortion was $549, and the mean cost of second-trimester (twenty weeks) abortion was $1,670 (range: $410–$5,386).19 In addition, a few studies have estimated average abortion costs through patient surveys.11,20 As stated above, one study surveyed 639 patients obtaining abortions at six geographically diverse facilities in 2011 and found that out-of-pocket expenses averaged $397 for a first-trimester abortion and $854 for a second-trimester abortion.11 Another study that surveyed 725 participants at thirty abortion facilities throughout the US between 2008 and 2010 found that among those whose insurance did not cover abortion, median out-of-pocket expenses were $575.20 The median charge for a medication abortion was $440, that for a first-trimester procedural abortion was $490, that for an earlier (fourteen to fewer than twenty weeks) second-trimester abortion was $750, and that for a later second-trimester abortion (twenty weeks or over) was $1,750.20 All of these studies reflect the out-of-pocket expense for abortion in some US states before 2017.
Our analysis aimed to fill a gap in the literature by providing comprehensive national data on out-of-pocket abortion charges over time, during the period 2017–20. We provide data on trends in self-pay charges and insurance acceptance by region for medication abortion, first-trimester procedural abortion, and second-trimester abortion.
Study Data And Methods
Data Collection
We used data from Advancing New Standards in Reproductive Health’s Abortion Facility Database, which includes data on publicly advertising abortion facilities and was systematically updated every summer during 2017–20. The database includes a wide range of facilities including doctor’s offices, public health centers, and hospital settings. Updates followed a structured process, including online searches to identify abortion facilities in the US and mystery shopper calls to confirm and obtain additional information from the facilities from the perspective of a potential patient. Each year we checked data for all facilities in the database from the prior year; identified any changes, including closures; and added any facilities that had newly begun to offer abortion care. We used methods similar to those described in our previous paper.3
We limited our online search to the search engine Google. We used the Chrome browser’s incognito mode to search for facilities by state and city, using the keywords “abortion clinic in [state]” and “abortion clinic in [city]” for all cities with a population of 100,000 or larger in each state and for the three largest cities for states that did not have a city of that size. We examined links to facilities from the first three pages of results for states and first two pages for cities. After each search, we cleared the browsing history, including cookies and other site data. When possible, we cross-checked the list using additional abortion provider directories such as ineedana.com and www.abortionfinder.org, as well as abortion facility organizational membership lists.
After updating the list of facilities through web searches and documenting any data found online, we conducted mystery shopper telephone calls to each facility to supplement any missing data. Mystery callers asked general questions about the facilities’ services, but when staff inquired about their personal details, callers replied that they were twenty years old and living in the same city as the facility and gave a last menstrual period date that would place them in the first trimester. To avoid giving more personal information, callers may have also said they were calling for a pregnant friend or family member. Mystery callers did not make appointments. The University of California San Francisco Institutional Review Board approved the study.
Through these searches and calls, we documented data on each abortion facility, including address with state and ZIP code; types of abortions offered; self-pay charges for medication abortion, first-trimester procedural abortion, and second-trimester abortion; and whether the facility accepted any type of insurance for abortion care. All facilities were categorized by state and by region, using US census categories. In 2017 and 2018 data collection on self-pay charges primarily reflected prices listed on facility websites. In 2019 and 2020 we relied more heavily on mystery shopper calls to collect first-trimester abortion prices when prices were not listed on websites. In all years, prices for second-trimester abortions were almost exclusively obtained from facilities’ websites and not through mystery shopper calls, contributing to greater levels of missing data because many websites did not contain prices. In addition, websites often offered ranges in prices, particularly for second-trimester abortions. In 2019 we did not record data on second-trimester costs at all. In some cases, particularly large hospitals, facilities were unable to give a self-pay price, leading to missing data.
Data Analysis
Facilities were included only if they reported being open and providing abortions in a given year. Abortion training sites, such as teaching hospitals, were included only if they publicly advertised abortion services. To compute charges for facilities that gave a range of prices for a certain abortion type (particularly second-trimester abortions), we first calculated mean prices for that procedure type per facility. Then facility charges were summarized by region to develop regional medians. We used medians because of the non-normal distribution of the cost data and to reduce the influence of outliers. To evaluate whether changes in median charges over time were statistically significant, we used Kruskal-Wallis tests, which provided p values for overall differences comparing all four years. This indicates whether any of the two years are different (not just 2017–20). For each abortion type, we calculated inflation-adjusted costs, using a Healthcare Inflation Calculator21 to estimate the price of abortion if it increased according to the natural inflation rate alone. We describe the number of facilities in each region that reported accepting any insurance and the percentage that accepted any insurance among the total number of open facilities that provided abortion.
To assess whether any trends may be due to differences in data collection method (website versus mystery calls) and the number of facilities represented over time, we performed a sensitivity analysis, replicating all cost and insurance analyses but restricting the data set to only facilities for which we had all four years of data. This analysis allowed us to determine whether the changes over time were merely a function of fluctuations in the proportion of facilities represented or actual changes in cost and insurance acceptance trends.
All statistical tests were two tailed, with significance set at 0.05. Analyses were performed using Stata 15.
Limitations
This analysis had several limitations. First, because in 2019 we made a decision to begin asking facilities about charges during the mystery call when they did not publish this information on their websites, the proportion of facilities represented in 2019 and 2020 increased dramatically from previous years. We did not document how each data point on patient charges was collected, and thus we were unable to analyze whether the method affected the results. In addition, for some facilities, particularly hospitals, we were unable to obtain exact charge data; instead, we received ranges of charges or no charge at all. Our sensitivity analyses, which included only facilities for which we had all years of data, found similar trends, suggesting that missing data did not alter overall trends.
Second, we did not collect charge data on second-trimester abortions for 2019, and because we used only charges that were published on facility websites for the other years (2017, 2018, and 2020), fewer than half of facilities were represented. We have no reason to believe that facilities that did not publish their prices on their websites would be systematically different from those that did. Finally, the costs of second-trimester abortion vary greatly depending on the gestation of the pregnancy. In this study we estimated a mean charge from a wide range of prices that were listed on a single facility’s website. This made it harder to generalize the charges reported here to patients’ actual charges. Nevertheless, we are able to report median second-trimester prices and identify trends by region.
Study Results
We identified between 751 and 776 publicly advertising abortion facilities in the US: 776 in 2017, 751 in 2018, 751 in 2019, and 760 in 2020. Consistent with our previous analysis of the 2017 data,3 the distribution of abortion facilities was not uniform across states. The largest numbers of facilities were in the West and Northeast (online appendix exhibit A1).22 Between 2017 and 2020 the Northeast and South saw a decrease in the number of open facilities (by fifteen and nineteen, respectively), whereas the Midwest and West saw an increase (by four and fourteen, respectively).
For all three abortion types, median self-pay charges varied by region, with higher median charges in regions with higher costs of living. In addition, median self-pay charges for abortion increased over time (exhibit 1).
Exhibit 1 Sample variability for self-pay charges for abortion in the US, by type of abortion, 2017–20
SOURCE Advancing New Standards in Reproductive Health’s Abortion Facility Database. NOTES The exhibit shows box and whisker plots of the distribution of self-pay charges for US facilities by year for each abortion type. Each plot shows the interquartile range (the boundaries of the box), the median (line within the box), 1.5 times the interquartile range (“whiskers”), and outliers (dots).
Exhibit 2 presents self-pay charge data for the three types of abortions in open facilities that offered abortion in 2017–20. For medication abortion, the median self-pay price significantly increased from $495 in 2017 to $560 in 2020. This was an absolute increase of 13 percent, which was more than would be expected as a result of health care inflation alone (8 percent). The median price for medication abortion in 2020 varied greatly by region, with the lowest being $490 in the South Atlantic and the highest being $730 in the West North Central region. Median charges increased in most regions between 2017 and 2020.
Exhibit 2 Median abortion self-pay charges in the US, by type of abortion, total and by census region, 2017–20
MedicationFirst-trimester proceduralSecond-trimester abortion20172018201920202017201820192020201720182020Total facilities providing service737714729735539529513494356357323Facilities representeda (%)3439979840459497242847Median abortion self-pay charge (US dollars)Total495500560560***475495559575***935960895Total with inflation adjustmentb4955055285374754855065159359541,014Census region Northeast495495534500**450456535512**802852768 New England619619650555657619650700852877828 Middle Atlantic450450500500***425425490500***540540725 Midwest475480535550***475495540625***710725820 East North Central468475500525***462469500545***695695745 West North Central650650720730*6506507307551,1881,2121,065 South450475520520***400450502550***828800900 South Atlantic415445475490***400400450492***778805750 East South Central588550600600650600600650800750900 West South Central556590650650***550578650688***950850938 West575575650650***500500664700***1,6751,5251,170 Mountain465490520540***465465560600***7381,2751,500* Pacific575575659680***500500700700***1,6751,6751,026
For first-trimester procedural abortion, median charges also significantly increased nationally over time, from $475 to $575 between 2017 and 2020 (exhibit 2). This was an absolute increase of 21 percent compared with an expected 8 percent increase based on health care inflation rates. Median price for first-trimester procedural abortion varied greatly by region in 2020, with the lowest being $492 in the South Atlantic and the highest being $755 in the West North Central region.
For second-trimester abortion, we obtained charge data for 24 percent of open facilities that offered second-trimester abortion in 2017, 28 percent in 2018, and 47 percent in 2020 (exhibit 2). In contrast to first-trimester procedural abortion prices, median second-trimester abortion charges decreased from $935 in 2017 to $895 in 2020, (p>0.05). This was an absolute drop of −4 percent compared with an expected 8 percent increase. Overall, as shown in the boxplots (exhibit 1), there was much greater variation in charges for second-trimester abortion than for medication abortion or first-trimester procedural abortion. For all three abortion types, median cost was significantly different among geographic subregions in 2020 (p<0.001 for all abortion types). Median costs for all fifty US states are listed in appendix exhibit A2.22
When we restricted our data set to include only facilities for which we had all four years of cost data (appendix exhibit A3),22 we still found a statistically significant increase in national median medication and first-trimester procedural abortion charges (p<0.001 for both). In addition, we saw similar increases in charges in regions; however, fewer of those increases were statistically significant. This could be due to the lower sample size when we restricted data to facilities with complete data. Among those 193 facilities for which we had all four years of medication abortion cost data, we found a 10 percent increase in absolute median charges, and 60 percent increased their medication abortion price between 2017 and 2020—a mean (median) of $52 ($31). Among the 151 facilities for which we had all four years of first-trimester procedural abortion data, there was a 16 percent increase in absolute charges, and 68 percent increased their first-trimester procedural abortion price between 2017 and 2020—a mean (median) of $110 ($50). Among the fifty-four facilities for which we had all four years of second-trimester abortion data, we found a 9 percent increase in absolute charges, and 65 percent increased their second-trimester abortion price between 2017 and 2020—a mean (median) of $35 ($50) (appendix exhibit A3).22
The percentage of open abortion facilities that accepted any type of insurance during 2017–20 varied widely by geographic region and year (exhibit 3). Nationally, there was a decline in the proportion of facilities that accepted any insurance, from 89 percent in 2017 to 80 percent in 2019, which was sustained in 2020. Declines were observed in all US regions. Although the South had the lowest proportion of facilities that accepted any insurance in each year, the Midwest saw the largest decline, from 88 percent in 2017 to 75 percent in 2020 (exhibits 3 and 4). When we restricted our data set to only facilities for which we had insurance data for all four years, we found a similar trend of a decline in insurance acceptance between 2017 and 2020 (appendix exhibit A4).21
Exhibit 3 Number and percent of abortion facilities in the US that accepted any insurance, total and by census region, 2017–20
2017201820192020No.%No.%No.%No.%Total facilities providing the service776—a751—a751—a760—aFacilities representedb—a92—a91—a97—a98Accepting any insuranceTotal63489606885918060180Census region Northeast20899197991889018688 New England551005410049744370 Middle Atlantic15398143991399814395 Midwest7388718869747075 East North Central5385518552735475 West North Central2095209517771676 South12171111691075910361 South Atlantic9975907388668567 East South Central10711071862754 West South Central1250114811331135 West23293227932278924289 Mountain3771377134653967 Pacific19598190981939620395
Exhibit 4 Percent of abortion facilities in the US that accepted any type of insurance, by census region, 2017–20
SOURCE Advancing New Standards in Reproductive Health’s Abortion Facility Database.
Discussion
This analysis fills a gap in offering recent, comprehensive, national, regional, and state-level data on abortion charges. We found that median self-pay charges for abortion varied by region and increased over time. Patient costs were generally higher in the Northeast and West than in the South and Midwest, which is consistent with differences in the cost of living. The self-pay price set by abortion-providing facilities is influenced by many factors, including the ability to rely on advanced practice clinicians for provision of care; costs of workforce salaries, rent, equipment, and liability insurance; amount of security measures required; and mandated construction resulting from state restrictions, and these costs will vary based on geographic location.23,24 As abortion provision becomes more regulated, often without any evidence that these regulations improve care,25 patient charges may continue to increase. Increased health care costs and staffing shortages in the context of COVID-19 may also have led to an increase in patient charges in 2020.26
We also found a decline in the proportion of facilities that accepted any insurance between 2017 and 2020. This finding may be due to increasing state-level policies prohibiting insurance coverage of abortion. However, few states passed laws restricting insurance use for abortion in this period. For the states that allow Medicaid coverage of abortion, this decline may be explained by the fact that state Medicaid reimbursement rates are extremely low and might not adequately cover a facility’s costs of providing abortion.27,28 With 75 percent of abortion patients living on low incomes and relying on Medicaid, accepting Medicaid causes financial challenges for facilities. In one study exploring insurance acceptance policies of abortion clinics, providers reported having to discontinue accepting Medicaid. Others reported that they had to increase the self-pay charges to offset those low reimbursements.24 Other studies found that some facilities were unable to remain open when reimbursement rates were too low.27,28 As administrative costs for facilities increase, it becomes less feasible for facilities to survive on low insurance reimbursement rates. It is critical that insurance plans evaluate their reimbursement rates and pay providers an amount that is commensurate with their actual costs of providing abortion care.
In addition, previous research suggests that facilities in states where Medicaid does not cover abortion are significantly less likely to accept any insurance for abortion.29 Again, given that a majority of abortion patients are low income, it may be impractical for facilities in non-Medicaid-coverage states to develop the administrative billing systems to charge private insurance for a small proportion of patients who have private insurance and opt to use it. In addition, facilities have reported that the largest difficulty in accepting private insurance was determining whether insurers would actually pay for the abortion care their clients received.24 Thus, there are multiple barriers for facilities, particularly those that specialize in abortion care, in accepting private insurance.
In the most recent year of our data, 2020, median costs were $560 for a medication abortion, $575 for a first-trimester procedural abortion, and $895 for a second-trimester abortion. These prices were higher than previously reported national estimates from 2014 and 2017.19,30 According to the Federal Reserve, only 76 percent of US adults would be able to cover a $400 emergency expense using just the money in their checking or savings accounts in 2019, meaning that one-quarter of people could not afford to pay for an abortion of any type at current median prices.31 For patients, these self-pay charges represent a substantial expense, particularly given that nationally, three-quarters of abortion patients are poor or low income and the majority have one or more children.9 In addition, patients almost always incur additional expenses beyond paying for the abortion itself, including for travel, child care, and time off work. A previous study found that most patients incurred ancillary expenses in the form of transportation (mean, $44), and a minority also reported lost wages (mean, $198), child care expenses (mean, $57), and other travel-related costs (mean, $140).11
Given the ever-increasing costs of abortion care, restoring federal Medicaid coverage of abortion by lifting Hyde restrictions or passing federal legislation such as the Equal Access to Abortion Coverage in Health Insurance (EACH) Act would remove this often-insurmountable barrier to abortion care for low-income people regardless of the state they live in. In addition, efforts are needed to ensure that reimbursement rates are reasonable so that abortion care services are sustainable. Previous research has shown that people who are economically disadvantaged are most likely to report financial and policy barriers to abortion care.32 In addition, research has found that living in a state that does not allow Medicaid coverage for abortion was associated with prolonged abortion seeking.15 Most recently, the COVID-19 pandemic and its subsequent economic devastation further highlights the perils of self-pay for abortion care. Many people in the US lost their employer-based insurance during the pandemic,1,33 which forced even more people to pay for abortion care out of pocket, whether they were uninsured or became eligible for Medicaid.
Black and Hispanic people, in particular, are most affected by Hyde restrictions, as they are disproportionately insured by the Medicaid program. In 2019 Medicaid was the source of payment for 65 percent of births among non-Hispanic Black women, 59 percent of births among Hispanic women, and 29 percent among non-Hispanic White women.34 The Hyde restrictions limit affordable abortion to those with economic resources, and repealing it is crucial for racial and economic justice.35
History shows that when abortion care is restricted, it is Black and Hispanic people who have the greatest challenges obtaining care.
History shows that when abortion care is restricted, it is Black and Hispanic people who have the greatest challenges obtaining care. Before the Roe v. Wade decision in 1973, making abortion legal throughout the country, middle-class White women in some states were able to secure a legal abortion or travel out of the country. They also were able to persuade trained physicians to provide an abortion clandestinely. Although some Black women had access to trained physicians and midwives, poor Black women had fewer safe or legal options. In New York City in the 1960s, 80 percent of deaths caused by illegal abortions involved Black and Puerto Rican women.36 The presence of restrictions on the use of insurance perpetuates economic and racial health care disparities.
Conclusion
An improved understanding of what patients must actually pay for an abortion is a crucial first step toward reducing financial barriers to abortion and helping ensure that public and private insurance coverage policies are informed by data. This study reports trends in national self-pay charges of three different types of abortion by region for the period 2017–20. It also finds that the proportion of facilities that accept any insurance declined during the four years of observation. To prevent this trend from continuing, public and private insurance reimbursement rates must be increased to reflect actual facility costs. It is vital that reimbursement be sufficiently high that facilities are more willing to accept insurance. In addition, expanding public insurance coverage of abortion in more states would direct public funds to the most economically vulnerable and could serve to reduce financial burdens and increase access to abortion care.
ACKNOWLEDGMENTS
This article was presented at the Virtual Annual Meeting of the National Abortion Federation, May 12, 2021. This research was supported through an Advancing New Standards in Reproductive Health (ANSIRH) Core Grant (to Ushma Upadhyay). The authors thank their summer interns, who helped update the University of California San Francisco/ANSIRH Abortion Facility Database over the years: Alejandra Vargas Johnson, Lauren Sobel, Mihiri Karunaratne, Mahima Krishnamoorthi, Yuki Davis, Atreyi Mitra, Salma Tayel, and Subeksha Sharma. The authors also appreciate helpful review comments from Katrina Kimport and editing from Rosalyn Schroeder.
NOTES
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