Medicaid: Shedding a Light on Abortion in the United States
Bioethics in Law & Culture Spring 2023 vol. 6 issue 2
Senior Research Associate
Charlotte Lozier Institute Elizabeth Castle
Abortion data in the United States is deeply flawed. Because data collection is voluntary on the part of the states, there is no single complete source of abortion data to enable research on the impact of abortion on American women, and the problem is only growing worse. As a result of abortion by mail, many chemical abortions are happening outside the healthcare system and are missing from state reporting and even from the abortion estimates independently produced by organizations like the Guttmacher Institute. In 2016, the Food and Drug Administration (FDA) loosened its complication reporting requirements to mandate that only deaths from chemical abortion must be reported. Compounding the problem, in the wake of the Dobbs decision, abortions have shifted to abortion-permissive states that put less of a priority on abortion data collection, if they attempt to collect data at all.[i]
Despite the lack of reliable information in this area, abortion is often promoted as an important tool that allows women to structure their families and plan their lives. These assertions are used to justify both the morality and legality of abortion: in its decision in Planned Parenthood v. Casey, the Supreme Court recognized that “people have organized intimate relationships and made choices that define their views of themselves and their places in society, in reliance on the availability of abortion in the event that contraception should fail. The ability of women to participate equally in the economic and social life of the Nation has been facilitated by their ability to control their reproductive lives.”[ii]
However, much of the research supporting these assertions is based on surveys of women who are undergoing abortions, either at the time of the abortion procedure or periodically thereafter. As just one example, the Turnaway Study is frequently cited as premier research comparing the experiences of women who obtained abortions versus those who were “turned away” from abortion centers due to advanced gestational age or other reasons.[iii] The Turnaway Study purports to show that women who are denied abortions do worse across the spectrum. However, the study suffers from significant methodological limitations, including large numbers of participants lost to follow-up and unclear protocols for selecting participants in the first place.[iv] Fewer than 1,000 women were included in the Turnaway Study, and they were followed for at most five years after seeking an abortion. Little has been published on how abortion truly fits into the lives of American women over a long period of time.
Medicaid Research Project
Perhaps the best source of U.S. abortion data comes from the states which fund abortion for Medicaid-eligible women. Unlike abortion survey research which typically captures a single snapshot in time, Medicaid data enables researchers to investigate the trajectory of a beneficiary’s medical experience over years or decades. As long as a woman remains eligible, her pregnancies and her interactions with the healthcare system can be linked in a de-identified manner for a holistic view of the type of healthcare she is receiving. This allows researchers to examine the effect of a pregnancy outcome on women’s health years later. Although only a subset of U.S. abortions are funded by the states, Medicaid data is an important resource for exploring the real-world impact of abortion on low-income American women.
Although the Hyde Amendment prevents federal Medicaid from funding abortions for reasons other than rape, incest, and a risk to the mother’s life, states have the ability to use their own tax dollars to fund abortions for Medicaid-eligible women. Claims data for all state and federal Medicaid expenditures for Medicaid enrollees – including publicly funded abortions – is available from the Centers for Medicare and Medicaid Services (CMS). The Charlotte Lozier Institute is conducting a series of studies using Medicaid claims data to shed light on the role of abortion in women’s family planning and its effect on their health. During the nearly two decades covered by the Lozier Institute studies, 17 states funded abortion beyond those aforementioned as eligible under the Hyde Amendment.
As a result of Dobbs, the ability to enact abortion policy has been returned to Americans and their legislators, and more than ever voters need to know what the actual effects of abortion are. Citizens of states that fund abortion deserve accurate research on the results of publicly funded abortion. As FDA approval of the abortion pill continues to be in flux, Americans need reliable research on the effects of chemical abortion on women’s health. Research using Medicaid data can go a long way toward filling all these knowledge gaps and serves an important role in the abortion debate.
The Society of St. Sebastian previously published a short summary of the analyses done using Medicaid data.[v] The purpose of this paper is to expand on that summary, provide an overview of the Medicaid studies that have been published, and detail how those studies contextualize and contradict some of the most important claims made about abortion in the United States.
Abortion and Family Planning
One of the strengths of Medicaid data is that it allows researchers to analyze healthcare outcomes over a long period of time. Because so many years of data are available, researchers can see how abortion – along with live birth and spontaneous pregnancy loss – fit into women’s lives. Often, abortion advocates argue that abortion serves an important family planning function, empowering women to structure their families and plan their lives by choosing whether to postpone or space a live birth, or whether to have children at all. The Medicaid data allows investigators to see whether those claims are borne out in real life.
A longitudinal study examined nearly 7.4 million pregnancies to Medicaid enrollees over a 16-year period.[vi] Each woman was assigned to a birth, abortion, or miscarriage cohort based on her index pregnancy outcome, or her first pregnancy recorded in the dataset. Compared to women whose index pregnancies ended in live birth or miscarriage, women who chose abortion in their first pregnancies went on to have more pregnancies overall, and those pregnancies were more likely to end in subsequent abortions. While the likelihood of an abortion increased and the likelihood of a birth decreased with each subsequent pregnancy for all three cohorts, women with index live births and miscarriages were always more likely to have a live birth than an abortion. The opposite was true for the abortion cohort. Women with an abortion in their index pregnancy were always more likely to have an abortion than a live birth in following pregnancies. This pattern held true for all age groups and races.
These findings were borne out by a second study that focused on a cohort of young women with the purpose of tracing the impact of a first pregnancy decision.[vii] This study analyzed data from young women who were 16 in 1999 up until their first pregnancy, which assigned them to one of three cohorts: abortion, miscarriage, or live birth. Because these women were so young when they entered the analysis, there can be reasonable certainty that their first pregnancies are captured in the study. In 1999, less than 0.5% of 15-year-old girls experienced a pregnancy, indicating that the data contained the first pregnancy for the vast majority of the young women in the study.
For every subsequent pregnancy, women in the abortion cohort were more likely than women in the birth cohort to have another abortion and less likely to have a live birth. In addition, they were more likely to have more pregnancies overall. Over the 17-year study period, women in the abortion cohort had 35% more pregnancies, including 53% more natural losses and over 4.3 times the number of abortions. However, they had only approximately half the number of births as did women in the birth cohort. Thirty-seven percent of the women in the abortion cohort never had a live birth.
Together, these studies demonstrate that a pregnancy decision can shape the rest of a woman’s life. The first live birth or abortion women experience can place them on a path that impacts the likelihood of the number of pregnancies they will experience and the number of children they will have. The studies also indicate that a first-pregnancy abortion may increase a woman’s lifetime risk of pregnancy complications: by increasing the number of pregnancies a woman is likely to experience, an abortion makes it more likely that she will suffer an adverse outcome sometime in her life. Additionally, many abortion-specific risks, such as poor psychological outcomes or uterine trauma, are compounded with multiple abortions.
Medicaid data also allows researchers to explore the role that abortion plays in low-income American women’s family structures. Often, abortion is promoted as an important family-building tool, allowing women to determine when and whether to have children and enabling healthy birth timing. One study explored the role of abortion in promoting healthy birth spacing by calculating the number of women on Medicaid who had an abortion that spaced two live births in up to five consecutive pregnancies.[viii] The study found that abortions that space live births are very rare among Medicaid-eligible women. Of almost 4.9 million women over the age of 13 who had at least one pregnancy, just one percent ever experienced an abortion separating two live births. Furthermore, just 10 percent of all women who had experienced at least three pregnancies and two live births had an abortion that separated live births.
Demonstrating a birth-spacing pregnancy sequence was associated with a greater interval between the first pregnancy and the second live birth. However, the average time to second live birth for both groups – those with a birth-spacing sequence and those without – fell within recommended guidelines. Abortion did not enable women to achieve a safer interval between births. This is an important finding because abortion advocates have argued that abortion promotes healthy birth spacing, with some researchers arguing that restrictive abortion policies lead to shorter birth intervals and that this can result in poor outcomes for both mothers and children.[ix],[x] One survey of women undergoing abortion found that 19 percent of abortions were performed on mothers who intended to have more children later.[xi] The authors estimated that abortion prevented nearly 78,000 short-interval births in 2014. However, the Medicaid research indicates that while some women may have abortions with the intention of postponing additional childbearing, in practice, very few will have another live birth after undergoing an abortion.
One of the most frequently repeated claims is that abortion is normal for mothers.[xii] Because data collected at the time of women’s abortion procedures shows that a majority of women undergoing abortion already have children, advocates of abortion assert that both childbirth and abortion are normal occurrences that are experienced by the same population of women. However, analysis of the Medicaid data shows that abortion is actually unusual for women who have children. Again including all women over the age of 13 who had at least one pregnancy, this study analyzed nearly 7.8 million pregnancies experienced by almost 4.9 million women over a period of 16 years.[xiii] The study showed that abortion is not a normal part of women’s reproductive lives and is unusual for mothers. Women with live births and no abortions made up nearly three-quarters of the study population and accounted for 88 percent of the births. In contrast, women with abortions but no births made up less than seven percent of the population but were responsible for over half the abortions. Women with both births and abortions represented less than six percent of the study population. Fifty-four percent of women who had abortions did not have a live birth during the study period.
The Medicaid data also sheds light on whether abortion is a long-term solution to difficult circumstances or whether women often find themselves in the same position repeatedly. One study analyzed 14 years of data from 1999-2012 from women enrolled in Medicaid who were born after 1982.[xiv] The analysis focused on the timing and outcome of subsequent pregnancies within three years of an index pregnancy. Nearly a quarter of women who had an abortion (23%) were pregnant again within one year, and 38% were pregnant again within two years. In contrast, less than 12% of the women who gave birth were pregnant again in the first year, and just 23% had conceived again within two years.
Rapid repeat pregnancy puts women at increased risk for pregnancy complications. The authors argue that the high rate of rapid repeat pregnancy following abortion indicates that these women may be experiencing a desire for a “replacement pregnancy” after the psychological stress of the abortion. Certainly, it suggests that abortion alone does not address women’s larger circumstances. The factors that led to the initial pregnancy in situations in which women felt unable or did not desire to carry to term may have contributed to the rapidity with which women became pregnant again.
Abortion research frequently focuses on women who get abortions and captures the impact on women in a single moment in time, but studies show that a woman’s feelings about her pregnancy and the way it impacts her subsequent decision-making can shift dramatically over time. By looking at all women who experienced a pregnancy, the Medicaid studies place abortion in the context of women’s entire reproductive experiences. These studies show that abortion is not a normal reproductive outcome. Although women may intend to simply delay having another child until a better time, in practice, abortion can set women on a different life course compared to women who give birth.
Abortion and Women’s Health
Medicaid claims data also enables a long-term look at the health effects of abortion, both physical and mental. Because the data contains the records of millions of women over long periods of time, health consequences can be identified that might not otherwise be obvious from shorter studies that analyze outcomes from fewer women. These include both physical outcomes and complications and the impact of abortion on women’s mental health.
The link between abortion and poor mental health is controversial, and additional robust research in this area continues to be necessary. The Medicaid studies make a valuable contribution, with one study following a cohort of nearly two million young women on Medicaid.[xv] Because women entered the study population at approximately 13 and a half years of age, the study likely captured these Medicaid beneficiaries’ first pregnancies. First, the study identified whether women experienced a pregnancy loss (miscarriage or abortion). Then the study analyzed women’s experiences following their first live births and compared women with and without a prior pregnancy loss. Although the study did not differentiate between abortion and miscarriage, it still provides a useful analysis of the impact of pregnancy loss in general on women’s mental health.
Compared to women without a history of pregnancy loss, women who had experienced a pregnancy loss prior to their first birth were around 35 percent more likely to need postpartum mental health treatment (PPT). Among women with no prior history of mental health treatment (MHT), experiencing a pregnancy loss was a risk factor for needing postpartum mental health treatment. Interestingly, among women with a history of MHT, women with a previous pregnancy loss had a lower likelihood of requiring PPT. This suggests that the heightened rates of mental health treatment among women experiencing pregnancy loss are not the result of pre-existing conditions. One striking exception is the subpopulation of women who had MHT within one year prior to their first pregnancy outcome. In this group, nearly 100 percent of all women who had a pregnancy loss later experienced postpartum mental health treatment.
This study aligns with a body of research demonstrating that pregnancy loss is associated with poor mental health outcomes.[xvi] However, the fact that pre-existing conditions are not solely responsible for mental health problems among women experiencing pregnancy loss serves to contrast with the Turnaway Study research, which argues that prior mental health problems and abuse are the most important factors in poor mental health outcomes after abortion. Overall, the higher rates of postpartum treatment sought by women who had previously suffered a pregnancy loss demonstrate that the mental health effects of an abortion or miscarriage can linger even after a subsequent live birth. Alongside the Medicaid research on pregnancy outcome sequences, this study suggests that having an abortion can have a long-term impact on a woman’s life and future pregnancies.
The Medicaid data also enables studies on the impact of abortion and other pregnancy losses on women’s physical health. Similarly, another study explored the impact of live birth versus pregnancy loss (abortion or miscarriage) on women’s cardiovascular health.[xvii] Specifically, the authors examined how a first pregnancy outcome affected women’s later experiences with cardiovascular disease. The study followed the experiences of more than one million young women on Medicaid who had at least one pregnancy. Each woman was added to the study at the age of 16 or younger to ensure that her first pregnancy was captured in the data. The researchers looked at women with no history of cardiovascular disease prior to their first pregnancy. In the first six months after a first pregnancy, women who had a live birth had much higher rates of cardiovascular disease than women who had a pregnancy loss. However, this pattern shifted after six months, and women with pregnancy losses experienced higher rates of cardiovascular disease for the remainder of the study period. Overall, women who had a pregnancy loss in their first pregnancy were 38 percent more likely to suffer cardiovascular disease than were women with live births and no pregnancy losses.
Cardiovascular disease is a leading cause of maternal mortality, accounting for more than a third of all deaths.[xviii] Some researchers have argued that denying women abortions places them at risk for maternal mortality, with one study finding that carrying a pregnancy to term is as much as 14 times more dangerous than having an abortion.[xix] However, the results of the Medicaid study show that pregnancy loss, including abortion, is actually associated with a heightened risk of cardiovascular disease. Although the study did not compare abortion and natural miscarriages, this initial analysis suggests that abortion will not lower women’s risk of maternal mortality from cardiovascular issues.
Additionally, Medicaid data also allows for studies examining the short-term impact of abortions on women’s health. One study analyzed all abortions for which the type of procedure could be determined and then linked each abortion to all emergency room visits occurring within 30 days.[xx] This methodology ensured that no follow-up emergency room visits were missed and that all were properly attributed to the initial abortion. These methods contrast with other studies that analyzed emergency room data only, without linking each visit to a preceding abortion, as well as with studies that tracked only emergency room visits that had been correctly coded as related to the abortion rather than capturing all ER visits following an abortion.[xxi],[xxii] This study examined emergency room visits for all reasons as well as visits that were specifically coded as related to pregnancy, which indicated that the visit was related to the abortion.
In this study, there were 423,000 abortions that resulted in over 121,000 emergency room visits within a month’s time. During the period of time covered by the study (2002-2015) chemical abortions were approximately 53% more likely to result in an abortion-related ER visit than were surgical abortions. Furthermore, the rate of ER visits for both surgical and chemical abortions increased over the course of the study period, but ER visit rate following chemical abortion increased more rapidly, jumping more than 500 percent.
The study also found that abortion-related emergency room visits were increasingly miscoded. Due to the study methodology, which started with a confirmed induced abortion, all subsequent emergency room visits with pregnancy codes within 30 days were clearly connected to the abortion. However, a large number of abortion-related ER visits were miscoded as miscarriages. By 2015, the final year of data analyzed in the study, 60% of pregnancy-related ER visits after chemical abortions demonstrated this miscoding.
A follow-up analysis explored whether this miscoding was putting women’s health at risk.[xxiii] Each emergency room visit was linked with any subsequent hospitalizations. Women whose chemical abortions were miscoded as miscarriages were twice as likely as women without miscoding to be admitted for surgery. They were also at significantly greater risk of requiring multiple hospital admissions. This counters assertions from abortion providers that there is no medical reason for a woman to inform an ER medical provider that she is undergoing a chemical abortion and that miscarriage and abortion are treated exactly the same. In fact, the study suggests that when women do not disclose a chemical abortion to emergency room personnel, or when healthcare professionals do not take a full medical history, women might not receive proper care in a timely manner.
The huge increase in the rate of abortion-related emergency room visits over the past two decades has ramifications for the FDA’s weakening of its safety regulations related to chemical abortion. The FDA has removed key protections, including a requirement that the abortion pill be dispensed in person, using the justification that chemical abortion is safe. The goal of the regulatory change is to make chemical abortion more accessible and to require less contact with the healthcare system for women seeking abortion. However, this research suggests that women are increasingly being shifted to the emergency department for follow-up care, and it is likely that this weakening of safety protections will result in further strain on hospitals.
As a group, all these studies indicate that abortion can have both an immediate and a prolonged effect on women’s mental and physical health. This research has relevance to the information that women should receive as part of the informed consent process and undermines assertions from abortion advocates that limiting abortion will put women at risk or contribute to an increase in maternal deaths. The sheer number of patients included in the studies, as well as the number of years of data analyzed, offers a unique perspective, allowing the identification of associations between abortion and subsequent health outcomes that might not be seen otherwise.
The abortion industry wants to depict abortion as a “normal” part of women’s lives. It seeks to promote abortion as having no detrimental effects on mental health and as a safe medical procedure with no long-term ramifications. However, very few of the claims made about abortion can be substantiated. Despite being legally available in the United States for over 50 years, and despite the thousands of pages of research published on abortion, many of the key arguments made in favor of abortion remain understudied.
In contrast to the claims of the abortion industry, Medicaid data demonstrates that abortion is unlike other pregnancy outcomes, and its effects are long-lasting. An abortion can change the course of a woman’s reproductive trajectory and the health outcomes that she experiences. In particular, analyses of Medicaid data reveal the impact of abortion on low-income women, at a time when accurate research on abortion and its effects on women is more important than ever. With the ability to enact abortion policy returned to Americans and their legislators, voters need to know what the actual effects of abortion are. Citizens of states that fund abortion deserve accurate research on the results of publicly funded abortion. As FDA approval of the abortion pill continues to be litigated, reliable research on the safety of chemical abortion specifically is critical.
The Medicaid data does have significant limitations since it is limited to low-income women and only covers portions of the country. Additionally, the datasets reflect claims for reimbursement, and information that would be valuable for research is not included, such as the precise gestational ages at which abortions occur or the specific reasons why abortions are performed. The federal government should make accurate and comprehensive abortion statistics a high priority, requiring a baseline level of reporting from all 50 states and promoting research in this area. Medicaid data cannot completely substitute for the flawed and incomplete data currently available from the Centers for Disease Control. However, in the absence of a comprehensive national reporting standard, Medicaid data remains the best source of data on abortion in the United States.
Key Words: Medicaid, Abortion
[i] Longbons T, Steupert M. Five things we don’t know about abortion in the U.S. (but could with better reporting). Published March 30, 2023. Accessed April 24, 2023. https://lozierinstitute.org/five-things-we-dont-know-about-abortion-in-the-u-s-but-could-with-better-reporting/
[ii] Planned Parenthood of Southeastern Pennsylvania v. Casey
[iii] Advancing New Standards in Reproductive Health. The Turnaway Study. Accessed April 20, 2023. https://www.ansirh.org/research/ongoing/turnaway-study
[iv] Reardon DC. The Embrace of the Proabortion Turnaway Study: Wishful Thinking? or Willful Deceptions? Linacre Q. 2018;85(3):204-212. doi:10.1177/0024363918782156
[v] Longbons T. Medicaid data shows abortion does not promote women’s health. Published December 9, 2021. Accessed April 20, 2023. https://www.societyofstsebastian.org/medicaid-abort-health-longbons
[vi] Studnicki J, Fisher JW, Reardon DC, Craver C, Longbons T, Harrison DJ. Pregnancy Outcome Patterns of Medicaid-Eligible Women, 1999-2014: A National Prospective Longitudinal Study. Health Serv Res Manag Epidemiol. 2020;7:2333392820941348. Published 2020 Jul 31. doi:10.1177/2333392820941348
[vii] Studnicki J, Longbons T, Reardon DC, et al. The Enduring Association of a First Pregnancy Abortion with Subsequent Pregnancy Outcomes: A Longitudinal Cohort Study. Health Serv Res Manag Epidemiol. 2022;9:23333928221130942. Published 2022 Oct 11. doi:10.1177/23333928221130942
[viii] Studnicki J, Fisher JW, Longbons T, Reardon DC, Craver C, Harrison DJ. Estimating the Period Prevalence of Publicly Funded Abortion to Space Live Births, 1999 to 2014. J Prim Care Community Health. 2021;12:21501327211012182. doi:10.1177/21501327211012182
[ix] Kramer R, Ehrenthal D. Understanding associations between state-level policy factors and very short inter-pregnancy intervals in the United States: The role of county urban-rural status. Presented at: Population Association of America Annual Meeting; April, 2019; Austin, TX. http://paa2019.populationassociation.org/abstracts/190476
[x] Russo NF, Horn JD, Tromp S. Childspacing intervals and abortion among blacks and whites: a brief report. Women Health. 1993;20(3):43-51. doi:10.1300/J013v20n03_03
[xi] Jones RK, Foster DG, Biggs MA. Fertility intentions and recent births among US abortion patients. Contraception. 2021;103(2):75-79. doi:10.1016/j.contraception.2020.11.007
[xii] Sander L. The mother majority. SLATE. Published 2011. Accessed April 20, 2023. https://slate.com/human-interest/2011/10/most-surprising-abortion-statistic-the-majority-of-women-who-terminate-pregnancies-are-already-mothers.html
[xiii] Studnicki J, Fisher JW, Longbons T, et al. Estimating the Period Prevalence of Mothers Who Have Abortions: A Population Based Study of Inclusive Pregnancy Outcomes. Health Serv Res Manag Epidemiol. 2021;8:23333928211034993. Published 2021 Jul 23. doi:10.1177/23333928211034993
[xiv] Reardon DC, Craver C. Intervals and Outcomes of First and Second Pregnancies in Low-Income Women: A Record-Linkage Longitudinal Prospective Cohort Study. Med Sci Monit. 2021;27:e931596. Published 2021 Jun 25. doi:10.12659/MSM.931596
[xv] Reardon DC, Craver C. Effects of Pregnancy Loss on Subsequent Postpartum Mental Health: A Prospective Longitudinal Cohort Study. Int J Environ Res Public Health. 2021;18(4):2179. Published 2021 Feb 23. doi:10.3390/ijerph18042179
[xvi] Reardon DC. The abortion and mental health controversy: A comprehensive literature review of common ground agreements, disagreements, actionable recommendations, and research opportunities. SAGE Open Med. 2018;6:2050312118807624. Published 2018 Oct 29. doi:10.1177/2050312118807624
[xvii] Tsulukidze M, Reardon D, Craver C. Elevated cardiovascular disease risk in low-income women with a history of pregnancy loss. Open Heart. 2022;9(1):e002035. doi:10.1136/openhrt-2022-002035
[xviii] Ouyang P, Sharma G. The Potential for Pregnancy Heart Teams to Reduce Maternal Mortality in Women With Cardiovascular Disease. J Am Coll Cardiol. 2020;76(18):2114-2116. doi:10.1016/j.jacc.2020.09.007
[xix] Raymond EG, Grimes DA. The comparative safety of legal induced abortion and childbirth in the United States. Obstet Gynecol. 2012;119(2 Pt 1):215-219. doi:10.1097/AOG.0b013e31823fe923
[xx] Studnicki J, Harrison DJ, Longbons T, et al. A Longitudinal Cohort Study of Emergency Room Utilization Following Mifepristone Chemical and Surgical Abortions, 1999-2015. Health Serv Res Manag Epidemiol. 2021;8:23333928211053965. Published 2021 Nov 9. doi:10.1177/23333928211053965
[xxi] Upadhyay UD, Johns NE, Barron R, et al. Abortion-related emergency department visits in the United States: An analysis of a national emergency department sample. BMC Med. 2018;16(1):88. Published 2018 Jun 14. doi:10.1186/s12916-018-1072-0
[xxii] Upadhyay UD, Desai S, Zlidar V, et al. Incidence of emergency department visits and complications after abortion. Obstet Gynecol. 2015;125(1):175-183. doi:10.1097/AOG.0000000000000603
[xxiii] Studnicki J, Longbons T, Harrison DJ, et al. A Post Hoc Exploratory Analysis: Induced Abortion Complications Mistaken for Miscarriage in the Emergency Room are a Risk Factor for Hospitalization. Health Serv Res Manag Epidemiol. 2022;9:23333928221103107. Published 2022 May 20. doi:10.1177/23333928221103107