Bringing evidence to the debate on abortion coverage in health reform legislation: findings from a national survey in the United States

1. Introduction

Divisions over abortion are a major obstacle for health reform legislation in the United States [1]. We use nationally representative data from a government survey 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.

2. Methods

Data are from the Medical Expenditure Panel Survey (MEPS). MEPS is sponsored by the Agency for Healthcare Research and Quality and provides nationally representative information based on data from patients, providers, and pharmacies (www.meps.ahrq.gov). MEPS defines expenditures as the sum of (1) out-of-pocket (OOP) costs and (2) payer payments, excluding premiums and over-the-counter drugs. Although data are from 2006, they are the most recent available and they 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 years as this group is more likely to be uninsured and to have abortions than older individuals [2]. We excluded those with $0 expenditures to avoid bias due to skewness. Data were weighted to reflect the US population.

3. Results

Annual out-of-pocket costs are:

Among all individuals ages 25–34 years:

• The median OOP expenditure is $258, which represents 0.82% of personal income

• 7.34% of individuals pay >10% of their income on health care.

Among uninsured individuals ages 25–34 years:

• The median OOP expenditure is $229, which represents 1.25% of personal income

• 13.68% of individuals pay >10% of their income on health care.

Among uninsured females ages 25–34 years:

• The median OOP expenditure is $265, which represents 1.89% of personal income

• 20.13% of individuals pay >10% of their income on health care.

Uninsured females ages 25–34 years pay more OOP than similar males (median $265 vs. $205).

• The percentage of OOP expenditures relative to income is twice that for young, uninsured females compared to similar males (1.89% vs. 0.98%).

• Uninsured individuals ages 25–34 years who reported difficulty obtaining needed care in the past year had higher OOP 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 OOP costs, the data should be relatively accurate and thus our finding would be unlikely to change.

4. Discussion

The median cost of first-trimester abortion care ($430) is almost twice the typical OOP health care expenses paid by young, uninsured individuals, and the median cost of second-trimester abortions ($1260) is about four times typical OOP expenses [3]. The cost of a first-trimester abortion represents 4% of income for uninsured females ages 25–34. Females and individuals who have difficulties obtaining needed health care have relatively higher OOP expenses and thus will be more impacted by a lack of abortion coverage. This is particularly true for women who need second-trimester abortion for health risks or due to fetal impairments or who are already paying a large portion of their income on health care. Furthermore, uninsured women currently pay twice as much OOP 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 impacted, at least initially, and some insured women currently pay OOP for abortions [4] However, it is well-documented that financial barriers, including small increases in OOP 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 [5, 6].

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% of women will have an induced abortion in their lifetime [3]. Our results suggest that those most in danger of having financial barriers to health care are those who may pay disproportionate OOP costs for abortions under proposed health reform legislation. 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.