Four in ten adults would not have enough money on hand to cover an unforeseen expense of $400, according to a recent Federal Reserve Board survey. At an average cost of $500, a first-trimester abortion is squarely out of reach for many women if insurance doesn’t cover their care.

That means out-of-pocket costs for abortion can be detrimental to families. We know from research that low-income people who aren’t able to use their public insurance to cover abortion care endure financial hardships as they work to find the funds. Less is known about people’s experiences accessing abortion through private health insurance such as employer-based insurance or insurance through the Affordable Care Act (ACA), which together cover a majority of people in the United States.

At Ibis Reproductive Health, we reviewed evidence on the topic and found that policyholders themselves lack information, and many are unsure if their insurance covers abortion. And in a study of marketplace plans—the insurance plans established through the ACA—the National Health Law Program (NHeLP) recently found that many ACA plans don’t cover abortion services, even in states with no restrictions on coverage.

Hurdles to using insurance to cover abortion are due in part to restrictions passed by lawmakers to limit private insurance coverage of abortion. Over 30 restrictions on insurance coverage of abortion have been passed by state legislatures in the past ten years. Meanwhile, the Trump administration recently finalized a rule designed to cause confusion among enrollees and limit access to insurance coverage of abortion. With ACA marketplace plans required to send a separate billing statement for abortion coverage, this new administrative burden will be passed on to individuals in the form of higher premiums—or plans will eventually drop abortion coverage altogether. As NHeLP’s report documents, many ACA plans have already placed restrictions on abortion coverage, such as lifetime or yearly limits on the number of abortions an enrollee can receive. With this new rule, coverage is likely to worsen.

In states where private insurance coverage of abortion is banned but an insurance rider (an extra monthly fee that someone can pay to have this coverage) is allowed, abortion coverage is still not accessible. Research has found that only one plan in one state actually included a rider option.

Restrictions aren’t the only reason people can’t have their abortion covered: In some states where private and marketplace insurance plans are able to cover abortion, the information about whether and when a certain type of abortion will qualify for coverage is unclear. Extreme limits on private insurance coverage, in addition to inconsistent or unavailable information on coverage, forces many to pay out-of-pocket for a reproductive health service that one in four women will use in their lifetimes.

The Affordable Care Act was designed to improve access to health care, especially for low- and middle-income people. For those paying for their insurance and actively trying to stay insured, an emergency health cost such as an abortion could have serious implications for the family’s finances. It is paramount to include better coverage for reproductive health services in plans and policy proposals to improve our health care system.

NHelp’s recent report reinforces other findings that have demonstrated that living in a state without restrictions on abortion coverage does not mean an insurance company will cover it. It is critical for consumers and advocates to speak up and ask insurance companies to offer transparent, clear, and comprehensive information on abortion coverage policies.

Affordability is key to increasing access to quality abortion care. With increasing restrictions on private insurance coverage of abortion, it is important to protect the coverage we have and to improve coverage of all reproductive health services in places where coverage is restricted.