Article

Contextualizing Medicaid reimbursement rates for abortion procedures

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Abstract

Objective Low Medicaid reimbursement rates have been cited as a key threat to abortion clinic sustainability in the United States. This study examines differences between Medicaid and Medicare reimbursements for abortion and miscarriage management procedures under a fee-for-service (FFS) model. Study design Using 2017 Medicaid and Medicare Physician fee schedules, we extracted reimbursement data for the two most commonly-billed abortion procedures and two miscarriage management procedures for 45 states and the District of Columbia (DC). We compared Medicaid and Medicare reimbursement rates for each procedure by state. Results Medicaid reimbursement rates for both procedures varied widely across the states. Medicaid rates for second-trimester abortion procedures had the widest range; 79to79 to 626. Median Medicaid reimbursement rates were lower than median Medicare rates for first- and second-trimester abortion procedures. Median reimbursement rates for first-trimester induced abortion were lower than median reimbursement rates for miscarriage management for both Medicaid and Medicare. Conclusion Our findings indicate that Medicaid reimbursement rates for abortion are low; the median patient cost for a first- and second-trimester abortion have been reported as 490and490 and 750, respectively. Median Medicaid reimbursement rates for a first- and second-trimester abortion covers approximately 37% and 41% of patient costs for a first- and second-trimester abortion. Further, while induced abortion procedures are similar to miscarriage management procedures, Medicaid and Medicare reimbursement rates are lower for first- and second-trimester abortion procedures. Implication statement Ensuring reimbursement rates are closely aligned with procedural costs bolsters provider willingness to accept Medicaid. Data that highlights the potential impact of fee-for-service reimbursement rates on healthcare provision and ultimately patient access can help inform healthcare policies. This is especially important as more states consider expanding Medicaid coverage of abortion.

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... ties) are substantially lower than the cost of care in many states,28,29 and the Medicaid certification process can be confusing and cumbersome30 to the point that some facilities decline to participate. In turn, some people with Medicaid coverage have to take time to find, and in some cases get to, a facility that takes this method of payment. ...
Article
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Background Medicaid is the most common type of health insurance held by abortion patients, but the Hyde amendment prohibits the use of Medicaid to pay for this care. Seventeen states allow state Medicaid funds to cover abortion. Methods We used data from a national sample of 6698 people accessing abortions at 56 facilities across the United States between June 2021 and July 2022. We compare patient characteristics and issues related to payment for the abortion across patients residing in states where state Medicaid funds covered abortion (Medicaid states) and those where it did not (Hyde states). We also examine which abortion patient populations were most likely to use Medicaid in states where it covers abortion care. Results In Medicaid states, 62% of respondents used this method to pay for care while a majority of individuals in Hyde states, 82%, paid out of pocket. Some 71% of respondents in Medicaid states paid USD0 and this was substantially lower, 10%, in Hyde states. In Hyde states, two‐thirds of respondents had to raise money for the abortion (e.g., by delaying bills) compared to 28% in Medicaid states. Within Medicaid states, groups most likely to rely on this method of payment included respondents who identified as Black (70%) or Latinx (66%), those in the lowest income group (78%) and those having second‐trimester abortions (75%). Discussion When state Medicaid funds cover abortion, it substantially reduces the financial burden of care. Moreover, it may increase access for groups historically marginalized within the health care system.
Article
In 2023 the editors of P erspectives 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.
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Due to changes in the political climate, access to safe and legal abortion is dramatically changing in the United States. A patchwork of state laws in the aftermath of the Dobbs decision, as well as, clinical, educational, and logistical factors exacerbates an already looming national shortage of abortion providers. Abortion has been siloed from other forms of comprehensive reproductive healthcare, and this directly affects the experience of both patients and providers. This chapter will explore the professional characteristics of individuals who provide abortion care, highlight the unique challenges for abortion providers, and discuss the public health impact of the marginalization of abortion care.
Article
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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.
Article
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.
Article
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 495to495 to 560) and first-trimester procedural abortion (from 475to475 to 575) but not second-trimester abortion (from 935to935 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.
Article
Medicaid is the largest publicly funded health insurance program in the United States, covering 76 million individuals as of August 2020. Research shows that Medicaid improves health and healthcare access on a variety of indicators. Abortion is a common reproductive health service in the United States. However, Medicaid coverage of abortion varies by state; with 34 states and the District of Columbia limiting themselves to a federal policy that only permits coverage under cases of incest, rape, or life endangerment. With 75% of abortion patients earning low incomes, Medicaid coverage of this service is particularly salient to abortion access. In this commentary, we describe the complexities of Medicaid coverage and reimbursement of abortion in the United States and the implications of this complexity. Further, we consider the potential impact of changes in abortion provision, including increasing provision of medication abortion and the use of healthcare delivery models such as telemedicine for medication abortion, on Medicaid coverage and reimbursement. Finally, we provide a few policy and practice recommendations for abortion coverage now and in the future.
Article
Objective On January 1, 2018, Illinois became the first Midwestern state to cover abortion care for Medicaid enrollees. This study describes state implementation of the policy, the impact on abortion providers, and lessons learned. Study Design We documented abortion providers’ perspectives on the service delivery consequences of Medicaid coverage for abortion in Illinois. We conducted in-depth interviews with clinicians and administrators (N=23) from 15 Illinois clinics, including clinics that provided other services and those primarily providing abortion. We conducted interviews in person or by phone between April and October 2019. They lasted ≤100 minutes, were audio-recorded, transcribed, and coded in Dedoose. We developed code summaries to identify salient themes across interviews. Results All participants supported the law and expected benefits to patients. Many struggled to implement the policy because of difficulties obtaining certification to bill the state Medicaid program, confusing and cumbersome paperwork requirements, reimbursement delays, confusing claim denials, and uncertain protocols for Medicaid patients covered under the exceptions defined by the Hyde Amendment. Nearly all participants expressed concern that low reimbursement rates were insufficient to cover costs. Implementation was easier for multiservice clinics and those nested in larger institutions. Several clinics closed during implementation; one clinic opened. Clinics leveraged internal resources, external funding, and technical assistance to ensure that Medicaid enrollees could receive care without costs. Conclusions Implementing Medicaid coverage for abortion requires proactive and responsive state institutions, improvements to reimbursement processes, and adequate reimbursement rates. In Illinois, successful implementation depended on clinic adaptability, external support, and advocacy. Implications Our research suggests that successful, sustainable implementation of Medicaid coverage for abortion depends on state policies that allow clinics to enroll patients, process claims in 30-90 days, and receive reimbursements covering the cost of care. Without these measures, ensuring immediate patient access may depend upon clinics mobilizing resources and external transitional support.
Article
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Background: To estimate the proportion of pregnant women in Louisiana who do not obtain abortions because Medicaid does not cover abortion. Methods: Two hundred sixty nine women presenting at first prenatal visits in Southern Louisiana, 2015-2017, completed self-administered iPad surveys and structured interviews. Women reporting having considered abortion were asked whether Medicaid not paying for abortion was a reason they had not had an abortion. Using study data and published estimates of births, abortions, and Medicaid-covered births in Louisiana, we projected the proportion of Medicaid births that would instead be abortions if Medicaid covered abortion in Louisiana. Results: 28% considered abortion. Among women with Medicaid, 7.2% [95% CI 4.1-12.3] reported Medicaid not paying as a reason they did not have an abortion. Existing estimates suggest 10% of Louisiana pregnancies end in abortion. If Medicaid covered abortion, this would increase to 14% [95% CI 12, 16]. 29% [95% CI 19, 41] of Medicaid eligible pregnant women who would have an abortion with Medicaid coverage, instead give birth. Conclusions: For a substantial proportion of pregnant women in Louisiana, the lack of Medicaid funding remains an insurmountable barrier to obtaining an abortion. Forty years after the Hyde Amendment was passed, lack of Medicaid funding for abortion continues to have substantial impacts on women's ability to obtain abortions.
Article
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Context: National and state-level information about abortion incidence can help inform policies and programs intended to reduce levels of unintended pregnancy. Methods: In 2015-2016, all U.S. facilities known or expected to have provided abortion services in 2013 or 2014 were surveyed. Data on the number of abortions were combined with population data to estimate national and state-level abortion rates. The number of abortion-providing facilities and changes since a similar 2011 survey were also assessed. The number and type of new abortion restrictions were examined in the states that had experienced the largest proportionate changes in clinics providing abortion services. Results: In 2014, an estimated 926,200 abortions were performed in the United States, 12% fewer than in 2011; the 2014 abortion rate was 14.6 abortions per 1,000 women aged 15-44, representing a 14% decline over this period. The number of clinics providing abortions declined 6% between 2011 and 2014, and declines were steepest in the Midwest (22%) and the South (13%). Early medication abortions accounted for 31% of nonhospital abortions, up from 24% in 2011. Most states that experienced the largest proportionate declines in the number of clinics providing abortions had enacted one or more new restrictions during the study period, but reductions were not always associated with declines in abortion incidence. Conclusions: The relationship between abortion access, as measured by the number of clinics, and abortion rates is not straightforward. Further research is needed to understand the decline in abortion incidence.
Article
Objectives: To determine the socioeconomic consequences of receipt versus denial of abortion. Methods: Women who presented for abortion just before or after the gestational age limit of 30 abortion facilities across the United States between 2008 and 2010 were recruited and followed for 5 years via semiannual telephone interviews. Using mixed effects models, we evaluated socioeconomic outcomes for 813 women by receipt or denial of abortion care. Results: In analyses that adjusted for the few baseline differences, women denied abortions who gave birth had higher odds of poverty 6 months after denial (adjusted odds ratio [AOR] = 3.77; P < .001) than did women who received abortions; women denied abortions were also more likely to be in poverty for 4 years after denial of abortion. Six months after denial of abortion, women were less likely to be employed full time (AOR = 0.37; P = .001) and were more likely to receive public assistance (AOR = 6.26; P < .001) than were women who obtained abortions, differences that remained significant for 4 years. Conclusions: Women denied an abortion were more likely than were women who received an abortion to experience economic hardship and insecurity lasting years. Laws that restrict access to abortion may result in worsened economic outcomes for women. (Am J Public Health. Published online ahead of print January 18, 2018: e1-e7. doi:10.2105/AJPH.2017.304247).
Article
Objectives: To assess the prevalence of abortion among population groups and changes in rates between 2008 and 2014. Methods: We used secondary data from the Abortion Patient Survey, the American Community Survey, and the National Survey of Family Growth to estimate abortion rates. We used information from the Abortion Patient Survey to estimate the lifetime incidence of abortion. Results: Between 2008 and 2014, the abortion rate declined 25%, from 19.4 to 14.6 per 1000 women aged 15 to 44 years. The abortion rate for adolescents aged 15 to 19 years declined 46%, the largest of any group. Abortion rates declined for all racial and ethnic groups but were larger for non-White women than for non-Hispanic White women. Although the abortion rate decreased 26% for women with incomes less than 100% of the federal poverty level, this population had the highest abortion rate of all the groups examined: 36.6. If the 2014 age-specific abortion rates prevail, 24% of women aged 15 to 44 years in that year will have an abortion by age 45 years. Conclusions: The decline in abortion was not uniform across all population groups. (Am J Public Health. Published online ahead of print October 19, 2017: e1-e6. doi:10.2105/AJPH.2017.304042).
Chapter
Most women seeking abortion pay out-of-pocket for care, partly due to legal restrictions on insurance coverage. These costs can constitute a hardship for many women. Advocates have sought to ensure insurance coverage for abortion, but we do not know whether the intermediaries between policy and patient abortion-providing facilities are able and willing to accept insurance. We interviewed 22 abortion facility administrators, representing 64 clinical sites in 21 states that varied in their legal allowance of public and private insurance coverage for abortion, about their facility's insurance practices, and experiences. Respondents described challenges in accepting public and/or private insurance that included, but were not limited to, legal regulations. When public insurance broadly covered abortion, its low reimbursement failed to cover the costs of care. Because of the predominance of low income patients in abortion care, this caused financial challenges for facilities, leading one in a state that allows broad coverage to nonetheless decline public insurance. Accepting private insurance carried its own risks, including nonpayment because costs fell within patients' deductibles. Respondents described work-arounds to protect their facility from nonpayment and enable patients to use their private insurance. The structure of insurance and the population of abortion patients mean that changes at the political level may not translate into changes in individual women's experience of paying for abortion. This research illustrates how legal regulations, insurer practices, and the socioeconomics of the patient population matter for abortion-providing facilities' decision-making about accepting insurance.
Article
Since 1976, federal Medicaid has excluded abortion care except in a small number of circumstances; 17 states provide this coverage using state Medicaid dollars. Since 2010, federal and state restrictions on insurance coverage for abortion have increased. This paper describes payment for abortion care before new restrictions among a sample of women receiving first and second trimester abortions. Data are from the Turnaway Study, a study of women seeking abortion care at 30 facilities across the United States. Two thirds received financial assistance, with those with pregnancies at later gestations more likely to receive assistance. Seven percent received funding from private insurance, 34% state Medicaid, and 29% other organizations. Median out-of-pocket costs when private insurance or Medicaid paid were 18and18 and 0. Median out-of-pocket cost for women for whom insurance or Medicaid did not pay was $575. For more than half, out-of-pocket costs were equivalent to more than one-third of monthly personal income; this was closer to two thirds among those receiving later abortions. One quarter who had private insurance had their abortion covered through insurance. Among women possibly eligible for Medicaid based on income and residence, more than one third received Medicaid coverage for the abortion. More than half reported cost as a reason for delay in obtaining an abortion. In a multivariate analysis, living in a state where Medicaid for abortion was available, having Medicaid or private insurance, being at a lower gestational age, and higher income were associated with lower odds of reporting cost as a reason for delay. Out-of-pocket costs for abortion care are substantial for many women, especially at later gestations. There are significant gaps in public and private insurance coverage for abortion.
Article
Objective: To evaluate the implementation of state Medicaid abortion policies and the impact of these policies on abortion clients and abortion providers. Data source: From 2007 to 2010, in-depth interviews were conducted with representatives of 70 abortion-providing facilities in 15 states. Study design: In-depth interviews focused on abortion providers' perceptions regarding Medicaid and their experiences working with Medicaid and securing reimbursement in cases that should receive federal funding: rape, incest, and life endangerment. Data extraction: Data were transcribed verbatim before being coded. Principal findings: In two study states, abortion providers reported that 97 percent of submitted claims for qualifying cases were funded. Success receiving reimbursement was attributed to streamlined electronic billing procedures, timely claims processing, and responsive Medicaid staff. Abortion providers in the other 13 states reported reimbursement for 36 percent of qualifying cases. Providers reported difficulties obtaining reimbursement due to unclear rejections of qualifying claims, complex billing procedures, lack of knowledgeable Medicaid staff with whom billing problems could be discussed, and low and slow reimbursement rates. Conclusions: Poor state-level implementation of Medicaid coverage of abortion policies creates barriers for women seeking abortion. Efforts to ensure policies are implemented appropriately would improve women's health.
Article
The Hyde Amendment bans federal Medicaid funding for abortion in the United States except if a pregnancy resulted from rape or incest or endangers the life of the woman. Some evidence suggests that providers do not always receive Medicaid reimbursement for abortions that should qualify for funding. From October 2007 to February 2008, semistructured in-depth interviews about experiences with Medicaid reimbursement for qualifying abortions were conducted with 25 respondents representing abortion providers in six states. A thematic analysis approach was used to explore respondents' knowledge of and experiences seeking Medicaid reimbursement for qualifying abortions, as well as individual, clinical and structural influences on reimbursement. The numbers of qualifying cases that were and were not reimbursed were assessed. More than half of Medicaid-eligible cases reported by respondents in the past year were not reimbursed. Respondents reported that filing for reimbursement takes excessive staff time and is hampered by bureaucratic claims procedures and ill-informed Medicaid staff, and that reimbursements are small. Many had stopped seeking Medicaid reimbursement and relied on nonprofit abortion funds to cover procedure costs. Respondents reporting receiving reimbursement said that streamlined forms, a statewide education intervention and a legal intervention to ensure that Medicaid reimbursed claims facilitated the process. The policy governing federal funding of abortion is inconsistently implemented. Eliminating administrative burdens, educating providers about women's rights to obtain Medicaid reimbursement for abortion in certain circumstances and holding Medicaid accountable for reimbursing qualifying cases are among the steps that may facilitate Medicaid reimbursement for qualifying abortions.
Article
When enacted in 1965, the original Medicaid legislation sought to finance access to mainstream medical care for the poor. I use data on visits to office-based physicians from the National Ambulatory Medical Care Survey in four years—1989, 1993, 1998 and 2003—to test the extent to which this goal has been achieved. Specifically, I test whether this goal has been achieved more in states that pay higher fees to physicians who treat Medicaid patients compared to states that pay lower fees. By comparing the treatment of Medicaid patients to that of privately-insured patients and by using state fixed effects, I am able to estimate the effects of changes in the generosity of Medicaid physician payment within a state on changes in access to care for Medicaid patients, therefore separating Medicaid’s effect on access to health care from any correlation between the Medicaid fee and other attributes of the state in which a patient lives. Using this method, I examine the effect of Medicaid fees on whether or not an office-based physician accepts Medicaid patients, on the fraction of a physician’s practice that is accounted for by Medicaid, and on the length of visit times with physicians. Results imply that higher Medicaid fees increase the number of private physicians, especially in medical and surgical specialties, who see Medicaid patients. Higher fees also lead to visit times with physicians that are more comparable to visit times with private pay patients. Copyright Springer Science+Business Media, LLC 2007
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