State-Level Variation in and Barriers to Medicaid Abortion Coverage.

Importance: Approximately 35% of individuals seeking abortion care use Medicaid for health insurance. Although the Hyde Amendment restricts use of federal funds for most abortions, states can supplement coverage using state funds. Understanding the scope of abortion coverage across states and potential barriers to access may help address health care inequities and inform interventions. Objective: To characterize state Medicaid abortion policies by conducting a qualitative analysis of publicly available state documents on Medicaid policy. Design, Setting, and Participants: This qualitative study analyzed Medicaid abortion policies across all 50 states and the District of Columbia (hereinafter, states). Data were systematically collected from publicly available Medicaid documents and state websites from May 2023 to February 2024. Main Outcomes and Measures: The main outcomes were key themes and descriptive statistics reporting on the scope of Medicaid abortion coverage and requirements for coverage across states, including documentation and procedures required of patients and physicians. Thematic analysis was performed to extract key themes found in abortion coverage policies, and descriptive statistics were used to show prevalence of identified themes across states. Results: The analysis of 94 documents revealed 3 key themes. First, the scope of coverage across states was heterogeneous. Eighteen states aligned with the current wording of the Hyde Amendment, 10 states described life endangerment without use of current Hyde Amendment wording, 17 states outlined additional coverage for other specified conditions for abortions, 6 states covered all abortions, and 1 state's policy did not mention required federal coverage for rape or incest exceptions. Second, states imposed various patient restrictions and requirements with regard to abortion care coverage, with 22 states mandating reporting requirements for abortions due to rape or incest, along with other administrative hurdles for patients seeking care. Third, physicians were tasked with many responsibilities, such as determining eligibility for Medicaid abortion coverage and complying with documentation and administrative requirements. Thirty-eight states explicitly required physician certification and justification for clinical conditions warranting coverage. Conclusions and Relevance: The findings of this qualitative study of state Medicaid abortion policies suggest that there is substantial heterogeneity among states regarding the scope of Medicaid abortion coverage and that there are numerous obstacles for patients and physicians in accessing this coverage. This heterogeneity and burden may impose an additional layer of complexity to abortion access. Measures and policies that improve transparency, clarity, and efficiency may enhance access to essential abortion care for vulnerable populations.