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Abortion Coverage And Health Reform: Bringing Evidence To Bear



January 13th, 2010

Editor’s Note: In addition to Kathryn Phillips and Daniel Grossman (pictures and bios above), coauthors of this article include Tracy Weitz, the Director of the Advancing New Standards in Reproductive Health (ANSIRH) program and Assistant Professor in the Department of Obstetrics, Gynecology and Reproductive Sciences, both at the University of California, San Francisco (UCSF); and James Trussell, Professor of Economics and Public Affairs and Director of the Office of Population Research at Princeton University.

Divisions over abortion are a major obstacle for health reform legislation. To examine how much uninsured individuals, who will be covered under health reform, currently pay out-of-pocket for health care, and how this compares to costs of abortion care, we used expenditure data from the Agency for Healthcare Research and Quality’s nationally representative Medical Expenditure Panel Survey (MEPS). Although the data are from 2006, they are the most recent available and are widely used to address policy questions.

We focused on the uninsured, as they are a key target for health reform. We also focused on individuals ages 25-34, as this group is more likely to be uninsured and to have abortions than older individuals. We excluded those with $0 health care expenditures (including out-of-pocket expenditures and expenditures by payers) to avoid bias due to skewness. Data were weighted to reflect the U.S. population.

The median cost of first-trimester abortion care ($430) is almost twice the typical out-of-pocket health care expenses paid by young, uninsured individuals, and the median cost of second-trimester abortions ($1,260) is about four times typical out-of-pocket expenses. Our results suggest that those most in danger of having financial barriers to health care are those who might have to pay disproportionate out-of-pocket costs for abortions under proposed health reform legislation. 

Detailed Findings: We found that for all individuals ages 25-34, the median out-of-pocket expenditure was $258, which represents 0.82 percent of personal income, and that 7.34 percent of individuals pay more than 10 percent of their income on health care. Among uninsured individuals ages 25-34, we found that the median out-of-pocket expenditure was $229, which represents 1.25 percent of personal income, and that 13.68 percent of individuals pay more than 10 percent of their income on health care.

Among uninsured females ages 25-34, we found that the median out-of-pocket expenditure was $265, which represents 1.89 percent of personal income, and that 20.13 percent of these individuals pay more than 10 percent of their income on health care. We also found that uninsured females ages 25-34 pay more out of pocket for health care than their male counterparts (median $265 versus $205). The percentage of out-of-pocket expenditures relative to income for young, uninsured females is twice that for similar males (1.89% vs. 0.98%).

Uninsured individuals ages 25-34 who reported difficulty obtaining needed care in the past year had higher out-of-pocket costs than uninsured individuals not reporting difficulty (median $313 vs. $213).

Although the median estimates may not be precise both because of the age of the data and possible underestimates of out-of-pocket costs, the data should be relatively accurate and thus our findings would be unlikely to change.

DiscussionAs stated above, the median cost of first-trimester abortion care ($430) is almost twice the typical out-of-pocket health care expenses paid by young, uninsured individuals, and the median cost of second-trimester abortions ($1,260) is about four times typical out-of-pocket expenses. The cost of a first-trimester abortion represents 4 percent of income for uninsured females ages 25-34.

Females and individuals who have difficulties obtaining needed health care have relatively higher out-of-pocket expenses and thus will be more affected by a lack of abortion coverage. This is particularly true for women who need second-trimester abortion because of health risks or fetal impairments or who are already paying a large portion of their income on health care.

Furthermore, uninsured women currently pay twice as much out of pocket for medical care – relative to income – compared to uninsured men, and this gender disparity is even more pronounced if payment for abortion care is required.

We recognize that much is unknown about the actual impact on women if the proposed abortion restrictions remain part of health reform legislation. Women with employer-sponsored insurance will not be affected, at least initially, and some insured women currently pay out of pocket for abortions. However, it is well documented that financial barriers, including small increases in out-of-pocket costs, decrease access to appropriate and timely care, often resulting in even greater economic and emotional costs, not only to the individual but also to society.

The concern is that proposed restrictions within health care reform further marginalize abortion services as different from other health care. Although the annual incidence continues to decrease, 1.21 million abortions were performed in the United States in 2005, making this one of the most common procedures undergone by women, and about 40 percent of women will get an abortion in their lifetime.

We respect that there are competing perspectives on the ethics of abortion coverage.  However, these nationally representative data suggest that two of the goals of health reform – to equalize access to care and reduce barriers to timely receipt of care – could be compromised if additional abortion restrictions are included in health reform legislation.  

 This research was partially funded by the William and Flora Hewlett Foundation. The authors are grateful to Su Ying Liang for data analyses.

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