Wednesday, June 6, 2018
June 1, 2018 (Tonic): Abortion Providers Are America’s Best Doctors, by Garnet Henderson:
Over the past two decades, the cost of medical care in the US has risen by about 3.6 percent per year, outpacing overall inflation by 70 percent. Meanwhile, the cost of an abortion has remained virtually the same. Prices do vary, from about $400 to $2,500 in the first or second trimester. This depends on the state, the provider, and the complexity of the procedure, generally determined by how far along in pregnancy the abortion is performed (for instance, one woman who wanted to terminate her nonviable pregnancy after 30 weeks was quoted $25,000 to $30,000). However, the average cost of a first-trimester abortion—they account for almost 90 percent of all abortions in the US—is about $500, a figure that has remained remarkably stable over time.
Providing abortions has not become more affordable. Instead, it has become significantly more expensive in many states, thanks to targeted regulation of abortion provider (TRAP) laws. These regulations single out abortion providers and require them to conduct medically unnecessary tests and procedures and operate in more expensive facilities.
“We’ve really tried to figure out how to comply with all the regulations and keep abortion as affordable as possible,” says Amy Hagstrom Miller, founder and CEO of Whole Woman’s Health, which provides abortion care in Illinois, Maryland, Minnesota, Texas, and Virginia.
In 2011, Texas passed a law requiring anyone seeking an abortion to have an ultrasound at least 24 hours in advance. The law went one step further than similar rules in other states by requiring that a physician perform the ultrasound and that the same physician perform the abortion.
“We knew our patients couldn’t afford to take off from work twice, arrange childcare twice, and pay more for the procedure on top of that. Across the state, we chose not to raise the price of an abortion. We had to work hard to get doctors to understand that we couldn’t charge extra to the patient for that second visit. The cost on our end went up quite a bit,” Miller says.
“I think providers are bending over backwards to keep costs low. They realize that cost can be prohibitive. Being unable to afford an abortion is one of the primary reasons that women end up carrying an unwanted pregnancy to term,” says Ushma Upadhyay, an associate professor at the University of California San Francisco and a researcher with UCSF’s Advancing New Standards in Reproductive Health program. For instance, abortion providers often intentionally keep the price of medication abortion and procedural abortion the same, even though the cost of providing those services can be quite different. “We would never want anyone to choose one method or the other just because of cost,” Miller says.
In keeping costs down, abortion providers are not compromising the safety of their patients. One large study found that the complication rate in abortion procedures was just 2.1 percent, with serious complications occurring only 0.23 percent of the time. This overall complication rate is significantly lower than for the other in-office procedures researchers used for comparison, including wisdom tooth extraction (7 percent) and tonsillectomy (8 to 9 percent).
Many of the providers who do offer abortion are performing the procedure at high volume, which may be one factor that helps control costs on their end. “Doctors doing high volume become more efficient and skilled at doing the procedure, and as procedure times fall, that makes services less expensive to provide. We see that for most services, but for most services they don’t actually adjust the price downward,” says Miriam Laugesen, an associate professor at the Columbia University Mailman School of Public Health and author of Fixing Medical Prices: How Physicians are Paid.
“A lot of my work has shown that the cost of providing medical care doesn’t usually relate to what is charged for it, or what insurance reimburses,” Laugesen says. In other words, if abortion providers are passing on any efficiency-derived savings to their patients, it is because they choose to do so when most healthcare providers do not.
One study of abortion patients in California found that they were highly satisfied with the care they received, rating it 9.4 out of 10 on average. Another study, which surveyed women who received an abortion in New York, New Jersey, and Illinois, found that 93 percent were very satisfied with their care. By contrast, in the most recent Gallup poll on the subject from 2016, only 65 percent of Americans said they were satisfied with their overall medical care.
“I do think we need more nuanced measures of quality of care. With abortion, women go in with a problem. A clinician can take care of the problem, and they leave so happy. It’s unlike many conditions where you have to go back for multiple treatments,” Upadhyay says. “That said, a lot of independent clinics have set up a model to really nurture the social and emotional needs of women, and they provide great quality of care.”
According to Laugesen, doctors tend not to be motivated to perform procedures that are less lucrative, pointing to the shortage of primary care doctors as evidence of this trend. Abortion providers, on the other hand, have chosen work that is highly stigmatized and frequently not reimbursed by insurance.
“You don’t work in an abortion clinic unless you love it. You can’t. You couldn’t come into work everyday being harassed, yelled at, having your life threatened,” says Kim Chiz, a registered nurse and executive director of Allentown Women’s Center in Bethlehem, Pennsylvania. “Many of our staff could leave and work elsewhere for twice as much money. But we love what we do because it allows our patients to live fully autonomous lives.”