Heterogeneity in Abortion Coverage: A Qualitative Analysis of State Medicaid Policies [ID 1222]

INTRODUCTION: Approximately 35% of individuals seeking abortion care depend on Medicaid for health insurance. The Hyde Amendment prohibits the use of federal funds for Medicaid-covered abortions, except in cases of rape, incest, or physical conditions which place the pregnant person at risk of death, although its implementation and the use of state funds to supplement coverage are state-dependent. Our study examines state Medicaid policies to characterize the scope of abortion coverage and coverage requirements across states. METHODS: We extracted data from Medicaid documents for all states and Washington, D.C., starting in May 2023 and updated February 2024. Using thematic analysis, we developed an iterative codebook to extract themes on scope of coverage and coverage requirements. RESULTS: Six states cover all abortions. All states but one mention rape or incest coverage. For clinical conditions covered, 18 states utilize Hyde Amendment wording, 10 mention life endangerment generally, and 17 mention coverage for additional conditions not defined in the Hyde Amendment, such as psychiatric conditions, fetal anomalies, or other medically necessary conditions. Themes extracted include 1) heterogeneous coverage of clinical conditions; 2) rigorous requirements for rape and incest coverage, such as reporting the incident to authorities; and 3) an onus on providers to determine coverage eligibility and fulfill administrative requirements. CONCLUSIONS/IMPLICATIONS: In many states, Medicaid abortion coverage is heterogenous and administratively burdensome for patients and providers. This study highlights state-dependent barriers to abortion coverage for patients with Medicaid and the need for policymakers to work towards more equitable access for this patient population.