Protecting and Increasing Abortion Access

For nearly 50 years, the constitutional right to an abortion in the United States vastly improved women’s labor force participation, educational outcomes, wages, and the probability of entering professional occupations. It reduced teen and young adult motherhood;¹ improved health outcomes and prevented deaths of both mothers and their children;²³ and enabled all women to exercise bodily autonomy, make personal medical decisions, and plan when and how to have a family. In short, the constitutional right to abortion was imperative for women’s economic advancement and well-being—and for the U.S. economy at large.

However, on June 24, 2022, the U.S. Supreme Court decision in Dobbs v. Jackson Women’s Health Organization eliminated the constitutional right to abortion, setting women back more than a generation. Yet a majority of adults—64 percent—support abortion in all or most cases, according to June 2023 polling.⁴ Moreover, Center for American Progress polling has found that voters overwhelmingly support early medication abortion—a two-step regimen that is used to end a pregnancy—and oppose its criminalization.⁵ Medication abortion accounts for more than half of all abortions in the United States and can be taken safely in the comfort of the patient’s own home through the use of telehealth.⁶

Although voters on the far ends of either political party are divided on abortion access, centrists from all parties tend to support positions in favor of abortion access.⁷ The majority—60 percent of moderate Republicans and 72 percent of conservative Democrats—support abortion in all or most cases. Notably, people who consider themselves “moderates” tend to make up the largest voting demographic, and the issue is more important now to voters than it was before Dobbs was decided in 2022. In May 2023, only 14 percent of respondents to a Gallup poll said that abortion was not a major issue that would affect their vote for major offices, compared with 25 percent in May 2020.⁸

Policymakers at the federal and state levels have an array of policy options available to deal with the harmful consequences of the Dobbs decision for women. These include measures to protect the privacy of women seeking abortions and the medical professionals who provide those services and steps to make abortion care more affordable and accessible. This chapter of the “Playbook for the Advancement of Women in the Economy” details the problems women now face accessing abortion care, the economic benefits of resolving them, and federal and state policy recommendations for doing so.

The problem

The radical Supreme Court majority’s decision in Dobbs overturned nearly 50 years of legal precedent, eradicating the constitutional right to abortion established in Roe v. Wade. This left policy decisions on access to abortion in the hands of the states, which has led to profound confusion among providers and patients.⁹ Some states reverted back to arcane pre-Roe laws, created new restrictive abortion access policies, or enacted broad criminal and civil sanctions against medical professionals for providing abortion care.¹⁰ Almost all of these new anti-abortion policy regimes are now facing litigation.

This confusion compounds the harms caused by the Hyde Amendment, which restricts the appropriations of the U.S. departments of Labor, Health and Human Services, and Education and their related agencies from being used to cover abortions.¹¹ This particularly affects Medicaid and Medicare, which is available to individuals under age 65 with certain medical conditions or disabilities. Low-income women, women of color,¹² and disabled women,¹³ the vast majority of whom are more likely to rely on public health insurance coverage, are disproportionately affected by this law.¹⁴

These barriers to abortion care may lead low-income women and women of color to enter fake women’s health centers—also called crisis pregnancy centers—that use politically motivated, manipulative, and misleading tactics to attempt to dissuade women from obtaining wanted abortions.¹⁵ Often, low-income women and women of color are targeted by these fake centers, which are able to operate outside of the same medical and legal regulations that are foisted upon abortion clinics and other licensed medical clinics and receive state and federal funds despite providing this medically inaccurate information.¹⁶

As of February 2024, seven states have heavily restricted abortion access up to the first 18 weeks of pregnancy, and another 14 have created full bans that outlaw abortion at all stages of pregnancy.¹⁷ The states that have banned abortion are predominantly located in the South and Midwest and tend to provide fewer public resources than other states in terms of women’s health and work.¹⁸ This geographic clustering of abortion bans has resulted in an uneven demographic distribution of the effects of restrictive abortion access policies. Black women and Native American women are more likely to live in states that ban or severely restrict abortion than the overall population of women, with 59 percent of Black women and 61 percent of Native American women ages 15 to 49 living in these regions compared with 48 percent of all women in that age range in the United States.¹⁹

The economic benefits

Numerous studies show that access to abortion increases women’s participation in the U.S. labor market and is especially critical for Black women. The pre-Roe repeal of restrictive abortion laws between 1969 and 1972 increased the labor force participation of Black women by about 6 percentage points. To put that into perspective, a 6 percentage-point increase in the labor force participation rate of Black women ages 20 and older in October 2023 would have been an increase of about 1 million women in the labor force.²⁰

Truly accessible abortion care also hinges on the ability to visit an abortion provider, which is also correlated with labor force activity. Research conducted prior to the Dobbs ruling shows that states with higher numbers of abortion providers also had higher levels of labor force participation among young women.²¹ Since Dobbs, the travel time to get to an abortion clinic has increased dramatically—the median travel time for women ages 15 to 44 living in states with full bans and six-week bans increased by 56 percent, and the mean travel time increased by 261 percent by September 2022.²²

The number of abortion care facilities is also in rapid decline. In April 2023, there were 762 brick-and-mortar abortion facilities in the United States, with 40 percent of those clinics exclusively providing medication abortion—all while the total number of facilities continues to decline. By September 2023, there were 757 brick-and-mortar abortion facilities, meaning five more facilities shuttered in just five months—roughly 13 percent of total closures. In March 2022, prior to Dobbs, there were 796 facilities.²³

The average cost of an abortion ranges widely²⁴—from nearly $600 to more than $2,000 without insurance.²⁵ And these costs do not account for the nonmedical costs of abortion care that can easily add up to several thousands of dollars, including transportation, hotels, child care, time off work, and more.²⁶ These costs extend beyond the individual: In total, abortion restrictions cost state economies an estimated $105 billion per year in 2021.²⁷

Furthermore, 85 percent of women report that cost is a primary reason for not getting a wanted abortion.²⁸ More than half of women seeking abortions live below the federal poverty level, 3 in 4 cannot cover essentials such as food and shelter, and more than 3 in 5 already have children.²⁹

Indeed, the cost of an abortion has a large effect on demand.³⁰ Those women who have insurance coverage through Medicaid³¹—and who live in states where state Medicaid can be used to cover abortion services—had lower odds of waiting more than two weeks for an abortion, were more likely to have an abortion earlier in a pregnancy, and were more likely to live within an hour of a clinic.³² This further emphasizes the importance of state policy to help low-income women and women of color receive the accessible abortion care they need, in spite of the Hyde amendment.

Studies prove that access to an abortion is the direct cause of improved economic well-being for women and their families. An analysis looking at pre- and post-Roe effects on household finances shows that a child not born due to access to legal abortion would have been 40 percent more likely to live in poverty had the pregnancies not been terminated.³³ Analysis using the Turnaway Study—a five-year study that compared the outcomes of women who wanted abortions but were denied one due to a gestational limit with a similar group of women who were not turned away—shows that women forced to carry an unwanted pregnancy to term were four times more likely to live below the federal poverty line.³⁴

Another study shows that those women who were denied an abortion experienced a 78 percent increase in past due debt and an 81 percent increase in bankruptcies, evictions, and court judgments than those who were able to get an abortion.³⁵ And women who were turned away from an abortion were six times more likely to receive Temporary Assistance for Needy Families in the first six months of the study than the group that was not turned away—and this discrepancy between groups persisted for up to five years.³⁶ Programs such as the Supplemental Nutrition Assistance Program and Special Supplemental Nutrition Program for Women, Infants, and Children also had higher recipiency rates among the group denied abortions, and the results held over a five-year and two-year period, respectively.

Motherhood among teens³⁷ and young adults before age 21³⁸—as well as teen marriage³⁹—declined because of expanded abortion access in the 1960s and 1970s. Research shows that there are substantial monetary benefits from delaying motherhood by one year, increasing mean hourly wages by 11 percent for women overall and annual earnings by 10 percent for Black women.⁴⁰ Studies also show that in the two decades following the 1970s state abortion reforms, the likelihood of going to a four-year college and obtaining a professional occupation after graduation rose as a result of increased abortion access, especially for Black women.⁴¹

Another study that controlled for the effect of contraceptive access and used more accurate econometric modeling during that same time period estimated that access to an abortion alone increased the likelihood of women attending a four-year college by 41 percent and the likelihood of earning a degree by 72 percent. This was even higher among Black women, whose probability of attending a four-year college increased by up to 200 percent.⁴²

These examples provide a backdrop for the current effects of the Dobbs decision and state restrictions that are already being felt by the many women who are traveling long distances for abortion care,⁴³ have been jailed for having abortions,⁴⁴ and who are unable to have wanted abortions. A recent study shows that births have increased by 2.3 percent in states with total abortion bans compared with those that have protected the right to an abortion, and the authors estimate that 20 percent to 25 percent of those who were seeking wanted abortions were unable to get them because of these restrictions. In particular, these bans had the largest effects on births for Hispanic women (4.7 percent), women ages 20–24 (3.3 percent), women who live in Texas (5.1 percent), and women who live in Mississippi (4.4 percent).⁴⁵ Policymakers must act now to expand access and stem the harmful consequences of state abortion bans.

The policy recommendations

Expanding abortion access would improve women’s health, economic security, and well-being.  Federal and state policymakers should act to expand access to abortions, decriminalize abortion, improve patient privacy, and reduce health care costs. Federal and state policymakers have a complementary set of actions they could take.

Federal policy recommendations

Nationwide action to protect the right to an abortion includes an array of policies:

• Repeal the Hyde Amendment:⁴⁶ The amendment prohibits public insurance from being used to cover abortion services. Repealing it would make abortion more accessible to low-income and disabled women, and it would also have a substantial impact on communities of color.
• Create accessible and clear explanations of HIPAA’s privacy rights on the Reproductiverights.gov website:⁴⁷ The Health Insurance Portability and Accountability Act (HIPAA) ensures that patients, health care workers, and hospital volunteers protect private medical information from being used by law enforcement with political motivations.
• Create best practices in collaboration with medical groups and experts:⁴⁸ Health care entities that provide abortion services that are dealing with law enforcement in a post-Dobbs environment need to have clear best practices for disclosure and detail only medically necessary information in patient records.
• Establish a legal hotline for suspected HIPAA privacy violations:⁴⁹ In addition to the existing online portal maintained by the Health and Human Services Office for Civil Rights, the executive branch should establish this hotline in partnership with the U.S. Department of Justice.

State policy recommendations

State policymakers have a number of policy actions they can take:

• Pass statutory protections and issue executive orders that protect abortion rights:⁵⁰ Taking these steps would ensure that these protections are codified in state law, and some executive orders could include funding to build out abortion access and affordability in underserved communities.
• Pass shield laws to protect patients and medical providers:⁵¹ Shield laws vary from state to state but most protect patients and/or medical providers from persecution by states that have criminalized abortion.
• Ensure all stakeholders administering a self-managed abortion are legally protected from civil and criminal sanctions:⁵² Legal protections should include patients, pharmacists, physicians, and other authorized health professionals.
• Make abortion more affordable:⁵³ Remove cost-sharing provisions for abortions and explicitly include medication abortions in state health plans.
• Authorize the use of state Medicaid funds to cover abortion services:⁵⁴ States should enable state Medicaid funds, which are not restricted by the Hyde Amendment, to pay for abortion services. As of June 2023, there were 17 states that allowed Medicaid to pay for medically necessary abortions.⁵⁵
• Fix payment issues and issue guidance for those who are enrolled in both Medicare and Medicaid to accelerate the process to cover services with state Medicaid funds:⁵⁶ Medicare is legally required to pay first, and rates are typically higher than Medicaid. Notwithstanding a Medicare rate for abortion services, claims are often held up by lengthy billing processes even in states that provide additional funds to cover abortion services.
• Remove restrictions on telehealth services for Medicaid enrollees:⁵⁷ These enrollees often work inflexible hours or live far from abortion clinics, which means they need guaranteed access to telehealth abortion services.
• Create know-your-rights guides:⁵⁸ Policymakers can work with state and local health departments supportive of abortion to post information about HIPAA rights.
• State attorneys should establish statewide reproductive rights task forces:⁵⁹ These task forces could coordinate meaningful access to abortion-related services and protection of medical providers.
• Create consumer advisories on the dangers of crisis pregnancy centers:⁶⁰ State attorneys general could craft these advisories for women seeking abortions and allow them to file crisis pregnancy center complaints.
• Protect the data privacy of those seeking abortions: State attorneys general and state consumer affairs departments could work with providers and advocate for private businesses to protect reproductive health information.
• Expand and train the abortion provider workforce:⁶¹ State lawmakers can enact legislation, which would have to be signed into law by their governors, that could expand the scope of training for various practitioners such as nurse practitioners, nurse midwives, licensed certified midwives, and physician assistants, as well as providers of abortion care.
• Continue to work to expand access to services that support abortion access: (see Chapter 3) State policymakers should work to support and expand key services that help women to obtain abortion services, such as high-quality, affordable child care (see Chapter 3); paid family and medical leave (see Chapter 6); transportation; and other supportive services that would help cover some of the nonmedical costs of abortion care. Additionally, they should lift up the work of direct advocacy organizations, including national and state abortion funds that help pay for these services.

Conclusion

In light of the ongoing post-Dobbs abortion restrictions in more and more states, policymakers at the federal and state levels must push to meaningfully expand access and affordability of abortion services of all types. Doing so is smart economic policy that lifts women’s employment, incomes, educational outcomes, and more. Inclusive economic policies that provide strong economic benefits to all must include a plan to expand access to abortion.

The author would like to thank Amina Khalique and Isabela Salas-Betch for their research assistance and Sabrina Talukder, Kierra Jones, Emily Gee, Rose Khattar, and Andrea Ducas for their thoughtful review.