In September 1977, a 27-year-old woman named
Rosie Jimenez died from an illegal abortion in McAllen, Texas. Her insurance,
Medicaid, no longer reimbursed abortions and she didn’t have the money to pay
for a legal the procedure out of pocket. Bereft of options, the student and
single mother visited a local midwife who performed a “back alley” abortion at
a fraction of the price. A few days later, Jimenez began hemorrhaging and
vomiting due to a bacterial infection in her uterus. After seven days in intensive
care at McAllen General Hospital, she died from organ failure and became known
as “first victim of the Hyde Amendment.”
Two months before Jimenez’s death, a law that barred federal money from paying for abortion services through Medicaid went into effect. “I certainly would like to prevent, if I could legally, anybody having an abortion, a rich woman, a middle-class woman, or a poor woman,” said the bill’s author, Henry Hyde of Illinois. “Unfortunately, the only vehicle available is the … Medicaid bill.”
Jimenez’s story illustrates the impact of laws that restrict insurance coverage of abortion. Forty-one years after the passage of the Hyde Amendment, insurance coverage, public and private, remains a key battleground in the fight over abortion rights. Last month, Texas and Oregon passed laws that banned private insurance coverage for abortion and required it, respectively. The diametric opposition of these laws, signed on the same day, threw into sharp relief the role that insurance coverage plays in ensuring affordability and accessibility of abortion care for all women, not just the privileged.
On August 15, Texas Governor Greg Abbott signed HB 214 into law, banning most insurance plans in the state from covering abortion, unless a woman’s life is in danger. Dubbed “Pro-Life Insurance Reform,” the measure means that private insurance plans, whether purchased through the Affordable Care Act exchange or provided through an employer, cannot cover abortion services. Regardless of insurance, Texan women have to cover the costs of abortion care out-of-pocket.
Two thousand miles away in Oregon, Governor Kate Brown signed the Reproductive Health Equity Act, which advocates are calling “the nation’s most progressive reproductive health policy.” Among other provisions, RHEA requires insurance companies to cover abortion care, as well as birth control, without charging a copay.
“For anyone who even dips their toe into this work, you soon realize that insurance coverage, or lack of coverage, is one of the biggest determining factors in whether or not someone can get an abortion,” said Katherine McGuiness, the Board President of the Network for Reproductive Options, or NRO, an abortion fund that serves Oregon and Idaho.
Abortions are expensive, which is why insurance coverage for abortion care is critical to making it accessible. The average out-of-pocket cost for abortions before ten weeks ranges from $300-$800, while second trimester procedures can cost thousands of dollars. And those costs don’t include related expenses that a woman will accumulate while getting an abortion, such as travel, accommodation, lost work time, and child-care.
While the Hyde Amendment targets low-income women through the Medicaid program, coverage bans on private insurance impact anyone with limited resources. A middle income person who lives paycheck-to-paycheck, is saddled with student loan debt, has family members to support, or recently faced an unforeseen expense may also find $500 unattainable. Given that more than half of Americans have less than $1,000 in their savings accounts (including thirty-four percent with no savings at all), these restrictions affect a large swath of women and can force them to make untenable choices. In a study conducted by Advancing New Standards in Reproductive Health (ANSIRH) at the University of California, San Francisco, half of abortion patients said they spent more than one-third of their monthly income to cover the costs associated with their abortion, potentially foregoing rent, utilities, or even food.
Elizabeth Nash, Senior State Issues Manager at The Guttmacher
Institute, said that in the 1990s, “nobody” covered contraception or
abortion, but after a series of advocacy campaigns, private insurers began
covering these services without much pomp. “Up until the early 2000s, abortion coverage was
typical,” she said. “It was a normal part of the package of services that were
Then came the furious debate around the Affordable Care Act, which devolved into a furious debate about abortion. One of the concessions made to get the ACA through was that states had the option to limit abortion coverage in plans offered through the exchanges, and 25 states have taken advantage of that offer. This laid the groundwork for more types of insurance restrictions. With Texas, 11 states now have private insurance coverage bans on the books. Many insurers in Texas already fail to cover abortion, so while the ban has a whiff of political theater, it’s also a deliberate attempt to choke off access to care.
One of the arguments used to justify the ban on federal funding for abortion is that taxpayers should not be “forced” to pay for something they are religiously or morally opposed to. Similarly, Governor Abbot’s argument for the Texas ban on private insurance coverage is that “no Texan is ever required to pay for a procedure that ends the life of an unborn child.” Except that’s not how taxes—or insurance—work. People don’t pick and choose where their money goes. Someone who opposes war still pays taxes that fund the military. A Jehovah’s Witness who believes it’s a sin to receive a blood transfusion still pays insurance premiums into a pool that pays for someone else’s transfusion.“I find puzzling the conversation about taxpayers paying for people’s abortions, as if people who have abortions aren’t taxpayers and shouldn’t also be able to have the taxes they pay go to supporting their healthcare like everybody else,” said Yamani Hernandez, the Executive Director of the National Network for Abortion Funds.
An aspect of the Texas law that attracted particular attention was that it necessitated the purchase of what was called “rape insurance.” In theory, the law allows women to buy supplemental insurance for abortion care, also known as “riders.” Since the insurance ban does not include exceptions for rape or incest, that means a woman who was raped and got pregnant would not have insurance coverage for an abortion unless, in advance of getting raped, she had bought a rider. Hence “rape insurance.”
But the rider system also means that anyone who wanted their insurance to cover abortion would have to anticipate that need in advance, which again, makes no sense. Unplanned pregnancies are, by definition, unplanned. There are countless reasons why unplanned pregnancies occur and why women choose to have abortions, but a healthcare system in which quality coverage depends on omniscience seems unreasonable. The whole point of insurance is to protect against unforeseen risk.
Furthermore, just because states permit
insurance companies to offer riders does not mean they actually do. According to a National Women’s Law Center (NWLC) survey,
there is no evidence that supplemental coverage is available in the seven
states where lawmakers have allowed it as an option. As a patchwork of
regulations across states makes abortion coverage more costly and complicated,
disincentives to offer this coverage are mounting for insurers nationwide.
The Reproductive Health Equity Act in Oregon aims to prevent this from happening. By requiring insurers to cover abortion, the state set the standard that abortion is healthcare and insurers have to cover it accordingly. In addition, creating a standard for coverage means Oregon women will definitively know they can use their insurance for abortion. Fifty-three percent of women pay out-of-pocket for abortion, even if they have insurance coverage, and this is often due to uncertainty.
“Many women with private insurance plans fail to use their coverage for reasons including because they assume abortion is not a covered service and because they were given incorrect information regarding their plan’s policies on covering abortions,” wrote Katrina Kimport and Brenly Rowland, two researchers from the University of California, San Francisco, in a study released in late August.
The opacity, complexity, and volatility of policies surrounding insurance coverage and abortion care don’t just cause financial problems for patients, but also for clinics. Independent abortion care providers perform sixty percent of abortions in the U.S., but they are rapidly disappearing. According to the Abortion Care Network (ACN), which tracks clinic closures, the number of independent providers has plummeted by nearly thirty percent in the past five years. Many such clinics have subsidy programs to keep costs low for their patients, and coverage bans will take an additional toll on their solvency. If the trend continues, more clinic doors will close. The fewer clinics there are, the farther women have to travel to get care and the more the costs stack up. If abortion is unaffordable for the vast majority of American women, it’s a right in theory, not in practice.