A new report from the National Health Law Program (NHeLP) found a lack of abortion coverage on the Affordable Care Act (ACA) state marketplaces, with plans in Delaware, Iowa, Minnesota, Nevada, West Virginia, and Wyoming failing to indicate whether they cover abortion beyond circumstances of rape, incest, or life endangerment.

Those plans include wording found in the discriminatory Hyde Amendment. 

“We are seeing stigma being played out in the ways plans cover abortion,” Fabiola Carrión, senior attorney with the NHeLP and one of the study’s authors, told Rewire.News. “It’s unfortunate this is happening in the marketplaces.”

Many of the plans incorporate the exact language found in the Hyde Amendment, which prohibits the use of public funds for abortions except in instances of rape, incest, or life endangerment, Carrión said. Some plans even surpass the restrictions in the Hyde Amendment, only covering abortion care under the life endangerment circumstance. 

The study’s authors analyzed publicly available information, including the plans’ summary of benefits and evidence of coverage documents, emulating the experience of someone shopping on the ACA marketplace. Information about abortion coverage is difficult to find, and because it is confusing, some people may opt to pay for the procedure themselves whether or not their plan covers it, Carrión said. Without insurance, “an in-clinic abortion in the first trimester can cost up to $1,500,” according to Planned Parenthood.

“This disproportionately affects middle- and low-income individuals who for whatever reason have decided not to continue a pregnancy,” Carrión said. “We are attorneys. The Affordable Care Act is our bread and butter, and we had a hard time finding this information. I can just imagine what it would be like for someone who doesn’t have the time.”

Access to abortion coverage in private insurance varies widely. Six states (Alaska, Colorado, Massachusetts, Montana, New Jersey, and Rhode Island) offer at least one plan on the ACA, or Obamacare, marketplace that includes abortion coverage, but that plan isn’t necessarily available to everyone in the state and may only be offered in certain counties, according to analysis from the Kaiser Family Foundation.

Twenty-six states and Washington, D.C. ban private insurance providers from covering abortion, either in all private plans or marketplace plans only, but even in the 24 states that do not ban abortion coverage, burdensome regulations on insurers may cause them to limit coverage options, said Leah Montgomery, director of government affairs and health finance at Planned Parenthood North Central States, which serves Minnesota, Nebraska, Iowa, North and South Dakota. 

“We should have state laws, really a federal law, requiring abortion services as an essential health benefit,” Montgomery told Rewire.News. “The full range of reproductive health care from birth control to prenatal care should all be covered because it is all health care.” 

Last November, the Trump administration issued a proposal to change the way ACA marketplace plans that include abortion coverage would need to bill policyholders. The proposal would require plans to issue two separate bills, and require policyholders to conduct two separate transactions for premium payments. Requiring multiple billing processes creates an unnecessary administrative burden on an insurer, making them less likely to offer abortion coverage, Montgomery said.

“Unless insurers are required to cover a certain service, it is really easy for them not to,” Montgomery said. “Politicians have targeted this medical service and made it difficult for insurers to provide this abortion coverage, which makes it difficult for patients.”

Several plans that offer coverage use confusing labels to describe abortion, such as “elective,” “therapeutic,” or “medically necessary,” Carrión said, and some plans even limit the number of abortions an enrollee can receive.

“A knee replacement is an elective procedure that some people have in order to walk a little bit better,” she said. “No one would argue a knee replacement isn’t a medically necessary procedure. I don’t know why we are still having to debate the same about abortion.”

Four states—California, New York, Oregon, and Washington—require ACA marketplace plans to include abortion care coverage, and Maine will join these states starting in January. Requiring insurance providers to include abortion coverage is key to ensuring access for marginalized populations, Carrión said. 

“Some states are not in a political environment where they could mandate all their plans cover abortions,” she said. “But they should certainly work with insurers to make sure the plans are transparent and provide comprehensive information for shoppers and enrollees about abortion coverage.”