Abortion as a Catastrophic Health Expenditure in the United States

Financial, Social, and Demographic Factors Associated With Obtaining an Abortion: A Longitudinal Study in Indiana in 2021-2022

OBJECTIVES

We aimed to 1) characterize those who did and did not obtain an abortion and reasons why, and 2) evaluate the association between various facilitators, including financial and social support, and accessing an abortion.

METHODS

Between June 2021 and April 2022, we recruited pregnant Indiana residents considering abortion through online posts, abortion funds, and abortion clinics. Respondents completed an online baseline survey and a follow-up survey 1 month later. Surveys collected information on sociodemographic characteristics, barriers and facilitators to abortion, and pregnancy outcome.

RESULTS

Among 221 participants, 77% obtained an abortion within 1 month. Among online and abortion fund recruits, those who identified as Black or African American or Hispanic/Latinx and those without insurance were less likely to have had an abortion than were white and insured participants. Financial support from abortion funds and clinics and social support from peer networks were associated with higher odds of accessing abortion care 1 month later. Among participants still seeking abortion at 1 month or who had given birth, 64% reported that needing to gather money to pay for the abortion or travel expenses/lodging was a barrier to care. Among those who were no longer considering abortion at 1 month and planned to continue their pregnancy, 28% reported doing so because they did not have the money for an abortion.

CONCLUSIONS

In a restrictive state policy environment, receipt of financial and social support was associated with greater likelihood of obtaining abortion within a month of reporting considering or seeking it among a sample of pregnant people in Indiana.

Changes in abortion access after implementation of Medicaid coverage in Illinois: a retrospective analysis

ABSTRACT

Introduction

In 2018, Illinois implemented House Bill 40 (HB-40), allowing state funds to provide Medicaid coverage for abortion. This study aimed to quantitatively measure changes in access among Illinois residents after the law's implementation, with a focus on changes experienced by Medicaid versus non-Medicaid patients.

Methods

We conducted a retrospective analysis using 67 462 abortion visits across 18 health centres comparing service delivery patterns 1 year before and 3 years after HB-40 implementation. We used a t-test and difference-in-differences regression to assess the policy's effect on mean gestational age at the time of abortion among Medicaid patients and non-Medicaid patients. We used χ2 tests to capture differences in insurance type used for payment, as well as differences between Medicaid and non-Medicaid patients in presenting at ≤11 weeks gestation, abortion method provided and time between scheduling and getting an abortion.

Results

From 2017 to 2020, the overall volume of abortions increased by 27% and the share of abortions paid for with Medicaid increased from 15% to 49%. Compared with non-Medicaid patients, Medicaid patients experienced a significant decrease in average gestational age at the time of abortion post-HB-40 (incidence rate ratio (IRR)=0.93, 95% CI 0.91 to 0.95, p<0.001). The proportion of Medicaid patients ≤11 weeks gestation increased post-HB-40 (76% to 83%; p<0.001) but did not change among non-Medicaid patients (89% to 90%; p=0.62). By 2020, the 13%-point gap that existed between the two groups in 2017 (76% and 89%) was reduced to 4 (86% and 90%). The proportion of medication abortions increased substantially for Medicaid patients post-HB-40 (27% to 46%; p<0.001) and increased slightly for non-Medicaid patients (51% to 53%; p=0.001), resulting in decreased gaps in medication abortions received between the two groups.

Conclusion

Medicaid coverage of abortion reduced insurance-related disparities for Medicaid patients, as shown by decreased gaps in average gestational age among Medicaid and non-Medicaid patients. It was also associated with increased medication abortions among Medicaid patients.

Catastrophic Health Expenditures for In-State and Out-of-State Abortion Care

Importance

Most US individuals who access abortion care pay out of pocket due to insurance coverage restrictions on abortion. More research is needed on the financial and psychological burdens of abortion seeking, particularly for those traveling across state lines for care.

Objectives

To estimate the proportion of patients seeking abortion who incur abortion-related catastrophic health expenditures (CHEs), assess whether CHE differs between those seeking care in state vs out of state, and examine the association of CHE with mental health symptoms.

Design, Setting, and Participants

In this cross-sectional study conducted before the Dobbs v Jackson Women's Health Organization decision, surveys were administered between January and June 2019 among individuals aged 15 to 45 years seeking abortion in 4 clinics located in abortion-supportive states (California, Illinois, and New Mexico). Participants completed self-administered questionnaires while awaiting their abortion appointment. Analyses were conducted from November 2023 to April 2024.

Exposure

Travel for abortion care, categorized as either out of state or in state based on participants' state of residence and the clinic location.

Main Outcomes and Measures

Self-reported abortion care costs and additional non-health care costs (eg, transportation, accommodation, and missed work), which were considered catastrophic if they were 40% or greater of participants' ability to pay (defined as monthly income remaining after meeting subsistence needs). Multivariable regression analyses were conducted to examine associations between CHE, out-of-state travel for abortion care, and mental health symptoms including stress, anxiety, and depression.

Results

Among the 675 participants included in the analytic sample, mean (SD) age was 27.33 (6.27) years; most were in their 20s (374 [55%]), and all but 196 (29%) sought abortion before or at 12 weeks' gestation. A total of 285 participants (42%) were estimated to incur abortion-related CHEs, which was associated with anxiety (APR, 1.13; 95% CI, 1.07-1.19) and depression (APR, 1.25; 95% CI, 1.12-1.39). Of people traveling from out of state (212 [31%]), more were likely to incur CHEs (138 [65%]) compared with those seeking care in state (147 of 463 [32%]) (APR, 2.24; 95% CI, 1.67-3.00).

Conclusions and Relevance

In this cross-sectional study of US patients seeking abortion, many individuals and their households were estimated to incur CHEs, particularly those traveling from out of state. The financial and psychological burdens of abortion seeking have likely worsened after the Dobbs decision, as more people need to cross state lines to reach abortion care. The findings suggest expansion of insurance coverage to ensure equitable access to abortion care, irrespective of people's state of residence, is needed.

Lifetime abortion incidence when abortion care is covered by Medicaid: Maryland versus five comparison states

OBJECTIVE

To estimate the association of Medicaid coverage of abortion care with cumulative lifetime abortion incidence among women insured by Medicaid.

DATA SOURCES AND STUDY SETTING

We use 2016-2019 (Pre-Dobbs) data from the Survey of Women studies that represent women aged 18-44 living in six U.S. states. One state, Maryland, has a Medicaid program that has long covered the cost of abortion care. The other five states, Alabama, Delaware, Iowa, Ohio, and South Carolina, have Medicaid programs that do not cover the cost of abortion care. Our sample includes 8972 women residing in the study states.

STUDY DESIGN

Our outcome, cumulative lifetime abortion incidence, is identified using an indirect survey method, the double list experiment. We use a multivariate regression of cumulative lifetime abortion on variables including whether women were Medicaid-insured and whether they were residing in Maryland versus in one of the other five states.

DATA COLLECTION/EXTRACTION METHODS

This study used secondary survey data.

PRINCIPAL FINDINGS

We estimate that Medicaid coverage of abortion care in Maryland is associated with a 37.0 percentage-point (95% CI: 12.3-61.4) higher cumulative lifetime abortion incidence among Medicaid-insured women relative to women not insured by Medicaid compared with those differences by insurance status in states whose Medicaid programs do not cover the cost of abortion care.

CONCLUSIONS

We found that Medicaid coverage of abortion care is associated with a much higher lifetime incidence of abortion among individuals insured by Medicaid. We infer that Medicaid coverage of abortion care costs may have a very large impact on the accessibility of abortion care for low-income women.

Seeking financial and practical support in an abortion-hostile state: Analysis of abortion fund data in Kentucky, 2014-2021: Analysis of abortion fund data in Kentucky

OBJECTIVES

Philanthropic abortion funds are integral to accessing care in the United States, providing both financial and practical assistance. Yet relatively little is known about those who seek these essential services. In this study, we analyzed data from a Kentucky abortion fund to assess characteristics of abortion fund callers.

METHODS

We analyzed 2014-2021 administrative data from the Kentucky Health Justice Network's (KHJN) Abortion Support Fund and compared them to abortion data from the Kentucky Department for Public Health (KDPH). We analyzed age, race, and pregnancy gestation at calling (KHJN) and abortion (KDPH), and calculated Z-scores and p-values to compare proportions in each category between the two data sources.

RESULTS

The fund supported 6162 people from 2014 to 2021, when 28,741 people had abortions in Kentucky. Compared with KDPH data, KHJN had a higher percentage of callers who were under age 30, a higher percentage of callers who were Black or another race, and a higher percentage of callers at 14 weeks' gestation or higher.

CONCLUSIONS

Compared with state data, KHJN supported a higher percentage of young people, people of color, and people at later gestations. These findings support evidence that structurally vulnerable groups are more likely to face barriers to care and that abortion funds provide essential support necessary for reproductive equity.

Making sense of the economics of abortion in the United States

In 2023 the editors of Perspectives on Sexual and Reproductive Health issued a special call for papers related to the economics of abortion. Ten of those submissions are included in this volume and address critical issues including: (1) the role Medicaid continues to play in abortion access and how changes in state Medicaid coverage of abortion have expanded and restricted abortion care use; (2) how low-income individuals without insurance coverage for abortion utilize resources from abortion funds and through crowdsourcing platforms; (3) how the price of medication abortion has decreased with the availability of telemedicine medication abortion and how providers of that service are making efforts to reduce those prices even further; and (4) how legally restricting abortion access has significant economic implications for state economies and the US society as a whole. In this introduction, I review the general scope of prior research on the economics of abortion in the US as it relates to stigma-induced silences, abortion seekers, abortion providers, and abortion assistance organizations. I then highlight the new contributions made by the articles contained in this special issue.

Abortion assistance fund staff and volunteers as patient navigators following an abortion ban in Texas

CONTEXT

Abortion assistance funds constitute an important part of the healthcare safety net by covering some of abortion patients' out-of-pocket costs. Few studies have examined the other ways abortion assistance fund staff and volunteers support callers who need help obtaining care.

METHODS

Between June and September 2020, we conducted in-depth interviews with 23 staff and volunteers at 11 local abortion assistance funds that helped Texans seeking abortion care following a March 2020 state executive order that prohibited most abortions. Interviewers explored respondents' experiences with callers whose appointments had been canceled or who traveled out of state and subsequent operational changes. We used both inductive and deductive codes in the thematic analysis.

RESULTS

Abortion assistance fund staff and volunteers bridged callers' information gaps about the services and financial resources available and helped create plans to secure care that accounted for callers' specific needs. They provided emotional support so callers felt it was possible to overcome logistical hurdles to get an abortion, even if that required out-of-state travel. Respondents described greater collaboration between Texas-based abortion assistance funds and out-of-state organizations to support callers' more complex logistical needs and increased costs. Some callers who encountered multiple barriers to care, including interpersonal violence, were unable to obtain an abortion, even with additional supports.

CONCLUSIONS

Local abortion assistance funds worked with Texas callers to co-create person-centered plans for care and expanded inter-organization collaborations. Initiatives that bolster local assistance funds' infrastructure and capacity will be needed as the abortion access landscape becomes further restricted and complex.

Patient experiences using public and private insurance coverage for abortion in Illinois: Implementation successes and remaining gaps

CONTEXT

Insurance coverage for abortion in states where care remains legal can alleviate financial burdens for patients and increase access. Recent policy changes in Illinois required Medicaid and some private insurance plans to cover abortion care. This study explores policy implementation from the perspectives of patients using their insurance to obtain early abortion care.

METHODOLOGY

Between July 2021 and February 2022, we interviewed Illinois residents who recently sought abortion care at ≤11 weeks of pregnancy. We also interviewed nine key informants with experience providing or billing for abortion or supporting insurance policy implementation in Illinois. We coded interview transcripts in Dedoose and developed code summaries to identify salient themes across interviews.

RESULTS

Most participants insured by Illinois Medicaid or eligible for enrollment received full coverage for their abortions; most with private insurance did not and faced challenges learning about coverage status. Some opted not to use insurance, often citing privacy concerns. Participants who benefited from abortion coverage expressed relief, gave examples of other financial challenges they could prioritize, and described feeling in control of their abortion experience. Those without coverage described feeling stressed, uncertain, and constrained in their decision-making.

CONCLUSION

When abortion was fully covered by insurance, it reduced financial burdens and enhanced reproductive autonomy. Illinois Medicaid policy-with seamless enrollment options and appropriate reimbursement rates-offers a model for improving abortion access in other states. Further investigation is needed to determine compliance among private insurance companies and increase transparency.

What attributes of abortion care affect people's decision-making? Results from a discrete choice experiment

OBJECTIVES

We aimed to measure both stated and experimentally "revealed" abortion provision preferences among US people with capacity for pregnancy.

STUDY DESIGN

In July 2022, we recruited US residents assigned female sex at birth and aged 18 to 55 years using Prolific, an online survey hosting platform. We asked participants what first-trimester abortion method and delivery model they would prefer. We also assessed abortion care preferences with a discrete choice experiment, which examined the relative importance of the following care attributes: method, distance, wait time for appointment, delivery model (telehealth vs in-clinic), and cost.

RESULTS

More than half of the 887 respondents (59%) self-reported a slight (22%) or strong (37%) preference for medication compared to aspiration abortion; 11% stated no preference. Our discrete choice experiment found that cost and wait time had a greater effect on hypothetical decision-making than did method and delivery model (discrete choice experiment average importances = 44.3 and 23.2, respectively, compared to 15.9 and 8.2, respectively). Simulations indicated that holding other attributes constant, respondents preferred medication to aspiration abortion and telehealth to in-clinic care.

CONCLUSIONS

This study, the first to examine abortion preferences in the United States, using a discrete choice experiment, demonstrates the importance of wait time and cost in abortion care decision-making. Our work indicates that for this population, factors related to health care financing and organization may matter more than clinical aspects of care.

IMPLICATIONS

Although people in this study preferred medication to aspiration abortion and telehealth to in-clinic care, wait time and cost of care played a greater role in care decision-making. Focusing solely on clinical aspects of care (i.e., method, delivery model) may ignore other attributes of care that are particularly important for potential patients.

Protect and Control: Coverture's Logics Across Welfare Policy and Abortion Law

In the aftermath of Dobbs v. Jackson Women's Health Organization, which overturned the federal constitutional right to abortion, states have begun to recriminalize the procedure. These abortion bans raise important questions about the political and social status of women and pregnant people in the United States. Moreover, restrictions in social welfare programs such as the Special Supplemental Nutrition Assistance Program for Women, Infants, and Children and Temporary Assistance for Needy Families, which serve low-income pregnant people and parents, raise similar questions. The regulation and administration of all three are framed by race, class, and gender. To understand how these restrictions (a) claim to protect women but ultimately function to control, police, and surveil and (b) rely on imagined, stereotype-laden psychological states such as vulnerability, irresponsibility, or irrationality, we turn to the British Common Law doctrine of coverture, which subsumed a married woman's legal, financial, and political identities under her husband's. The American colonies, and later, states of the United States, drew from British Common Law to craft laws that regulated relationships between men and women. Taken together, this analysis can provide a more comprehensive accounting of the cumulative harms experienced by women, poor people, people of color, and pregnant people in today's health and social welfare landscape. We conclude with recommendations for psychologists and other mental health providers to address, in practice and advocacy, the ethical dilemmas and obligations raised by the reach of coverture's logics in people's lives.

The Role of Telehealth in Promoting Equitable Abortion Access in the United States: Spatial Analysis

BACKGROUND

Even preceding the Supreme Court's 2022 Dobbs v. Jackson Women's Health Organization decision, patients in the United States faced exceptional barriers to reach abortion providers. Abortion restrictions disproportionately limited abortion access among people of color, young people, and those living on low incomes. Presently, clinics in states where abortion remains legal are experiencing an influx of out-of-state patients and wait times for in-person appointments are increasing. Direct-to-patient telehealth for abortion care has expanded since its introduction in the United States in 2020. However, the role of this telehealth model in addressing geographic barriers to and inequities in abortion access remains unclear.

OBJECTIVE

We sought to examine the amount of travel that patients averted by using telehealth for abortion care, and the role of telehealth in mitigating inequities in abortion access by race or ethnicity, age, pregnancy duration, socioeconomic status, rural residence, and distance to a facility.

METHODS

We used geospatial analyses and data from patients in the California Home Abortion by Telehealth Study, residing in 31 states and Washington DC, who obtained telehealth abortion care at 1 of 3 virtual abortion clinics. We used patients' residential ZIP code data and data from US abortion facility locations to document the round-trip driving distance in miles, driving time, and public transit time to the nearest abortion facility that patients averted by using telehealth abortion services from April 2021 to January 2022, before the Dobbs decision. We used binomial regression to assess whether patients reported that telehealth was more likely to make it possible to access a timely abortion among patients of color, those experiencing food insecurity, younger patients, those with longer pregnancy durations, rural patients, and those residing further from their closest abortion facility.

RESULTS

The 6027 patients averted a median of 10 (IQR 5-26) miles and 25 (IQR 14-46) minutes of round-trip driving, and 1 hour 25 minutes (IQR 46 minutes to 2 hours 30 minutes) of round-trip public transit time. Among a subsample of 1586 patients surveyed, 43% (n=683) reported that telehealth made it possible to obtain timely abortion care. Telehealth was most likely to make it possible to have a timely abortion for younger patients (prevalence ratio [PR] 1.4, 95% CI 1.2-1.6) for patients younger than 25 years of age compared to those 35 years of age or older), rural patients (PR 1.4, 95% CI 1.2-1.6), those experiencing food insecurity (PR 1.3, 95% CI 1.1-1.4), and those who averted over 100 miles of driving to their closest abortion facility (PR 1.6, 95% CI 1.3-1.9).

CONCLUSIONS

These findings support the role of telehealth in reducing abortion-related travel barriers in states where abortion remains legal, especially among patient populations who already face structural barriers to abortion care. Restrictions on telehealth abortion threaten health equity.

Anesthetic Considerations for Second-Trimester Surgical Abortions

Although most abortion care takes place in the office setting, anesthesiologists are often asked to provide anesthesia for the 1% of abortions that take place later, in the second trimester. Changes in federal and state regulations surrounding abortion services may result in an increase in second-trimester abortions due to barriers to accessing care. The need for interstate travel will reduce access and delay care for everyone, given limited appointment capacity in states that continue to support bodily autonomy. Therefore, anesthesiologists may be increasingly involved in care for these patients. There are multiple, unique anesthetic considerations to provide safe and compassionate care to patients undergoing second-trimester abortion. First, a multiday cervical preparation involving cervical osmotic dilators and pharmacologic agents results in a time-sensitive, nonelective procedure, which should not be delayed or canceled due to risk of fetal expulsion in the preoperative area. In addition, a growing body of literature suggests that the older anesthesia dogma that all pregnant patients require rapid-sequence induction and an endotracheal tube can be abandoned, and that deep sedation without intubation is safe and often preferable for this patient population through 24 weeks of gestation. Finally, concomitant substance use disorders, preoperative pain from cervical preparation, and intraoperative management of uterine atony in a uterus that does not yet have mature oxytocin receptors require additional consideration.

Catastrophic Health Care Expenditure Following Brachial Plexus Injury

PURPOSE

Brachial plexus injuries (BPIs) are devastating to patients not only functionally but also financially. Like patients experiencing other traumatic injuries and unexpected medical events, patients with BPIs are at risk of catastrophic health expenditure (CHE) in which out-of-pocket health spending exceeds 40% of postsubsistence income (income remaining after food and housing expenses). The individual financial strain after BPIs has not been previously quantified. The purpose of this study was to assess the proportion of patients with BPIs who experience risk of CHE after reconstructive surgery.

METHODS

Administrative databases were used from 8 states to identify patients who underwent surgery for BPIs. Demographics including age, sex, race, and insurance payer type were obtained. Inpatient billing records were used to determine the total surgical and inpatient facility costs within 90 days after the initial surgery. Due to data constraints, further analysis was only conducted for privately-insured patients. The proportion of patients with BPIs at risk of CHE was recorded. Predictors of CHE risk were determined from a multivariable regression analysis.

RESULTS

Among 681 privately-insured patients undergoing surgery for BPIs, nearly one-third (216 [32%]) were at risk of CHE. Black race and patients aged between 25 and 39 years were significant risk factors associated with CHE. Sex and the number of comorbidities were not associated with risk of CHE.

CONCLUSIONS

Nearly one-third of privately-insured patients met the threshold for being at risk of CHE after BPI surgery.

CLINICAL RELEVANCE

Identifying those patients at risk of CHE can inform strategies to minimize long-term financial distress after BPIs, including detailed counseling regarding anticipated health care expenditures and efforts to optimize access to appropriate insurance policies for patients with BPIs.

Seeking abortion care in Ohio and Texas during the COVID-19 pandemic

OBJECTIVES

Political and public health responses to the COVID-19 pandemic changed provision of abortion care and exacerbated existing barriers. We aimed to explore experiences of individuals seeking abortion care in 2 abortion-restrictive states in the United States where state policies and practice changes disrupted abortion provision during the pandemic.

STUDY DESIGN

We conducted 22 semistructured interviews in Texas (n = 10) and Ohio (n = 12) to assess how state executive orders limiting abortion, along with other public health guidance and pandemic-related service delivery changes, affected individuals seeking abortion care. We included individuals 18 years and older who contacted a facility for abortion care between March and November 2020. We coded and analyzed interview transcripts using both inductive and deductive approaches.

RESULTS

Participants reported obstacles to obtaining their preferred timing and method of abortion. These obstacles placed greater demands on those seeking abortion and resulted in delays in obtaining care for as long as 11 weeks, as well as some being unable to obtain an abortion at all.

CONCLUSIONS

Political and public health responses to the COVID-19 pandemic - exacerbated pre-pandemic barriers and existing restrictions and constrained options for people seeking abortion in Ohio and Texas. Delays were consequential for all participants, regardless of their ultimate ability to obtain an abortion.

IMPLICATIONS

During the COVID-19 pandemic, state executive orders and clinic practices exacerbated already constrained access to care. Findings highlight the importance of protecting timely care and the full range of abortion methods. Findings also preview barriers individuals seeking abortion may encounter in states that restrict or ban abortion.

Measurement and Operationalization of the Social Determinants of Health and Long-Acting Reversible Contraception Use in the U.S.: A Systematic Scoping Review

Introduction

The objective of this review was to conduct a systematic evaluation of the measurement and operationalization of the social determinants of health in research on long-acting reversible contraception use in the U.S. To contribute to the ongoing refinement of the quality of social determinants of health and long-acting reversible contraception use research, this systematic scoping review examines how social determinants of health are measured and operationalized in studies that examine long-acting reversible contraception initiation and usage at the patient level.

Methods

A detailed search of 5 electronic databases (PubMed, Embase, Web of Science, CINAHL, and PsycINFO) was conducted between December 2020 and January 2021 according to PRISMA guidelines. Determinants were assessed using the Dahlgren and Whitehead model. The protocol and data extraction template were developed a priori.

Results

A total of 27 articles representing 26 studies were included in our study. A total of 12 studies were retrospective and cross-sectional in design; the remaining studies were a combination of designs. Healthcare services and health insurance were identified as the most frequently researched categories of determinants. There was wide variation in reported operationalization of race and ethnicity, limited engagement with sexuality, and uneven geographic representation across studies.

Discussion

This systematic scoping review is the first, to the best of our knowledge, to focus on the measurement and operationalization of social determinants of health and on current long-acting reversible contraception use research. Future research on the impact of social determinants of health on long-acting reversible contraception use must explore the full range of factors shaping contraceptive decision making and use and focus on equity-informed data collection methods and reporting.

Catastrophic health expenditure among Chinese adults living alone with cognitive impairment: findings from the CHARLS

BACKGROUND

The catastrophic health expenditure of older adults results in serious consequences; however, the issue of whether cognitive status and living situations contribute to such financial burdens is uncertain. Our aim was to compare the differences in catastrophic health expenditure between adults living alone with cognitive impairment and those adults living with others and with normal cognition.

METHODS

We identified 909 observations of participants living alone with cognitive impairment (cases) and 37,432 observations of participants living with others and with normal cognition (comparators) from the 2011/2012, 2013, 2015 and 2018 waves of the China Health and Retirement Longitudinal Study (CHARLS). We used propensity score matching (1:2) to create matched cases and comparators in a covariate-adjusted logistic regression analysis. Catastrophic health expenditure was defined as an out-of-pocket cost for health care ≥40% of a household's capacity to pay.

RESULTS

In comparison with participants living with others and with normal cognition, those adults living alone with cognitive impairment reported a higher percentage of catastrophic health expenditure (19.5% vs. 11.8%, respectively, P < 0.001). When controlling for age, sex, education, marital status, residence areas, alcohol consumption, smoking status and disease counts, we found that this subpopulation had significantly higher odds of having catastrophic health expenditure (odds ratio [OR] = 1.89, 95% confidence interval [CI]: 1.40, 2.56). Additional analyses confirmed the robustness of the results.

CONCLUSIONS

This study demonstrated that adults living alone with cognitive impairment in the CHARLS experienced a high burden of catastrophic health expenditure. Health care policies on social health insurance and medical assistance should consider these vulnerable adults.

Trends In Self-Pay Charges And Insurance Acceptance For Abortion In The United States, 2017-20

The Hyde Amendment prevents federal funds, including Medicaid, from covering abortion care, and many states have legal restrictions that prevent private insurance plans from covering abortion. As a result, most people pay for abortion out of pocket. We examined patient self-pay charges for three abortion types (medication abortion, first-trimester procedural abortion, and second-trimester abortion), as well as facilities' acceptance of health insurance, during the period 2017-20. We found that during this time, median patient charges increased for medication abortion (from $495 to $560) and first-trimester procedural abortion (from $475 to $575) but not second-trimester abortion (from $935 to $895). The proportion of facilities that accept insurance decreased over time (from 89 percent to 80 percent). We noted substantial regional variation, with the South having lower costs and lower insurance acceptance. Charges for first-trimester procedural abortions are increasing, and acceptance of health insurance is declining. According to the Federal Reserve, one-quarter of Americans could not pay for a $400 emergency expense solely with the money in their bank accounts-an amount lower than any abortion cost in 2020. Lifting Hyde restrictions and requiring public and private health insurance to cover this essential, time-sensitive health service without copays or deductibles would greatly reduce the financial burden of abortion.

Provider and community stakeholder perspectives of expanding Medicaid coverage of abortion in Illinois

Background

Many people seeking abortion encounter financial difficulties that delay or prevent them from accessing care. Although some patients qualify for Medicaid (a public program that can help cover health care costs), laws in some states restrict the use of Medicaid for abortion care. In 2017, Illinois passed House Bill 40 (HB-40), which allowed patients with Medicaid to receive coverage for their abortion. This study aimed to understand how HB-40 affected abortion affordability from the perspectives of individuals that work directly or indirectly with abortion patients or facilities providing abortion care.

Methods

We conducted interviews with clinicians and administrators from facilities that provided abortion services; staff from organizations that provided resources to abortion providers or patients; and individuals at organizations involved in the passage and/or implementation of HB-40. Interviews were audio-recorded and transcribed. We created codes based on the interview guides, coded each transcript using the web application Dedoose, and summarized findings by code.

Results

Interviews were conducted with 38 participants. Participants reflected that HB-40 seemed to remove a significant financial barrier for Medicaid recipients and improve the experience for patients seeking abortion care. Participants also described how the law led to a shift in resource allocation, allowing financial support to be directed towards uninsured patients. Some participants thought HB-40 might contribute to a reduction in abortion stigma. Despite the perceived positive impacts of the law, participants noted a lack of public knowledge about HB-40, as well as confusing or cumbersome insurance-related processes, could diminish the law’s impact. Participants also highlighted persisting barriers to abortion utilization for minors, recent and undocumented immigrants, and people residing in rural areas, even after the passage of HB-40.

Conclusions

HB-40 was perceived to improve the affordability of abortion. However, participants identified additional obstacles to abortion care in Illinois that weakened the impact of HB-40 for patients and required further action, Findings suggest that policymakers must also consider how insurance coverage can be disrupted by other legal barriers for historically excluded populations and ensure clear information on Medicaid enrollment and abortion coverage is widely disseminated.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07761-5.

"We have to respect that option": The abortion aversion complex in safety-net healthcare organizations

In July 2019, the Trump administration began implementing its domestic gag rule to ban discussion of abortion in pregnancy options counseling and ensure physical separation of contraceptive and abortion services at clinical sites funded by the federal government's Title X Family Planning program. In this paper, we examine how organizational policy utilization correlated with organization-level protocols for discussing abortion in options counseling interactions while the domestic gag rule policy was under legal contest. From April 2018 to July 2019, we conducted in-depth interviews with 50 administrators in charge of setting clinical protocols regarding options counseling after a positive pregnancy test at 20 Title X-covered and 14 non-Title X-covered safety-net healthcare organizations in Ohio. We found that organizational characteristics and Title X policy utilization did not explain the heterogeneity in approaches to abortion referral that administrators reported. Administrators from 2 of 20 organizations covered by Title X policy requirements pre-emptively restricted discussion of abortion in their facilities in advance of policy enactment. Meanwhile, administrators from 10 of 14 non-Title X-covered organizations did not restrict discussion of abortion. Our analysis demonstrates how safety-net healthcare organizations' response to federal policy is shaped by administrators' institutional entrepreneurship within the abortion aversion complex: a pattern of policy miscomprehension and endorsed abortion stigma that facilitates the structural stigmatization of abortion within safety-net healthcare organizations. We conclude that current efforts to reverse the domestic gag rule will fail unless local abortion aversion complexes are targeted with intervention.

Timing of pregnancy discovery among women seeking abortion. Contraception 2021;104:642-647. [PMID: 34363842 DOI: 10.1016/j.contraception.2021.07.110]

OBJECTIVE

Little is known about the incidence and causes of delay in recognition of pregnancy. Delay in pregnancy recognition is associated with later presentation for abortion and exacerbates the burdens in accessing care. Using Turnaway study data, this study assessed the prevalence of later pregnancy recognition among a sample of people who obtained or were denied a wanted abortion.

STUDY DESIGN

The Turnaway Study included telephone interviews of 956 women who sought an abortion in the first trimester or just over or under the gestational limit of one of 30 abortion facilities across the United States and in-depth interviews with 31 who completed 5 years of surveys. We describe women's experiences discovering pregnancy and conducted multivariate analyses assessing factors associated with later pregnancy discovery (after 13 weeks since last menstrual period [LMP]).

RESULTS

Most women seeking second trimester abortions recognized their pregnancy more than 8 weeks after their LMP; more than 1 in 5 recognized pregnancy after 20 weeks. In interviews, women explained that recognition was delayed because of a lack of pregnancy symptoms or concurrence of other conditions with symptoms similar to pregnancy. According to multivariate analyses, women who had never given birth (adjusted odds ratio [aOR] = 1.71; 95% confidence interval [CI]: 1.24, 2.35) and those who used hormonal contraceptives in the month of conception (aOR = 1.83; 95% CI: 1.35, 2.47) were more likely to discover pregnancy after 13 weeks.

CONCLUSION

Laws imposing gestational limits will make abortion unavailable to people who discover pregnancy after the limit. Such bans are likely to disproportionately affect people using contraceptive methods to prevent pregnancy and those who have never given birth.

IMPLICATIONS

Some pregnant people have few pregnancy symptoms and/or have conditions with symptoms similar to pregnancy, such as irregular periods or chronic pain. Gestational limits to abortion are likely to disproportionately affect people who recognize pregnancy later in pregnancy, particularly those without prior pregnancy experiences and who are using contraception.

State abortion policies and Medicaid coverage of abortion are associated with pregnancy outcomes among individuals seeking abortion recruited using Google Ads: A national cohort study

OBJECTIVE

A major challenge to understanding barriers to abortion is that those individuals most affected may never reach an abortion provider, making the full impact of restrictive policies difficult to measure. The Google Ads Abortion Access Study used a novel method to recruit individuals much earlier in the abortion-seeking process. We aimed to understand how state-level abortion policies and Medicaid coverage of abortion influence individuals' ability to obtain wanted abortions.

METHODS

We employed a stratified sampling design to recruit a national cohort from all 50 states searching Google for abortion care. Participants completed online baseline and 4-week follow-up surveys. The primary independent variables were: 1) state policy environment and 2) state coverage of abortion for people with Medicaid. We developed multivariable multinomial mixed effects models to estimate the associations between each state-level independent variable and pregnancy outcome.

RESULTS

Of the 874 participants with follow-up data, 48% had had an abortion, 32% were still seeking an abortion, and 20% were planning to continue their pregnancies at 4 weeks follow-up. Individuals in restricted access states had significantly higher odds of planning to continue the pregnancy at follow-up than participants in protected access states (aOR = 1.70, 95% CI = 1.08, 2.70). Individuals in states that do not provide coverage of abortion for people with Medicaid had significantly higher odds of still seeking an abortion at follow-up (aOR = 1.80, 95% CI = 1.24, 2.60). Individuals living in states without Medicaid coverage were significantly more likely to report that having to gather money to pay for travel expenses or for the abortion was a barrier to care.

CONCLUSIONS

Restrictive state-level abortion policies are associated with not having an abortion at all and lack of coverage for abortion is associated with prolonged abortion seeking. Medicaid coverage of abortion appears critical to ensuring that all people who want abortions can obtain them.