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Friday, July 7, 2023

The Dobbs Decision — Exacerbating U.S. Health Inequity

Harvey, S. M., et al. (2023).
New England Journal of Medicine, 
388(16), 1444–1447. 

Here is an excerpt:

In 2019, half of U.S. women living below the FPL were insured by Medicaid. Medicaid coverage rates were higher in certain groups, including women who described their health as fair or poor, women from marginalized racial or ethnic groups, and single mothers. Approximately two thirds of adult women enrolled in Medicaid are in their reproductive years and are potentially at risk for an unintended pregnancy. For many low-income people, however, federal and state funding restrictions created substantial financial and other barriers to accessing abortion services even before Dobbs. Notably, the Hyde Amendment greatly disadvantaged low-income people by blocking use of federal Medicaid funds for abortion services except in cases of rape or incest or to save the pregnant person’s life. In 32 states, Medicaid programs adhere to the strict guidelines of the Hyde Amendment, making it difficult for low-income people to access abortion services in these states.

Before the fall of Roe, Medicaid coverage could determine whether women in some states did or did not receive abortion services. Since the implementation of the post-Dobbs abortion bans, abortion care is even more restricted in entire regions of the country. Access to abortion services under Medicaid will continue to vary by place of residence and depend on the confluence of restrictions or bans on abortion care and Medicaid policies currently in effect within each state. In the new landscape (see map), obtaining abortion services has become even more challenging for low-income women in most of the country, despite the fact that most states have expanded Medicaid coverage.

After Dobbs, complete or partial bans on abortion went into effect in more than a dozen states, forcing people in those states to travel to other states to access abortion care. More than a third of women of reproductive age now live more than an hour from an abortion facility and will probably face additional barriers, including costs for travel and child care and the need to take time off from work. Regrettably, people who already had poorer-than-average access pre-Dobbs face even greater health burdens and risks. For example, members of marginalized racial and ethnic groups that face disproportionate burdens of pregnancy-related mortality are more likely than other groups to have to travel longer distances to get an abortion post-Dobbs.

As a result of the overturning of Roe, a substantial proportion of people who want abortion services will not have access to them and will end up carrying their pregnancies to term. For decades, research has demonstrated that abortion bans most severely affect low-income women and marginalized racial and ethnic groups that already struggle with barriers to accessing health care, including abortion. The economic, educational, and physical and mental health consequences of being denied a wanted abortion have been thoroughly documented in the landmark Turnaway Study. Thanks to nearly 50 years of legal abortion practice, we now have a robust body of research on the safety and efficacy of abortion and the impact of abortion restrictions on people’s socioeconomic circumstances, health, and well-being.

Innovative strategies, such as telemedicine for medication abortion services, can improve access to abortion care. Self-managed, at home, medication abortions are safe, effective, and acceptable to many patients. In states where abortions are legal that are bordered by states where abortions are banned, telemedicine could mean the difference between patients being able to simply drive across the state line, in order to be physically in the state providing care, and having to drive to a clinic that could be hundreds of miles away. In addition, Planned Parenthood affiliates have plans to launch mobile services and to open clinics along state borders where abortion is illegal in one state but legal in the other.