With Restrictions Tightening Elsewhere, California Moves to Make Abortion Cheaper
Kaiser Health News, SACRAMENTO, Calif. — Even as most states are trying to make it harder to get an abortion, California could make it free for more people.
State lawmakers are debating a bill to eliminate out-of-pocket expenses like copays and payments toward deductibles for abortions and related services, such as counseling.
The measure, approved by the Senate and headed to the Assembly, would apply to most private health plans regulated by the state.
So far this year, 559 abortion restrictions have been introduced in 47 state legislatures, 82 of which have already been enacted, said Elizabeth Nash, a state policy analyst at the Guttmacher Institute, a nonpartisan research institute that studies abortion and reproductive health care.
That’s already the third-highest number of abortion restrictions adopted in a year since the U.S. Supreme Court’s landmark Roe v. Wade ruling of 1973, which affirmed the legal right to an abortion, she said.
By comparison, just a handful of bills, including California’s, would make it easier or cheaper to terminate a pregnancy, she said.
The state legislature is considering the bill just as the fate of Roe v. Wade has been thrown into question. The conservative-leaning Supreme Court has agreed to review later this year a Mississippi law that bans abortions after 15 weeks, and its ruling could end or weaken Roe.
“It’s tough to know your reproductive rights may be in question again after it’s been decided for 40 years,” said state Sen. Lena Gonzalez (D-Long Beach), author of the California bill, SB 245. “We’re taking a stance, not just to make abortions available but to make them free and equitable.”
Abortion opponents believe the state should instead make birth and maternity care more affordable, said Wynette Sills, director of Californians for Life.
Instead of giving patients more choices in their reproductive health care and family planning, this bill promotes just one option, Sills said.
“If we’re trying to look out for the economically disadvantaged, I think it’s repulsive that the best we can offer is a free abortion,” she said.
California already offers broad protection for abortion. It’s one of six states that require health insurance plans to cover abortions, and most enrollees in the state’s Medicaid program for low-income people, Medi-Cal, pay nothing out-of-pocket for the procedure.
When Bella Calamore decided to seek an abortion in May 2020, she thought the procedure would be free through Medi-Cal. But at the clinic, she learned that her father had recently enrolled her in his Blue Cross Blue Shield plan, which told her she would owe $600 after insurance was applied.
“Financially, it just didn’t seem reasonable for me to spend that,” said Calamore, 22, of Riverside. A college student, she had lost her job as a waitress during the covid pandemic and had no income. The abortion cost more than her rent that month, she said.
Calamore sat in her car, surrounded by anti-abortion protesters, and tried to figure out what to do. She decided to pay for the abortion, leaving $200 in her bank account, barely enough for food for the rest of the month.
Calamore later got involved with NARAL Pro-Choice America, a group that promotes abortion rights, and testified before the Senate Health Committee.
The bill would not apply to the millions of Californians whose health insurance plans are regulated by the federal government. Out of approximately 23,000 women who get abortions in California each year, roughly 9,650 would be affected by this bill, according to an analysis by the California Health Benefits Review Board.
The board estimates the bill would lead to a 1% increase in abortions among those whose cost sharing would be eliminated, or the equivalent of about 100 additional abortions per year.
While the measure likely would not significantly increase abortions, waiving costs would help those who would otherwise have to make financial sacrifices, like falling behind on rent or cutting back on groceries, said Jessica Pinckney, executive director of Access Reproductive Justice, a fund that helps people pay for abortions.
“We’ve noticed a lot of callers who had private insurance plans and really restrictive copays or high deductibles,” Pinckney said. “They’re really creating a barrier.”
The cost of an abortion rises as a pregnancy progresses. A medical abortion, in which pills are used to terminate a pregnancy, costs California patients an average of $306 out-of-pocket, according to the board’s analysis, but isn’t available after 10 weeks.
After that, the only option is a surgical abortion, which costs an average of $887 out-of-pocket in California. As a pregnancy advances, the cost goes up and fewer providers are willing to perform an abortion.
“The moment that a person finds out that they’re pregnant, the clock is ticking, as well as the meter,” said Fabiola Carrión, a senior attorney with the National Health Law Program.
Several other states expanded abortion access this year. New Mexico repealed its pre-Roe law that banned abortion in case Roe is overturned, and Virginia repealed a ban on abortion coverage in plans sold through the state’s marketplace. Hawaii expanded the category of medical professionals who can provide abortions, and Washington now requires student health plans that cover maternity care to cover abortions as well.
New Jersey lawmakers are considering a comprehensive abortion-rights bill that would eliminate cost sharing for abortions, but advocates aren’t optimistic about its chances.
Meanwhile, total abortion bans have been passed in Oklahoma and Arkansas this year, as have bans on abortion after six weeks in Texas, Idaho, South Carolina and Oklahoma (Oklahoma has passed three different bans on abortion this year). None have gone into effect, leaving time for court challenges, said Nash, from the Guttmacher Institute.
Eliminating abortion costs for patients has been tried in other states, including Oregon, which adopted a comprehensive abortion rights law in 2017 that included language similar to California’s. A handful of other states have provisions to reduce out-of-pocket costs.
States have learned — from contraception coverage and from California’s experience requiring health plans to cover abortions — that simply requiring something doesn’t ensure patients can get it, Nash said. “Cost sharing is a huge barrier to accessing services that you need to remove so people can actually get the care they need,” she said.
Most essential health care, like routine immunizations, preventive services and contraception, is already covered at no cost to the patient. Advocates of SB 245 say abortion is just as essential and should be treated the same way.
The California Association of Health Plans disagrees. This measure is one of several this year that would eliminate out-of-pocket costs for treatments or medicines, including insulin and other drugs for chronic diseases, said Mary Ellen Grant, a spokesperson for the association.
“We find this concerning as these bills would cumulatively increase premiums for all health plan enrollees,” Grant wrote in an email.
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.
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Click here to download PDF version: Fact Sheet: Science of Fetal Pain
Unborn babies can feel pain by 20 weeks gestation or earlier
- The old, uninformed notions that unborn and newborn babies cannot feel pain are refuted by a growing body of scientific evidence. The published scientific literature shows that unborn babies can experience pain at 20 weeks gestational age (20 weeks LMP, since Last Menstrual Period, the fetal age estimate used by most obstetricians) or earlier. Two common methods are used to measure the age of an unborn baby: Probable post-fertilization age (PPF, used by embryologists) measures the age of the unborn baby from the actual date of conception, while gestational age measures from the first day of the mother’s last menstrual period (LMP, approx. two weeks before conception). Medical practitioners have been using the latter method as standard medical practice for decades, and for the purpose of this paper ages refer to gestational age unless otherwise indicated.
- A comprehensive review of the scientific literature including neural development, psychology of pain sensation, and moral implications of fetal pain, concludes that unborn babies may experience pain as early as 12 weeks.
The review notes that neural connections from periphery to brain are functionally complete after 18 weeks.
“Nevertheless, we no longer view fetal pain (as a core, immediate, sensation) in a gestational window of 12–24 weeks as impossible based on the neuroscience.”
The review points out that a fetus may not experience pain in the same way as an adult, but does indeed experience pain as a real sensation, and that this pain experience has moral implications.
Significant because this unbiased review of the scientific evidence and agreement on existence of fetal pain, as early as 12 weeks and certainly after 18 weeks, comes from two highly credentialed medical professionals, one pro-choice.
“The two authors came together to write this paper through a shared sense that the neuroscientific data, especially more recent data, could not support a categorical rejection of fetal pain.”
- Embryological development shows presence of pain sensory mechanisms and neurophysiology. The basic anatomical organization of the human nervous system is established by 6 weeks. The earliest neurons in the cortical brain (the part responsible for thinking, memory, and other higher functions) are established starting at 6 weeks. Nerve synapses for spinal reflex are in place by 10 weeks. Sensory receptors for pain (nociception) develop first around the mouth at 7 weeks , and are present throughout the skin and mucosal surfaces by 20 weeks. Connections between the spinal cord and the thalamus (which functions in pain perception in fetuses as well as in adults) are relatively complete by 20 weeks.
- Contradicting the claim that the brain cortex is necessary to experience pain and suffering, decordate individuals as well as animals lacking higher cortical structures obviously do feel pain. In fact, the human brain cortex does not fully mature until approximately 25 years of age, yet infants, children, and teenagers obviously can experience pain.
- Fetal reactions provide evidence of pain response. The unborn baby reacts to noxious stimuli with avoidance reactions and stress responses. As early as 8 weeks the baby exhibits reflex movement during invasive procedures. There is extensive evidence of a hormonal stress response by unborn babies as early as 18 weeks  including “increases in cortisol, beta-endorphin, and decreases in the pulsatility index of the fetal middle cerebral artery.” Two independent studies in 2006 used brain scans of the sensory part of unborn babies’ brains, showing response to pain. They found a “clear cortical response” and concluded there was “the potential for both higher-level pain processing and pain-induced plasticity in the human brain from a very early age.”
- Ruth Grunau, a pediatric psychologist at the University of British Columbia, said, “We would seem to be holding an extraordinary standard if we didn’t infer pain from all those measures.”
- Brain responses & connections. In 2013 a study used functional magnetic resonance imaging (fMRI) to study the brains of healthy human babies still within the womb, from 24-39 weeks . They found that functional neuronal connections sufficient to experience pain already exist by 24 weeks .
- Increased sensitivity to pain. In 2010 one group noted that “the earlier infants are delivered, the stronger their response to pain.” This increased sensitivity is due to the fact that the neural mechanisms that inhibit pain sensations do not begin to develop until 34-36 weeks , and are not complete until a significant time after birth. This means that unborn, as well as newborn and preterm, infants show “hyperresponsiveness” to pain. Authors of a 2015 study used the fMRI technique to measure pain response in newborns (1-6 days old) vs. adults (23-36 years old), and found that “the infant pain experience closely resembles that seen in adults.”  Babies had 18 out of 20 brain regions respond like adults, yet they showed much greater sensitivity to pain, responding at a level four times as sensitive as adults.
Unborn babies are treated as patients by fetal surgeons, and receive pain medication
- Fetal surgeons recognize unborn babies as patients. A leading children’s hospital performed nearly 1,600 fetal surgeries between 1995 and June 2017. Perinatal medicine now treats unborn babies as young as 18 weeks for dozens of conditions. Pain medication for unborn patients is routinely administered as standard medical practice.
- One of the premier fetal surgeons makes the obvious point: “Fetal therapy is the logical culmination of progress in fetal diagnosis. In other words, the fetus is now a patient.”
- A European fetal surgery team states: “The administration of anesthesia directly to the fetus is critical in open fetal surgery procedures.”
- The leading textbook on clinical anesthesia says: “It is clear that the fetus is capable of mounting a physiochemical stress response to noxious stimuli as early as 18 weeks.”
- A recent review of the evidence concludes that from the 15th week of gestation onward, “the fetus is extremely sensitive to painful stimuli, and that this fact should be taken into account when performing invasive medical procedures on the fetus. It is necessary to apply adequate analgesia to prevent the suffering of the fetus.”
- A prenatal surgery group that has performed many fetal surgeries informs the mother before the surgery: “You will be given general anesthesia, and that anesthesia will put your baby to sleep as well. In addition, during the prenatal surgery, your unborn baby will be given an injection of pain medication and medication to ensure that the baby doesn’t move.”
Babies are surviving and thriving at ever younger pre-term ages when given appropriate care and treatment
- Survival of extremely preterm infants has increased significantly as doctors realize advantages of active care for such young patients. Ages of survival have dropped from 28 weeks to 24 weeks and now less than 22 weeks.
- The British Association of Perinatal Medicine (BAPM) now recommends that all babies born as early as 22 weeks’ gestation be given active care and resuscitation.
- A Journal of Perinatology study found that if extremely preterm babies were routinely given care, as many as 53% of those born at 22 weeks’ gestation survived, compared to only 8% if active care was not given, challenging physician attitudes on survival as well as thoughts about the age limit of viability.
- Survival of babies born at 22 weeks’ gestation in Sweden increased to 58 percent if the preterm babies were given intensive care, demonstrating what is possible if active care and caring attitudes are applied.
- Groundbreaking New England Journal of Medicine study demonstrated that babies delivered as young as 22 weeks can survive, and active intervention for treatment greatly improves their survival.
- An NIH-funded study of infants who were delivered at 22-24 weeks and who received active treatment observed increasing rates of survival without any neurological impairment. Yet, three-fourths of those delivered at 22 weeks still received no active care.
- 60% of infants born at 22 weeks who receive active hospital treatment will survive.