Most people who’ve seen a doctor in the US have been surprised by a medical bill—hidden costs or prices that hardly correspond to the expense or complexity of the procedure, like $629 for applying a Band-Aid. Call an abortion clinic, on the other hand, and they will tell you exactly what they charge for the procedure out of pocket. As barriers to abortion access have increased dramatically, providers have taken intentional steps to keep the service as affordable as possible, without compromising safety or quality of care.
Over the past two decades, the cost of medical care in the US has risen by about 3.6 percent per year, outpacing overall inflation by 70 percent. Meanwhile, the cost of an abortion has remained virtually the same. Prices do vary, from about $400 to $2,500 in the first or second trimester. This depends on the state, the provider, and the complexity of the procedure, generally determined by how far along in pregnancy the abortion is performed. (For instance, one woman who wanted to terminate her nonviable pregnancy after 30 weeks was quoted $25,000 to $30,000.) However, the average cost of a first-trimester abortion—which account for almost 90 percent of all abortions in the US—is about $500, a figure that has remained remarkably stable over time.
This is not because providing abortions has become more affordable. To the contrary, it has become significantly more expensive in many states thanks to targeted regulation of abortion provider (TRAP) laws. These regulations single out abortion providers and require them to conduct medically unnecessary tests and procedures and operate in more expensive facilities.
Despite a 2016 Supreme Court decision overturning some provisions of a Texas TRAP law, 23 states still have laws on the books that regulate abortion clinics beyond what is necessary. Many of these mimic the standards of ambulatory surgical centers—including hallways and doorways wide enough for hospital gurneys—even though those centers perform much riskier procedures and use higher levels of sedation than abortion clinics do. It’s not as if abortion providers are working in substandard facilities—because they are overregulated and held to a much higher standard than most other medical facilities, they don’t have the option of not staying up to date.
“We’ve really tried to figure out how to comply with all the regulations and keep abortion as affordable as possible,” says Amy Hagstrom Miller, founder and CEO of Whole Woman’s Health, the lead plaintiff in the challenge to the Texas TRAP law. Whole Woman’s Health operates clinics in Maryland, Virginia, Texas, Minnesota, and Illinois.
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For example, in 2011, Texas passed a law requiring anyone seeking an abortion to have an ultrasound at least 24 hours in advance. The law went one step further than similar rules in other states by requiring that a physician perform the ultrasound, and that the same physician perform the abortion.
“We knew our patients couldn’t afford to take off from work twice, arrange childcare twice, and pay more for the procedure on top of that. Across the state, we chose not to raise the price of an abortion. We had to work hard to get doctors to understand that we couldn’t charge extra to the patient for that second visit. The cost on our end went up quite a bit,” Miller says.
“I think providers are bending over backwards to keep costs low. They realize that cost is so prohibitive. Being unable to afford an abortion is one of the primary reasons that women end up carrying an unwanted pregnancy to term,” says Ushma Upadhyay, an associate professor at the University of California San Francisco and a researcher with UCSF’s Advancing New Standards in Reproductive Health program. For instance, abortion providers often intentionally keep the price of medication abortion and procedural abortion the same, even though the cost of providing those services can be quite different. “We would never want anyone to choose one method or the other just because of cost,” Miller says.
There are plenty of practical reasons for first-trimester abortion to be inexpensive. “We could provide that care indefinitely at a low cost if we weren’t subject to so many restrictions,” says Kim Chiz, a registered nurse and executive director of Allentown Women’s Center in Bethlehem, Pennsylvania. An in-clinic first trimester abortion is short—the procedure itself lasts five to ten minutes, not including preparation and recovery time—and is extremely low-risk. Medication abortions, which are gaining in popularity, are so simple and safe that they can be offered entirely via telemedicine, though few states allow telemedicine abortion.
“Most of us have come into this profession from a human rights and justice framework, not only from a medical background. We are motivated by issues including economic justice. Many of the reasons people need abortions are economic: Most of our patients already have children and can’t afford to care for another child,” Miller says.
About 75 percent of abortion patients in the US are poor or low-income. Only 17 states allow Medicaid to pay for abortions outside the cases of rape, incest, and endangerment of the mother’s life, and 11 states restrict private insurance coverage of abortion. In 2014, 53 percent of abortion patients paid for their care out of pocket.
“We found that a majority of women with private insurance didn’t use it, either because the plan didn’t cover abortion or because they assumed it didn’t,” says Upadhyay in reference to a 2013 study. This means that abortion providers often have to help patients navigate their insurance and—in contrast with most areas of the medical field—they also help patients figure out how to pay for their procedures out of pocket. Whole Woman’s Health has three full-time staff members who help connect patients with abortion funds and other resources to help them raise the money they need. All of this is to say that abortion providers operate with a high awareness of the costs they’re passing on to patients, whereas most medical facilities are more focused on dealing with insurance companies.
Yet in keeping costs down, abortion providers are not compromising the safety of their patients. One large study found that the complication rate in abortion procedures was just 2.1 percent, with serious complications occurring only 0.23 percent of the time. This overall complication rate is significantly lower than that of the other in-office procedures researchers used for comparison, including wisdom tooth extraction (7 percent) and tonsillectomy (8 to 9 percent).
Because 90 percent of US counties currently have no abortion provider, abortion often comes with added costs that are outside of providers’ control. Twenty-seven percent of women aged 15 to 44 would have to travel 30 miles or more to reach their nearest clinic—and women in 27 cities would have to travel at least 100 miles—which means paying for travel, possible overnight stays, and taking multiple days off work if there’s a mandatory waiting period.
Many of the providers who do offer abortion are performing the procedure at high volume, which may be one factor that helps control costs on their end. “Doctors doing high volume become more efficient and skilled at doing the procedure, and as procedure times fall, that makes services less expensive to provide. We see that for most services, but for most services they don’t actually adjust the price downward,” says Miriam Laugesen, an associate professor at the Columbia University Mailman School of Public Health and author of Fixing Medical Prices: How Physicians are Paid.
“A lot of my work has shown that the cost of providing medical care doesn’t usually relate to what is charged for it, or what insurance reimburses,” Laugesen says. In other words, if abortion providers are passing on any efficiency-derived savings to their patients, it is because they choose to do so when most healthcare providers do not.
Efficient as abortion providers may be in the face of costly requirements like ultrasounds, multiple visits, and unnecessary facility modifications, there are still other hidden costs like litigation and security, she says. Most medical practices do not need to mount legal challenges to restrictions on the care they provide or worry about the safety of their employees and patients, but for abortion providers this is all part of doing business. “It’s really admirable that, in the face of rising costs, they’ve maintained the affordability of the service,” Laugesen says.
Abortion clinic staff are also willing to take on more roles than they might perform elsewhere. “That’s a pretty common theme in independent clinics. I’m the executive director, the director of nursing, and today I’m in scrubs because I was also working in the recovery room,” Chiz says.
“There’s no one who’s been here for more than five years who doesn’t know four to six different jobs.”
Clinics vary in their business structures and staffing policies, but they recognize how much the work demands of their staff. “We work hard to make human resource policies that are grounded in the principles of reproductive justice, meaning they are equitable and family-centered,” Chiz says. “Even though we are a small business, we match a 401K and offer health insurance. We have a generous vacation and sick time policy. When the staff are well taken care of, they are more able to work really hard and be as efficient as possible.”
Abortion clinics also work together in ways that other types of medical practices may not, she says, banding together to find affordable sources of medication and supplies. Chiz believes that this ethos of collaboration also helps abortion clinics give high-quality care to patients.
“Independent abortion clinics are experts in team-based care. I’ve worked in primary care, acute care, critical care, a variety of settings. Here, there’s great collaboration across a variety of educational backgrounds. You’ll see a physician having a conversation with a medical assistant, an RN, and the front desk staff, collaborating to figure out how to give the best care to a patient,” Chiz says.
One study of abortion patients in California found that they were highly satisfied with the care they received, rating it of 9.4 out of 10 on average. Another study, which surveyed women who received an abortion in New York, New Jersey, and Illinois, found that 93 percent were very satisfied with their care. By contrast, in the most recent Gallup poll on the subject from 2016, only 65 percent of Americans said they were satisfied with their overall medical care.
“I do think we need more nuanced measures of quality of care. With abortion, women go in with a problem. A clinician can take care of the problem, and they leave so happy. It’s unlike many conditions where you have to go back for multiple treatments,” Upadhyay says. “That said, a lot of independent clinics have set up a model to really nurture the social and emotional needs of women, and they provide great quality of care.”
Whole Woman’s Health follows this model, connecting each patient with a counselor who offers support through the medical, logistical, and emotional aspects of the procedure. “Many patients say it’s the best healthcare experience they’ve ever had. And not all of that is billable to insurance,” Miller says.
According to Laugesen, doctors tend not to be motivated to perform procedures that are less lucrative, pointing to the shortage of primary care doctors as evidence of this trend. Abortion providers, on the other hand, have chosen work that is highly stigmatized and frequently not reimbursed by insurance.
“You don’t work in an abortion clinic unless you love it. You can’t. You couldn’t come into work everyday being harassed, yelled at, having your life threatened,” Chiz says. “Many of our staff could leave and work elsewhere for twice as much money. But we love what we do because it allows our patients to live fully autonomous lives.”
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