Despite a landmark pro-choice law and Democratic Gov. J.B. Pritzker’s promise to make Illinois “the most progressive state in the nation for access to reproductive health care,” barriers remain for people seeking abortion care, according to abortion rights advocates and providers.

Passed by Illinois Democrats in June, the Reproductive Health Act declared abortion a “fundamental right” and wiped away unenforced anti-choice provisions enacted in the last 44 years, including husbands’ ability to block their wives’ abortions and a variety of medically unnecessary targeted regulations of clinics. Abortion rights advocates hope the law will lead to greater access across the state and for people in neighboring states that severely restrict abortion, including Indiana, Missouri, and Wisconsin.

“We’ve made fantastic progress in ensuring access to abortion in the past couple of years,” Brigid Leahy, senior director of public policy at Planned Parenthood Illinois, told Rewire.News.

But barriers remain, as insurers and state agencies have yet to fully catch up to the new pro-choice policies. And the law does not address other issues that affect patients, including Illinois’ parental notification law, a dearth of clinics in parts of the state, and a growing number of Catholic hospitals in Illinois that don’t offer a full spectrum of reproductive health care.

Lee Hasselbacher, senior policy researcher at the Center for Interdisciplinary Inquiry and Innovation in Sexual and Reproductive Health at the University of Chicago, said the act removed a nonenforceable ban on later abortion care and codified some court orders. While not a change in current policy, the codification allays fears about dormant anti-choice laws. The act also established an “affirmative right” to abortion that could affect future state court rulings.

“When any case comes up in the future, it has to be judged against that law,” she said.

She said good implementation will be key in making Illinois a model state for access to abortion care.

“The most pressing thought for folks right now, among the providers I talk to, is: ‘Now that we have some of these good laws in place, how do we make sure they’re implemented well and that access continues to improve through their implementation?'” Hasselbacher told Rewire.News.

Insurance Coverage Challenges 

The inflection point for abortion access came in September 2017, when then-Gov. Bruce Rauner (R) signed HB 40, which allowed Illinois Medicaid and state employees’ plans to cover abortion care. But the administration didn’t follow up. Hasselbacher said after the legislation became law, there was a lack of support from the state government.

“[There was] not a lot of clarity at the time from the state agency,” she told Rewire.News. “Previous to the current administration, there wasn’t as much support for this law being put into effect. Folks were feeling frustrated trying to contact the state agency trying to get guidance.”

Two years after the law took effect, many clinics still struggle because of low reimbursement rates or the complicated process of getting approved to bill Medicaid.

“We didn’t physically bill Illinois Medicaid until two months ago,” Alison Dreith, executive director of Hope Clinic for Women in Granite City, told Rewire.News, adding that a donor was helping cover the difference for Medicaid patients seeking abortion care. “We had to get a whole new electronic medical records system that would allow us to bill Medicaid and do a lot of complying with the state. When those reimbursement rates came back to us, they were very low.”

Dr. Allison Cowett, co-medical director at Family Planning Associates in Chicago, told Rewire.News that it was only in the past few weeks that the rate was updated from what it was in the 1970s.

Even so, more abortions are state funded than before the law. The Illinois News Network reported a 274 percent increase in abortions paid for by Illinois Medicaid over the first six months of 2018, after HB 40 went into effect. Despite the sharp increase, it was from a low baseline: In the first six months of the previous year, Medicaid only covered 84 abortions. These were likely cases of life endangerment, health risk, or pregnancies that resulted from rape or incest.

Medicaid paid an average of $77 per procedure, 6 percent of what clinics had billed, based on 2018 figures the Illinois News Network reported.

Even for providers who were already contracted with Medicaid and have a process for billing, challenges remain. Until the start of November, billing Medicaid involved paperwork that differed from the electronic claims that were usually sent, according to advocates and providers. Leahy of Planned Parenthood Illinois said the process required a separate staff person to take care of the billing.

“Every Medicaid provider will tell you how slow it is to be reimbursed by Medicaid,” she said. “But if you layer in [that] this process is slowed down even more because everything’s being processed on paper by hand, it is quite a problem. … We’re very pleased the system is changing and that the department is now going to be treating the billing of abortion just like all the other services that Medicaid covers, which is what the [HB 40] law says it should be doing.”

Hasselbacher said one of the biggest effects of the Reproductive Health Act could be the requirement for private insurance to cover abortion like any other pregnancy-related care, but that it hasn’t actually had an impact yet because plans haven’t yet been updated. She said she expects the change to become clear over the next few months as insurance plans are updated for the next calendar year. She noted that the law doesn’t change common issues people have with their insurance like high deductibles, which have been rising in the United States.

Along with high-deductible plans, Megan Jeyifo, executive director of the Chicago Abortion Fund, said many are left out of Medicaid and private insurance coverage, including some people who have little income but are over the Medicaid threshold.

As insurance funding increases in the state and the need for travel increases, abortion funds are shifting their resources to cover travel and other costs beyond the procedure. The Chicago Abortion Fund is doing more case management as well. Jeyifo said it was a major shift since the time she started, when the fund would typically send the patient a voucher for the cost of the procedure. 

“It’s way more logistics,” she said. “Way more.”

Case management could involve helping arrange the appointment, travel, or child care, Jeyifo said. And the fund is increasingly dealing with needs beyond the procedure itself.

“We are checking in with folks, and making sure, if they have other issues in their life, that we can provide other resources for them,” she said. “It’s an honor to be able to do this with folks. But it’s absolutely different than it was previously.”

‘The Last Remaining Legal Obstacle’ 

The 1995 Parental Notification Act, which was stayed by an injunction until 2013, was not affected by the Reproductive Health Act. The law requires minors to notify their parents that they’re getting an abortion at least 48 hours beforehand. Leahy called it the “last remaining legal obstacle” for abortion access in the state. It presents an unnecessary hurdle for teens seeking abortion care, she said, and it is potentially dangerous to pregnant teenagers in abusive or otherwise unsafe homes.

“We would really refer to it as a teen endangerment act,” she said.

The ACLU of Illinois, which battled the law in court, has documented a number of instances of harm coming to teenagers in other states due to parental notice requirements. After the law went into effect, the ACLU of Illinois created a project to represent teenagers free of charge in judicial bypass hearings.

Cowett characterized the forced parental notification law as a “major barrier,” and noted that virtually every request for a judicial waiver gets approved—a 2015 Chicago Tribune story reported that the ACLU attorneys in the state had never had a client’s petition turned down.

“Everyone who goes through the judicial bypass end[s] up being granted, so why are we putting young women in this uncomfortable position?” Cowett asked. 

Advancing New Standards in Reproductive Health (ANSIRH) at the University of California, San Francisco conducted a study on 1,577 women at Hope Clinic both before and after Illinois’ parental notification law went into effect in 2013. The study compared outcomes between minors and young adults who were close in age but not affected by the law. The study found that fewer minors overall received abortions after the law. Among minors traveling to Illinois from out of state, the proportion receiving a second trimester abortion increased. The percentage of parents of minors who were aware of the abortion increased, with no corresponding change in parents’ support. 

An earlier study found that the number of minors receiving abortion care slightly decreased following implementation of the law, though researchers could not conclude that the difference was significant.

Researchers noted in both papers that, because the studies only looked at people receiving abortion care, they could be underestimating the effect, and that the decline could be attributable to the ongoing decline in abortions across age groups, including adolescents.

Illinois representatives advanced a bill this year to repeal the Parental Notification Act, but it did not advance to a floor vote.

Abortion Care Deserts Persist 

Many of Illinois’ clinics are concentrated in or around Chicago, meaning pregnant people in most parts of the state have to travel to get an abortion. According to 2017 data from the Guttmacher Institute, 90 percent of counties in Illinois don’t have a clinic, leaving about 37 percent of women of reproductive age, or nearly a million women, needing to travel to access abortion. The number of Illinois abortion care providers peaked in the years after Roe v. Wade, declining from 87 clinics in 1976 to 37 in 2000. It has since plateaued and stands at 40 today. 

Dreith said that despite progress, the decline in clinics remains an impediment to access for many. 

“Illinois is similar to California in that clinics are also closing,” she told Rewire.News. “There are large swaths of the state with no provider.”

The lack of clinics in the northwest corner of the state means a number of Illinois residents come to the Emma Goldman Clinic in Iowa. Many of those callers used to be served by a Peoria, Illinois, clinic that closed in June, Francine Thompson, executive director of the Iowa clinic, told Rewire.News. 

One consequence of leaving Illinois for care is that the pregnant person’s abortion is not eligible for state funding, Thompson said. “The financial barriers are certainly big ones,” she said.

Dreith said the distance meant patients at her clinic often need to arrange child care, travel, and time off work in addition to the appointment.

Meanwhile, a growing number of hospitals in the state are owned by Catholic health-care systems that don’t provide abortion or contraception. For low-income people in Cook County, most of the available Medicaid managed care plans leave them disproportionately reliant on Catholic hospitals, according to a recent study Rewire.News on in June. Nearly 15 percent of people in Cook County live under the poverty line.

Beyond restrictions, many advocates Rewire.News spoke to are concerned about patients misunderstanding the law, fed by anti-choice information, worried social media posts, and headlines that lack context. Dreith said she has fielded panicked calls from patients who didn’t realize an anti-choice law they saw in the news was in another state, blocked by a court, or both.

She said she wanted “to reassure patients in Illinois and surrounding states that we’re working hard to be as welcoming as possible.”

Leahy echoed her comments, encouraging pregnant people seeking abortion services to reach out to a clinic or use online tools like Planned Parenthood’s Abortion Care Finder.

“There are people who really want to help you with getting the care that you need,” she said.

Correction: A previous version of this story said the Reproductive Health Act changed which abortion procedures advanced practice nurses could perform.