This is part of Tonic’s Healthcare Guide series. See the other guides here, and find the glossary here. Download the PDF version of this guide here and a find a PDF of the master document here.So you’re pregnant and don’t want to be, or you have a wanted pregnancy but the fetus has a fatal anomaly or the pregnancy could threaten your health. Whatever the case, you want an abortion. Here’s how to get the care you need.
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The answer may seem obvious, because you can Google that, right? But crisis pregnancy centers (CPCs)—fake clinics designed to look like abortion providers that actually exist to convince pregnant people not to get abortions—have gamed the Google maps system. They may appear first in search results, and may even claim to provide abortions.CPCs also intentionally open near real abortion clinics, and even open up in spaces formerly occupied by abortion clinics. “I once visited a clinic in Jacksonville, Florida, and there’s a CPC right across the street. They used the very same language and font for their sign so they would look as much like the real clinic as possible,” says Oriaku Njoku, the co-founder and executive director of Access Reproductive Care-Southeast, an abortion fund. Njoku also recalled helping a caller from South Carolina who was lied to by a CPC, where staffers told her she was only 12 weeks pregnant when she was actually 21 weeks along.There are several ways to verify that a clinic is real in order to avoid being misled by a CPC. The National Abortion Federation (NAF) has a comprehensive directory of providers, and all Planned Parenthood health centers are listed here. However, just because a clinic isn’t a Planned Parenthood affiliate doesn’t mean it isn’t reputable—two-thirds of abortions are performed by independent providers. In addition to the NAF directory, many independent providers are members of the Abortion Care Network, which maintains its own list. Njoku also suggests contacting your local abortion fund, which can help you find a trusted provider.
How do I find the nearest abortion provider?
In some cases, especially in major cities, you may be able to go to your regular gynecologist or at least get a referral from their office. The latter is especially true in the case of a pregnancy that is nonviable or poses a risk to your health, as some providers are more willing to offer referrals in those instances. However, fewer than two-thirds of OB/GYN residency programs offer abortion training, and only a small number of OB/GYNs in private practice perform abortions. In many places, a specialized clinic with trained, experienced providers is the best option.Despite evidence that advance practice clinicians (APCs) like certified nurse midwives, nurse practitioners, and physician assistants can safely provide abortions, 42 states mandate that only physicians can perform procedural abortions, and 34 allow physicians only to administer medication abortion. California is the one state with a law on the books explicitly allowing APCs to perform abortions.
Can my regular OB/GYN do it?
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Twenty-seven states have a waiting period—most commonly 24 hours—in between counseling and the abortion itself. Fourteen of these states require that the counseling be done in person, which means you’ll have to make two trips to the clinic. In other states, this counseling can be done over the phone.
Is there a waiting period for getting an abortion?
Most states—37, to be exact—require some level of parental involvement in your decision to get an abortion if you’re under 18. Most of these require parental consent, but 11 require only that parents be notified, and seven allow another adult relative (like a grandparent) to consent. Because the Supreme Court ruled that parents cannot have complete control over a minor’s decision to get an abortion, most states have some way around these parental consent or notification laws. Usually this is done by judicial bypass, meaning you can ask a judge for permission to get an abortion without notifying your parents. Thirty-four of the 37 states also allow people under 18 to get an abortion without parental involvement in cases of medical emergency, and 15 the 37 states allow people under 18 to get an abortion in cases of incest, abuse, neglect, or assault.You can use this chart to figure out what the laws are in your state. Your provider or local abortion fund will also be familiar with state laws and may be able to help connect you with organizations like Jane’s Due Process that help with the judicial bypass procedure.
What if I’m under 18? Are there extra rules?
At your appointment, a doctor or other health professional will take your medical history, vital signs, and talk to you about the options available to you. Most providers perform an ultrasound. Many states require it, and some even require the provider to show and describe the ultrasound image, while others simply require that the provider offer to show you the image.
What happens during the appointment?
The vast majority (two-thirds) of abortions in the US happen at or before eight weeks of pregnancy. Early in pregnancy, you generally have two options: medication abortion or aspiration abortion.Medication abortion, which is FDA-approved for use up to 10 weeks after your last menstrual period, involves taking two pills. The first, mifepristone, works by blocking the hormone progesterone, which is necessary to sustain the pregnancy. Between six and 48 hours later you take the second pill, misoprostol, which causes the uterus to contract and expel the pregnancy. Cramping and bleeding usually starts within one to four hours of taking misoprostol, and lasts for several hours after that. You could experience some intermittent cramping for one or two days afterward.Because of FDA restrictions—which are currently being challenged by the American Civil Liberties Union (ACLU)—mifepristone, the first pill, has to be dispensed by a registered provider. (It’s literally not available at retail pharmacies.) Nineteen states require that the provider hand the pill to you in person, meaning a telemedicine appointment is out of the question. Though many people prefer medication abortions because they can be done at home, medication abortion is a slightly longer process and usually requires a follow-up visit to make sure the termination is complete. If you live in a state that bans telemedicine abortion, this means at least two trips to the clinic, and three if you live in a state that has a waiting period and requires in-person counseling.
What happens during the procedure itself?
Aspiration (or suction) abortion is usually done up to between 14 and 16 weeks pregnancy. In this procedure, the provider dilates your cervix and uses gentle suction to remove the contents of the uterus. This is usually done using a local anesthetic, though some clinics may offer additional anesthesia.A dilation and evacuation, or D&E, is the most common procedure used in the second trimester of pregnancy. Because the cervix needs to be dilated further than for an aspiration abortion, the provider may start the dilation process the day before the procedure or earlier on the day of. The provider then uses suction and, if needed, other medical instruments to empty the uterus. D&E procedures are often, but not always, performed under some level of sedation. The D&E procedure is one of the latest targets of anti-abortion lawmakers, who have banned it in multiple states. Bans are in effect in Mississippi and West Virginia, but have been blocked by legal challenges in seven other states.
In Roe v. Wade, the Supreme Court held that abortion must be legal up to the point of fetal viability, and after viability if a woman’s life or health is in danger. There is disagreement about when exactly a fetus is viable, but it is generally held to be around 24 weeks. Many states have laws on the books banning abortion at viability. Several now have laws banning abortion at 20 weeks postfertilization, or 22 weeks’ gestation, based on the inaccurate claim that a fetus can feel pain at that point.
How far along in pregnancy can I get an abortion?
Numerous states have tried to ban abortion even earlier in pregnancy, and some of these cases could make it all the way to the Supreme Court—which now has a 5-4 conservative majority thanks to Brett Kavanaugh’s confirmation. Four states have laws that would immediately ban abortion if Roe were overturned.Even though abortions in the second trimester are generally legal, the farther along you get in pregnancy, the fewer providers there are who will be willing or able to perform your procedure. Some providers only offer medication abortion or don’t offer abortions after the first trimester because unnecessary regulations make later abortions too difficult to provide.
That depends on what kind of insurance you have—and if you have to travel out of state for the procedure. Most employer-based health insurance plans provide coverage for abortion, but how much you’ll end up paying will vary (more on that below). However, 11 states have laws that limit abortion coverage in all private (aka non-government) insurance plans, which is an umbrella term for plans you get through your employer and coverage you buy online. The 11 states that limit coverage in private plans are: Idaho, Indiana, Kansas, Kentucky, Michigan, Missouri, Nebraska, North Dakota, Oklahoma, Texas, and Utah. For many of them, the only allowable exception is if the mother’s life is in danger.Nine of those 11 states allow abortion coverage through the purchase of an additional rider, but very few riders are actually available for people to buy. “Abortion riders are really a bait and switch that we see when states or federal policymakers are proposing bans on abortion. It’s completely impractical. Most people are not planning ahead to have an abortion,” says Megan Donovan, a senior policy manager at the Guttmacher Institute.
I have health insurance. Does that cover abortion?
A whopping 26 states have abortion coverage restrictions specific to the health plans people buy through the Affordable Care Act online marketplaces. Some states do have exceptions, allowing plans to cover abortion in situations like rape, incest, or life endangerment. Take a look at this chart to see if your state has restrictions for private insurance.If you have a student health insurance plan, it may cover abortion. “Student plans are not governed by state laws. A state ban on abortion coverage doesn’t necessarily mean that it impacts a student health plan,” says Fabiola Carrion, senior staff attorney at the National Health Law Program.
Most people seeking abortions are poor or low income, meaning they are more likely to be uninsured or have insurance through Medicaid, a government-run insurance program. Since 1976, the Hyde Amendment has blocked the use of federal Medicaid funds for abortion. Narrow exceptions were added later on, allowing coverage of abortion in cases of rape, incest, or life endangerment. (The Hyde Amendment isn’t even a law: It’s a rider that has been tacked on to every major spending bill since 1976.)Medicaid is jointly funded by the federal government and the states, which means states can use their own funds to cover abortion. Seventeen states have such coverage policies in place—some by choice but most by court order. “Medicaid coverage [for abortion] is really only available in 16 states, because Arizona has a court order but doesn’t actually provide the coverage,” Donovan says. South Dakota only pays for abortions through Medicaid in cases of life endangerment, violating the federal standard by excluding rape and incest. Congress has control over Washington, DC, and has blocked Medicaid coverage for abortion there almost continuously since 1989.
I have Medicaid. Does government insurance cover abortion?
Since the introduction of the Hyde Amendment, similar restrictions have been placed on health insurance plans other than Medicaid that are also offered through the federal government. This affects government employees, active military and veterans, Peace Corps volunteers, Native Americans, people incarcerated or detained in federal prison, and those with coverage through the Children’s Health Insurance Program (CHIP). According to Guttmacher, 22 states also restrict abortion coverage for state employees.
When you use your health insurance—whether you have coverage through an employer, a marketplace plan, or Medicaid—the insurance company sends a document, usually called an explanation of benefits or (EOB), to the policy holder explaining what the provider charged and how much insurance will pay for your care. This is a concern for many people seeking an abortion.“Only four in 10 privately insured abortion patients use their insurance to pay for the procedure. For the other six in 10 who are privately insured but don’t use their coverage, it could be that they have a plan that doesn’t cover abortion, or the provider isn’t in network, or they have a high deductible, or that they don’t want to use their insurance," Donovan says. "There are confidentiality concerns given the stigma around abortion. People may be concerned that an employer, partner, or family member will find out.”
What if I’m on a parent’s or partner’s insurance plan and I don’t want them to find out about my abortion?
Federal law prevents your employer from accessing sensitive health information without your permission, so your employer won’t find about your abortion because you used your insurance. You can also ask your health insurance company not to send your parents or partner an explanation of benefits, or to send it to a different location. Unfortunately, federal law only requires them to honor that request if disclosing the information would endanger you. However, 13 states have put stronger protections in place.
If you don’t have insurance, or aren’t able to use your insurance, the average cost of a first-trimester abortion is around $500, whether it’s a medication abortion or an aspiration procedure. However, there are large variations from state to state and from clinic to clinic. “Generally, when you’re between six and 12 weeks, the price is the same. But once you’re 13 weeks, every week the price goes up,” Njoku says. A second-trimester abortion may cost more than twice as much as a first-trimester abortion, or more. Abortion providers tend to be more transparent about cost than many other medical providers, and clinics will usually tell you up front how much they charge.Unfortunately, even if you have an insurance plan that covers abortion, it may be difficult to figure out exactly what, or how much, is covered. “Right now, we’re looking at the way in which marketplace plans describe abortion coverage [in the states where it’s legal]. Plans are all over the place, from 50 percent cost sharing, to charging a $250 copay, to subjecting the abortion to a deductible, and the deductibles can be $2,000 or more,” Carrion says. That’s right—sometimes it may be cheaper to pay for an abortion out-of-pocket than to use your health insurance.
How much will I pay out of pocket?
Your local clinic is likely to be familiar with health plans in your area, and may be able to help you figure out what is covered. “We even give patients talking points sometimes to help when contacting their insurance companies,” says Tristina Fitzpatrick, director of patient services at Allentown Women’s Center in Pennsylvania. This kind of guidance can be very helpful because insurers can lack understanding about what an abortion actually entails, Carrion says. “If there is a difference in coverage between medication abortion and aspiration abortion, or second-trimester abortion, often that is not explained in the policy documents. Most plans consider abortion a surgical procedure, which means that patients end up paying more than they need to, and may be under the false impression that they’re having major surgery,” she says.
Yes, funds from a health savings account (HSA) or flexible spending account (FSA)—where you set aside money tax-free for medical expenses—can be used to pay for all or part of a legal abortion. (It’s considered a qualified medical expense.)
Can I use my HSA or FSA to pay for an abortion?
Sometimes, the nearest clinic is across a state line, or there’s not a provider in your state that offers the procedure you need. Using insurance across state lines—whether private or public— is possible, but tricky. “One big problem is that an out-of-state provider is probably out-of-network. Depending on your insurance, if you’re out-of-network, you may have much worse reimbursement or none at all. Abortion providers often have trouble getting in-network in the first place,” says Adam Sonfield, also a senior policy manager at the Guttmacher Institute. So you can submit receipts to your insurance company, but you might not get much money back.
What if I have to travel out of state? Will my insurance still cover it?
This is where abortion funds come in. Not only can they help cover the cost of the procedure itself, they can help with the additional expenses that now come along with abortion for many people.“There are over 70 funds all around the country. We’re all autonomous organizations and everybody does it a little differently,” says Njoku of Access Reproductive Care-Southeast. “We happen to have staff, other funds are run entirely by volunteers. Some funds have a hotline, and some funds have a cold line, where you leave a voicemail and they’ll call you back.”The staff or volunteers at an abortion fund will talk with you to get an idea of how much your abortion is going to cost you in total—not just what the clinic is going to charge. They will also ask how much you think you can realistically contribute, and offer what they can to help.“There’s no guarantee that we will be able to fully fund anything, but we’ll do our best,” Njoku says. In addition to financial support, some funds have volunteers who help provide logistical support, like giving patients a ride to the clinic or providing childcare. Some clinics may also be able to help with these extra costs, Fitzpatrick says.
What about added costs like travel, childcare, and lodging?
Miscarriage care involves the same procedures as abortion. A doctor may prescribe you misoprostol (the second pill used in medication abortion) to help your body expel the pregnancy, or perform a vacuum aspiration, or, if you were farther along, a D&E. Bans on insurance coverage of abortion do not affect coverage for miscarriage, so if you have insurance you should be covered.But you could still run into some problems. For example, a case in Arizona made headlines in June 2018 when a pharmacist refused to dispense misoprostol to a woman with a non-viable pregnancy that her doctor said would ultimately end in a miscarriage. A Michigan woman faced a similar issue in July 2018. Some states (and some pharmacies) require pharmacists with religious objections to have another pharmacist fill the prescription.
Do abortion restrictions affect miscarriage care?
“Generally speaking, what happened in Arizona is rare. Catholic hospitals are a much bigger issue,” Guttmacher’s Sonfield says. “You don’t know if the hospital will treat you if they think what you’re experiencing is the aftermath of an abortion as opposed to a miscarriage. That is really hard to prove either way. And even if they believe it is a miscarriage, some of the ways in which the ethical directives for Catholic hospitals have been interpreted lead to truly substandard care for miscarriage and pregnancy complications.”Unfortunately, it can be difficult to figure out a hospital’s policies regarding miscarriage and pregnancy complications. And, in many places, a Catholic hospital may be your only choice. At the very least, says Sonfield, you should be able to find out whether your local hospital follows Catholic hospital directives so you have an idea of what to expect.More Tonic Healthcare Guides:If You’re a College StudentIf You’re PregnantIf You’re on Birth ControlIf You Need an AbortionIf You’re Trans or Non-binaryIf You Have a Mental Health IssueIf You’re Addicted to OpioidsGlossary of Health Insurance TermsSign up for our newsletter to get the best of Tonic delivered to your inbox.