Experiences of Women Seeking

State-Subsidized Insurance for

Abortion Care in Massachusetts
An Evaluation by the Massachusetts Abortion Funds

April 2011

Report prepared by Katey Gorski and Danielle Bessett, Ph.D.

on behalf of the Eastern Massachusetts Abortion (EMA) Fund,
the Jane Fund of Central Massachusetts, and the
Abortion Rights Fund of Western Massachusetts
Acknowledgements
This report was authored by Katey Gorski and Danielle Bessett, Ph.D. Wendy Brovold was responsible for
graphic design and layout.

The following Massachusetts abortion fund volunteers provided assistance and advice at various stages of the
evaluation and the report’s preparation: Mirian Barrientos; Deepani Jinadasa, MPH; Eunice Ko; April Lambert;
Ryann Milne-Price; Sarah Morton, Nicole Mushero, Marcy Ostrow, Judith Plaskow, Ph.D.; Sam Porter, Erin
Kate Ryan; Megan Smith; and Anne Williamson.

This report also benefitted from input from: Megan J. Peterson of the National Network of Abortion Funds;
Karen Edlund and Jill Clark of the Massachusetts Department of Public Health; Kate Bicego of Health Care For
All; Andrea Miller of NARAL Pro-Choice Massachusetts; Liz Janiak of the Harvard School of Public Health;
and Sarah Fuller of Planned Parenthood League of Massachusetts.

Evaluation activities were supported by the Smith College Praxis Program, The Smith College Government
Department’s Leanna Brown ’56 Fellowship, and the Charlotte Ellertson Social Science Postdoctoral
Fellowship. This report was made possible by an advocacy grant and technical assistance from the National
Network of Abortion Funds. The views expressed in this publication are those of the authors and do not
necessarily represent the views of the funders.

We are grateful to all of the abortion fund volunteers who participated in the evaluation and to the women who
shared their experiences.

For more information about the report, please contact Danielle Bessett, Ph.D., at danielle.bessett@uc.edu.

Suggested citation: Gorski K and D. Bessett. 2011. Experiences of Women Seeking State-Subsidized Insurance
for Abortion Care in Massachusetts: An Evaluation by the Massachusetts Abortion Funds, Cambridge, MA:
EMA Fund, an affiliate of the National Network of Abortion Funds.

2
Table of Contents
Executive Summary........................................................................................................................................ 4

Background......................................................................................................................................................7
Abortion funding in the U.S..............................................................................................................................7
Health insurance reforms in Massachusetts......................................................................................................8
Abortion funds.................................................................................................................................................. 9

Methods............................................................................................................................................................10
Procedures.........................................................................................................................................................10
Sample characteristics.......................................................................................................................................10
Limitations........................................................................................................................................................ 10

Findings............................................................................................................................................................11
Applications for subsidized insurance.............................................................................................................. 11
Pregnancy outcomes......................................................................................................................................... 12
Payment sources for abortion care & costs.......................................................................................................13
Insurance status at time of interview.................................................................................................................13
Satisfaction with application process................................................................................................................14
Satisfaction with using subsidized insurance to cover abortion care................................................................16
Barriers to insurance coverage: information.....................................................................................................16
Barriers to insurance coverage: retention mechanisms.....................................................................................16
Barriers to abortion care coverage: delays in insurance enrollment................................................................. 17
Consequences of delays.................................................................................................................................... 18

Discussion.........................................................................................................................................................18
What works in Massachusetts...........................................................................................................................18
What isn’t working in Massachusetts............................................................................................................... 19

Recommendations........................................................................................................................................... 21

References........................................................................................................................................................ 23

3
Executive Summary
Background & Objective
Massachusetts leads the country in insuring its citizens, has expanded eligibility criteria for subsidized insurance
and implemented other insurance reforms, and is among the minority of states that provide subsidized state
insurance for abortion services. Taken together, these policies suggest that Massachusetts women should not
encounter significant barriers to coverage for abortion care. Two years into implementation of health care
reform, the three non-profit abortion funds that provide financial counseling and direct grants to women in need
of abortion care – the Jane Fund of Central Massachusetts, the Eastern Massachusetts Abortion (EMA) Fund,
and the Abortion Rights Fund of Western Massachusetts (ARFWM) – continued to experience high volume of
demand from women who appeared to be eligible for health insurance. From April to October 2010, the funds
undertook an evaluation of their referral process for subsidized insurance in the Commonwealth. The object
of this evaluation was to learn whether or not women obtained subsidized insurance, if insurance was used
for abortion services, the length of delays incurred as a result of the insurance application process, pregnancy
outcomes, and the consequences of those delays for women seeking abortion. The evaluation also sought to
assess women’s satisfaction with their insurance experience and to identify the barriers encountered in obtaining
insurance or its use for abortion services.

Methods
This report is based on telephone interviews with 39 low-income women presumed eligible for subsidized
insurance about one month after contact with Massachusetts abortion funds. A total of 91 women were referred
for follow-up interviews, and the response rate was 43%.

Findings
More than half the women interviewed described delaying their abortions while they tried to secure subsidized
insurance. Only one third of the 32 who applied for subsidized insurance secured coverage of their abortion.
Delays limited women’s ability to obtain medication abortion; one woman decided to continue her pregnancy
once she was unable to obtain medication abortion. Another woman “timed out” of an in-state surgical abortion
when she was unable to obtain insurance quickly and she also continued the pregnancy. One woman had a
miscarriage before becoming insured. Nineteen paid out of pocket or in combination with abortion fund grants
to pay for their care, usually because they were approaching a fee increase for their procedures. Delays also
increased travel time to alternate providers and stress for women as they worried about their ability to obtain an
abortion in a timely way.

Conclusion
The findings reported herein demonstrate that a policy of abortion coverage in state-subsidized plans does
not insure access to abortion care. Women do, in fact, experience difficulties in obtaining state insurance that
impeded their ability to obtain coverage for time-sensitive procedures. Delays in enrollment for subsidized
insurance led women to postpone abortion care and to choose between having to pay out of pocket for medical
care to which they were entitled or risking not obtaining this care. We estimate that poor women and abortion
funds paid for at least one third of abortions that ought to have been covered by a subsidized insurance plan, but
that figure may be as high as two-thirds of this sample. Intangible costs included stress, prolonged pregnancy
symptoms, increased travel time, and limited access to medication abortion. Delays prevented two women from
obtaining the abortions they sought. Unnecessary delays should be a matter of concern to policy makers in the
Commonwealth, because procedures at later gestational ages are more expensive and delays may increase costs
to the state. Enrollment procedures for subsidized insurance in Massachusetts need improvement to insure
residents obtain necessary medical care in a timely way.

4
Recommendations
1. Protect coverage for low-income women’s abortion care in the Commonwealth during
implementation of national health reform.
Low-income women’s lives are improved by comprehensive coverage of sexual and reproductive health
services. We must value the abortion services that are covered by the Commonwealth regardless of
insurance program and the vital role they play in women’s lives.

2. Prioritize expedited enrollment and presumptive eligibility for all pregnant women, regardless of
pregnancy intentions.
Failing to provide all pregnant women with expedited access to care constrains their ability to obtain not
only abortion services, but also prenatal services for continued pregnancies if applications are not tracked
correctly. The Commonwealth should consistently expedite enrollment in subsidized insurance for
pregnant women whether they intend to terminate the pregnancy or carry it to term and build upon the
successful MassHealth Prenatal program to create new options of presumptive eligibility for abortion
care.

3. Improve enrollment processes for subsidized insurance in the Commonwealth.

The Health Connector and MassHealth authorities must continue to work to speed enrollment for
subsidized insurances to insure all residents can obtain the care to which they are entitled with ease and
dignity. Improvement of enrollment processes is especially important for women to access the full range
of abortion procedures in a timely way.

4. Fortify client retention for subsidized insurance in the Commonwealth.

While re-enrollment processes are necessary, this research demonstrates that some Massachusetts
residents lose access to needed services for some period of time as a result. Strengthening renewal
mechanisms is likely to eliminate delays related to re-enrollment for pregnant women as well as other
eligible Massachusetts residents. Not only would this improve women’s ability to secure the pregnancy
outcome they want, but it might also reduce the risk of an unwanted pregnancy through better and more
regular access to more effective contraceptives.

5. Train enrollment representatives to avoid expression of their personal biases when assisting clients.
Abortion stigma, whether enacted or perceived, makes applicants reluctant to disclose their pregnancies
and abortion intentions. Encountering biases limits women’s ability to seek expedited enrollment for
abortion services and damages the professionalism for which most enrollment representatives strive.

6. Improve information resources for women seeking to obtain insurance information for abortion
coverage.
Our findings document low health insurance literacy and women’s reports of confusion at insurance
information provided by the Commonwealth. In order to make appropriate choices about health care
and insurance, women must be educated about their coverage options under subsidized insurance by
providing clear and accessible information about plan types, specific benefits (including abortion), and
health insurance terminology. Information should be age-appropriate for young women who are applying
for insurance for the first time.

5
7. Improve abortion fund referrals through trainings in subsidized insurance.
Funds should continue to refer clients to Health Care for All (HCFA) for assistance with enrollment, but
also explore whether enrollment efficacy varies among community health centers and hospitals. Notably,
funds must educate women that many subsidized insurance plans cover abortion care before referring
them to HCFA; they should advise clients to disclose their pregnancies. Funds should tell clients
success stories so that women do not pay out of pocket for services that should be covered, but must also
explicitly encourage women to keep in contact as the process moves forward so that they do not feel
alone in the process and lose access to the important resources that abortion funds can provide.

8. Conduct more research on potentially underserved populations.

Women who did not find their way to abortion funds or who could not be contacted for this study are
likely to be even more vulnerable than those who participated in the follow-up interviews and, as a result,
may have been less successful in obtaining abortion care. More research is needed to investigate the
outcomes of these women and other disadvantaged groups.
Background
Abortion funding in the U.S.
Medicaid is a jointly funded federal and state program that funds medical insurance for low-income residents
of each state. In the first three years after the Supreme Court’s historic 1973 ruling in the case of Roe v. Wade,
federally-funded Medicaid plans covered abortion, and “federal Medicaid paid for about one-third of all abortions”
(Fried, 2005). In 1977, Congress implemented the Hyde Amendment, which now prohibits federal funding for
abortion except in cases of rape, incest and danger to the life of the woman; in 1980 the Supreme Court ruled that
the federal government was not constitutionally
obligated to use federal funds to cover the cost of
abortion care (Towey et al, 2005). The funding of
Medicaid abortions was subsequently left to the
discretion of each state, and 35 states do not provide
Most analyses suggest Medicaid
Medicaid funding for abortion (National Network
of Abortion Funds, 2010). Additional laws now coverage of abortion is an important
prevent federal health care programs from covering factor in low-income women’s ability
abortion for women in the military and Peace Corps, to obtain abortion care and terminate
disabled women on Medicare, Native women using unwanted pregnancies.
Indian Health Services, federal employees, and
federal prisoners (Towey et al, 2005).

Scholars debate the magnitude of the effect

that public funding bans have on the number of
abortions, but most analyses suggest that Medicaid
coverage of abortion is an important factor in low-income women’s ability to obtain abortion care and terminate
unwanted pregnancies (Boonstra, 2007). ¹ While most women who want abortion care are able to secure it, a
number of studies estimate that 18–35% of women who would have had an abortion continued their pregnancies
because they were unable to secure Medicaid funding (Morgan SP and Parnell AM, 2002; Trussell et al, 1980;
Henshaw et al, 2009). Those who do secure abortion care typically do so at the expense of their personal or
household finances, such as by deferring rent or utilities payments or using a credit card (Boonstra 2007).

Given that abortion care is time sensitive, delays are particularly important aspect of abortion funding (Jones
and Weitz, 2009). Delaying abortion care is a matter of concern because, although abortion is very safe, the
risk to women increases with gestational age (Bartlett et al, 2004; Drey et al, 2006). The cost of a procedure
increases with gestational age of the pregnancy: As Boonstra (2007) put it, “the longer it takes for poor women
to obtain an abortion, the harder it is for them to afford it.” Research shows that 67% of low-income women
having an abortion report they would have preferred to have had the procedure earlier (Finer et al, 2006). The
Guttmacher Institute found that low-income women take longer to confirm a suspected pregnancy, perhaps
because they have less access to pregnancy testing (Finer et al, 2006). When they are able to obtain abortion
care, they also take longer to make arrangements (usually payment) for their abortion, when controlling for
other characteristics (Finer et al, 2006). Because of this, low-income women take up to three weeks longer
than other women to obtain an abortion (Finer et al, 2006). Medicaid-eligible women in states with Medicaid
coverage obtain the procedures nearly a week earlier than near-poor women in the same states (Henshaw et al,
2009). Yet there remain many questions about how Medicaid works in states that cover abortion care and little
work has examined women’s experiences of the process of obtaining abortion care with Medicaid.

¹ See also Boonstra and Sonfield, 2000; Center for Disease Control, 1980; Cook et al, 1999; Henshaw and Wallisch, 1984; Hussey, 2010; Kacanek et al, 2010;
Kaposy, 2009; Levine et al, 1996; Medoff, 2008; Morgan and Parnell, 2002; Sonnfield et al, 2008; Torres et al, 1986; Towey, 2005; Trussell et al, 1980; Zavodny
and Bitler, 2010.

7
Health insurance reforms in Massachusetts
Massachusetts is one of just 15 states that use their own money to pay for abortion care as part of their state-
run Medicaid programs (National Network of Abortion Funds, 2010). Medicaid pays for 27% of abortions in
these states compared with less than 1% in states where the state-run Medicaid program does not cover most
medically-necessary abortions (Henshaw & Finer, 2003). Massachusetts, like many states, passed a ban on
abortion coverage following the Hyde Amendment, but in 1981 the Massachusetts Supreme Judicial Court ruled
in Moe vs. Secretary of Administration and Finance that low-income women have the right to Medicaid funding
for all “medically necessary” abortion (Mass. Gen. Laws Ann. ch. 176G, § 17; Agénor et al, 2009). “Medically-
necessary” abortion is defined by the Commonwealth as an abortion that is “necessary in light of all factors
affecting the woman’s health” (Mass. Regs. Code tit. 130, § 484.001, 433.455).

The Commonwealth of Massachusetts is also seen as a model for national health care reform (Gold, 2009).
Massachusetts has sought to improve access to affordable, high-quality care through universal health
insurance through the groundbreaking reforms since 2006 with An Act Promoting Access to Affordable,
Quality, Accountable Health Care. “Chapter 58” and subsequent revisions seek to reduce uninsurance in the
Commonwealth through individual and business mandates, changes to dependency statutes, market reforms,
reforms targeted at student and young-adults, and – most importantly for the question explored here – through
expansion of state-subsidized plans.

In addition to increased eligibility for children, Massachusetts reforms exempted adults with incomes below
100 percent of the Federal Poverty Level (FPL), as well as specific groups with incomes greater than 100
percent of the FPL but at or below 150 percent of the FPL, from paying premiums, through the MassHealth
(Massachusetts Medicaid) program. Reforms also created Commonwealth Care, a subsidized program available
to Massachusetts residents who earn less than 300% FPL, are not eligible for enrollment in another health
insurance program (including MassHealth or Medicare), and are either not working or work for an employer
that does not provide a health benefit. Commonwealth Care and a non-subsidized program, Commonwealth
Choice, are administered by the Commonwealth Health Insurance Connector Authority, an independent state
agency responsible for various aspects of health care reform. Both MassHealth and Commonwealth Care offer
different plans which vary by geographic area and services covered.

Although space prevents a thorough description of each plan within the MassHealth and Commonwealth Care
programs, we note that uninsured pregnant women who are residents of Massachusetts and who declare incomes
that are less than 200% FPL are
presumed eligible for MassHealth
Prenatal. This allows women
to obtain short-term outpatient
prenatal care while they wait to be
The presumptive eligibility that characterizes
approved for MassHealth Standard.
The presumptive eligibility that MassHealth Prenatal is a much-needed
characterizes MassHealth Prenatal benefit for women who want prenatal care
is a much-needed benefit for for pregnancies they wish to carry to term.
women who want prenatal care for Unfortunately, MassHealth Prenatal does not
pregnancies they wish to carry to cover abortion care.
term. Unfortunately, MassHealth
Prenatal does not cover abortion care.
Thus, women who seek subsidized
insurance to cover abortion care are
unable to claim presumptive eligibility and must wait to be approved for MassHealth Standard or another similar
plan. MassHealth Prenatal has no comparable program within Commonwealth Care.

8
The Commonwealth Care program mirrors MassHealth in many ways, including the coverage of abortion care
for enrollees in these subsidized plans. Depending on the plan type, abortion care is provided free of charge or
subject to co-payments ranging from $50-$100 (Commonwealth Health Insurance Connector Authority, 2011).
Unlike MassHealth, which can be applied retroactively to services provided within ten days of activation,
Commonwealth Care coverage does not begin until the first of the next month after a resident over 150% FPL
has been determined eligible, selected a health plan, and paid a premium. Commonwealth Care coverage is not
retroactive.

Although not within the scope of this report, we note that the Health Safety Net (formerly known as “Free
Care”) currently covers emergency health care for people who are ineligible for other plans or who cannot
afford them, with certain restrictions. These services include abortion care in the first two trimesters for a
Massachusetts resident. Unfortunately, Health Safety Net can only be used at certain locations, primarily in the
Boston area, and cannot adequately serve women across the Commonwealth who need abortion care.

As a result of these reforms, uninsurance in Massachusetts in 2010 was the lowest in the country at 1.9%,
though the Massachusetts Division of Health Care Finance and Policy reports that low-income residents were
more likely to be uninsured (nearly 4.0% among those with family incomes less than 150% of the FPL and
2.9% among those with family income between 150 and 299% of the FPL) (2010). Although he did not address
rates of unintended pregnancy in his analysis, Whelan (2010) has speculated that universal health insurance in
Massachusetts and the coverage of low-income adults through subsidized insurance programs, in particular, did
not increase abortion rates, but may have actually contributed to declining abortion rates in the Commonwealth.

Abortion funds
Abortion funds are typically grassroots, philanthropic organizations that assist women in financing an abortion.
Funds help women with financial counseling, make loans or grants, assist with travel arrangements, and – in
eligible states – advise women on how to apply for insurance. The National Network of Abortion Funds has 100
member funds in the U.S., Canada, and Mexico, as well as one fund that operates internationally.

Massachusetts has three abortion funds: The Abortion Rights Fund of Western Massachusetts, the Jane Fund of
Central Massachusetts, and the Eastern Massachusetts Abortion Fund. Each fund works slightly differently, but
all three are non-profit organizations staffed by volunteers and supported by private donors. Women find these
funds online, through the phone book, or by referral from friends, family, or abortion providers. Each fund
asks clients to leave a message on a voicemail system, and an intake volunteer from the fund returns the call
as soon as possible to see how best to assist the woman in question. Funds collect information from clients and
advise on potential strategies to finance their abortion care. The three Massachusetts funds use different rubrics
for determining whether or not they will make a grant, and grant amounts vary based on the specifics of the
situation and the resources the fund has available. If a grant is made, arrangements for payment are made with
the woman’s chosen clinic. In some cases all three funds work together to help a woman pay for her procedure.

If the intake volunteer believes a woman is eligible for subsidized insurance, s/he provides guidance about the
application process, materials needed, and abortion coverage of different plans. Although clients can apply
online, by mail, or by telephone, funds typically advise them to apply in person at regional enrollment centers
or a local community health center, hospital, or other community organization that has been approved to submit
state insurance applications. Applications made in person are generally believed to be received by enrollment
representatives and hence processed more quickly than applications made through other modalities. Funds
also often refer clients to a non-profit insurance advocate helpline run by Health Care For All (HCFA) in
Massachusetts, which can act as a liaison between clients and the state insurance apparatus.

9
Methods
This paper reports information gathered by the abortion funds from April to October 2010 through systematic
qualitative interviews with women they referred to subsidized insurance programs.

Procedures
From April 2010 to September 2010, abortion fund volunteers asked women they referred to subsidized
insurance programs to participate in a follow-up interview by telephone approximately one month after
their initial contact with the funds. Funds determine eligibility for state insurance programs based on clients’
self-reports; clients younger than 18 and non-English speakers were not invited to participate in follow-up
interviews. Clients were informed that participating in this follow-up call would not affect their ability to
receive a grant from the fund, their enrollment in subsidized insurance, or their health care services. Clients
were informed that non-identifying details of their experiences could be used for advocacy purposes and that
their identities would be protected by changing their names and personal details as needed. All names used in
this report are pseudonyms.

Follow-up interviews were conducted from May 2010 through October 2010. These interviews covered: current
insurance status; pregnancy outcome; if terminated, date and funding source; if enrolled in subsidized insurance,
date of activation, mode of enrollment, and experiences related to enrollment process; billing experience; and
conversation notes. Most follow-up interviews were conducted 1 month to 6 weeks after women’s initial contact
with the abortion fund, but 6 women were interviewed between 7 and 9 weeks after their initial contact because
they could not be reached earlier.

The interviewer maintained handwritten notes on interviews. The authors used SPSS to calculate descriptive
statistics and conducted thematic analysis using both a priori categories and codes and inductive analysis
techniques. Vignettes were chosen to illustrate both common themes in women’s experiences and to document
unusual outcomes.

Sample characteristics
Ninety-one eligible women initially agreed to participate in the follow-up interview, 52 of whom either could
not be reached for follow-up at the numbers provided because there was no answer or because the number was
disconnected (37) or who declined to participate when they were called (15). ² The response rate is 43%; 39
women participated in the follow-up interview.

Thirty-nine follow-up interviews were completed with English-speaking women who met the eligibility
requirements for subsidized insurance programs in Massachusetts: women whose household income is less than
300% FPL, who are uninsured, who are U.S. citizens or have been permanent residents for more than five years,
and who are Massachusetts residents.

Participants reported household incomes from paid work from $0 to $60,000 a year, with a mean of $11,971.
Reported ages ranged from 18 to 43, with a mean of 24 years old. Sixteen respondents lived in eastern
Massachusetts, 13 in central Massachusetts, and 10 in western Massachusetts. Fourteen lived in households with
children. Gestational age at first contact with funds ranged from 4-22 weeks, with a median of 7 weeks.

Limitations
The sample for this qualitative project came from a very particular universe: women who found their way to
abortion funds. Women who were already on subsidized insurance, who were referred to insurance by abortion

² An additional 14 cases were referred for follow-up interviews but were not eligible for subsidized insurance because they were currently insured, were not citizens
and did not meet the residency requirements, were minors, or did not speak English. Because these groups were not targeted by the evaluation, we do not address their
outcomes in this report.

10
clinics, or who sought insurance independently may have had different experiences. Thus, the sample is not
representative, and it does not purport to estimate the full number of subsidized insurance-eligible women in
Massachusetts who needed abortion care during the period in question.

Each of the funds reported instances in which they felt the need to prioritize connecting women to abortion care
rather than confirming they might be available for a follow-up interview. This was especially true for women
who were further along in their pregnancies and for whom timely access to care was particularly pressing.
Thus, while we cannot ascertain eligibility for any woman who could not be contacted or who was enrolled in
insurance after the follow-up interview, the number of cases considered here – 91 – is likely to be a very low
estimate for Massachusetts women who were eligible for state-subsidized insurance and needed abortion care
over the six-month period under study.

The philanthropic safety net provided by the abortion funds also makes it difficult to assess the full potential
effect of enrollment delays on pregnancy outcomes. Unless women had already applied for subsidized insurance,
abortion funds typically provided women
approaching the second trimester with
grants and insurance referrals with the
knowledge that those referrals were
more likely to provide future access to Delays of abortion care documented in
health care than to cover abortion care. this report would likely be much longer
When funds were able to provide greater
without access to this private philanthropy.
proportions of funding to avoid the risk
of women going into the second trimester
or to secure immediate care for women
already in their second trimester, women
had greater access to earlier abortion than they would have had if they were entirely dependent on their own
resources. Delays of abortion care documented in this report would likely be much longer without access to this
private philanthropy.

Women in this study expressed some uncertainty about their insurance status and specific dates of insurance
activation, abortion date, and gestational age at the time of abortion, so their self-reported insurance status and
estimates of delays may be inaccurate.

Findings
Applications for subsidized insurance
All 39 women who participated in follow-up interviews reported that they were provided with contact
information to enroll in subsidized insurance. Of these, 32 women filed formal applications.

Seven women did not apply for subsidized insurance: 2 hoped to obtain insurance through their employers, 2
had particularly urgent health needs, 2 decided not to apply after speaking with enrollment representatives, and
1 woman said her previous experience with MassHealth led her to believe that it would not be activated in time.

It was not uncommon for women to use more than one method to apply or seek help with their insurance
application, and many women in our sample did so. Among the 21 women who applied and were currently
enrolled or had been approved for subsidized insurance, the HCFA hotline was named the single most
successful method for ultimately becoming insured (8 women), followed by MassHealth regional enrollment

11
centers (6 women), and “other” modes of enrollment, usually community health centers/hospitals (3 women).
Four women could not name the place they applied or were unsure of their mode of enrollment. Among the 11
women who applied and were still uninsured or were unsure if they were insured at the time of the interview, 1
applied via HCFA, 1 via MassHealth enrollment centers, and 2 via “other” modes of enrollment. Seven of this
uninsured/unsure group could not name their mode of enrollment.

Four uninsured women who had not applied for subsidized insurance indicated that they intended to apply for
subsidized insurance in the future, based on information they learned from the referrals and interview process.

Pregnancy outcomes
Thirty-six of the 39 women interviewed terminated their pregnancies, 1 woman miscarried, and 2 women
intended to carry their pregnancies to term at the time of follow-up. (See Table 1.) All 7 women who did not file
formal applications for subsidized insurance terminated their pregnancies, with the assistance of abortion fund
grants and cash they raised for the procedure.

Pregnancy Outcomes

Uninsured None 12 1 0 13
Unsure if insured MassHealth 2 1 0
4
Employer Plan 1 0 0
Insurance pending MassHealth 2 0 0
3
Employer Plan 1 0 0
Insured MassHealth 16 0 1
19
Commonwealth Care 2 0 0
Total 36 2 1 39
12
Payment sources for abortion care & costs
Ten women used state-subsidized insurance to pay for their abortion care: in other words, 31% of the 32 women
who applied for subsidized insurance were able to secure coverage for abortion care or about 28% of the 36
women who terminated their pregnancies. (See Table 2.) All but one of these women used a MassHealth plan to
pay for abortion care and reported no co-pay at the time of the abortion. Colleen, the only woman who secured
Commonwealth Care for her procedure at 14 weeks gestation, reported paying $50 for her co-pay.

Table 2: Reported Payment Sources for Abortion

Payment Source Number of Cases
MassHealth 9
Commonwealth Care 1
Grant from abortion fund and cash 19
Cash, but no grant 7
Total 36

Seven women paid for their abortion in cash, reporting costs between $450-$610. Another 19 women paid for
their abortion care with a combination of an abortion fund grant and cash: although these women frequently
indicated that they could not recall exact amounts, they reported grant amounts ranging from $25-$700 and
cash contributions ranging from $50-$500. ³ Women reported raising cash by obtaining funds from the man
involved in her pregnancy, by borrowing money from friends and family, by asking for a salary advance, by
selling personal items, and by taking credit card advances.

All of the women who paid in cash or in combination with an abortion fund grant were uninsured at the time of
their abortion. We documented no instances where a woman was enrolled in subsidized care but elected to pay
out of pocket rather than use her insurance.

Insurance status at time of interview

By the follow-up interview, nearly 60% of women who had applied for subsidized insurance were enrolled in
insurance. (See Table 1) Two women reported that they had been told their applications for MassHealth plans
had been approved but were unsure if they were currently insured; another 2 women were unsure if they were
currently insured through MassHealth. Nine women, or 28% of those who applied for subsidized insurance,
were still uninsured at the time of the follow-up interview.

Ten women who paid for their abortions

in cash and/or with abortion fund grants
while waiting for their applications to be Women reported raising cash by
processed were later enrolled in subsidized
obtaining funds from the man
insurance programs or accepted pending
activation. One woman miscarried and involved in her pregnancy, by
was subsequently enrolled in subsidized borrowing money from friends
insurance. Nine women were pursuing and family, by asking for a salary
subsidized insurance at the time of advance, by selling personal items,
follow-up, although they had already and by taking credit card advances.
had abortions. Both of the 2 women who
continued their pregnancies because they
were unable to obtain insurance coverage

³ Providers also provide additional contributions to clients working with abortion funds, ranging from $25-$80 for first trimester procedures and $75-$100 for second
trimester procedures.

13
for abortion care had applied for insurance, but were still uninsured or unsure about their status at the time of the
follow-up interview.

Satisfaction with application process

A theme common to all interviews was the difficulty of navigating the application process for subsidized
insurance; this was particularly pronounced among younger women. Women reported difficulty obtaining
accurate information both about subsidized insurance in general and their applications in particular. Some
reported receiving poor or conflicting advice from MassHealth staff; it was particularly difficult to correct a
problem with an application. Clients reported trouble getting through to MassHealth representatives and cited
being put on hold and automated messages as common sources of frustration. Some reported making daily
phone calls to MassHealth or Commonwealth Care with little progress to show for it. Clients also expressed
considerable dissatisfaction with the delays associated with applying for subsidized insurance.

The overwhelming majority of women described their contact with funds and subsequent referrals as a helpful
gateway to securing subsidized insurance. Clients reported high satisfaction with HCFA staff, although a few
complained that they had to call the hotline and leave messages more than once to obtain help. Clients who used
HCFA were more likely to be satisfied with MassHealth. Eight of the clients who had been referred to HCFA
were able to enroll in MassHealth within fourteen days; of these, three were enrolled within twenty-four hours.
Many women commented on how professional and helpful the insurance advocates were and that they had been
unaware of the resources available to help them with their insurance.

14
Four women complained that they had not received sufficient information from the abortion funds to apply for
subsidized insurance for their abortion care. Three did not apply; one applied after learning from HCFA that
subsidized insurance covers abortion in Massachusetts.

Although HCFA recommends that women disclose their pregnancies to enrollment staff, 12 women did not
disclose their pregnancy or abortion intentions when applying for subsidized insurance. Women who did not
disclose both the pregnancy and their need for an abortion reported longer delays in enrollment and slightly
more problems, such as being put on the wrong plan. Clients indicated that they did not share their pregnancy
status or abortion intentions because they were concerned about the privacy of their medical records, because

15
they were concerned about abortion stigma and potential discrimination by enrollment representatives, because
they planned to end their pregnancy and thus didn’t see themselves as “really” pregnant, and because they were
unaware it was significant to enrollment.

One woman, Jenna, reported a comment about abortion by a MassHealth representative that she felt was
judgmental and inappropriate. No woman reported problems with abortion stigma with HCFA staff.

Satisfaction with using subsidized insurance to cover abortion care

Although fewer than half of the women who applied for subsidized insurance secured funding for their
abortions, women who were able to secure insurance coverage for their abortions reported high satisfaction
with coverage provided. Once insured and connected with a provider who accepted their subsidized insurance
plan, women did not report problems using their insurance for abortion care. Although women sometimes
complained that the billing staff at clinics could not help them obtain insurance, once women were enrolled on
subsidized insurance, they described the process as working quite smoothly because clinic staff appeared to
understand the system.

No woman insured through MassHealth or Commonwealth Care reported receiving a bill for her abortion.
Because most interviews were conducted a month to six weeks after initial contact with funds (and thus usually
less than a month since the procedure), this evaluation is not well-positioned to assess longer-term billing issues.

Barriers to insurance coverage: information

Follow-up interviews provided evidence of low insurance literacy; respondents often had difficulty naming
their insurance plans and were unable to distinguish between different levels of subsidized insurance, both
between plans (e.g., Commonwealth Care and MassHealth) and within plans (different types of MassHealth and
Commonwealth Care Managed Care Options). Recognizing these distinctions was often crucial because only
some types of MassHealth cover abortion. Women often were unaware that the disclosure of their pregnancy
would expedite their application and assist with correct tracking of their application.

A lack of knowledge about abortion coverage by MassHealth and Commonwealth Care was also a barrier to
obtaining insurance quickly. Many women reported that they only learned about coverage of abortion care
when they discussed billing with the clinic or when they sought assistance from abortion funds. As a result,
some women spent time making arrangements to obtain an abortion before applying for subsidized insurance,
losing precious time in the application process.

Barriers to insurance coverage: retention mechanisms

Sixteen women had previously been enrolled on subsidized insurance, but complained that staying enrolled
on these plans was challenging. Women who had been “bumped off” explained that they had been disenrolled
from subsidized plans because of (often
temporary) changes in employment,
because they had recently turned 18,
because of changes in their student status,
or because they moved and had not Applying for subsidized insurance was
received reactivation forms required to associated with long delays. Although
maintain their insurance. A few argued that pregnant women’s applications are
they could only explain their disenrollment supposed to be expedited, it often took
through administrative error on the part several weeks to get enrolled even if
of the Commonwealth. Women who had
everything went smoothly.
previously been enrolled in subsidized
insurance appear to be more likely to be
able to secure coverage for their abortion
16
than other women. Women also reported difficulty
knowing if their insurance was active; in a few cases,
women arrived for their abortion appointments only
to find that they were no longer insured. Without the assistance of the
abortion funds, 19 women may
Barriers to abortion care coverage: delays in have been unable to pay for their
insurance enrollment
Applying for subsidized insurance was associated
abortion care because they could
with long delays. Although pregnant women’s not access state-subsidized care
applications are supposed to be expedited, it often in a timely way.
took several weeks to get enrolled even if everything
went smoothly. Application processes were often
characterized by reports of errors, missing forms, or
lost supporting documents, extending the application period even longer for many women. The time frame of
follow-up interviews does not allow us to obtain a clear estimate of the time needed to obtain insurance since such
a large proportion of those who applied were still waiting to be insured at the time of follow-up. However, more
than half the women interviewed reported delaying their abortions while they tried to secure subsidized insurance.
The average reported delay of abortion care was about 17 days; as noted above, this figure must be contextualized
within a context of relatively strong philanthropic funding. Without the assistance of the abortion funds, 19
women may have been unable to pay for their abortion care because they could not access state-subsidized care
in a timely way.

17
Consequences of delays
Delays caused considerable stress as women tried
to manage symptoms, often without disclosing the
pregnancy to employers, friends, and family members, Lana, a 19-year-old who first
particularly their parents and their children. Women contacted the funds at 23 weeks’
also reported constant worry about being able to afford a gestation, described “timing out”
termination if the pregnancy continued too long. of an in-state surgical abortion
This delay had more severe consequences for a few
when she was unable to become
women: Ariana, whose procedure was delayed by 3 enrolled right away.
weeks while waiting to be enrolled on MassHealth,
reported having to travel an hour and a half to see a new
provider, which increased the cost of travel and put her into the early second trimester. MassHealth ultimately
covered Ariana’s abortion. Lana, a 19-year-old who first contacted the funds at 23 weeks’ gestation, described
“timing out” of an in-state surgical abortion when she was unable to become enrolled right away; nor would
MassHealth cover abortion care provided by out-of-state providers. Lana ultimately continued her pregnancy,
intending to make an adoption plan, but explained that she was very disappointed by MassHealth: “If I had had
MassHealth, I would have gone right ahead and had the procedure.” Both of these women were subjected to
additional stress and health risks by the lack of timely coverage.

Delays also limited women’s ability to obtain medication abortion. As medication abortion is typically
provided through the 63rd day after the first day of a woman’s last menstrual period, several women reported
considerable anxiety that they might not obtain insurance in time. Although at least 1 woman was able to obtain
and use Commonwealth Care for a medication abortion in a timely way, the approaching deadline prompted
abortion funds to provide grants to at least 2 desperate women. Both women were later deemed eligible for
MassHealth, implying that the costs for abortion should have been covered by insurance. A third woman, Jane
reported being so fearful of “surgical abortion” that she ultimately felt she had to continue her pregnancy after
her struggles with MassHealth put her past the limit for medication abortion. Jane first applied for insurance
at 6 weeks’ gestation; by the time of follow-up 37 days later, she was still unsure if she had been approved for
MassHealth. The delays caused by attempts to enroll in subsidized insurance had a disproportionate impact on
women who sought medication abortion, forcing them to pay out of pocket or placing their preferred method for
termination out of reach.

Discussion
What works in Massachusetts
Our findings demonstrate that, once enrolled on subsidized insurance and connected to a provider who accepted
that insurance, women encounter little difficulty obtaining coverage for their abortion care. HCFA appears to
be the most effective way for pregnant women seeking abortions to become enrolled in MassHealth in a timely
manner, especially for those who have a previous history with MassHealth.

We also find that privacy safeguards seem to be working for women who use MassHealth and Commonwealth
Care. No woman reported receipt of a billing statement or a statement of benefits during the time we
interviewed them.

We speculate that women who are already mothers may already be enrolled in state-subsidized insurance as a
result of increased familiarity with the system or initiatives to increase the eligibility of mothers of young children;
this may explain why our sample contains fewer households with children (36%) than might be expected from

18
national studies (Jones et al, 2010). If so, this suggests
that some women are able to maintain their enrollment
and bypass both the application process and contact with
the funds.
By covering abortion services,
Although only a third of the women who applied were Massachusetts helps to create
able to secure coverage in time for their abortions, a gateway to being insured for
those who did were relieved and grateful that the future preventative care that all
Commonwealth covers the full spectrum of reproductive women need and deserve.
health care.

One theme of the interviews centered on the abortion as

a defining moment in women’s lives that clarified their
priorities and the need to take care of themselves and their health in the future. By covering abortion services,
Massachusetts helps to create a gateway to being insured for future preventative care that all women need and
deserve.

What isn’t working in Massachusetts

Delays in enrollment for subsidized insurance led women to postpone abortion care, sometimes by many weeks.
The delays also forced women to choose between having to pay out of pocket for medical care to which they
were entitled or risking not obtaining this care. We estimate that poor women and abortion funds paid for at
least 10 abortions that ought to have been covered by a subsidized insurance plan to which they were entitled,
but that number may be as high as 21 within this small sample. Unnecessary delays should be a matter of
concern to policy makers in Massachusetts and states where state-run Medicaid programs do cover abortion
care, because procedures at later gestational ages are more expensive and delays may increase costs to the state.
Delays also increase health risks of the procedure.

The intangible costs of enrollment delays must also be taken into account. Stress about money and pregnancy
disclosure, frustrations with insurance bureaucracy, additional travel costs, seeing unfamiliar providers, and the
19
management of pregnancy symptoms all contributed
to make women’s lives difficult at an already
challenging time (Finer et al, 2005). In 2 cases, the
delays meant that women were unable to obtain the
abortions they sought. These 2 cases also demonstrate
Unnecessary delays should be a
that failing to provide all pregnant women with
presumptive eligibility and expedited access to care matter of concern to policy makers
may constrain their ability to obtain not only abortion in Massachusetts and states where
services, but also services for continuing pregnancies state-run Medicaid programs do cover
if their applications are not tracked correctly. abortion care, because procedures
at later gestational ages are more
The 2 women who intended to carry their pregnancies
expensive and delays may increase
to term after failing to obtain coverage for abortion
services did not benefit from targeted programs, such costs to the state.
as prenatal-only plans with presumptive eligibility;
we speculate that their applications were tracked for
standard coverage required for abortion care and that they were unaware that they could obtain coverage for
limited services sooner.

Women indicated that information from the state insurance system – including websites, form letters, as well
as interpersonal interactions with staff – was often confusing and out-of-date by the time notifications reached
them, which is consistent with other research (Bessett et al, 2010; Ibis Reproductive Health and MDPH Family
Planning Program, 2009). This made it difficult for women to stay insured, and thus contributed to the need to
re-apply. Evidence of information barriers was further illustrated by the small number of applications that were
approved in a matter of days once women were connected with insurance advocates. Often these were women
who had previously been dropped from subsidized insurance for administrative reasons that could be corrected
easily once the reason for the disruption was understood.

Some clients reported that MassHealth enrollment representatives made contradictory statements about their
coverage and, in one case, engaged in judgmental commentary to a woman seeking to obtain an abortion.
Enrollment representatives may need additional training in the Commonwealth’s coverage of reproductive care
and the limits of professional speech.

This paper reports the experiences of women

Stress about money and
pregnancy disclosure,
frustrations with insurance
bureaucracy, additional travel
costs, seeing unfamiliar
providers, and the management
of pregnancy symptoms all
contributed to make women’s
lives difficult at an already
challenging time.
who could be contacted for follow-up
interviews. Women who could not be reached
for interviews because of disconnected
numbers (71% of those who could not be
reached for follow-up interviews) are likely
the most vulnerable of the initial sample,
with low housing security and unreliable
contact information. Because stable contact
information is required for subsidized
insurance, it is likely that the insurance
outcomes for women who could not be
reached are even less promising than for
those described above. More research should
be done to understand the outcomes of these
women.

20
Recommendations
1. Protect coverage for low-income women’s abortion care in the Commonwealth during
implementation of national health reform.
Low-income women’s lives are improved by comprehensive coverage of sexual and reproductive health
services. We must value the abortion services that are covered by the Commonwealth regardless of
insurance program and the vital role they play in women’s lives.

2. Prioritize expedited enrollment and presumptive eligibility for all pregnant women, regardless of
pregnancy intentions.
Failing to provide all pregnant women with expedited access to care constrains their ability to obtain
not only abortion services, but also prenatal services for continued pregnancies if applications are not
tracked correctly. The Commonwealth should consistently expedite enrollment in subsidized insurance
for pregnant women whether they intend to terminate the pregnancy or carry it to term and build upon
the successful MassHealth Prenatal program to create new options of presumptive eligibility for abortion
care.

3. Improve enrollment processes for subsidized insurance in the Commonwealth.

The Health Connector and MassHealth authorities must continue to work to speed enrollment for
subsidized insurances to insure all residents can obtain the care to which they are entitled with ease and
dignity. Improvement of enrollment processes is especially important for women to access the full range
of abortion procedures in a timely way.

4. Fortify client retention for subsidized insurance in the Commonwealth.

While re-enrollment processes are necessary, this research demonstrates that some Massachusetts
residents lose access to needed services for some period of time as a result. Given that so many women
in this study reported being dropped from subsidized insurance before becoming pregnant, strengthening
renewal mechanisms is likely to eliminate delays related to re-enrollment for this group as well as other
eligible Massachusetts residents. Not only would this improve women’s ability to secure the pregnancy
outcome they want, but it might also reduce the risk of an unwanted pregnancy through better and more
regular access to more effective contraceptives.

5. Train enrollment representatives to avoid expression of their personal biases when assisting clients.
Abortion stigma, whether enacted or perceived, makes applicants reluctant to disclose their pregnancies
and abortion intentions. Encountering biases limits women’s ability to seek expedited enrollment for
abortion services and damages the professionalism for which most enrollment representatives strive.

6. Improve information resources for women seeking to obtain insurance information for abortion
coverage.
Our findings document low health insurance literacy and women’s reports of confusion at insurance
information provided by the Commonwealth. In order to make appropriate choices about health care
and insurance, women must be educated about their coverage options under subsidized insurance by
providing clear and accessible information about plan types, specific benefits (including abortion), and
health insurance terminology. Information should be age-appropriate for young women who are applying
for insurance for the first time.

21
7. Improve abortion fund referrals through trainings in subsidized insurance.
Funds should continue to refer clients to HCFA for assistance with enrollment, but also explore whether
enrollment efficacy varies among community health centers and hospitals. Notably, funds must educate
women that many subsidized insurance plans cover abortion care before referring them to HCFA; they
should advise clients to disclose their pregnancies. Funds should also help women develop questions
for the HCFA hotline or enrollment representatives. Because some clients have the perception that
government health programs can never work quickly and thus do not think it is worth applying, funds
should also tell clients success stories so that women do not pay out of pocket for services that should
be covered. Yet funds must also explicitly encourage women to keep in contact as the process moves
forward so that they do not feel alone in the process and lose access to the important resources that
abortion funds can provide.

8. Conduct more research on potentially underserved populations.

The outcomes of this qualitative study point to some problems with enrollment and maintenance on
subsidized insurance in the Commonwealth. Women who did not find their way to abortion funds or who
could not be contacted for this study are likely to be even more vulnerable than those who participated in
the follow-up interviews and, as a result, may have been less successful in obtaining abortion care. More
research is needed to investigate the outcomes of these women and other disadvantaged groups.

22
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Contact information for and additional information about the Massachusetts abortion funds can be found at:

The Jane Fund of Central Massachusetts

www.janefund.org

Abortion Rights Fund of Western Massachusetts

www.arfwm.org

The Eastern Massachusetts (EMA) Fund

www.emafund.org