Maryland has enacted a law that allows special funds collected from insurers under the ACA to be used for abortion care.
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Jonathan Newton/For The Washington Post/Getty Images
Maryland is the first state to tap into a 15-year-old fund connected to the Affordable Care Act, to help solve a more recent problem: helping pay the expenses of patients who travel to Maryland for an abortion.
The law passed this spring, and went into effect on July 1.
Since the Supreme Court overturned Roe v. Wade in 2022, states like Maryland where abortion remains legal have seen an increase in abortion procedures including patients who can’t get a legal abortion in their home state. Many of those patients need financial assistance for the procedure itself, or to pay for travel from other states and lodging while they recover.
That financial aid is often provided by local and regional abortion funds, like the Baltimore Abortion Fund. They are nonprofits that help individuals pay for reproductive care, travel and related expenses.
But as more and more patients have traveled to Maryland, some of the abortion funds have exhausted their resources. That puts financial pressure on abortion providers in Maryland who want to serve those traveling patients, as well as uninsured or low-income Marylanders seeking the same care.
Clinicians in Maryland performed about 39,000 abortions last year, a 26% increase from 2020, according to the Guttmacher Institute, a nonprofit focused on sexual health research.
Maryland is now the first state in the nation to pass a law using a much-forgotten aspect of the Affordable Care Act to help fund that care. The money comes from fees paid by insurance companies who participate in the ACA marketplaces.
Maryland’s move represents an innovative solution for states that have opened their doors to out-of-state patients, but are grappling with the logistics and costs of the increased clinical demand in a post-Roe landscape.
“This bill is super important for Maryland, we’re making sure our clinics stay open,” said Maryland state Del. Lesley Lopez, a Democrat who sponsored the bill. “Maryland has been a leader on a lot of reproductive bills for the past 30 years, and so in that way, this bill fits into that legacy.
“It’s also nationally significant, because there’s 25 or 26 other states that can take this model and run with it. We’re looking for California, Illinois, New York, those bigger states that are sitting on potentially hundreds of millions of dollars to take what we’ve done here in Maryland and implement it there.”
Financial dilemma
With abortion now restricted or illegal in 22 states, jurisdictions like Maryland have become a destination for patients from as close as neighboring West Virginia and as far as Texas.
With a staff of six, the Baltimore Abortion Fund helps patients pay for bus or plane tickets, lodging in Maryland, and sometimes even meals while they travel. The fund spends about a million dollars a year on that support. Calls to its confidential helpline have increased by 50-60% every year since Roe was overturned, said Lynn McCann-Yeh, the fund’s co-director.
The fund disburses aid on a weekly basis, meting out funds as people call in. Often the weekly allotment is depleted after just one or two days.
“Sometimes that means that our helpline is closing within 24 to 48 hours at the start of the week, because there’s just too much demand for the amount of resources that we have,” McCann-Yeh said.
“There are many, many more dozens of callers each week that are just getting a voicemail message saying that we’ve run out of support.”
A new way to pay for abortions
To help, Maryland’s legislature turned to a pot of money established under the 2010 Affordable Care Act. Under the law, states could decide to require insurance plans sold on the ACA “marketplaces” to cover abortion. The plans were required to charge a minimum fee of at least $1/month on every plan bought through the marketplace.
That money was then put into an account that would be used to pay when insured patients received abortion care.
More than 90% of the patients at Partners in Abortion Care receive financial assistance through various abortion funds.
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Scott Maucione/WYPR
The state accounts were necessary because of a another federal law, the Hyde amendment, that restricts the federal government from paying for abortions (except for cases involving rape, incest or serious medical risk to the patient.)
Because the federal government partially subsidizes insurance plans sold through the ACA marketplaces, the commercial insurers had to use their own money to pay the monthly fee for each policyholder.
“Insurers have quietly complied with the ACA special rules resulting in these segregated accounts that have millions of dollars in them intended for abortion coverage, ” Duffy said.
Over time, the accumulated fees in such accounts have outstripped the withdrawals for abortion care for women on those insurance plans. Maryland’s account has grown to $25 million, and it continues to take in about $3 million each year.
Maryland’s new law allows the state health department to tap those funds and allocate up to $2.5 million a year in grants to the abortion funds operating in Maryland, who can then use that money for the traveling patients, low-income patients in Maryland, or those who have no insurance coverage at all.
“We know that we will be able to use those funds wisely and to make sure that we’re not turning away any patient due to their inability to pay,” said Ramsie Monk, the director of development at the Women’s Health Center of Maryland, a clinic that is on the West Virginia border.
Without assistance from abortion funds, many of the patients seen at clinics would not be able to pay for their care, says Dr. Diane Horvath, an OB/GYN at Partners in Abortion Care, a clinic in College Park, Maryland. Unlike some other clinics, which only offer abortion up to 16 weeks of pregnancy, Partners in Abortion Care can provide an abortion later in pregnancy. Those procedures are more complicated and more expensive.
More than 90% of the patients at Partners in Abortion Care receive financial assistance through various abortion funds.
“I would say a typical patient that we see probably every week is somebody who’s already got at least one child, they’re working a job that doesn’t offer substantial leave for medical care, it may not offer health insurance, or the insurance it offers doesn’t cover abortion, particularly when they’re coming from out of state and they’re struggling and living paycheck to paycheck,” Horvath said.
Opponents push back on state’s role
Anti-abortion groups in Maryland opposed the bill, claiming that it forces some insurance consumers to pay for procedures they may not agree with.
“This bill uses insurance premiums from insured women to abort the children of uninsured women,” Laura Bogley, the executive director of Maryland Right to Life, told the state legislature on March 6.
“Many of those uninsured women are non-Maryland residents who are trafficked into the state for late term abortions that are restricted by other states.”
The bill’s supporters deny that traveling patients are being trafficked when they are traveling of their own volition in search of health care.
The law officially went into effect on July 1, and the first tranche of money must be transferred to the state health department by the fall, before they can start making grants.
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