Association of Medicaid Expansion With Access to Abortion Services for Women With Low Incomes in Oregon

Online Medication Abortion Direct-to-Patient Fulfillment Before and After the Dobbs v Jackson Decision

Importance

Online pharmacies have emerged as stakeholders in abortion care since the US Food and Drug Administration (FDA) relaxed in-person dispensing requirements in 2020. The role of online pharmacies in dispensing abortion medications following the Dobbs v Jackson Women's Health Organization decision on June 24, 2022, is understudied.

Objective

To describe medication abortion prescription fulfillment patterns for 1 online pharmacy 1 year before and after the Dobbs v Jackson decision, considering patient, prescriber, and state policy characteristics.

Design, Setting, and Participants

This cross-sectional study assesses deidentified medication abortion prescription fulfilment data from 1 online pharmacy. Prescribers sent prescription requests to the online pharmacy, which dispensed abortion medications to patients by mail. The study sample included prescription requests fulfilled by the online pharmacy between June 20, 2021, and June 24, 2023, for patients aged at least 18 years who received the combined medication abortion regimen. Data were analyzed from July 2023 to July 2024.

Exposures

The US Supreme Court Dobbs v Jackson decision on June 24, 2022.

Main Outcomes and Measures

Patient and prescriber characteristics are described, including patient age, state to which the prescription was sent, medications prescribed, and prescribing prescriber's clinic care modality (in-person only, hybrid [in-person and virtual], and virtual only). States were grouped according to the Guttmacher Institute classification of policy support for abortion (most or very supportive, somewhat supportive, and somewhat restrictive). Fulfillment trends were disaggregated by prescriber modality and state policy environment; 2 states with similar telehealth but differing coverage policies (Illinois and Colorado) were compared.

Results

The dataset included 87 942 observations. Most prescriptions were sent to individuals younger than 30 years (57.1%), with a mean (SD) age of 28.7 (6.4) years. Throughout the study period, the greatest volume of prescription requests came from states with most or very supportive policies and from prescribers at virtual-only platforms. More prescriptions were sent in the year after Dobbs v Jackson (daily mean [SD], 88.5 [47.2] prescriptions in March 2022 vs 201.5 [97.5] prescriptions in March 2023) with fulfillment spikes following the Dobbs v Jackson leak on May 2, 2022, and decision on June 24, 2022. State policy contexts mirrored the overall trends, while prescriber modality trends were unique, with a big spike in fulfillment at 12 weeks after the Dobbs v Jackson decision for hybrid clinics compared with in-person-only clinics and telehealth-only platforms, which saw their largest spikes in mean daily prescription fulfillment the week immediately after Dobbs v Jackson. Illinois and Colorado had similar fulfillment trends, with spikes immediately following the Dobbs v Jackson decision and overall higher fulfillment after Dobbs v Jackson, with a daily mean (SD) of 10.5 (7.0) prescriptions in Illinois and 8.8 (5.7) prescriptions in Colorado in March 2022 versus 26.6 (13.6) prescriptions in Illinois and 16.7 (10.1) prescriptions in Colorado in March 2023.

Conclusions and Relevance

These findings illustrate the increasingly critical role online pharmacies play in direct-to-patient abortion care provision in the US and the strong linkages between virtual-only prescribers and online pharmacies. These findings suggest that barriers to accessing online pharmacies for abortion care should be removed.

The impact of state Medicaid coverage of abortion on people accessing care in three states

CONTEXT

Medicaid is a major funder of reproductive health services, including family planning and pregnancy-related care, especially for people with limited income and people of color. Federal Medicaid funds cannot be used for abortion however 16 states allow state Medicaid funds to pay for abortion. In recent years, Illinois and Maine implemented, and West Virginia discontinued, state Medicaid coverage of abortion.

METHODOLOGY

With retrospective procedure- and patient-level data obtained from clinics in these three states, we used an interrupted time series design, multivariable regression models, and descriptive statistics to assess changes in procedure volume and patients' share of total procedure price (patient price).

RESULTS

In Maine and Illinois, implementing state Medicaid coverage of abortion contributed to an immediate overall increase in abortion access (as seen by a rise in monthly procedure volume at the time of the policy's implementation), a decrease in patient price (by 36% in Maine and 44% in Illinois) after policy implementation as compared to pre-implementation, and overall improved access among people of color. Conversely, when West Virginia discontinued coverage, access to care decreased, patient price increased by 130%, and the share of abortion procedures among people of color decreased.

CONCLUSIONS

In the fragmented abortion access landscape of the post-Roe era, our study provides new evidence that financial assistance offered through state Medicaid policies that cover abortion may be most helpful to those facing traditional structural inequities to access, while discontinuation of Medicaid coverage of abortion further burdens those already economically marginalized.

Patient experiences using public and private insurance coverage for abortion in Illinois: Implementation successes and remaining gaps

CONTEXT

Insurance coverage for abortion in states where care remains legal can alleviate financial burdens for patients and increase access. Recent policy changes in Illinois required Medicaid and some private insurance plans to cover abortion care. This study explores policy implementation from the perspectives of patients using their insurance to obtain early abortion care.

METHODOLOGY

Between July 2021 and February 2022, we interviewed Illinois residents who recently sought abortion care at ≤11 weeks of pregnancy. We also interviewed nine key informants with experience providing or billing for abortion or supporting insurance policy implementation in Illinois. We coded interview transcripts in Dedoose and developed code summaries to identify salient themes across interviews.

RESULTS

Most participants insured by Illinois Medicaid or eligible for enrollment received full coverage for their abortions; most with private insurance did not and faced challenges learning about coverage status. Some opted not to use insurance, often citing privacy concerns. Participants who benefited from abortion coverage expressed relief, gave examples of other financial challenges they could prioritize, and described feeling in control of their abortion experience. Those without coverage described feeling stressed, uncertain, and constrained in their decision-making.

CONCLUSION

When abortion was fully covered by insurance, it reduced financial burdens and enhanced reproductive autonomy. Illinois Medicaid policy-with seamless enrollment options and appropriate reimbursement rates-offers a model for improving abortion access in other states. Further investigation is needed to determine compliance among private insurance companies and increase transparency.

Association of Availability of State Medicaid Coverage for Abortion With Abortion Access in the United States

OBJECTIVE

To evaluate the association between state Medicaid coverage for abortion and abortion access measures among U.S. patients.

METHODS

We analyzed data from the Guttmacher Institute's 2014 Abortion Patient Survey. Respondents were included if they reported being enrolled in Medicaid, regardless of whether Medicaid covered the abortion. The exposure was self-report of residence in a state where Medicaid can be used to pay for abortion. Access outcomes included more than 14 days' wait time between decision for abortion and abortion appointment, presentation at more than 10 weeks of gestation when in the first trimester, and travel time more than 60 minutes to the clinic. Multivariable regression was performed to test the association between state Medicaid abortion coverage and dichotomous access outcomes, controlling for patient demographics.

RESULTS

Of 2,579 respondents enrolled in Medicaid who reported state of residence, 1,694 resided in states with Medicaid coverage for abortion and 884 resided in states without Medicaid coverage for abortion. Patients residing in states with Medicaid coverage for abortion had lower odds and rates of waiting more than 14 days between deciding to have an abortion and the appointment (adjusted odds ratio [aOR] 0.70; 95% CI 0.57-0.85, 66.8% vs 74.1%, P <.001), having abortions at more than 10 weeks of gestation when in the first trimester (aOR 0.62; 95% CI 0.49-0.80, 13.6% vs 20.1%, P <.001), and traveling more than 60 minutes to the abortion clinic (aOR 0.63; 95% CI 0.51-0.78, 18.7% vs 27.6%, P <.001) when compared with patients residing in states without Medicaid coverage for abortion.

CONCLUSION

Availability of state Medicaid coverage for abortion is associated with increased abortion access. Our findings support repealing the Hyde Amendment to promote equitable access to reproductive health care, particularly in the post-Roe era.

Provider and community stakeholder perspectives of expanding Medicaid coverage of abortion in Illinois

Background

Many people seeking abortion encounter financial difficulties that delay or prevent them from accessing care. Although some patients qualify for Medicaid (a public program that can help cover health care costs), laws in some states restrict the use of Medicaid for abortion care. In 2017, Illinois passed House Bill 40 (HB-40), which allowed patients with Medicaid to receive coverage for their abortion. This study aimed to understand how HB-40 affected abortion affordability from the perspectives of individuals that work directly or indirectly with abortion patients or facilities providing abortion care.

Methods

We conducted interviews with clinicians and administrators from facilities that provided abortion services; staff from organizations that provided resources to abortion providers or patients; and individuals at organizations involved in the passage and/or implementation of HB-40. Interviews were audio-recorded and transcribed. We created codes based on the interview guides, coded each transcript using the web application Dedoose, and summarized findings by code.

Results

Interviews were conducted with 38 participants. Participants reflected that HB-40 seemed to remove a significant financial barrier for Medicaid recipients and improve the experience for patients seeking abortion care. Participants also described how the law led to a shift in resource allocation, allowing financial support to be directed towards uninsured patients. Some participants thought HB-40 might contribute to a reduction in abortion stigma. Despite the perceived positive impacts of the law, participants noted a lack of public knowledge about HB-40, as well as confusing or cumbersome insurance-related processes, could diminish the law’s impact. Participants also highlighted persisting barriers to abortion utilization for minors, recent and undocumented immigrants, and people residing in rural areas, even after the passage of HB-40.

Conclusions

HB-40 was perceived to improve the affordability of abortion. However, participants identified additional obstacles to abortion care in Illinois that weakened the impact of HB-40 for patients and required further action, Findings suggest that policymakers must also consider how insurance coverage can be disrupted by other legal barriers for historically excluded populations and ensure clear information on Medicaid enrollment and abortion coverage is widely disseminated.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07761-5.

Association of Affordable Care Act Medicaid Expansions with Births Among Low-Income Women of Reproductive Age

Background: This study examined the association between Medicaid expansions under the Affordable Care Act (ACA) and births among low-income women of reproductive age in the United States. Methods: We used data from the 2008 to 2019 American Community Survey to estimate the association between state adoption of Medicaid expansion under the ACA and the percent of low-income women of reproductive age with a birth in the past year using a difference-in-difference research design. Subgroup analysis was explored by race and ethnicity, age group, educational attainment, marital status, and number of children. Results: We found that Medicaid expansion was associated with a small reduction in births among low-income women of reproductive age by 0.45 percentage points (95% confidence interval: -0.84 to -0.05). In subgroup analyses, we found reductions in births among Hispanic women, American Indian or Alaska Native women, women 25-29 years of age, women 35-39 years of age, unmarried women, and women with more than three children. Conclusions: Reductions in births associated with Medicaid expansion could suggest that expanding Medicaid addressed previously unmet reproductive health care needs among low-income women of reproductive age. The reductions in births among low-income women that we observe were occurring among some groups with higher unintended pregnancy rates, including Hispanic women, American Indian or Alaska Native women, young women, and unmarried women. These findings underscore the importance of reproductive health care access through insurance coverage on empowering women to have control over their reproductive decision-making and timing.

Postabortion Medicaid Enrollment and the Affordable Care Act Medicaid Expansion in Oregon

Background: The Affordable Care Act Medicaid expansion had the potential to increase continuity of insurance coverage and remove barriers to accessing health services following an abortion in states where Medicaid pays for abortion. We examined the association of Medicaid expansion with postabortion Medicaid enrollment and described postabortion preventive reproductive services among Medicaid-enrolled women in Oregon. Methods: We used Medicaid claims and enrollment data to identify abortions to women ages 20-44 in 2009-2017 (N = 30,786), classified into a treatment group-those likely to be affected by Medicaid expansion-and a comparison group. Outcomes included Medicaid enrollment (number of months enrolled and any lapse in enrollment) in the 6 and 12 months postabortion. Difference-in-differences analyses were used to compare outcomes preexpansion (2009-2012) and postexpansion (2014-2017) for treatment and comparison groups. Linear regression models were adjusted for age, race/ethnicity, rurality, and month. We described receipt of preventive reproductive services in 0-2 months and in 3-12 months postabortion. Results: Medicaid expansion was associated with enrollment increases of 2.0 and 4.7 months and with declines in any enrollment lapse of 54 and 48 percentage-points over 6 and 12 months postabortion, respectively (p < 0.001). Many who remained enrolled through postabortion received preventive care including contraceptive services (41%) and screening for sexually transmitted infections (23%). Conclusions: Medicaid expansion may increase continuity of insurance coverage for those receiving abortions, and in turn promote access to preventive services that can improve subsequent reproductive health outcomes.