Last summer, when arguing in court in favor of Senate Bill 206, a harsh law that would force at least one of Wisconsin’s abortion clinics to close its doors, a state official compared ending a pregnancy to buying a fancy car.
“If I decided I’m going to buy a Mercedes-Benz but I cannot get financing for that car and I don’t have the funds to buy it, am I prevented from buying a Mercedes-Benz?” Assistant Attorney General Clayton Kawski asked an expert witness during the hearing.
Reproductive rights proponents retorted that basic women’s health care is hardly a luxury good. But for many of the pregnant women who struggle to navigate a maze of state laws that make it increasingly burdensome and expensive to get an abortion, it might as well be.
Across the country, state legislatures have passed hundreds of different measures intended to choke off access to abortion. Although those laws are typically framed in terms of legal restrictions, they also drive up the price tag of the procedure for low-income women in significant ways.
A ThinkProgress examination of the potential fees that could be accrued by two archetypal Wisconsin women found that the process of obtaining an abortion could total up to $1,380 for a low-income single mother saddled with charges related to gas, a hotel stay, childcare, and taking time off work. For a middle-income woman living comfortably in a city with no children and public transit options to the clinic, meanwhile, those fees dropped to $593.
Like all medical procedures, the cost of an abortion varies widely depending on the clinic and the state. Prices also change depending on the gestation of the pregnancy and the type of anesthesia a patient may require. While there is no standard fee on a state or national level, out-of-pocket costs for an abortion can range anywhere from $375 in the first trimester to $6,531 at 22 weeks, according to national data collected by ThinkProgress.
And that doesn’t account for the fees that accumulate as a result of the legislative barriers to the procedure, which end up disproportionately burdening women of limited resources and economic means. For instance, abortion is routinely excluded from Americans’ insurance plans, leaving many patients to shoulder the entire cost of an unexpected health event on their own.
“Any time we see these restrictions, it means that people who are low-income who face other barriers in trying to access health care will always be the ones who are affected by it,” said Lindsay Rodriguez, the communications manager at the National Network of Abortion Funds, which is composed of dozens of state-level organizations that help women pay for their abortions.
The mounting fees can quickly become prohibitive. According to researchers at the University of California, San Francisco, more than 4,000 women were denied abortions in 2008 because they were past the gestational limit — largely because it took them too long to try to save up the money for it. Nearly six in ten participants said they couldn’t get an abortion earlier because of travel and procedure costs.
These restrictions, the researchers concluded, “present an undue burden because many women do not realize they are pregnant until later in pregnancy and cannot travel to other states for abortion care. Additionally, women who raise children born from unintended pregnancies have higher rates of economic and educational disadvantages.”
The real-world consequences stemming from this web of complex restrictions are evident in Wisconsin, where a decision on SB 206 could be handed down at any time over the next few months. If SB 206 is allowed to take effect, doctors will be required to have medically unnecessary admitting privileges from local hospitals, which reproductive health advocates say would force at least one of the state’s clinics to shut down. But even aside from the looming threat of more clinic closures, legislative hurdles ensure that it’s no easy feat to get an abortion there.
“We’re in a horrible situation here in Wisconsin, and I don’t think people are aware until they need an abortion,” said Rep. Chris Taylor (D), the former public policy director for Planned Parenthood of Wisconsin and a fierce advocate for reproductive rights in the state legislature. “It’s just totally humiliating and degrading, the whole process for women.”
To begin with, women’s geographical access to the procedure is limited. There are currently only four clinics operating in the state: Two in Milwaukee, one in Madison, and one in Appleton, a quaint city tucked in the northeast region of Wisconsin. If patients live outside of those three areas, transportation is one of the biggest issues that they face, according to Nicole Safar, the current policy director at Wisconsin’s Planned Parenthood affiliate. “Wisconsin is an incredibly rural state and it’s not easy to get from one metro area to another if you don’t have a car,” Safar said.
And even if women do have access to transportation, there’s no guarantee they will be anywhere near a clinic — more than 95 percent of the state’s counties are without one. As one young woman from Madison who preferred to remain anonymous told ThinkProgress in an email: “My family has a cottage in rural Wisconsin and I have absolutely no idea where one would find an abortion in that part of the state.”
Women are also legally mandated to have an in-person counseling session with a doctor who must show them illustrations of a fetus at various stages of pregnancy. The state requires them to have a mandatory ultrasound; their doctor must also show and describe those images to them. After that initial consultation, they must wait at least 24 hours before they’re allowed to return to the clinic.
This requirement — also known as a waiting period — has “dramatically” increased the burden on women in the state, according to Nora Cusack, the treasurer of the Women’s Medical Fund, a nonprofit organization that assists Wisconsin residents who need help paying for an abortion and helps fund around 700 procedures annually. While 26 states across the country have some type of waiting period in place, Wisconsin is one of just 11 that stipulates the initial counseling session must take place in person, which requires patients to make two separate trips to the clinic. For women who are geographically isolated from abortion providers, this requirement means they must make two round trips or plan an overnight stay at a nearby hotel.
Then, patients in Wisconsin can finally have their abortion. Until recently, they could only have a surgical procedure, because state lawmakers passed such onerous restrictions on the abortion pill that clinics were forced to temporarily stop offering medication abortion altogether. Both options are available again — but, if women are insured through the Medicaid program or through a plan on Obamacare’s marketplace, their provider won’t cover either procedure.
It’s not hard to see how these logistical hurdles could put a significant financial strain on people who are already struggling. According to research conducted by the Guttmacher Institute, about 42 percent of U.S. abortion patients have incomes that fall below the federal poverty line. Most are unmarried and already juggling parental responsibilities for at least one child. Although the abortion rate has been dropping nationally, that trend isn’t evident among the poorest women, who continue to struggle with a disproportionate number of unintended pregnancies. For those women, the dollar signs add up quickly.
“Most of the women, if they have a job it doesn’t include sick pay, and most of them have kids, and so what do you do with your kids?” Cusack pointed out. “If they have a job they’re in a low-income job, they don’t have benefits, they don’t have health care.”
Jane Collins, a professor of community and environmental sociology and gender and women’s studies at the University of Wisconsin, has conducted extensive research into the policies that affect Wisconsin residents living at the poverty line. At the trial regarding SB 206 this summer, she testified against the state’s admitting privileges law, arguing that decreasing the number of clinics in the state would place an untenable burden on poor women.
During her testimony, Collins pointed out that low-income women wouldn’t be able to afford bus fare or gas money to travel farther from their homes, using basic demographic data on income and household structure to model the negative monetary impact the law would have.
It’s a useful thought experiment that can extend to the women who might currently seek abortion services, even before a ruling on SB 206 is handed down. Imagine a single mother in her late 20s who lives in a small town in northern Wisconsin and works minimum wage jobs in the service sector to support her family. Call her Laura.
Making just about $18,000 per year at two different part-time jobs, Laura can’t afford another child; when she realizes she’s pregnant, she knows she wants to get an abortion. In order to do so, she’ll have to drive about 200 miles from her home in Park Falls to get to the abortion clinic located in Appleton, which isn’t open on the weekends. If she can get two appointments on consecutive days during the week — one for the mandatory counseling session, and a second for the procedure itself — she’ll save time and gas, but she’ll need to shell out money for a nearby hotel.
CREDIT: ThinkProgress/Andrew Breiner
Laura will lose out on $145 in missed wages if she has to skip two days of her regular shifts at work to make the trip to Appleton. She’ll also have to pay someone around $200 to babysit her child while she’s gone. (That’s according to Collins’ research, relying on the $10 per hour rate that the state will reimburse overnight child care under the human services department.) The round trip drive to Appleton will cost her about $40 in gas money, assuming her car gets 22 miles to the gallon. Once she’s there, the counseling session will cost $125 and a 13-week surgical procedure will cost $600 out of pocket, according to employees at the Appleton Central Health Center, and Laura’s Medicaid coverage won’t pay for any of it. Laura will need to spend $70 to stay one night in a hotel close to the clinic.
For many women, these collateral fees are untenable — “even an unexpected cost of $44 can pose a burden,” researchers from the Guttmacher Institute wrote in a 2012 report on the costs of abortion services. “For women pulling together money to pay for the procedure as well as transportation and missed work, these relatively small amounts can prove impossible to procure and could prevent women from obtaining a wanted abortion.”
All told, the costs associated with Laura’s abortion total $1,180. That’s assuming she’s a single mom of one. If she has two kids, and needs overnight childcare services for both of them (at the same rates noted above), the price tag could rise to $1,380. If Laura works about 50 hours a week, about 25 hours at each of her part-time jobs, her total abortion costs are equivalent to nearly an entire month of wages.
Among the Americans with annual salaries and savings accounts and credit cards, that may sound doable. An unexpected cost of just over $1,000 could be difficult to swallow, but not completely outside the realm of possibility. That’s not always the case for people living in poverty. Women who are already having trouble coming up with the $500 to $600 dollars they need for their abortion can hardly afford the extra costs that rapidly accrue as a consequence of harsh state laws.
“I think people have a hard time grasping that that $600 can be an absolute barrier. It can be the difference between having your civil rights and not having them,” Collins said. “If you keep adding up the expenses of the extra miles, the need to pay for childcare, you’re going to reach a wall — a point when you’re not going to be able to pay.”
These costs take a special toll on women in communities where English isn’t a typical first language, or where they may lack the necessary identification to travel through border patrol checkpoints in states like Texas, explained Rodriguez. “So even sometimes with all of our resources and everything that we can pull together, the state laws being as they are, there will always be more need than we can provide monetarily.”
There are other, less tangible impacts as well. The numbers calculated above don’t necessarily capture the psychological and emotional costs of Laura’s experience. Perhaps she had to beg a friend to lend her their car for the two-day trip, which was a logistical nightmare because most of her friends needed their cars to get to work. Maybe she had to take a loan from family members because she still needed to pay her rent, and was unable to ask for assistance without disclosing her unintended pregnancy, which was uncomfortable. Spending a night away from her child may have been difficult, and traveling from a small rural town to an unfamiliar city — navigating a new area and finding parking — may have been stressful. Asking her boss for time off work could have strained their relationship, forced her to share information she would have preferred to keep private, or even put her job in jeopardy.
These logistical and psychological stressors may not come with a clearly defined price tag, but they can certainly complicate the process for low-income women like Laura seeking an abortion, Collins noted.
“If you wanted to borrow your friend’s car for a couple hours you could probably do that without much of an explanation. But if you’re going to be gone for three days, you need to tell people where you are — the people who have cared for your children, who loaned you the money, who loaned you the car, your partner,” she said. “Those things create stress and potentially breach confidentiality.”
This situation can play out very differently for people with higher incomes and easier access to urban clinics.
Consider a different type of Wisconsin woman in her late 20s, someone we’ll call Mary. She lives in a popular and accessible neighborhood in Madison and makes about $40,000 per year working for a nonprofit organization. If Mary finds out she’s unexpectedly pregnant and wants to have an abortion, she doesn’t have to travel terribly far. There’s one clinic in the city that performs abortions — Planned Parenthood in Madison East — which is a 30-minute bus ride from her apartment and will cost just $4 round trip. She’ll pay the same $125 for the state-mandated counseling session and $460 to take the abortion pill, a non-surgical procedure that is available to her because she was able to make an appointment earlier in her pregnancy. Mary can take two sick days from her salaried job without losing out on pay, she doesn’t have children to worry about, and her employer-sponsored insurance may even cover a portion of the procedure’s fees.
In total, the sum of Mary’s costs are significantly lower than Laura’s — just $593 — and that’s without taking her potential insurance benefits into account. It’s also a much smaller portion of her annual earnings.
Of course, not every woman who seeks an abortion will accrue Mary and Laura’s fees, or be forced to navigate the hurdles specific to their circumstances in Wisconsin. Some may live within walking distance of a clinic; others may end up traveling to closer cities out-of state. Some may have generous employer-sponsored insurance plans and mainstream bank accounts; others, who are “unbanked” and unable to access short-term loans through typical banking channels, may end up saddled with debt after borrowing money from pay day lenders.
Regardless of the individual circumstances, however, there are women all over the country who are struggling to afford the cost of their reproductive health care. The Guttmacher Institute has found that about half of the women who seek abortions are forced to ask for outside financial help because they can’t pay for the procedure on their own. “We definitely have seen people who need more assistance than they did before,” Rodriguez said in reference to the hotline workers affiliated with the National Network of Abortion Funds.
When does an abortion become a luxury car? And how expensive does the procedure have to get before the courts are required to step in and preserve low-income women’s rights under Roe v. Wade?
Amid an increasing number of court battles over the same type of admitting privileges law that’s up for review in Wisconsin, these are the questions looming in the forefront of reproductive rights advocates’ minds. As this specific abortion restriction makes its way to the Supreme Court, the dilemma will likely be resolved by the most powerful justices in the country. And proponents of reproductive rights are not necessarily optimistic about how the issue will fare in front of the conservative Roberts Court.
The last Supreme Court case that significantly reshaped abortion policy, Planned Parenthood v. Casey, held that states cannot impose an “undue burden” on women seeking abortions — a vague statute that essentially left the door open for conservative lawmakers to enact new restrictions to test the boundaries of the law. In many ways, Casey hollowed out Roe; it is the vehicle that facilitated the counseling sessions, forced waiting periods, mandatory ultrasounds, and clinic restrictions currently in place across the country. It is why states have been allowed to pass laws specifically intended to shut down women’s health centers .
CREDIT: ThinkProgress/Dylan Petrohilos
And years later, the precise definition of what constitutes an “undue burden” has still not been settled. Lawyers representing abortion providers have repeatedly argued that imposing medically unnecessary barriers to the procedure and regulating clinics out of existence should fall under that category, since those policies ultimately prevent some impoverished women from exercising their reproductive rights. But that argument has not swayed some of the more conservative judges on the appellate courts.
The split is becoming particularly pronounced in the U.S. Court of Appeals for Fifth Circuit, which comprises Louisiana, Mississippi, and Texas — states that have all passed similar admitting privileges laws.
In Texas, where the policy has shuttered dozens of abortion clinics and left poor women along the border with few health resources whatsoever, a federal judge ruled last March that the clinic closures do not show an undue burden. But in Mississippi, where the same policy puts the state’s sole clinic in jeopardy, the courts have been more sympathetic. Lawyers representing the state argued that the law doesn’t represent an undue burden because women can travel to Tennessee, Louisiana, or Alabama to end a pregnancy. But the Fifth Circuit disagreed, ruling that “Mississippi may not shift its obligation to respect the established constitutional rights of its citizens to another state.”
This month, Mississippi appealed that decision to the Supreme Court, saying that the inconsistent rulings from the Fifth Circuit on identical abortion policies need to be resolved. Are admitting privileges an undue burden or not? How few abortion clinics can a state have before women’s reproductive rights are officially violated? They’re big questions, and in order to figure out the answer, it’s impossible to separate — as Wisconsin’s assistant attorney general attempted to do — the legal issues from the economic issues.
At least one sitting member of the U.S. Supreme Court has weighed in on this issue recently. In an interview with MSNBC published this month, Justice Ruth Bader Ginsburg said that abortion has become “inaccessible to poor women” — a reality, she conceded, that is a “crying shame.”
Note On Methodology: To collect the data used in the interactive map, ThinkProgress contacted abortion clinics, abortion funds, and reproductive health organizations in each of the 50 states, and gathered data from research organizations including the Kaiser Family Foundation. When we were unable to independently verify the number of clinics in a state, we relied on data collected by the Guttmacher Institute in 2011. Prices were verified by calling at least one clinic per state, but price ranges are not necessarily reflective of every single clinic there.