Insurance in a post-Roe world, and a grassroots network of abortion funds

Dan: Hey there— today’s episode started with a question that seemed pretty of-the-moment, and very much our kind of question: The Supreme Court overturned Roe v Wade last summer — how does that affect … my insurance coverage?

And we found a couple of things.

One, it’s probably NOT changing your insurance— not yet. For a lot of people, not at all. But if you get your insurance from work, there is no one answer. We’ve entered an extremely weird period, and we’re gonna be here for a while.

And two: Producer Emily Pisacreta’s reporting for this episode shows: There’s actually another question, a whole nother story here that turns out to be even more our kind of thing. Hey Emily.

Emily: Hey Dan. And yep. This is a story about people organizing to help each other get the health care they need— building a huge network, and making the most of limited resources, in the face of so much powerful opposition.

Dan: Yeah, and look: however you happen to feel about abortion itself, I hope you’ll agree: that’s the kind of story we all can learn from.

This is An Arm and a Leg, a show about why health care costs so freaking much, and what we can maybe do about it. I’m Dan Weissmann. I’m a reporter, and I like a challenge, so our job on this show is to take one of the most enraging, terrifying, depressing parts of American life, and bring you something entertaining, empowering and useful.

And just to start off with what’s not changing, in terms of insurance and abortion: a lot of states had already passed laws against insurance plans covering abortion even before the Supreme Court struck down Roe v. Wade..

Emily: Right. And there’s a piece of federal law called the Hyde Amendment that says federal funds can never go to pay for abortion. So that cancels out abortion coverage for anyone on, say, Tricare.

Dan: That’s insurance for folks in the military —

Emily: yes, and Medicare

Dan: Wait, Medicare?

Emily: Yes… there’s 9 million people younger than 65 on Medicare. People with disabilities. But the biggest number of people this affects is Medi-CAID.

Dan: And *states* pay for some of Medicaid. Does that make a difference?

Emily: It does. Some states put their own money into paying for abortions in their Medicaid programs. But if your state has a ban on abortion now, they’re not doing that.

And the same thing goes for insurance plans people buy on the Obamacare marketplace— because when people get subsidies on those plans, it’s the federal government paying for those subsidies. So much about your abortion coverage depends on what state you live in.

Dan: And again, all of that was true before abortion became illegal in some states. So, no change. And if you live in a state where abortion is still legal, nothing’s changing there either.

But here’s where we get to the weird part.

Because: Most people who get insurance from work, their insurance isn’t regulated by the states.

It’s a piece of legal arcana that has a bunch of weird impacts on a lot of us.

But it raises a question: If you live in a state where abortion is now illegal — but your insurance from work isn’t regulated by that state… what now?

I mean, we’ve heard about big-name companies like Amazon saying, We’ll do what it takes to make sure our workers can get access to abortion. Help them travel to places where abortion is legal. But how’s that supposed to even work?

I spent some time talking with people who get paid to consult with the big cheeses at all kinds of companies, to help them design their employee benefits. And in this case, maybe re-design on the fly.

For instance:

Roberta Casper Watson: My name is Roberta Casper Watson. I like to use all three names

Dan: She’s a partner at the Wagner Law Group, and the laws that govern this kind of health insurance have been her specialty for forty years. I asked her what happens with health insurance now that Roe is overturned.

Roberta Casper Watson: I mean, the short answer to what’s gonna happen is we don’t know.

Dan: Here’s the mechanics: when companies offer to pay for their workers to still access abortion, they’re not writing you a check. For a bunch of legal reasons — and tax savings — they’re gonna run it through their health plan.

The fact that lots of big employer health plans aren’t regulated by state governments gives them a lot of leeway. But Roberta says they’re still incurring some legal risk by trying to work around state restrictions.

Roberta Casper Watson: There are going to be test cases and, you know, an employer who wants to take any action should think about whether it wants to put itself at risk of being one of the test cases.

Dan: Because there’s a lot to test. For instance: A Texas law from 2021 gave private citizens the right to sue anybody involved in an abortion for ten thousand bucks.

The Supreme Court said that was OK, but it leaves questions open: What if your business is based in Seattle, but you’ve got workers in Texas? Can you get sued?

Roberta Casper Watson: It’s not clear that you can, but it’s not a hundred percent clear that you can’t either.

Dan: Some states are contemplating laws that would make it a crime to help somebody get an abortion. Could an employer get caught up? Nobody knows yet. That’s the point. Roberta says she tells companies: You tweak your health plan to help workers in a state like Texas travel for abortion? You could become a defendant in a test case.

Roberta Casper Watson: And usually on most topics, that kind of a statement kills their interest. Uh, on this topic, it’s not killing their interest.

We have a number of clients that are willing. So if they’re willing to take some risk, then I have a multi page list of advice that I give them of things to think about — how they want to structure it.

Dan: I will NOT go into what’s on that multi-page list here, but there’s also this.

Even if you’re an employer that’s ready to jump through all those legal hoops to tweak your health plan— and take on some of those legal risks — you’ve got another task: Get your insurance company to sell you a plan with the tweaks you want.

And folks like Roberta tell me insurance companies aren’t OFFERING new policy options to help workers travel to get abortion care. You want something like that as part of your health plan, you’re negotiating with companies like United or Aetna for a custom deal.

A company the size of Amazon can presumably get a custom deal. I asked Roberta: would smaller ones have a harder time?

Roberta Casper Watson: It depends. It depends on some combination of their motivation and how big, and important you are. I mean, an employer with 50 employees probably can’t get much of anything no matter how badly it wants it.

Dan: So: If you live in a state where abortion is now illegal, what your coverage looks like depends on some combination of what your employer wants, how bad they want it, and how much clout they have with insurance companies to get a custom deal.

And on how various test cases unfold over who-knows-how-long.

Emily: So Dan, you’re basically saying abortion is like everything else in American health care, only a little more so: What you get access to is pretty much 100 percent not up to you, and subject to change at any time.

Dan: Um, yes.

Emily: But abortion is also different, isn’t it? I mean, insurance coverage for all kinds of health care is spotty in the US. But people still use their insurance to pay for most of their health care here.

For abortion, research shows that people use commerical insurance – meaning insurance from their job or the Obamacare marketplace – only about 14% of the time. The vast majority of people having an abortion pay out of pocket.

Dan: Emily, this is probably where we mention that you spent a bunch of years working for Planned Parenthood.

Emily: Yes.

Dan: Which does gives people a clue about what where you’re coming from on this topic— and it’s also a credential. You come to this knowing a lot.

So: Why don’t people tend to use insurance to pay for abortion? Even if lots of people can’t, lots of people could.

Emily: Well, Rachel Jones, a researcher on insurance coverage and abortion with the Guttmacher Institute, told me that one reason is that people have high deductibles. If your insurance hasn’t kicked in, you’re stuck using cash.That’s not super surprising. But another big reason is privacy. Maybe you’re on your parents insurance, or your partner’s plan, and they’re opposed to abortion. Or maybe they’re fine with it, but you just don’t want to talk about it. Insurance might send one of those explanation-of-benefit letters home. Are you gonna be there to intercept it before anyone sees it?

Dan: Yeah, I had not thought about that before we talked.

Emily: Or like, maybe you don’t even know abortion is something that you can even use your insurance for. In one study Rachel did, her team polled people in the waiting room at an abortion clinic about why they were paying out of pocket. A third of them didn’t know whether their insurance covered abortion.

Dan: Wow, OK. Did not know. So, it’s a relevant question: how much does an abortion cost out of pocket?

Emily: It depends where you go, and how far along your pregnancy is, and what kind of abortion you’re having. But generally speaking, the average cost of a first-trimester abortion, the most common kind of abortion — not counting any travel you might have to d,— is a little more $500.

Dan: Which, in terms of the kinds of medical bills we talk about on this show, is… on the low side? But that’s only because medical bills get so wild so quickly. Five hundred bucks is a lot of money for most people.

Emily: Totally. Especially on short notice. Because abortions get more expensive, slightly riskier, and much, much harder to access the further along you are. Plus, like… no one wants to be pregnant longer than they need to be. So people have to scramble. And Dan, we often hear about people scrambling to figure out how to pay for health care. It’s kind of a sick, sad American pastime.

But here’s where abortion is different again. Because not only have people been organizing for decades to protect access to abortion— some groups have organized expressly to help people pay for abortion. to help people in the midst of the scramble. They’re called abortion funds.

Dan: And this is where things get very Arm and a Leg, in my opinion. Because these are examples of people organizing to help each other get the medical care they need, when they need it, without going completely broke.

And this is a whole network of people who have been doing just that — for years. Under tough circumstances. One of the folks you talked with now runs the National Network of Abortion Funds.

We’ll start with her origin story, right after this.

This episode of An Arm and a Leg is produced in partnership with Kaiser Health News. That’s a non-profit newsroom covering health care in America. KHN is not affiliated with the giant health care player Kaiser Permanente. We’ll have more information about KHN at the end of this episode.

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Emily, you spoke with Oriaku Njoku Tell us about that conversation.

Emily: Oriaku’ story — the story of how she started an abortion fund, and became the director of a national network of abortion funds — starts when she worked as a receeptionist at an abortion provider. At first it seemed like just a typical customer service job, in an upscale neighborhood in Atlanta.

Oriaku Njoku: I was like, “Oh, I talk to rich white women every day at the spa that I’m working at. Transferable skills. It’ll be great.” And my eyes were opened so wide in that moment, on the very first clinic day.

Emily: She says right away she noticed that even in the fancy neighborhood, many poor women of color were coming in for appointments. And she fielded calls all day long of people needing to cancel or reschedule because they couldn’t scrape together enough money, either for the abortion itself, to travel there in time, or for childcare.

Oriaku Njoku: All of the hoops and hassle that people have to navigate through. I mean, it’s shameful. And this is not how people should have to access basic healthcare. So I was like, “We should start an abortion fund!”

Emily: She and four co-founders started ARC Southeast. An abortion fund now supporting patients in six states. But it started much smaller than that.

Oriaku Njoku: I was so naive. Oh, so, so naive. I was like, “If we can just get like $2,000 to be able to help people with rides and pay for some abortions, like, that’ll be awesome.”

Emily: Two thousand dollars did not go as far as she expected.

Oriaku Njoku: I remember one of my first abortions that we funded was like $1,500, which was a young person traveling from Mississippi to get an abortion with their mom. And it was — I mean, not only the cost of the abortion, but all of the logistical expenses — I was like: “Well, I thought 2000 was gonna be great for a couple of bus tickets. This is definitely not enough.”

Emily: Over six years, Oriaku and their cofounders raised a ton of money. And from 2016 to 2022, helped support more than 26,000 people with their abortions.

Figuring out how to help that many people was not easy. They had to make a lot of hard decisions. Like, do they fund 100% of medical and travel costs for a small number of people, or distribute smaller amounts to more people.

Oriaku Njoku: You know, we definitely made the decision to fund a larger amount of people, but also to work in collaboration with other abortion funds within our network to make sure that those costs — and the logistical needs even — were fully being met.

Emily: Which meant their money went a lot further. But it also meant a lot of coordinating. Connecting with other abortion funds, and volunteers in other states to match people’s specific needs.

Oriaku Njoku: There’s not a monolithic abortion experience. Everyone has various obstacles, including fear, shame, stigma that contribute to getting an abortion.

Emily: Oriaku became Executive Director of the National Network of Abortion Funds in June, less than two weeks before the Supreme Court overturned Roe v Wade.

Dan: So, she took on a big job. Emily, how does all this work on a local level? Like what are the nuts and bolts of what these funds do?

Emily: There are over 90 local funds that make up the network, and they all work a little differently.

But here’s the basic idea.

You book an appointment with an abortion provider. Once you have your appointment, you go online and you search for an abortion fund in your area. Or maybe the abortion provider themself gives you a number to call when you tell them you don’t have the money.

From there, the abortion fund goes on a full court press to help get you to your appointment. Maybe it’s money directly to you for a bus ticket, like Oriaku initially said. Maybe it’s money sent directly to to the abortion provider in your name. Or maybe it’s the name of a safe, free place to stay near your appointment.

Tyler Barbarin: always the goal is to get people in whatever situation they’re in to get them to meet the appointment appointment date that they’ve set.

Emily: That’s Tyler Barbarin. If you’ve ever left a message for the New Orleans Abortion Fund, and got a call back, you might have talked to her.

Tyler Barbarin: As much as, like, calling strangers kind of gives me the ick, it’s still — it’s worth it.

Emily: It’s worth it to her because she’s been in their shoes. She remembers what it was like needing an abortion and not knowing how to pay for it. She was broke, and overwhelmed. She ended up getting cash from her mom to pay for it. The relief of having someone to rely on when she was under a lot of pressure has stayed with her ever since. And she decided she wanted to be that person for someone else.

Tyler Barbarin: Being able to serve the function that my mom served for me in that moment, that was like — it felt very chaotic, but to know I was gonna meet my appointment date, it was just a sigh of relief.

Emily: Now Tyler and her colleagues at the fund are taking on a monster task of getting people in the Gulf south, where abortion has been almost completely banned since Roe was overturned, to appointments hundreds, maybe even thousands, of miles away. And reassuring them that that’s even allowed.

Tyler Barbarin: People are scared. They don’t know what they can do. They don’t know what is legal.

Emily: But she says the work hasn’t changed as much as you might think. Travelling really long distances for abortion care was already the norm for people in the South.

Tyler Barbarin: a lot of people were not living in a world, um, where Roe actually materialized and meant that they could access abortion care. A lot of people were already in the situation that now we as a country are grappling with

Emily: Which means the work is tough and has been for a while. Tyler was a volunteer when she started, but the organization eventually decided that the need for help was so great, and volunteer management so complicated, that it was worth bringing staff on full time to work these calls. Plus it just seemed like the right thing to do.

Tyler Barbarin: We didn’t want to ask for a lot of labor from people without compensating them.

Emily: The way Tyler tells it, economic justice is really central to how abortion funds see their mission— from paying their employees a living wage, to making sure no one who calls them has to justify their needs.

Tyler Barbarin: I’m gonna ask you a couple of questions to get an idea of the logistics, but I also believe you. You know, people are very used to having to bare all of their trauma, or bare all of their pain, in order to be deemed worthy of care.

Emily: Abortion funds typically have no means testing. Here’s Oriaku.

Oriaku Njoku: To ask people: What’s the total size of your household? What is your monthly income? Those questions are absolutely not necessary in determining whether or not someone deserves to get support for their basic healthcare.

Reproductive justice is also economic justice. Any income requirements, means testing — there really is no place for that

Emily: Reproductive justice. That’s something Oriaku and Tyler both talk about a lot. It’s the larger movement that this network sees itself as part of.

Reproductive justice, the movement, has developed over the years by women of color starting from the 1990s. It’s sort of distinct from the reproductive rights movement, led by organizations like NARAL and Planned Parenthood, which — especially in the 90’s — was centered around the concept of choice.

Reproductive justice changes the frame. It recognizes that for lots of people, particularly people of color, reproductive choices are constrained by more than just abortion laws.

It emphasizes not just the right to have an abortion, but the right to have children if you want them, and bring them up in safe and healthy communities. So it’s access to abortion, but also…

Oriaku Njoku: things like trans justice, disability justice, economic justice, being able to get basic healthcare or to get jobs or to have affordable housing.

Emily: Oriaku says this broad vision drew her in before she ever took those first phone calls at that clinic in Atlanta. Actually, her interest in working at an abortion clinic grew out of an experience a reproductive justice conference.

Oriaku Njoku: That was the first time that I saw all of the things that would make me feel like I’m other, all of the things that would make me feel different — whether that’s me being a first generation Igbo Nigerian American, a black woman, a queer person in the South, a fat person in this country — there’s a place for all of those identities to be honored and respected.

Emily: They say this shared sense of purpose, and radical inclusivity is a part of what draws people in and keeps them involved.

Oriaku Njoku: Even though we know that the work is happening in this ridiculously hostile legal and political climate, knowing what we’re fighting for — knowing what we’re working towards — is what gives me, and so many people doing this work, a lot of hope.

Emily: Yeah. And Dan,

Dan: Yep.

Emily: Oriaku mentioned a hostile legal climate. And earlier you were talking about those legal uncertainties that employers are looking at if they want to help their workers travel for abortion. Obviously, abortion funds have to worry about those too.

Dan: And employers, you know, they get some legal cover by running the whole operation through an employee health plan. Abortion funds don’t get that shield. So Emily, what’s their plan?

Emily: The national network basically just said, they plan to lend legal support, and I mean, it is a fluid situation.

I asked Tyler about this too, she said she doesn’t like to think about it too much. Which is fair. She says she’s trying to stay focused on the work in front of her.

Dan: I’m struck by the fact that people have been organizing these funds for more than 25 years. And it seems like it’s always been both a big swing — the whole idea of reproductive justice — and very much one step at a time. Like a lot of people seem to get involved as volunteers — Oriaku was like “Let’s start an abortion fund!”

Emily: Yep. In a recent annual report, the National Network of Abortion Funds says about half of its member funds are run by volunteers.

Dan: It’s impressive, as an example of people coming together to take on something big, and sticking with it, and sticking together.

Emily: And it’s still uphill. That same report said that abortion funds helped tens of thousands of people — but that was only a little more than half of the people who called looking for help.

Dan: Emily, thanks for bringing this story to us.

Emily: It was my pleasure. I learned so much doing this story.

Dan: Me too.

And you know, we’ve been reporting a lot on people who start something, it starts small. I’m thinking about folks like Jared Walker, of course, who started off just collecting a dollar at a time, to help one family at a time. And who now says his group has wiped out 20 million dollars in medical bills by helping people get charity care.

Which is — and this is wild — still a tiny number, compared to the amount of need out there for this exact thing: Hospitals have admitted to billing patients for 2.7 billion dollars that could have been forgiven through charity care in a single year.

All of it is both sobering and inspiring. It’s a lot of one-step-at-a-time.

It reminds me of talking to Jenny Spring from Cincinnati, who raised money to pay off a million dollars in medical debt for her neighbors — with fund-raisers like a taco bar, and home-made tags for Christmas gifts. She said, “Why not? What else have you got do?”

And this is where I make a pitch: Because what’s become the project of this show— figuring out how we can help each other survive this mess of a health-care system — it’s big. There’s not exactly an easy, simple path.

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This episode of An Arm and a Leg was produced by Emily Pisacreta and me, Dan Weissmann, and edited by Marian Wang.

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