Strategies for Securing Funding for Abortion Under the Hyde Amendment: A Multistate Study of Abortion Providers’ Experiences Managing Medicaid

摘要

Objectives. We investigated systematic barriers, identified by previous research, that prevent women from obtaining Medicaid coverage for an abortion even when it should legally be available: when the pregnancy resulted from rape or incest or threatens the mother's life. We also aimed to document strategies to improve access to federal Medicaid funding in qualifying cases. Methods. We conducted in-depth interviews from 2007 to 2009 with representatives of 49 facilities that provided abortions in 11 states. Interviews focused on participants’ experiences and strategies in seeking federal Medicaid funding for abortions. We coded data both inductively and deductively and analyzed them thematically. Results. Common strategies described by the few participants who secured Medicaid funding for abortions in cases of rape, incest, and life endangerment were facility-level interventions, such as developing relationships with Medicaid staff, building savvy billing departments, and encouraging clients to advocate for themselves, as well as broader legal and collaborative strategies. Conclusions. Multipronged state-level interventions that combine advocacy, legal, and on-the-ground resources show the most promise of increasing access to federal Medicaid funding for abortion care. Low-income women's access to reproductive health care services in the United States is limited by many health care providers’ difficulties navigating the Medicaid reimbursement system. 1 , 2 Addressing the challenges providers experience securing reimbursements is critical to ensuring access to reproductive health care for a significant number of low-income women. Indeed, Medicaid, a joint federal and state project, is the largest health insurance program in the United States. 3 In 2006 it provided coverage for 7.3 million women, or 12% of all women of reproductive age. 4 Since 1976, the Hyde Amendment has prevented women on Medicaid from using their insurance for abortion care, with few exceptions. Currently, the amendment prohibits the use of federal funds for abortions except when the pregnancy results from rape or incest, or when it endangers the mother's life. States have the option to use their own funding to expand Medicaid coverage for abortions in a broader range of circumstances, but only 17 do. Thirty-two states ban the use of state Medicaid funding for abortions except in the cases outlined by the Hyde Amendment; South Dakota, in open violation of federal law, covers abortions only when the mother's life is endangered. 5 A growing body of evidence shows that the implementation of these exceptions is inconsistent and that several systematic barriers prevent health care providers from securing Medicaid coverage for women seeking abortions for pregnancies in cases of rape, incest, or life endangerment. 6 – 8 Identified obstacles to securing federal Medicaid funding include complex paperwork requirements, inconsistent support from Medicaid when filing claims, and frequent inappropriate denials of submitted claims. 6 When Medicaid coverage for abortion care is inaccessible or denied, low-income women must scramble to find other resources to cover the cost of the procedure. The search for funding for an abortion can force women to delay a desired abortion or continue an unwanted pregnancy. 6 – 13 In some cases, women with life-endangering conditions must delay treatment while they raise money for their abortion. 6 What strategies can be used to prevent women in these circumstances from being denied timely access to abortion services? We investigated abortion providers’ experiences navigating obstacles to securing Medicaid coverage for qualifying abortions for their clients.