Leveraging the Tools Available: Using the Hyde Amendment to Preserve Minimum Abortion Access and Mitigate Harms in Restrictive States.

The overturn of Roe v. Wade has resulted in fewer rights and resources for people seeking abortion care, particularly in the South. The Hyde Amendment has historically restricted abortion access for those enrolled in Medicaid. We argue here that its guarantees of minimum abortion coverage should be leveraged to offset harms where possible.

Are Illinois Contraceptive Providers Comfortable Providing Care to Adolescents? Results From a Statewide Provider Needs Assessment.

OBJECTIVES: Legislation allows adolescents to access comprehensive contraceptive care; however, provider practices remain unclear. We examined predictors of provider knowledge and comfort surrounding the provision of contraceptive care to adolescents. METHODS: We mailed a survey to Illinois contraceptive providers (n = 251). Study outcomes include 1) knowledge of adolescent consent laws, 2) comfort asking for time alone with adolescents, 3) comfort providing contraception to adolescents without parental consent, and 4) comfort providing long-acting reversible contraception (LARC) to adolescents without parental consent. Using multivariable logistic regression, we estimated adjusted odds ratios (aORs) and 95% confidence intervals (CIs). RESULTS: Most providers are knowledgeable of consent laws (90%) and report being comfortable asking for time alone with adolescents (94%) and comfortable providing contraception to adolescents without parental consent (88%). Having a large proportion of patients who are eligible for family planning services was associated with increased comfort asking for time alone with adolescents (aOR, 7.03; 95% CI, 1.58-31.3) and providing contraception to adolescents (aOR, 4.0; 95% CI, 1.4-11.1). Only one-half (54%) were comfortable providing LARC methods to adolescents, with higher comfort among providers who: received more than 2 days of formal family planning training (aOR, 2.77; 95% CI, 1.2-6.2), specialized in obstetrics-gynecology (aOR, 5.64; 95% CI, 2.1-15.1), and had a patient population with more than 50% patients from minoritized racial/ethnic groups (aOR, 2.9; 95% CI, 1.2-6.6). CONCLUSIONS: Although knowledge of consent laws was high, gaps remain. Only one-half of our sample indicated comfort with the provision of LARC methods without parental consent. Additional efforts to increase provider comfort with all contraceptive methods and training on adolescent-centered practices may be required to meet the needs of adolescent patients.

Provider and community stakeholder perspectives of expanding Medicaid coverage of abortion in Illinois.

BACKGROUND: Many people seeking abortion encounter financial difficulties that delay or prevent them from accessing care. Although some patients qualify for Medicaid (a public program that can help cover health care costs), laws in some states restrict the use of Medicaid for abortion care. In 2017, Illinois passed House Bill 40 (HB-40), which allowed patients with Medicaid to receive coverage for their abortion. This study aimed to understand how HB-40 affected abortion affordability from the perspectives of individuals that work directly or indirectly with abortion patients or facilities providing abortion care. METHODS: We conducted interviews with clinicians and administrators from facilities that provided abortion services; staff from organizations that provided resources to abortion providers or patients; and individuals at organizations involved in the passage and/or implementation of HB-40. Interviews were audio-recorded and transcribed. We created codes based on the interview guides, coded each transcript using the web application Dedoose, and summarized findings by code. RESULTS: Interviews were conducted with 38 participants. Participants reflected that HB-40 seemed to remove a significant financial barrier for Medicaid recipients and improve the experience for patients seeking abortion care. Participants also described how the law led to a shift in resource allocation, allowing financial support to be directed towards uninsured patients. Some participants thought HB-40 might contribute to a reduction in abortion stigma. Despite the perceived positive impacts of the law, participants noted a lack of public knowledge about HB-40, as well as confusing or cumbersome insurance-related processes, could diminish the law's impact. Participants also highlighted persisting barriers to abortion utilization for minors, recent and undocumented immigrants, and people residing in rural areas, even after the passage of HB-40. CONCLUSIONS: HB-40 was perceived to improve the affordability of abortion. However, participants identified additional obstacles to abortion care in Illinois that weakened the impact of HB-40 for patients and required further action, Findings suggest that policymakers must also consider how insurance coverage can be disrupted by other legal barriers for historically excluded populations and ensure clear information on Medicaid enrollment and abortion coverage is widely disseminated.

Lessons learned: Illinois providers' perspectives on implementation of Medicaid coverage for abortion.

OBJECTIVE: On January 1, 2018, Illinois became the first Midwestern state to cover abortion care for Medicaid enrollees. This study describes state implementation of the policy, the impact on abortion providers, and lessons learned. STUDY DESIGN: We documented abortion providers' perspectives on the service delivery consequences of Medicaid coverage for abortion in Illinois. We conducted in-depth interviews with clinicians and administrators (N = 23) from 15 Illinois clinics, including clinics that provided other services and those primarily providing abortion. We conducted interviews in person or by phone between April and October 2019. They lasted ≤100 minutes, were audio-recorded, transcribed, and coded in Dedoose. We developed code summaries to identify salient themes across interviews. RESULTS: All participants supported the law and expected benefits to patients. Many struggled to implement the policy because of difficulties obtaining certification to bill the state Medicaid program, confusing and cumbersome paperwork requirements, reimbursement delays, confusing claim denials, and uncertain protocols for Medicaid patients covered under the exceptions defined by the Hyde Amendment. Nearly all participants expressed concern that low reimbursement rates were insufficient to cover costs. Implementation was easier for multiservice clinics and those nested in larger institutions. Several clinics closed during implementation; one clinic opened. Clinics leveraged internal resources, external funding, and technical assistance to ensure that Medicaid enrollees could receive care without costs. CONCLUSIONS: Implementing Medicaid coverage for abortion requires proactive and responsive state institutions, improvements to reimbursement processes, and adequate reimbursement rates. In Illinois, successful implementation depended on clinic adaptability, external support, and advocacy. IMPLICATIONS: Our research suggests that successful, sustainable implementation of Medicaid coverage for abortion depends on state policies that allow clinics to enroll patients, process claims in 30 to 90 days, and receive reimbursements covering the cost of care. Without these measures, ensuring immediate patient access may depend upon clinics mobilizing resources and external transitional support.

Family planning service provision in Illinois religious hospitals: Racial/ethnic variation in access to non-religious hospitals for publicly insured women.

OBJECTIVES: To identify religious affiliations of hospitals and access to family planning (FP) care available to publicly insured women in Cook County, Illinois. DESIGN: We analyzed Illinois public insurance enrollment data and family planning service claims (2015-2018) for women 18-45. RESULTS: Eighty-five percent of Black/Hispanic women were enrolled in Medicaid managed care plans with a higher percentage of Catholic healthcare than Cook County as a whole compared to 75% of White women (p<0.0001). There were fewer FP services at Catholic (IRR 0.072, 95% CI 0.068-0.076) and Christian non-Catholic (IRR 0.55, 95% CI 0.53-0.56) compared to non-religious hospitals. CONCLUSIONS: Medicaid managed care plans may restrict family planning care by limiting patients to religious hospitals.

Well-woman Care Barriers and Facilitators of Low-income Women Obtaining Induced Abortion after the Affordable Care Act.

OBJECTIVES: This study uses the abortion visit as an opportunity to identify women lacking well-woman care (WWC) and explores factors influencing their ability to obtain WWC after implementation of the Affordable Care Act. METHODS: We conducted semistructured interviews with low-income women presenting for induced abortion who lacked a well-woman visit in more than 12 months or a regular health care provider. Dimensions explored included 1) pre-abortion experiences seeking WWC, 2) postabortion plans for obtaining WWC, and 3) perceived barriers and facilitators to obtaining WWC. Interviews were transcribed and analyzed using ATLAS.ti. RESULTS: Thirty-four women completed interviews; three-quarters were insured. Women described interacting psychosocial, interpersonal, and structural barriers hindering WWC use. Psychosocial barriers included negative health care experiences, low self-efficacy, and not prioritizing personal health. Women's caregiver roles were the primary interpersonal barrier. Most prominently, structural challenges, including insurance insecurity, disruptions in patient-provider relationships, and logistical issues, were significant barriers. Perceived facilitators included online insurance procurement, care integration, and social support. CONCLUSIONS: Despite most being insured, participants encountered WWC barriers after implementation of the Affordable Care Act. Further work is needed to identify and engage women lacking preventive reproductive health care.

Variation in Pregnancy Options Counseling and Referrals, And Reported Proximity to Abortion Services, Among Publicly Funded Family Planning Facilities.

CONTEXT: As frontline providers, publicly funded family planning clinics represent a critical link in the health system for women seeking information about pregnancy options, yet scant information exists on their provision of relevant services. Understanding their practices is important for gauging how well these facilities serve patients' needs. METHODS: A 2012 survey of 567 publicly funded family planning facilities in 16 states gathered information on referral-making for adoption and abortion services, and perceived proximity to abortion services. Chi-square, multivariable logistic regression and multinomial logistic regression analyses were performed to assess differences among facilities in referral-making and reported proximity to abortion services. RESULTS: Abortion referrals were provided by a significantly smaller proportion of providers than were adoption referrals (84% vs. 97%). Health departments and community health centers were significantly less likely than comprehensive reproductive health centers to refer for abortion services and to have a list of abortion providers available (odds ratios, 0.1-0.2). Rural facilities were more likely than urban ones to report a distance of more than 100 miles to the closest first-trimester abortion provider (relative risk ratio, 11.4), second-trimester abortion provider (8.7) and medication abortion provider (8.0). Health departments were more likely than comprehensive reproductive health centers not to know the location of the closest first-trimester, second-trimester or medication abortion provider (2.5-3.5). CONCLUSION: A better understanding of disparities in provision of pregnancy options counseling and referrals at publicly funded family planning clinics is needed to ensure that women get timely care.