Catastrophic Health Expenditures for In-State and Out-of-State Abortion Care

Most US individuals who access abortion care pay out of pocket due to insurance coverage restrictions on abortion. More research is needed on the financial and psychological burdens of abortion seeking, particularly for those traveling across state lines for care.

To estimate the proportion of patients seeking abortion who incur abortion-related catastrophic health expenditures (CHEs), assess whether CHE differs between those seeking care in state vs out of state, and examine the association of CHE with mental health symptoms.

In this cross-sectional study conducted before the Dobbs v Jackson Women's Health Organization decision, surveys were administered between January and June 2019 among individuals aged 15 to 45 years seeking abortion in 4 clinics located in abortion-supportive states (California, Illinois, and New Mexico). Participants completed self-administered questionnaires while awaiting their abortion appointment. Analyses were conducted from November 2023 to April 2024.

Travel for abortion care, categorized as either out of state or in state based on participants' state of residence and the clinic location.

Self-reported abortion care costs and additional non-health care costs (eg, transportation, accommodation, and missed work), which were considered catastrophic if they were 40% or greater of participants' ability to pay (defined as monthly income remaining after meeting subsistence needs). Multivariable regression analyses were conducted to examine associations between CHE, out-of-state travel for abortion care, and mental health symptoms including stress, anxiety, and depression.

Among the 675 participants included in the analytic sample, mean (SD) age was 27.33 (6.27) years; most were in their 20s (374 [55%]), and all but 196 (29%) sought abortion before or at 12 weeks' gestation. A total of 285 participants (42%) were estimated to incur abortion-related CHEs, which was associated with anxiety (APR, 1.13; 95% CI, 1.07-1.19) and depression (APR, 1.25; 95% CI, 1.12-1.39). Of people traveling from out of state (212 [31%]), more were likely to incur CHEs (138 [65%]) compared with those seeking care in state (147 of 463 [32%]) (APR, 2.24; 95% CI, 1.67-3.00).

In this cross-sectional study of US patients seeking abortion, many individuals and their households were estimated to incur CHEs, particularly those traveling from out of state. The financial and psychological burdens of abortion seeking have likely worsened after the Dobbs decision, as more people need to cross state lines to reach abortion care. The findings suggest expansion of insurance coverage to ensure equitable access to abortion care, irrespective of people's state of residence, is needed.