Self-Pay Options Are Critical for True Abortion Equity: Avoiding Gaps in Abortion Access

Acknowledgements: MSFC leaders across Massachusetts medical schools.

Since the overturning of Roe v. Wade in June 2022, access to abortion has been severely limited across the United States. The increasing state-led criminalization of abortion is forcing thousands of people to travel hundreds or even thousands of miles to receive essential abortion services. As medical students in Massachusetts, we feel that it is important to consider where gaps exist in abortion care and how we can best bridge these gaps in care as we train in a state with many protections for abortion care.

Not all states where abortion is legal, provide comparable insurance coverage for abortion care. Eleven states have laws in effect that prevent private insurance companies from covering abortion care; 22 states restrict coverage for public employees; and, 25 states have restrictions on abortion coverage for plans through health insurance exchanges. Additionally, insurance companies can independently decide what type of abortion care to cover, and often reimbursing at rates too low to sustain abortion providers. This has led to fewer clinics being able to accept insurance in recent years.

Financial barriers prevent many patients from accessing abortion care, even in states where abortion is legal. As the Hyde Amendment prevents the use of federal funds for abortion care, patients covered by Medicaid, patients who are federally employed, patients insured through the military, and patients receiving care through the Indian Health Services are prohibited from accessing insurance-covered abortion care. Though some states have elected to cover abortion services in their own statewide health insurance plans, such as MassHealth in Massachusetts, this is rare and relies on ever-changing political norms and legislation.

MassHealth and state-mandated coverage of abortion services helps many residents pay for care. 2022 laws shield providers from laws in other states, regardless of patient location. This is imperative to protect providers who prescribe medication abortion via telehealth. The Obstetrics and Gynecology Department at UMass Chan in Worcester proposed a plan to introduce self-pay options for procedural abortions, which is now being finalized. They hope to propose a similar self-pay plan for medication abortions in the near future. Low-income patients are able to take advantage of discounts proportional to their income. Even with discounts, however, the procedures can be prohibitively expensive. The estimated prices range from $3,000 to $15,000 with the highest discount, $7,000 to $31,000 with the lowest discount, and $12,000 to $52,000 without a discount. A representative of the program stated that self-pay options are primarily offered to out-of-state patients who cannot use their insurance or are not insured. Other hospital systems offering self-pay include Boston Medical Center.

Many academic medical centers do not offer self-pay options for medication or procedural abortion care. While other centers only have self-pay options for medication abortion, such as Beth Israel Deaconess Medical Center in Boston. Patients presenting to these locations in need of self-pay options are usually directed to local Planned Parenthood clinics or other independent abortion facilities in the state.

The Planned Parenthood League of Massachusetts (PPLM) has standardized state-wide self-pay options for both medication and procedural abortions up to a gestational age of 20 weeks and 6 days. The cost of an abortion at PPLM increases with increasing gestational age, from $700 for an abortion up to eleven weeks gestational age to $1400 for an abortion up to 20 weeks gestational age. Beyond 20 weeks, PPLM refers the patient to a hospital system that is able to provide complex abortion care.

Self-pay packages for abortion services are one way to bridge the abortion care coverage gap and provide more access to care to uninsured or underinsured patients, patients whose insurance does not cover abortion services, and those traveling for care. Self-pay packages are predetermined prices for select services. For abortion, these include medication and procedural costs, varying by factors such as location of services and pregnancy gestation. A study of self-pay packages from 2017 to 2020 found that the median cost of medication abortion and first-trimester procedural abortion increased from $495 to $560 and from $475 to $575, respectively. Second-trimester abortion cost decreased from $935 to $895. This study also found that health insurance coverage for abortion care began declining across many states from 2017 to 2020.

In 2021, a Federal Reserve survey showed that 1 in 4 Americans could not cover a $400 emergency expense, less than the cost of the average U.S. self-pay abortion. Patients cannot postpone an abortion to save up without compromising access to care by progressing further into an unwanted pregnancy.

Community-based abortion funds have attempted to fill this gap. Abortion funds are small organizations, usually led by small staff and volunteers, that collect donations from grassroots fundraising, institutional donors, and grants. In 2020, the National Network of Abortion Funds found that over 220,000 people requested help from its member abortion funds, and over 190,000 were given some level of funding. On average, patients were given $215 to cover abortion costs. To use this funding, patients most often must receive care at a clinic that has a “self-pay” option for which the clinic can accept pledges from the abortion funds for payment. This works well for clinics that have standard prices that they can quote patients. However, this model fails when a patient is seen at a clinic that does not have transparent pricing and a “self-pay” option.

As providers seek to make abortion accessible in the post-Roe era, they must consider how patients pay for these services. For those traveling from restrictive states, self-pay becomes the lifeline to essential care. As clinicians strive to provide abortions to all patients in need throughout the US in the post-Roe era, self-pay options must be made more available to remove financial barriers to essential medical care.

From left to right: Jill Jones, Katherine Wasden, Aisvarya (Ash) Panakam, Anna Roselle