Patients paid increasingly more for medication abortion and first-trimester procedural abortion from 2017 to 2020, while the percentage of facilities accepting health insurance declined, researchers found.

From 2017 to 2020, median patient charges for medication abortion rose from $495 to $560, representing a 13% increase, which was higher than healthcare inflation alone, at 8%, according to Ushma Upadhyay, PhD, MPH, and colleagues from the University of California San Francisco, who reported their findings in Health Affairs.

Also, first-trimester procedural abortions increased from $475 to $575, representing a 21% increase, the study found.

“We already know that collecting the money to pay for an abortion is extremely burdensome on patients,” Upadhyay told MedPage Today. “So these rising costs, coupled with increasing restrictions, really are putting abortion care out of reach for many people.”

One major reason that women pay for abortions is the Hyde amendment, a law that prevents federal funds from being used to pay for abortion services, including plans for Medicaid recipients, federal employees, military personnel, and Peace Corps volunteers, she noted.

Black and Hispanic patients are among those most impacted by Hyde restrictions as they are disproportionately insured by Medicaid, the authors said.

Sixteen states use their own funds to pay for abortions for low-income women enrolled in Medicaid, Upadhyay added, but others have doubled down on insurance restrictions and prevented private insurers, by law, from covering abortion services. Even in states where Medicaid does cover abortion through state funding, low reimbursement rates and increasing costs compel some facilities to refuse insurance, Upadhyay added.

The upshot is the same. Patients without the funds to pay for abortions often delay care or give up seeking an abortion entirely, she said. In fact, time to raise money for travel and procedure costs was the number one reason that patients who were denied the service due to gestational age limits reported delaying seeking an abortion.

The trend in rising self-pay charges during the first trimester matters, explained Upadhyay, because most abortions occur during the first trimester — approximately 93%, according to a 2021 Morbidity and Mortality Weekly Report study.

Upadhyay and colleagues did not ask clinics to explain the rationale for the increased charges. However, prior studies found that factors have included rent, staff salaries, security, equipment, liability insurance, and restrictions calling for states to meet certain standards in order to operate, she said.

One of the most common restrictions are ambulatory surgical requirements, which mandate that any facility providing abortions must be equipped with a surgical center.

Upadhyay co-authored a 2018 JAMA study that showed no difference in complications whether an abortion was done in an ambulatory surgery center or an office-based setting, and “So, that is a requirement that is not based in any evidence but increases facility costs dramatically,” she said.

The percentage of facilities accepting insurance for abortion fell from 89% to 80% during this time. Facilities in Southern states and the Midwest showed the lowest acceptance of insurance, Upadhyay said.

The study concludes that eliminating Hyde restrictions and mandating that both public and private health insurance cover abortion without any copay or deductible would “greatly reduce the financial burden of abortion.”

However, Upadhyay told MedPage Today that as abortion becomes more heavily regulated, patient charges will continue to increase. And if the Supreme Court allows states to impose “gestational bans,” like Mississippi’s prohibition on abortion after 15 weeks, facilities will raise self-pay charges to make up for lower patient volumes.

Study Details

Data were collected using the Advancing New Standards in Reproductive Health’s Abortion Facility Database and were updated each summer from 2017 to 2020.

Researchers tracked each facility’s address, self-pay charge for medication, first trimester or second trimester abortion, and whether they accepted insurance.

Upadhyay and colleagues located 751 to 776 publicly advertised abortion facilities throughout the study period. The largest share of facilities were located in the West and Northeast.

Charges for second-trimester abortions fell from $935 to $895, a drop of 4%, said Upadhyay, but that trend may have been influenced by gaps in the data. Researchers did not track charges for second trimester abortions in 2019, and some “facilities were unable to give a self-pay price,” they wrote.

Upadhyay and her colleagues also saw wide variation in self-pay charges across regions. Median prices for medication abortions and first-trimester procedural abortions were lowest in the South Atlantic and highest in the North Central region.

“Between 2017 and 2020 the Northeast and South saw a decrease in the number of open facilities … whereas the Midwest and West saw an increase,” the study noted.

Researchers did not track how each data point was arrived “and thus we were unable to analyze whether the method affected the results,” the study noted.

Also, some facilities only provided a range of charges rather than “exact charge data” and some shared no charges at all. In addition, because researchers used only the charges listed on facility websites for 2017, 2019, and 2020 “fewer than half of facilities were represented.” Costs of second-trimester abortions also varied widely based on gestational age.

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