Evidence-Based Advocacy is a monthly column seeking to bridge the gap between the research and activist communities by profiling provocative new abortion research that activists may not otherwise be able to access.
Passed in 1976, the Hyde Amendment prohibits federal Medicaid funding for abortion procedures. Under Hyde, a person with Medicaid as their health insurance can only use their insurance to cover the cost of an abortion if the pregnancy is the result of rape or incest, or the pregnancy endangers that person’s life. While Hyde has placed these deplorable restrictions on abortion coverage for almost 40 years, some states have attempted to correct this injustice—17 states use their own funds voluntarily to cover abortion. While advocates fight to repeal Hyde and restore federal funding for abortion through Medicaid, we assume that abortion access in the 17 “Hyde-free” states is much more equitable than in the 34 states that do not provide such coverage. But are people in states with voluntary Medicaid coverage of abortion actually able to use Medicaid to pay for an abortion? Do they have insurance coverage of abortion both in theory and in practice?
Two new research briefs from Ibis Reproductive Health document the reality of Medicaid coverage of abortion in Arizona and Maryland, two of the 17 states that use their own funds to pay for abortions. Arizona is court-ordered to provide states funds to cover “medically necessary” abortions, while Maryland offers voluntary Medicaid coverage regardless of the pregnancy circumstance. In an ideal world, these requirements would mean that individuals in Maryland and Arizona would have no trouble using their state Medicaid to pay for an abortion. As you can probably guess, this is a far cry from what’s really happening in these states.
Ibis conducted in-depth interviews with abortion providers in Maryland to gauge their experiences seeking Medicaid coverage for their patients’ abortions. These providers explained that while their state Medicaid theoretically covers abortion regardless of the circumstances, in practice, it rarely covered abortion at all. Providers reported insurmountable challenges engaging with the Medicaid office. For example, Medicaid staff did not know when and if abortions qualify for coverage, the complicated billing process through Medicaid was confusing and time-consuming, and Medicaid did not reimburse for providing abortions that should have been covered. These barriers sometimes led providers to stop working with Medicaid altogether. This systemic level incompetence is unacceptable and obviously does not meet the needs of people seeking abortions and clinics providing that health care service.
To gain a more robust understanding of the circumstances in Arizona, Ibis interviewed abortion providers about their experiences with Medicaid and also spoke with low-income women about their how they paid for their abortions. Similar to the Maryland findings, Arizona’s Medicaid coverage does not meet women or provider’s needs. Women shared that it’s extremely difficult to enroll in Medicaid, that Medicaid rarely covers abortion services even in “qualifying circumstances,” and that they often go without other reproductive health care, such as pap smears and pre-natal care, because Medicaid refused to cover these costs as well. Just like in Maryland, abortion providers reported that they face administrative challenges dealing with Medicaid, and that Medicaid often refuses to cover abortion care because a woman’s medical condition is, unbelievably, “not life threatening enough.”
Both abortion providers and women seeking abortion services were incredibly critical of the Medicaid system. One woman interviewed in Arizona summarized her experience this way:
“I had to put off a lot. I sacrificed so much just so I could come up with the money…Like, my light, I had to do payments ‘cause they were about to shut it off…and it was embarrassing…I had to survive off food boxes too…I had to sacrifice real quick.”
We’ve come to expect and denounce these awful circumstances in states in which Medicaid doesn’t cover abortion, but these Ibis research reports reveal that having Medicaid coverage of abortion doesn’t necessarily guarantee access to timely safe abortion care ostensibly covered by a state. Medicaid coverage is in theory an invaluable resource, but in reality it is not accessible at all if the system does not work properly or actually cover the procedures it is supposed to cover. As the experiences of low-income women and abortion providers in both Arizona and Maryland suggest, mandating Medicaid coverage of abortion is a far cry from guaranteeing that people can access an abortion when they need one.
These findings also make clear that at the federal level, repealing the Hyde Amendment is a necessary but not sufficient condition for ensuring access to safe abortion care for people in need. In addition to advocating for the repeal of the Hyde Amendment, Ibis provides action steps to improve the experiences that women and providers have with Medicaid. They suggest streamlining the Medicaid enrollment and application process, educating patients, providers, and Medicaid staff about the law, increasing reimbursement rates for abortion providers and lowering the administrative burden of dealing with Medicaid offices, as well as involving pro-choice stakeholders and organizations in advocating for these changes. Many abortion funds, such as the Massachusetts and California Funds, are already doing this—it would be wonderful to see mainstream pro-choice organizations take this on as well.
Pushing for Medicaid reform is not sexy, especially when we’re talking about insurance enrollment and doing away with bureaucratic red tape. The pro-choice movement has a lot on its plate, but in order to guarantee abortion access for all, we have to put as much effort into making Medicaid a just and equitable system as we put into our efforts to repeal Hyde and guarantee private insurance coverage of abortion. Medicaid can be a critical resource in theory, but in order to meet the needs of low-income people, the system must function properly in reality. And we must address the reality, however complex and daunting, that repealing the Hyde Amendment doesn’t guarantee universal abortion care coverage for low-income people.