Research Article| Volume 104, ISSUE 1, P20-23, July 2021

Changes needed in Medicaid coverage and reimbursement to meet an evolving abortion care landscape


      Medicaid is the largest publicly funded health insurance program in the United States, covering 76 million individuals as of August 2020. Research shows that Medicaid improves health and healthcare access on a variety of indicators. Abortion is a common reproductive health service in the United States. However, Medicaid coverage of abortion varies by state; with 34 states and the District of Columbia limiting themselves to a federal policy that only permits coverage under cases of incest, rape, or life endangerment. With 75% of abortion patients earning low incomes, Medicaid coverage of this service is particularly salient to abortion access. In this commentary, we describe the complexities of Medicaid coverage and reimbursement of abortion in the United States and the implications of this complexity. Further, we consider the potential impact of changes in abortion provision, including increasing provision of medication abortion and the use of healthcare delivery models such as telemedicine for medication abortion, on Medicaid coverage and reimbursement. Finally, we provide a few policy and practice recommendations for abortion coverage now and in the future.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Contraception
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


      1. U.S. Department of Health and Human Services. 2020 Medicaid & CHIP enrollment data. Available at:

      2. U.S. Supreme Court. Atkins v. Rivera, 477 U.S. 154, 156-57 (1986). Available from:

      3. Congress. U.S. Code § 1396a(a)(23)(C). State plans for medical assistance. Available from:

      4. Congress. U.S. Code §1396u-2. Provisions relating to managed care. Available from:

      5. U.S. Centers for Medicare and Medicaid Services, 2017 share of Medicaid enrollees in managed care. Available at: (last visited January 14, 2021)

      6. Congress. U.S. Code § 1396a(a)(25)(C). State plans for medical assistance. Available from:

      7. Congress. U.S. Code §§ 447.15, 447.20. Acceptance of State payment as payment in full. Available from:

        • Margerison CE
        • MacCallum CL
        • Chen J
        • Zamani-Hank Y
        • Kaestner R.
        Impacts of Medicaid expansion on health among women of reproductive age.
        Am J Prev Med. 2020; 58: 1-11
        • Harvey SM
        • Gibbs SE
        • Oakley LP.
        Association of Medicaid expansion with access to abortion services for women with low incomes in Oregon.
        Women's Health Issues, 2020 (ISSN 1049-3867)
        • American Hospital Association
        “Table 4.4: Aggregate hospital payment-to-cost ratios for private payers, Medicare,”.
        Trendwatch chartbook. American Hospital Association, Chicago, IL2015
        • Cunningham PJ
        • Nichols LM.
        The effects of Medicaid reimbursement on the access to care of Medicaid enrollees: a community perspective.
        Med Care Res Rev. 2005; 62: 676-696
        • Polsky D
        • Richards M
        • Basseyn S
        • Wissoker D
        • Kenney GM
        • Zuckerman S
        • et al.
        Appointment availability after increases in Medicaid payments for primary care.
        N Engl J Med. 2015; 372: 537-545
        • Shen YC
        • Zuckerman S.
        The effect of Medicaid payment generosity on access and use among beneficiaries.
        Health Serv Res. 2005; 40: 723-744
        • Sonchak L.
        Medicaid reimbursement, prenatal care and infant health.
        J Health Econ. 2015; 44: 10-24
        • Gray B.
        Do Medicaid physician fees for prenatal services affect birth out-comes?.
        J Health Econ. 2001; 20: 571-590
        • Jones R
        • Witwer E
        • Jerman J.
        Abortion incidence and service availability in the United States, 2017.
        Guttmacher Institute, 2019 (Available at:
        • Grossman D
        • Ralph L
        • Raifman S
        • Upadhyay U
        • Gerdts C
        • Biggs A
        • et al.
        Lifetime prevalence of self-induced abortion among a nationally representative sample of U.S. women.
        Contraception. 2018; 97: 460
        • Donovan M.
        Medication abortion and the changing abortion landscape.
        Guttmacher Institute, 2019 (Available at:)
      8. American Civil Liberties Union. Access denied: origins of the Hyde Amendment and other restrictions on public funding for abortion. Available at:

      9. U.S. Department of Defense and Labor, Health and Human Services, and Education Appropriations Act, 2019 and Continuing Appropriations Act, 2019, Pub. L. No. 115-245, 132 Stat. 2981, 3118, §§ 506-07 (2018) (the Hyde Amendment). Available from:

      10. Guttmacher Institute. Medicaid coverage of abortion. State laws and policies. 2021. Available at:

        • Donovan M.
        EACH Woman Act offers bold path toward equitable abortion coverage.
        Guttmacher Institute, 2019 (Available from:)
      11. U.S. Centers for Medicare and Medicaid Services, State Medicaid Manual: Chapter 4 § 4332.B. Available from:

        • U.S. Government Accountability Office
        Medicaid: CMS action needed to ensure compliance with abortion coverage requirements.
        GAO-19-159: Published:, 2019 (Available at:)
      12. Legal Institute. U.S. Code § 1396r-8. Payment for covered outpatient drugs. Available from:

        • Carríón F.
        When states fail to cover abortions under Medicaid, NHelp steps.
        National Health Law Program, 2019 (Available at:)
        • Dennis A
        • Blanchard K.
        Abortion providers' experiences with Medicaid abortion coverage policies: a qualitative multistate study.
        Health Serv Res. 2013; 48: 236-252
        • Young YY
        • Thompson TA
        • Cohen DS
        • Blanchard K.
        Contextualizing Medicaid reimbursement rates for abortion procedures.
        Contraception. 2020; 102: 195-200
        • Dennis A
        • Blanchard K.
        A mystery caller evaluation of Medicaid staff responses about state coverage of abortion care.
        Women's Health Issues. 2012; 22: e143-e148
        • Kacanek D
        • Dennis A
        • Miller K
        • Blanchard K.
        Medicaid funding for abortion: providers' experiences with cases involving rape, incest, and life endangerment.
        Perspect Sex Reprod Health. 2010; 42: 79-86
      13. Kimport K and Rowland B. Taking insurance in abortion care: policy, practices, and the role of poverty, in: Jacobs Kronenfeld J, Health and health care concerns among women and racial and ethnic minorities, research in the sociology of health care, 35, Bingley, UK: Emerald Publishing. 2017; 39–57

        • Upadhyay UD
        • Schroeder R
        • Roberts SCM.
        Adoption of no-test and telehealth medication abortion care among independent abortion providers in response to COVID-19.
        Contracept X. 2020; 2100049
        • American College of Obstetricians and Gynecologists
        COVID-19 FAQs for obstetricians-gynecologists, gynecology.
        ACOG, Washington, DC2020 (Available at:)
        • National Abortion Federation
        National Abortion Federation.
        Clinical policy guidelines, Washington DC2020
      14. American College of Obstetricians & Gynecologists v. FDA, Civil Action No. TDC-20-1320 (2020). Available from:

      15. California Department of Health Care Services. Medi-Cal: important news about women's health services. 2020. Available at:

      16. U.S. Centers for Disease Control and Prevention. Prepare your practice for COVID-19. Available at:

      17. Center for Connected Health Policy. Telehealth coverage policies in the time of COVID-19. Available at:

      18. Klein A. Preventing and responding to sexual violence in disasters: a planning guide for prevention and response. Louisiana Foundation Against Sexual Assault and National Sexual Violence Resource Center. 2012 Available at:

        • Shalini M
        • Tushar S.
        Gender-based violence during COVID-19 pandemic: a mini-review.
        Front Glob Women's Health. 2020; 1: 4
        • Weitz TA
        • Taylor D
        • Desai S
        • Upadhyay UD
        • Waldman J
        • Battistelli MF
        • et al.
        Safety of aspiration abortion performed by nurse practitioners, certified nurse midwives, and physician assistants under a California legal waiver.
        Am J Public Health. 2013; 103: 454-461
      19. COVID-19 brings changes to nurse practitioner scope of practice.
        Am J Nurs. 2020; 20 ( 14
        • Barnes H
        • Maier CB
        • Altares Sarik D
        • Germack HD
        • Aiken LH
        • McHugh MD
        Effects of regulation and payment policies on nurse practitioners' clinical practices.
        Med Care Res Rev. 2017; 74: 431-451
      20. All Above All. EACH ACT Fact Sheet Available from:

        • Thompson TA
        • Sonalkar S
        • Butler JL
        • Grossman D.
        Telemedicine for family planning: a scoping review.
        Obstet Gynecol Clin North Am. 2020; 47: 287-316
        • Donovan M.
        Improving access to abortion via telehealth.
        Guttmacher Institute, 2019 (Available at:)
        • Roberts SCM
        • Johns NE
        • Williams V
        • Wingo E
        • Upadhyay UD.
        Estimating the proportion of Medicaid-eligible pregnant women in Louisiana who do not get abortions when Medicaid does not cover abortion.
        BMC Women's Health. 2019; 19: 78
        • Upadhyay UD
        • McCook AA
        • Bennett AH
        • Cartwright AF
        • Roberts SCM.
        State abortion policies and Medicaid coverage of abortion are associated with pregnancy outcomes among individuals seeking abortion recruited using Google Ads: a national cohort study.
        Soc Sci Med. 2021; (Epub ahead of print. PMID: 33642070)113747
        • Foster DG
        • Ralph LJ
        • Biggs MA
        • Gerdts C
        • Roberts SCM
        • Glymour MA.
        Socioeconomic outcomes of women who receive and women who are denied wanted abortions.
        Am J Public Health. 2018; 108: 407-413
        • Foster DG.
        Effect of an unwanted pregnancy carried to term on existing children's health, development, and care.
        Contraception. 2014; 90: 305