Patients often have to fight for coverage, even if their plans include the procedure.

Demonstrators show support for Planned Parenthood and reproductive rights in Chicago, Illinois on February 10, 2017.
 Photo by Scott Olson/Getty Images

Erika Christensen’s pregnancy ended at 32 weeks. But her fight to get her abortion covered by insurance had just begun.

In 2016, Christensen found out that the baby she was carrying had abnormalities that doctors called “incompatible with life.” “If it made it through birth, it would choke to death and die,” said Garin Marschall, Christensen’s husband. Christensen, now 36, and Marschall, 39, had very much wanted the child, which would have been their first. But after doctors gave them the bad news, they decided on abortion.

New York state, where they lived, bans the procedure after 24 weeks unless the mother’s life is at risk. Since there was no immediate risk to Christensen, she had to travel to a clinic in Colorado, one of only a few states with doctors who perform late-term abortions, an experience she has described in interviews at Jezebel. Her insurance covered abortion, but the clinic didn’t take it. So Christensen paid $10,000 out of pocket, which her mother withdrew from her 401k.

After the procedure, Christensen requested a reimbursement from her insurance company. She got back about $800. She asked the company to review the decision, which meant months of waiting and hours on the phone.

Ultimately, the insurance company reimbursed her around $3,000. The experience, so soon after the loss of a wanted pregnancy, prolonged her family’s pain and “kept us from being able to just start the grieving process,” Christensen said. “It felt like abuse to have these conversations again and again.”

Christensen’s experience is unusual in some ways — most abortions take place early in pregnancy and cost far less. But her struggle with insurance is surprisingly common — even insurance that ostensibly covers abortion may not actually pay for the procedure. That leaves patients scrambling to pay their bills out of pocket or even trying to do the procedure at home. And it leaves clinics with difficult choices, as Katrina Kimport and Brenly Rowland, researchers from Advancing New Standards in Reproductive Health (ANSIRH), a group at the University of California, San Francisco, note in a study released to the public Thursday. Given the insurance landscape, they write, “facilities might reasonably conclude that they cannot afford to take insurance and keep their doors open.”

Insurance coverage for abortion is often insufficient, even in states that allow it

Most people who get abortions pay out of pocket because they’re uninsured, they don’t want to go through their insurance (sometimes they’re worried an insurance bill could lead to family members finding out about the procedure), or their state restricts insurance coverage for abortion.

The Hyde Amendment bans the use of federal Medicaid funding to pay for abortions except in cases of rape, incest, or a threat to the mother’s life; 22 states have similar restrictions on state Medicaid funds. Meanwhile, 26 states restrict abortion coverage in private plans offered on the insurance exchanges, and 11 restrict abortion coverage in all private plans.

But even if patients have insurance that covers abortion, they or the clinic may end up footing the bill, according to the UCSF study. Kimport, a sociologist, and Rowland, an interviewer, talked to administrators in charge of 64 clinics in 21 states. They found that even in states where Medicaid was legally allowed to cover abortion, some Medicaid insurance providers declined to cover the procedure.

Private insurance presented similar roadblocks. In many states that don’t restrict private coverage of abortion, insurers can still choose whether to offer it or not. And some impose restrictions that conflict with the realities of abortion care.

One insurer would only pay for medication dispensed by a pharmacist, according to a doctor quoted in the study. But the FDA requires medication abortion, which accounts for nearly a third of all abortions, to be administered to a patient by a clinician, not a pharmacist. “I fought and fought” with one insurer to get medication abortion covered, said the doctor. After eight years of trying to challenge the rule, the doctor said, “I finally just gave up.”

Because of the way another insurer’s policies are written, abortion could only be reimbursed for patients over 12 years old, Kimport said. “When they had a patient who was under 12, there was simply not a way to get that reimbursed.”

For patients, insurance problems can have disastrous effects

When insurance companies fail to cover abortion, patients can suffer, especially if they live at or near the poverty line. They may need to delay while they get the money together, resulting in a later and costlier procedure, said Daniel Grossman, director of ANSIRH. The average cost of an abortion at 10 weeks is around $500; by 20 weeks, that rises to around $1,500. Financial obstacles can also push women to try to self-induce an abortion, potentially putting their lives at risk.

For low-income women, abortion costs can mean going without necessities. In her work with an abortion fund in California, Destiny Lopez, now co-director of the group All* Above All, saw women who were forgoing rent or food to pay for their abortions. “I vividly remember the day that I provided literally a tank of gas to a young couple that had to have a termination,” she said.

Even for those who are able to rely on family members for money, the experience of fighting with insurance companies can take a toll. Kate Carson had an abortion at 36 weeks after finding out that her daughter had a fatal brain abnormality. That meant coming up with $25,000 with just a weekend’s notice — her parents took the money out of their retirement account. Carson had insurance through Blue Cross Blue Shield, but since she had to travel out of state, from Massachusetts to Colorado, her insurer only reimbursed her a small amount of the total. “Every bill that came in the mail and every refusal from insurance was like a knife in my heart,” she said.

A representative from Blue Cross Blue Shield of Massachusetts said that employers decide which services their plans cover. If a service is covered and a patient receives it out of state, the reimbursement is typically based on how much a Blue Cross Blue Shield plan in that state would pay.

Patients choose late-term abortion for a variety of reasons. Jenny, who asked that her last name not be used, decided to seek an abortion after she found out her baby had a major heart defect that would likely leave him in a vegetative state, dependent on a ventilator and feeding tube. “I’m a nurse and I know how this stuff goes,” she said. “I didn’t want him to have that quality of life.”

Christensen considered carrying her child to term, even though a previous surgery meant she would have to have a C-section. But she realized that he would probably die soon after delivery “if he even made it that far,” she told Jezebel. Ultimately, she said, “I couldn’t put him through that suffering when we had the option to minimize his pain as much as possible.”

Insurance problems also put clinics at risk

The idiosyncrasies of insurance coverage for abortion also mean clinics may never get reimbursed for the abortions they perform. In states where Medicaid does cover abortion, reimbursement rates for the procedure are typically very low. The Medicaid reimbursement “doesn’t even come close to the expenditures” for an abortion, a counseling manager at one facility told Kimport and Rowland.

Medicaid reimbursements are low for many services, but since patients seeking abortions are disproportionately low-income, abortion clinics see an especially high percentage of patients with Medicaid. That means low reimbursement rates can pose a serious threat to a clinic’s survival. Some clinics have to make an uncomfortable choice between accepting Medicaid — and potentially going out of business — or declining the insurance so they can continue to see patients, Kimport and Rowland note.

Reimbursement rates are generally higher for private insurance, but the many restrictions and quirks involved mean clinics can never be sure if an insurer will pay them. “Providers are always rolling the dice,” said Kimport. Some practices choose not to accept private insurance — the Boulder Abortion Clinic, where Christensen had her abortion, has a contract with Kaiser but does not take other public or private insurance.

Meanwhile, some abortion practices have costs that neither public nor private insurance reimbursements truly reflect. Dr. Warren Hern, who performed Christensen’s abortion, estimates that 50 percent of what his patients pay goes toward security for his practice. “Pediatricians do not have to have armed guards and bulletproof windows,” he said. “We do.”

Changing the insurance picture starts with changing the law — but it doesn’t end there

Since their experience, Christensen and Marschall have become advocates for the Reproductive Health Act, which would make abortion after 24 weeks legal in New York state if the fetus is not viable or if the mother’s health is threatened. That would allow women in Christensen’s situation to stay in New York and get abortions from in-network doctors, making it more likely for insurance to cover the procedure. New York allows state Medicaid coverage for abortion, and most private insurers also cover the procedure, said Liz Krueger, a state senator and sponsor of the bill.

The Reproductive Health Act has passed the state assembly but not yet received a vote in the Republican-dominated state senate. Krueger is hopeful that it might move forward when the senate comes back into session in January 2018. Public opinion is on the bill’s side, she said, and in an election year, senators may be especially motivated to listen to their constituents’ concerns. The Trump administration has created anxiety and an appetite for change on many issues, she said. “There’s real momentum in New York state for voters to say, ‘We don’t trust Washington, we need this done here.’”

A few other states have recently passed similar laws. The Reproductive Health Equity Act, passed in Oregon this year, requires insurers, including the state’s Medicaid program, to cover abortion at no cost to the patient.

But one of the biggest barriers to insurance coverage for abortion around the country is the Hyde Amendment. Though it restricts only federal funding for abortion, it affects the private insurance markets as well, since many private insurers take their cues from the federal Centers for Medicare and Medicaid Services, said Marschall, who has become something of an insurance expert since Christensen’s abortion.

The EACH Woman Act, introduced in the House in January, would repeal Hyde, allowing Medicaid recipients, government employees, and anyone else with government-sponsored health care to receive coverage for abortion. It would also bar states from banning abortion coverage in private plans on the exchanges.

There’s likely little appetite in the current Congress for repealing Hyde. But advocates for the bill are realistic about their approach, said Lopez. “We know that if we’re undoing 42 years of bad policy, it’s not going to take one Congress to fix that,” she explained. “What’s important about the bill is it allows us to have a conversation we haven’t had in this country about public and private insurance coverage of abortion.”

Even repealing Hyde wouldn’t necessarily fix the problem of low reimbursement rates, as Kimport and Rowland note. Simply allowing Medicaid to cover abortion wouldn’t mean that clinics would actually get reimbursed for the full cost of the procedure. But advocates are at work on the state level to try to raise rates, Lopez said. Sometimes that means working with groups trying to raise rates for other services, she added. “Some of these issues are larger than just abortion care.”

The barriers to change are many, but advocates like Christensen remain committed to the fight. Until New York changes its law, “I will feel like I’m not allowed to grieve,” she said. “I’m going to stay acutely angry and rageful until it’s made right.”