Abortion is an essential part of comprehensive reproductive health care. It is a common medical procedure that one in four women in the United States obtains in her lifetime.1 People in need of abortion must be able to access abortion care when they have made the decision to end a pregnancy. Yet, accessing abortion care can be costly, making insurance coverage critical for people seeking abortion.
Despite the importance of insurance coverage of abortion, state politicians have taken abortion coverage away from people who have decided to have an abortion. Some politicians have passed state laws that prohibit private insurance plans from offering coverage of abortion and other states withhold coverage of abortion from people who are insured through the Medicaid program.
Without affordable coverage of abortion, many people are forced to forgo care–threatening both their physical and economic health. And because of structural racism and other inequities, these laws disproportionately hurt people of color, young people, low-income people, and women.
In contrast, other state governments have taken action to promote the health and economic security of their communities by ensuring that plans provide comprehensive insurance coverage that includes abortion. Every state should do what it can to ensure the best health outcomes for its residents.
States Deny Coverage of Abortion to People Qualified and Enrolled in Medicaid
A federal law known as the Hyde Amendment bans abortion coverage for people enrolled in Medicaid, except in the very limited circumstances of when a person’s life is endangered, or they are a survivor of rape or incest.2 Although states can use their own funds to cover abortion beyond those very limited circumstances, many states have chosen not to cover abortion for people enrolled in Medicaid who are already struggling to make ends meet.
- Thirty-four states have chosen not to comprehensively cover abortion for people enrolled in Medicaid.3
- One of those states even violates federal law by denying coverage to people enrolled in Medicaid seeking abortion after rape or incest:4 People in South Dakota can only get Medicaid coverage for an abortion if their life is endangered.
- Congress has prohibited the District of Columbia from using its own local funds to provide D.C. residents enrolled in Medicaid with coverage of medically necessary abortions.5
States Deny People Access to Insurance Coverage of Abortion in Private Plans
Before passage of the Affordable Care Act (ACA), most private health insurance plans covered abortion.6 Unfortunately, the ACA allows states to prohibit private insurance plans from offering health insurance that includes abortion.7
- Twenty-five states have laws that prohibit insurance issuers from offering health care plans that include abortion coverage in the insurance Marketplaces set up by the ACA.8
- Eleven of those twenty-five states go even further and prevent all plans—including employer sponsored plans—in the state from offering coverage of abortion as part of a comprehensive health care plan.9
This means that people in those twenty-five states are not able to access a health plan in the Marketplace that covers abortion and may not be able to access a plan that provides insurance coverage for abortion at all–just because of where they live and how they are insured. Most of these state laws contain exceptions for only the most extreme situations, such as when the pregnancy endangers the woman’s life or was the result of rape or incest. But some do not even allow plans to cover abortion in those extreme circumstances.
- Louisiana and Tennessee do not allow a woman in even those difficult or life-threatening circumstances to have insurance coverage of abortion.10
- Eight states do not allow private insurance plans to cover abortion when a woman is pregnant as a result of rape or incest.11
Some of the state laws that prohibit insurance companies from offering abortion coverage purport to allow insurers to sell separate coverage for abortion. But shortly after implementation of the ACA, insurers in several states where supplemental coverage is allowed reported that no such plans were actually offered. Since then, there has been no evidence that this type of coverage has become available.12
In any event, requiring people who may become pregnant to rely on supplemental coverage for an unanticipated medical expense defeats the purpose of insurance coverage and creates additional burden and expense for those who could become pregnant.
States Ensure that People Have Insurance Coverage for Abortion
Some states require insurance plans to include abortion coverage. Thanks to lawmakers who have worked to fight for abortion coverage, pregnant people in some states can use their private or public insurance to obtain abortion care. When lawmakers are responsive to the needs of their residents, the people in that state thrive and quality of care improves.
- Six states–California, Illinois, Maine, New York, Oregon, and Washington–require nearly all private insurance plans to provide coverage for abortion.13
- Sixteen states use their own funds to make sure women enrolled in Medicaid have coverage for abortion.
- Nine of these states provide coverage under court orders requiring provision of abortion coverage for individuals enrolled in Medicaid.14
- Seven of these states voluntarily provide abortion coverage for individuals enrolled in Medicaid.15
Unfortunately, the Trump Administration targeted states that either allow or require plans to cover abortion. It imposed a substantial penalty on at least one state–California–that requires plans to provide coverage, and it added additional, arbitrary burdens on plans that include abortion coverage. It is an attempt to scare insurance companies out of covering abortion care in the twenty-five states where abortion is either allowed or required in the ACA Marketplace.16
Comprehensive Coverage that Includes Abortion is Necessary to Protect Women’s Health and Economic Security
States should ensure that abortion is included in all health insurance plans. When politicians deny people comprehensive health coverage that includes abortion, many pregnant people may face high out-of-pocket costs for these services and in some instances may be unable to obtain an abortion at all. The harm from these laws falls hardest on people struggling to make ends meet, queer people, women, people of color, and young people–the Hyde Amendment, for example, has disproportionately impacted Black, Indigenous and People of Color (BIPOC) communities for decades–but these laws jeopardize the health and economic security of every person denied insurance coverage of abortion.
When a pregnant person is denied coverage of abortion, she faces threats to her health.
- Many of the laws restricting insurance coverage of abortion offer no exception even where abortion is necessary to protect the patient from serious, permanent, and even life-shortening health conditions, such as damage to heart, lungs, or kidneys.
- Some people denied coverage of abortion will be forced to postpone an abortion while attempting to find the necessary funds. Although abortion is an extremely safe procedure, delays increase the health risks of the procedure.17
- And many are forced to delay so much that they lose care entirely as they pass gestational limits on
abortion care imposed by state politicians.
- When a woman is denied an abortion, she is at higher risk of staying in an abusive relationship, which puts her life and safety at risk.18
- When a person has decided to have an abortion, it is important that no politician prevent them from access to safe medical care. Politicians should be providing coverage of abortion so pregnant people can see a licensed, quality health provider if they choose.
When a person is denied coverage of abortion, they may be forced to choose between basic necessities and obtaining needed abortion care.
- Without coverage of abortion, a pregnant person may be forced to carry the pregnancy to term or need to raise money for the procedure through forgoing basic necessities, borrowing money, or selling a precious item.19
- More than half of women who get abortions without coverage spend the equivalent of more than one-third of their monthly income on the procedure and its associated costs.20
Half of women who obtain an abortion live below the federal poverty level, and seventy-six percent of women cannot afford basic living expenses.21
When a person is denied coverage of abortion, they face increased costs and delays.
- A person who has to pay for their abortion out of pocket may be forced to delay the procedure to raise the necessary funds.
- Fifty-eight percent of abortion patients say they would have had their abortion earlier if they could have. Nearly sixty percent of women who experienced a delay in obtaining an abortion cite the time it took to make arrangements and raise the money to pay for it.22
When a person is denied coverage of abortion, they may face long-term consequences.
- When a pregnant person is living paycheck to paycheck, denying coverage for an abortion can push them deeper into poverty. One study found that a woman who is unable to get an abortion is more likely to be living in poverty one year later than a woman who received the abortion care she needed. And for years after pregnancy, women who are denied an abortion experience more debt, lower credit scores, and greater financial instability than their peers who were not denied an abortion.23
- Without the ability to access the abortion care she needs; a woman is three times more likely to be unemployed compared to women who were able to access the procedure. This has major financial consequences for the woman’s family unit, as the majority of women seeking abortion already have children and do not have enough money to cover living expenses.24
- Studies show that when political interference restricts Medicaid coverage of abortion, it forces one in four lower income women seeking an abortion to carry an unwanted
pregnancy to term.25
For too long, politicians have interfered in reproductive health decisions by banning insurance coverage of abortion. When it comes to the decision of whether to become a parent, it is vital that a person is able to consider all the options available, however little money she makes, however she is insured, or wherever she lives. States should recognize this and ensure that every person has insurance coverage that meets their needs, including abortion. Because as restrictions on abortion coverage clearly demonstrate, the constitutional right to abortion is meaningless to many if they do not have the means and support to exercise it.
1. Induced Abortion in the United States (Sept. 2019), available at https://www.guttmacher.org/
2. Id. Knox-Keane Health Care Service Plan Act of 1975, CAL. Health & Safety Code § 1340 et seq.;
H.B. 3391, 79th Leg., 2017 Reg. Sess. (Or. 2017);
3. Kaiser Family Foundation, State Funding of Abortions Under Medicaid (2020), available at
4. S.D. codified laws § 28-6-4.5 (2017).
5. H.R. 1158, 116th Cong. (2020).
6. Guttmacher Inst., Memo on Private Insurance Coverage of Abortion (Jan. 19, 2011), available at
7. 442 U.S.C. § 18023(b)(1).
8. Alabama, Arizona, Arkansas, Florida, Georgia, Idaho, Indiana, Kansas, Kentucky, Louisiana,
Michigan, Mississippi, Missouri, Nebraska, North Carolina, North Dakota, Ohio, Oklahoma,
Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, and Wisconsin. Ala. Code
§ 26-23C-3 (2012); Ariz. Rev. Stat.. § 20-121 (2012); Ark. Code § 23-79-156 (2013); Fla. Stat. §§
627.64995, 627.66996, 641.31099 (2011); Ga. Code Ann. §§ 33-24-59.17, 45-18-4 (2014); Idaho
Code Ann. § 41-1848 (2011); Ind. Code §§ 27-8-33, 16-33-4-1 (2012); Ind. Code §§ 27-8-13.4, 27-
13-7-7.5 (2014); Kan. Stat. Ann. § 40-2,190(b) (2011); Ky. Rev. Stat. Ann § 304.5-160; La. Rev. Stat.
Ann. § 22:1014 (2011); Mich. Comp. Laws §§ 550.541-551(2014); Miss. Code Ann. §§ 41-41-97,
41-41-99 (2010); Mo. Ann. Stat. § 376.805 (2012); Neb. Rev. Stat. §§ 44-8402, 44-8403(1) (2011);
N.C. Gen. Stat. § 58-51-63 (2013); S.B. 353, Gen. Assemb., 2013 Sess. (N.C. 2013); N.D. Cent.
Code § 14-02.3-03; Ohio Rev. Code. Ann. § 3901.87 (2012); Okla. Stat. Tit. 63, § 1-741.3 (2011);
40 Pa. Cons. Stat. § 33(2013); S.C. Code. Ann. § 38-71-238 (2012); S.D. Codified Laws § 58-17-147
(2012); Tenn. Code Ann. § 56-26-134 (2010); Tex. Ins. Code Ann. § 1696.002 (2017); Utah Code
Ann. § 31A-22-726 (2012); Wis. Stat. § 632.8985 (2012).
9. Idaho, Indiana, Kansas, Kentucky, Michigan, Missouri, Nebraska, North Dakota, Oklahoma, Texas
and Utah. See id.
10. La. Rev. Stat. Ann. § 22:1014 (2011); Tenn. Code Ann. § 56-26-134 (2010).
11. Kansas, Kentucky, Michigan, Missouri, Nebraska, North Dakota, Oklahoma and Texas. Kan.
Stat. Ann. § 40-2,190(b) (2011); Ky. Rev. Stat. Ann § 304.5-160; Mich. Comp. Laws §§ 550.541-
551(2014); Mo. Ann. Stat. § 376.805 (2012); Neb. Rev. Stat. §§ 44-8402, 44-8403(1) (2011); N.D.
Cent. Code § 14-02.3-03; Okla. Stat. Tit. 63, § 1-741.3 (2011); Tex. Ins. Code Ann. § 1696.002
12. Caroline Rosenzweig et. al., Kaiser Family Foundation, Abortion Riders: Women Living in States
with Insurance Restrictions Lack Abortion Coverage Options (2018), available at https://www.
13 . 42 U.S.C. § 18023(b)(2).
14. Knox-Keane Health Care Service Plan Act of 1975, CAL. HealtH & safety code § 1340 et seq.;
Or. Rev. Stat. § 743A.067 (2019); N.Y. Ins Law § 3217 (2015); N.Y. Comp. codes R. & Regs. tit.
11, § 52.2 (2016); Me. Rev. Stat. tit. 24-A, § 4320-M; Wash. Rev. Code § 48.43.073 (2018); 775 Ill.
Comp. Stat. 55/1, 905, 910, 999 (2019).
15. Alaska, California, Connecticut, Massachusetts, Minnesota, Montana, New Jersey, New Mexico,
and Vermont. See Alaska v. Planned Parenthood, 28 P.3d 904 (Alaska 2001); Committee to
Defend Reprod. Rights v. Myers, 625 P.2d 779 (Cal. 1981); Doe v. Maher, 515 A.2d 134 (Conn.
Super. Ct. 1986); Doe v. Wright, No. 91 CH 1958 (Ill. Cir. Ct. Dec. 2, 1994); Moe v. Sec’y of Admin.
& Fin., 417 N.E.2d 387 (Mass. 1981); Women of Minn. v. Gomez, 542 N.W.2d 17 (Minn. 1995);
Jeannette R. v. Ellery, No. BDV-94-811 (Mont. Dist. Ct. May 22, 1995); Right to Choose v. Byrne,
450 A.2d 925 (N.J. 1982); New Mexico Right to Choose/NARAL v. Johnson, 975 P.2d 841 (N.M.
1998); Doe v. Celani, No. S81-84CnC (Vt. Super. Ct. May 26, 1986).
16. Hawaii, Oregon, Illinois, Maine, Maryland, New York, and Washington. Haw. Code R. §17-
1722.3-18(3) see also Haw. Dep’t of Human Servs., Med-QuestDiv., Memo No. FFS-1512, https://
FFS-1512.pdf; Or. Rev. Stat. §743A.067 (2019); 775 Ill. Comp. Stat. 55/1, 905, 910, 999 (2019); Me.
Stat. tit. 22, § 3196 (2019); Md. Code Regs. 10, § 9.02.04(G); N.Y. Soc. Serv. Law § 365-a(2), a(5)
(b); Wash. Admin. Code 182-532-120 (2019).
17. “Abortion is an essential component of comprehensive health care. It is also a time-sensitive
service for which a delay of several weeks, or in some cases days, may increase the risks or
potentially make it completely inaccessible. The consequences of being unable to obtain an
abortion profoundly impact a person’s life, health, and well-being.” https://www.acog.org/news/
National Academies of Sciences, Engineering and Medicine, The Safety and Quality of Abortion
Care in the United States, Washington, DC: National Academies Press, 2018. DOI: https://doi.
18. Diana Greene Foster, PhD, Turnaway Study, (2020), available at https://www.ansirh.org/
19. “40% of Americans cannot afford an unexpected $400 expense” Board of Governors of the
Federal Reserve System: Report on the Economic Well-Being of U.S. Households in 2017 – May
2018, available at https://www.federalreserve.gov/publications/2018-economic-well-beingof-
us-households-in-2017-dealing-with-unexpected-expenses.htm; Guttmacher Inst., Memo
on Private Insurance Coverage of Abortion (Jan. 19, 2011), http://www.guttmacher.org/media/
20. Guttmacher Inst.: Medicaid Funding of Abortion, (Jan. 2020), available at https://www.
21. Guttmacher Inst.: United States Abortion Demographics, available at https://www.guttmacher.
org/united-states/abortion/demographics; Advancing New Standards in Reproductive Health,
Socioeconomic Impact of being Denied Abortion, Issue Brief (2018), available at https://www.
22. Lawrence B. Finer et al., Timing of Steps and Reasons for Delays in Obtaining Abortions in
the United States, 74 Contraception 334, 335 (2006), available at www.guttmacher.org/
23. Supra note 18.
24. Supra note 19.
25. Stanley K. Henshaw et al., Guttmacher Inst., Restrictions on Medicaid Funding for Abortions: A
Literature Review (2009), available at http://www.guttmacher.org/pubs/MedicaidLitReview.pdf.