Financial Hardships Caused by Out-of-Pocket Abortion Costs in Texas, 2018

Abstract

Objectives. To identify financial hardships related to costs of obtaining abortion care in Texas, which has the highest uninsured rate in the United States and restricts insurance coverage for abortions.

Methods. We surveyed patients seeking abortion at 12 Texas clinics in 2018 regarding costs and financial hardships related to abortion care. We compared mean out-of-pocket costs and the percentage reporting hardships across income and insurance categories.

Results. Of 603 respondents, 42% were Latinx, 25% White, and 21% Black or African American, and most (62.0%) reported having low incomes (< 200% federal poverty level). Mean out-of-pocket costs were $634, which varied little across insurance groups. Patients with low incomes were more likely to obtain financial assistance from an abortion fund than were wealthier patients (12.3% vs 1.6%, respectively; P < .05). Financial hardships related to abortion costs were more common among uninsured (57.6%) and publicly insured (55.1%) patients than those with private insurance (48.2%). One in 5 (19.8%) uninsured respondents delayed buying food to pay for abortion care.

Conclusions. Restrictions on insurance coverage for abortions result in high out-of-pocket costs and major financial hardships for most patients with low incomes in Texas. (Am J Public Health. 2022;112(5):758–761. https://doi.org/10.2105/AJPH.2021.306701)

Health care services are increasingly unaffordable for low- and middle-income US families because of copayments and deductibles and high uninsured rates, especially in states that have not expanded Medicaid under the Affordable Care Act.¹ Although abortion access is associated with greater long-term financial stability,² patients paying out of pocket (often in excess of $500) may experience financial hardships (e.g., delaying or being unable to pay for food, bills, or rent). People living in or near poverty, who make up the majority of those obtaining abortions,³ are especially vulnerable.

Texas has not expanded Medicaid eligibility and has the nation’s highest uninsured rate.⁴ Like 32 other states, Texas’s Medicaid program excludes abortion care except in cases of rape, incest, and life endangerment. Texas also restricts coverage for abortion care in private insurance plans. We surveyed Texas abortion patients to determine the prevalence of financial hardships related to out-of-pocket costs of obtaining care.

METHODS

We recruited patients seeking abortion care in 7 Texas cities between June and December 2018. We selected independent and Planned Parenthood–affiliated facilities that offered both medication and procedural abortions up to at least 14 weeks since patients’ last menstrual period.

A study coordinator approached patients seeking abortion in facility waiting rooms. Eligibility criteria included being aged 18 years or older, being English or Spanish speaking, and having completed the preabortion ultrasound required by Texas law. Participants completed the self-administered survey on a tablet at their preabortion consultation, abortion, or follow-up visit after providing digital informed consent. Participants received a $20 gift card.

The survey collected demographic information, reproductive health history, and preferences regarding abortion care, and drew from previous studies assessing patients’ access to abortion care.^5,6 We classified participants with incomes of less than 200% of the federal poverty level (FPL; $3463 monthly for a family of 3 in 2018 per the 2018 Department of Health and Human Services poverty guidelines) as having low incomes.

Primary outcome variables for this analysis included patients’ self-reported out-of-pocket costs for abortion care, whether they received financial assistance from abortion funds (nonprofit organizations that help cover some costs), and whether they experienced financial hardships, including needing to sell valuable possessions or delaying expenses (rent, bills, food, childcare, medical care, or other expenses) to pay for abortion care. Using Stata version 16.1 (StataCorp LP, College Station, TX), we compared the mean out-of-pocket costs and the percentage reporting financial hardships across insurance types and income groups, with SEs adjusted for clustering at the clinic level.

RESULTS

A total of 603 people completed the survey; 42% were Latinx or Hispanic, 25% White, and 21% Black or African American. At 11 (of 12 total) facilities where research staff approached patients directly, the response rate was 76%. (Response rates at the final remaining clinic were not available because staff there referred interested patients to a research assistant.) About half (46%) of respondents were uninsured, and 8% were covered by public insurance (Medicaid, Tricare, VA, or Medicare). Most (62%) respondents had incomes of less than 200% of the FPL, and 40% (including 47% of those with lower incomes) had experienced a financial hardship in the preceding year. Ninety-four percent of respondents received an abortion during the first 13 weeks and 6 days since the respondent’s last menstrual period, and 4% between 14 and 22 weeks.

The mean cost of abortion care was $634 and ranged from $586 for participants with public insurance to $644 for privately insured participants (Table 1). Fewer than 1 in 12 (8%) respondents received financial assistance from an abortion fund; lower-income patients were more likely than those with incomes at 200% or more of the FPL to receive such assistance (12.3% vs 1.6%; P < .01).

TABLE 1—

Patients’ Costs and Financial Hardships Related to Obtaining Abortion Care in Texas: 2018

	Insurance Coverage			Income		Total (n = 603)
Uninsured (n = 278)	Public (n = 49)	Private (n = 249)	< 200% FPL (n = 374)	≥ 200% FPL (n = 187)
Mean out-of-pocket cost, $	634	586*	644	617	667	634
Abortion costs caused financial hardship, %	57.6*	55.1	48.2	61.2*	38.0	53.0
Sold something of value, %	27.3*	18.4*	10.0	23.8*	10.2	18.9
Delayed expenses, %
Rent	13.0*	4.1	4.8	11.0*	3.7	8.3
Bills	29.5	32.7	28.1	34.0*	18.7	28.0
Food	19.8*	8.2	10.0	17.1*	9.6	14.4
Childcare	3.2	4.1	1.2	3.2	1.1	2.3
Other health care	4.0	2.0	1.6	3.7	2.1	3.0
Other nonmedical services	20.1	18.4	16.9	22.2*	12.8	18.4
Received assistance from an abortion fund, %	11.9*	14.3*	3.2	12.3*	1.6	8.3

Note. FPL = federal poverty level as determined by the 2018 Department of Health and Human Services poverty guidelines. In 2018, 200% of FPL was $3463 monthly for a family of 3.

^*P < .05 for comparison of means or proportions between insurance and income categories, with SEs adjusted for clustering at the clinic level and where private insurance and income ≥ 200% FPL are reference groups.

More than half of uninsured (57%) and publicly insured (55%) patients reported financial hardship related to the cost of their abortion, compared with 48% of privately insured respondents. Three fifths (61%) of low-income respondents experienced financial hardship, compared with 38% of respondents with incomes at or below 200% of the FPL.

Overall, 19% of respondents sold something of value to pay for abortion care, and this was most common among low-income (24%) and uninsured (27%) respondents. One in 5 (20%) uninsured respondents and 17% of low-income respondents reported that they delayed buying food to pay for their abortion. The most common financial hardships related to out-of-pocket abortion costs were delayed bills (28%) and delayed nonmedical expenses (18%).

DISCUSSION

Patients in our study frequently reported financial hardships related to paying out-of-pocket abortion costs. More than 1 in 6 patients reported selling something of value, and 14% delayed buying groceries. Our study supports previous research from Texas,⁶ Arizona,⁵ and across the United States⁷ that finds substantial financial hardship related to abortion costs.

Financial hardships attributed to abortion were common regardless of insurance status. Although some states use nonfederal funds to cover abortion care in Medicaid programs, Texas—like most other states—does not, which may explain why publicly insured and uninsured patients reported similar rates of financial hardship. Publicly insured respondents’ somewhat lower out-of-pocket costs ($586 vs $644 for privately insured respondents) may be attributable to clinics offering “sliding scale” financial assistance to low-income patients or to those experiencing rare exceptions (rape, incest, life endangerment) that allow public plans to cover abortion services. Privately insured respondents’ relatively high rates of financial hardship because of abortion costs are likely related to a Texas law prohibiting private “marketplace” plans from covering abortion care, in addition to high deductibles, fear of unwanted disclosure, and bureaucratic barriers.

Our sobering finding that 1 in 5 uninsured women seeking abortion care delayed buying food for their family is consistent with research showing that food insecurity is associated with out-of-pocket medical expenses.⁸ Abortion care, because it is often uniquely excluded from insurance coverage, may be more likely to lead to food insecurity than other unexpected medical conditions. Notably, difficulty paying for food was attenuated for patients covered by Medicaid, perhaps because they were also eligible for the Supplemental Nutrition Assistance Program.

Most people living in poverty are unable to afford an unexpected $400 expense of any type,⁹ which is less than the typical out-of-pocket cost for abortion care in our study. Some abortion restrictions in Texas and other states, such as those requiring patients to make 2 in-person visits and allowing only physicians to provide abortion care—despite evidence that advanced practice clinicians can safely provide first-trimester abortion care¹⁰—increase costs to patients.¹¹ Out-of-pocket costs will likely increase under Texas’s recent ban on abortion after approximately 6 weeks since the last menstrual period, causing many patients to have to pay for travel, missed work, childcare, and other expenses.

The Women’s Health Protection Act, introduced in both the House of Representatives and the Senate, would provide insurance coverage for abortion care to people with Medicaid and prohibit states from limiting abortion coverage in private plans. These changes, as well as allowing nonphysicians to provide abortion care and eliminating other restrictions not supported by medical evidence, would be meaningful steps toward achieving equity in access to reproductive health services.

Our study has several limitations. Our findings may not be generalizable to other states or to minors (who we excluded because of privacy concerns). We did not verify respondents’ self-reported out-of-pocket payments with providers. Poverty-related stigma may have led some respondents to underreport financial hardships, leading to underestimation of abortion cost–related difficulties. We did not quantify the dollar value of items sold or expenses delayed to pay for abortion care.

PUBLIC HEALTH IMPLICATIONS

Restrictions that limit insurance coverage for abortion care contribute to major financial hardships for patients. State and federal policymakers should reconsider insurance restrictions on abortion care, which disproportionately harm low-income families.