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Sexual Studies: Behind the High Cost of Abortion

June 08, 2013
The CSPH

highcostabortionEvery Saturday, The CSPH highlights news or recent research in the field of human sexuality. This week we’re looking at a new study from researchers at the Guttmacher Institute and the University of California—San Francisco that examines how US abortion patients finance these services and how this impacts their economic lives.
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Debates about abortion in typically concentrate on choice, yet for many, access, particularly financial access, is a substantial, superseding factor in that choice. Where abortions in the United States cost at minimum several hundred dollars, and where numerous barriers and restrictions exist legislating how private and public insurance may be used to pay for these services, money matters when we talk about abortion. Low-income and poor people in this country disproportionately experience unwanted pregnancy and the need for abortions, due in large part to a lack of access to health care and services to prevent pregnancy, including education and contraception, how and how much individuals pay for their abortions is a social justice issue. This study aims to understand how specifically insurance and out-of-pocket payments are used to fund abortion services, as well as what other expenses patients incur, and what sorts of assistance they utilize to pay for the experience.
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Demographics/Methodology
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Data for this analysis were taken from a larger study of abortion care patients conducted between May and July 2011 at six abortion providers across the country (located in major cities in Arkansas, California, Georgia, Illinois, New Jersey, and Texas). Respondents were eligible for inclusion if they were a patient at a clinic seeking an abortion or abortion follow-up appointment, were aged 15 or older, and could speak English or Spanish, and were recruited over three to seven consecutive days at each facility.
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Participants completed anonymous surveys via a self-administered iPad-based questionnaire in English or Spanish, assisted by a research assistant, and received $20 remuneration for their participation. Ultimately, 757 individuals were invited to participate, and surveys were collected from 651 of these individuals. The information collected for this analysis included questions on the amount paid for the abortion; where and how those funds were obtained; the relative ease or difficulty in paying for the abortion; out-of-pocket expenses related to transportation, lodging, childcare, and lost wages; and women’s emotions related to the financial resources to pay for abortion care.
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The manuscript provides numerous tables documenting the demographic and other characteristics of the study sample (pp. 19-22). Briefly, however, the age groups of the participants in the study sample approximated those found in the national sample (with 50% below 25 and approximately 25% between 25 and 29) and had similar health insurance coverage percentages (about one-third each by Medicaid, private or other insurance, or none). Participants in this study were somewhat more likely to be unmarried than the national sample and were substantially more likely to be non-Hispanic black (and conversely less of all other races), below 100% of the federal poverty status, and at a later stage in their pregnancy (measured by weeks since last menstrual period).
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What did they find?
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In total, although two-thirds of participants had either private or public insurance, only 22% of these used insurance to pay for their abortion care, with individuals with Medicaid using it to pay for their services twice as often as those with private insurance.
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The most common reason women reported for not using their health insurance to pay for the procedure was because it was not covered by their plan (either learning this from the facility or insurance company themselves or else just assuming that it was not covered). The next most common reason was a lack of knowledge as to whether the procedure would be covered. Other reasons included not wanting to use insurance (including due to a fear of others discovering that they had undergone the procedure) or having their insurance not accepted by the facility. On average, participants paid the clinic $382; however, individuals obtaining second-trimester abortions paid substantially more ($854 on average).
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Forty one percent of all patients in the sample indicated that it was somewhat or very difficult to pay for the procedure. Among participants who received assistance (59% of those not using insurance and 29% of those who were), the male involved in the pregnancy was the most common source (60%), and were equally likely to report receiving a facility discount, using an abortion fund, or obtaining assistance from a family member.
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Beyond abortion services, two-thirds reported incurring additional expenses for transportation (averaging $44); more than a quarter reported about $200 in lost wages, and approximately one in ten had to pay for childcare (averaging about $60). Additionally, to cover expenses, a third of participants in the sample had to delay or forego paying bills, rent, or other expenses.
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Strengths and Weaknesses
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This study had a large sample size and broad eligibility criteria, so its findings can be more representative of the population in general. It also asked detailed and extensive questions about financing to provide lots of useful information. It cannot be taken to be truly representative, though, as it over-represents certain populations (particularly the poor, non-Hispanic blacks, and individuals getting second trimester abortions). However, as this is a descriptive study not intended to test hypotheses, ensuring participation from these groups is important, as they are disproportionately affected by the problem. Additionally, the study manuscript itself suffers from ambiguous or vague reporting, making it challenging as a critical reader to picture the specific methodology and thus appropriately understand its findings.
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Conclusion
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Even with insurance, the majority of participants paid for their abortion services out of pocket due to lack of abortion coverage for their particular plans. Reducing private insurance barriers to abortion may enable access to these services for individuals who cannot afford to pay on their own. As well, given that most people obtaining abortions are poor or low-income, the expansion of Medicaid in states where its coverage extends to abortion may substantively increase access for residents of those states, while conversely, eliminating Medicaid restrictions against abortion services may assist those individuals who currently cannot afford abortion services because of Medicaid limitations in their state. This study also shows that the cost of receiving an abortion is more complex than meets the eye: it increases as one progresses further into their pregnancy, and also involves numerous other factors, including transportation, missing wages, and childcare. As there are still numerous areas of the country where abortion providers, or facilities that will provide second-trimester abortions, cannot be found for miles, keeping these issues in mind are vital for ensuring abortion services for those in need.
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Citation:
Jones, R.K., Upadhyay, U.D., & Weitz, T.A. (2013). At what cost?: Payment for abortion care by U.S. women. Women’s Health Issues, 23(3): p. e173-e178.

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