Some states are moving to limit abortion coverage under the Affordable Care Act. (Chris Greenberg/Bloomberg News)

Arizona could soon become the latest state to block women from purchasing insurance plans through the federal health-care exchanges that cover abortion. The trend started soon after the Affordable Care Act created the marketplaces, granting states the power to decide if and how Obamacare plans cover termination.

Supporters argue Arizona’s controversial measure will stop taxpayer money from funding procedures some deem immoral. The bill sailed through the state House and Senate this week, and it now awaits approval or veto from Gov. Doug Ducey, a Republican.

After the Affordable Care Act passed, President Obama signed an executive order emphasizing no federal funds can be used to cover abortions beyond the Hyde Amendment limitations. In other words, the government won’t pay for terminations unless a woman’s life is threatened, or unless the pregnancy resulted from rape or incest.

Some Republicans don’t think that’s nearly enough. It’s hard to track if insurers are truly separating funds, they say. Last year, the Government Accountability Office examined 18 plans in 10 states with no laws restricting abortion coverage. They found 17 of 18 issuers were not separately billing consumers.

The bill’s detractors, however, point out that paying for so-called “elective” abortions with federal dollars is already illegal. The Arizona bill won’t save any ideologically opposed taxpayers a dime, they say; but it will further limit health-care options for the neediest women.

As of last year, more than 1,000 plans in 28 states provide some coverage for elective abortions. Twenty-four states restrict coverage for service. Five have also passed laws banning coverage under private insurance markets. The Kaiser Family Foundation created a handy map showing coverage differences across the country:


Map courtesy of the Kaiser Family Foundation

Health economists argue squashing access to abortion contributes to a disproportionately high rate of unplanned births among low-income women, who have the least resources to absorb the economic shockwaves of unexpected family additions. That drives inequality.

Well-off women who face unplanned pregnancies are far more likely to have abortions, recent research from the Brookings Institution found: Thirty-two percent of those surveyed in the highest income bracket had an abortion in the past year, compared to 9 percent of poor pregnant women, likely deterred by financial barriers.

Equalizing abortion rates, researchers calculated, could reduce the unintended birth ratio by a third.


Graphic courtesy of the Brookings Institution

About 40 percent of the country’s estimated 3.1 million uninsured women of reproductive age (and who are eligible for tax credits) can enroll in a marketplace plan that provides abortion coverage, according to Kaiser data. Sixty percent, however, don’t have that option. Roughly 1.76 million women live in states that banned abortion coverage through Obamacare plans.

That creates staggering out-of-pocket costs for women seeking the procedure. A clinic-based abortion at 10 weeks gestation costs between $400 and $550, Kaiser reports said. An abortion at 20 weeks — which can be recommended if a woman is having severe but not necessarily life-threatening health problems, or if serious abnormalities are detected in the fetus — can cost more than $1,600.

Limiting access to the procedure in some areas might fuel health disparities across racial groups. A study published this year found black newborns covered by Medicaid were nearly twice as likely to die from an anomaly in states without Medicaid coverage of abortion as in states with such coverage.

And curbing termination in, say, Arizona might not reduce the country’s aggregate number of procedures performed. A NBER paper analyzing abortion rates from 1974 to 1988 found implementing restrictions on Medicaid funding for abortion diminished the amount of in-state services but drove up rates among nearby states, “suggesting one of the main effects of these policies is to induce cross-state migration for abortion.”

The GAO report didn’t investigate whether providers illegally used federal subsidies to pay for elective procedures, The Post’s Michelle Ye Hee Lee notes over on Fact Checker. The Department of Health and Human Services has since issued new regulations to clarify abortion billing requirements.

The Arizona Section of the American Congress of Obstetricians and Gynecologists “strongly opposes” the latest procedure-blocking bill because it “allows the Arizona government to decide what private insurance plans can offer to patients,” Eric Reuss, treasurer of the medical group, wrote in a recent column for the Arizona Republic. “The exclusion of abortion coverage from marketplace plans denies women the option to choose insurance that covers all manner of health care.”

Abortion coverage, arguably the most hotly debated issue in American health care, was among the last issues negotiated when lawmakers passed the Affordable Care Act. The compromises necessary to move the law forward satisfied pretty much no one, regardless of political leanings.

Before Obamacare became law, the House passed an amendment that would have prohibited any plans in the marketplaces from receiving federal subsidies if they covered abortion. Democrats quickly rallied against the measure, proposing instead that states could individually prohibit abortion coverage in their ACA health insurance marketplace, and plans providing such coverage must divide funds so that no federal dollars are spent on the services.

Nowadays, some states use their own funds to cover medically necessary abortions. Some have opted to prevent private insurers from covering the procedure. Several have enacted private plan restrictions and have also banned abortion coverage from Obamacare plans -- some more restrictive than the Hyde limitations. And the economic disparities persist.

 

*An earlier version of this post miscounted the number of women living in states that banned abortion coverage through Obamacare plans.

*