Where you live has a lot to do with whether or not you have access to health plans that cover abortion. Also important: whether you get insurance through a job, the federal and state marketplaces, or programs like Medicaid and Medicare.
Unfortunately, that's often the first response to any question that begins with, "does health insurance pay for...?"
Sometimes that answer is a shock. In the case of abortion coverage, though, it's expected if you live in the United States. After all, Americans seem to be as divided on the issue as ever, according to various sources.
For example, a recent poll conducted by the Pew Research Center found that nearly 60 percent of U.S. adults say abortion should be legal in all or most cases. Just under 40 percent say it should be illegal all or most of the time.
A Gallup poll from earlier this year found that 18 percent of Americans say abortion should always be illegal. And 23 percent say it should be legal in all circumstances. Fifty percent say it should be legal, but only in certain situations.
That same poll found that 49 percent of Americans say they're "pro-choice," while 46 percent say they're "pro-life.
Perhaps unsurprisingly, political party affiliation appears to play a pretty strong role in how someone feels about abortion. In fact, another Pew report found that 75 percent of Democrats say abortion should be legal in all or most cases. Sixty-five percent of Republicans, on the other hand, say it should be illegal in all or most cases.
Given abortion's continued status as a hot-button social issue, is it any wonder U.S. health insurance companies differ wildly in how they do and don't cover its costs?
Keep reading to learn more about that as well as why insurers operate as they do in this situation. Also covered here: how various types of health insurance plans--including those offered by Medicare and Medicaid and those sold on the federal and state marketplaces--treat this coverage.
First, a bit of history.
For most Americans, abortion first became a political football in the early 1970s, when Roe v. Wade made it legal from coast to coast.
Well, that U.S. Supreme Court ruling also spurred much of the upheaval that continues to affect the health insurance space regarding how it deals with abortion coverage.
Three years after Roe v. Wade, Congress passed the "Hyde Amendment." This piece of legislation basically barred the use of federal funds to pay for an abortion. The only exceptions: rape, incest, or if carrying the pregnancy to term would endanger the woman’s life.
After passage, federally funded abortions dropped from around 300,000 per year to just a few thousand, said the ACLU.
The Hyde Amendment isn't a permanent law, by the way. Instead, it's a "rider" that Congress has to renew each and every year.
That may not be true for much longer, though. Earlier this year, Republicans introduced a bill, H.R. 7 (or the No Taxpayer Funding for Abortion and Abortion Insurance Full Disclosure Act of 2017), which, if passed by the Senate, will enshrine the amendment into law.
Regardless, the Hyde Amendment's already affected a number of federal programs since its initial passage.
Its purpose was to limit Medicaid coverage of abortion. But it now limits how Medicare, the Children’s Health Insurance Program (CHIP), and the Indian Health Service cover the procedure.
That's not all. Many federal women's health programs also currently follow guidelines that are similar to the ones laid out in the Hyde Amendment. Among them: the Federal Employees Health Benefits Program, the military’s TRICARE program, and Peace Corps, and the federal prison system.
And then there's the Affordable Care Act, also known as the ACA and Obamacare. It, too, limits abortion coverage, although in a slightly different way than the programs mentioned above.
Obamacare limits how health plans cover abortion in a couple of ways.
For starters, it fails to include abortion among the 10 categories of "essential" benefits U.S. health insurance companies must cover. (A few examples of categories insurers do have to cover: inpatient and outpatient hospital care, prescription drug coverage, and preventive services.)
As a result, insurance companies generally are free to decide whether or not they provide some amount of abortion coverage in their health plans. Many do and many do not--much like how health insurers tend to treat infertility coverage.
Why are insurers "generally" free to make this decision? Because they're only free to do so if the health plans in question are sold in states that haven't banned abortion coverage. (More on that in a minute.)
Obamacare allows states to limit how health plans sold through their local insurance marketplaces cover abortions. So far, 26 states have taken the government up on that offer.
Don't assume living in a state that has yet to put one of these bans in place means you can get a marketplace plan covering abortions. According to a report from the Henry J. Kaiser Family Foundation, six states without abortion coverage bans don't offer any marketplace plans that include it at the moment.
Also, insurance companies that operate in states without an abortion coverage ban must jump through several hoops if they want to sell health plans that cover abortions. The gist: they're required to take certain steps to ensure no federal funds help pay for an abortion.
It's already been said that the Hyde Amendment keeps federal Medicaid funds from being used to pay for abortions unless incest, rape, or life endangerment are involved. It doesn't, however, keep states from using their own funds to cover all or most of their Medicaid enrollees' abortions.
Seventeen states currently do just that. They are:
Not all of these states willingly allow their Medicaid programs to cover abortions, mind you. In fact, only four of the states listed here voluntarily provide this coverage. The other 13 provide it under court orders. One, Arizona, is under court order to provide it but does not do so.
As for how the rest of the 50 states, as well as the District of Columbia, treat this situation:
And what about the remaining state? Its Medicaid program only pays for abortions that are necessary to save the woman's life. (For the curious: the state in question is South Dakota.)
Surely you're more likely to be able to find health insurance that covers abortion if you get it through an employer or buy it on the private market, right? Wrong.
To begin with, states regulate all fully insured individual, small, and large group plans that are issued to their residents. (The federal government regulates self-insured plans.)
Also, states have the power to restrict how those same health plans cover--or don't cover--abortion.
Combine the two, and it's easy to see how where you live plays an important role in whether or not you can find health insurance that provides this coverage.
Eleven states currently prohibit all private health insurance plans from covering abortion care unless the woman's life is in danger. They are:
(Two of these states, Utah and Indiana, also make exceptions for cases of rape and incest.)
On the other hand, three states--California, New York and Oregon--now require all individual and employer health plans to cover abortion.
What if you live in one of the many states not mentioned here? Insurers there are free to decide for themselves if their private health plans do or don't cover abortion. There are no laws on the books in those states that require or ban such coverage.
A: The main reason it matters is abortions aren't cheap. As a result, many American women rely on health insurance to help cover the procedure's costs.
For example, according to one recent national survey, 24 percent of women paid for their abortion using Medicaid coverage. Fifteen percent used private insurance to pay for their abortion.
That's right in line with what Katherine McGuiness, the Board President of the Network for Reproductive Options, an abortion fund that serves Oregon and Idaho, recently told The New Republic. “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."
Without the right health insurance, many women can't afford an abortion, which pro-choice proponents say threatens both their physical and economic health.
Abortions performed before the 10-week mark often cost between $300 and $800 if paid for out of pocket, The New Republic reports. Those performed later, such as during the second trimester, tend to cost a lot more--sometimes to the tune of a few thousand dollars.
These estimates only cover the procedure itself. Related expenses like lost work time and travel cause the price to jump even higher.
The National Women's law Center says than 920,000 American women had an abortion in 2014. This means about 19 percent of all pregnancies, not including miscarriages, were ended by an abortion that year.
Also, around 1.5 percent of women between the ages of 15 and 44 had an abortion in 2014. About half of those women reported having had one or more previous abortions.
A: As you've heard a few times already, the Hyde Amendment bars the use of federal funds to pay for abortions (unless incest, rape, or life endangerment are involved). It doesn't keep states from using their own funds to pay for them in a wider range of situations via their local Medicaid programs.
In fact, 17 states currently cover all or most of their Medicaid enrollees' abortions.
Thirty-two states follow the Hyde Amendment and only pay for Medicaid enrollees' abortions if a woman is raped, the victim of incest, or if the pregnancy puts her life in danger. The District of Columbia's Medicaid program operates in the same way.
A: Only in certain circumstances. Again, this coverage is limited due to the passage of the Hyde Amendment.
As for when Medicare covers abortions, one is if the pregnancy is the result of rape. Another is if the pregnancy is the result of incest. Medicare also covers abortions that need to be performed because the pregnancy is putting a woman's life in danger.
To learn more about the kinds of medical treatments and services Medicare does and doesn't usually cover, read our "Ultimate Guide to Medicare."
A: It depends on where you live.
The Affordable Care Act allows states to restrict how plans sold through their health insurance marketplaces cover abortions. At the moment, 26 states do this to varying degrees.
Six other states don't limit how their marketplace plans cover abortion. But they also don't currently offer any marketplace plans that include such coverage.
If you live in any of these states, you won't find a marketplace plan that covers abortion outside a limited number of situations. See nwlc.org for more information.
A: It could mean a great deal. But how great a deal depends on how any law that replaces Obamacare is written.
Had it passed, one of the replacement bills before Congress last year would have gone well beyond the Hyde Amendment's restrictions to limit how marketplace health plans could cover abortion.
In particular, it proposed barring people from using federal tax credits to buy plans from the federal and state marketplaces that cover abortion. That alone could change the entire health insurance landscape, suggests Adam Sonfield, a senior policy manager for the Guttmacher Institute.
After all, “there’s no reason insurers would sell any plans that cover abortion because everyone would be wanting to use these tax credits,” he told The New York Times earlier this year.
That same bill also aimed to keep small employers from taking advantage of federal tax credits if their health insurance plans cover abortion. And it would have hindered health insurers of all sizes and stripes from receiving certain kinds of federal funds if they covered abortion.
That particular bill didn't pass. But it's likely others will be introduced and voted on in 2018.
How those bills compare to the AHCA is anyone's guess. It's a good bet, though, that should one of them replace Obamacare during the current presidency, it will only further restrict how various kinds of health insurance cover abortion.
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