GAO Finds that Some State Medicaid Programs Are Not Meeting Federal Health Coverage Requirements

State-reported information on Medicaid coverage of abortions

While federal law prohibits federal funding for abortions in most circumstances, state Medicaid programs are required to cover abortions in limited circumstances. A recent report by the U.S. Government Accountability Office (GAO) presents the results of a survey of state Medicaid programs’ abortion coverage. One state reported not covering abortions in cases of rape or incest, and 14 states reported not covering the drug used in medication abortions, which they are generally required to cover if the abortion is otherwise eligible for federal funding.

The U.S. Centers for Medicare & Medicaid Services (CMS) is responsible for monitoring state compliance with federal requirements. To receive federal funding, state Medicaid programs are supposed to meet federal health care coverage requirements. These include coverage for abortion, but only in cases of rape, incest, or if the woman's life is endangered.

“The recent GAO report on state compliance with abortion coverage requirements is stunning in that it not only documents the variation on access for women to abortions among the states, it also provides clear evidence that CMS is not providing the necessary oversight to ensure that federal laws for coverage are being followed,” says Janet Heinrich, DrPH, RN, FAAN, a research professor at George Washington University’s Milken Institute School of Public Health. Prior to coming to GW, she worked as a senior advisor at U.S. Center for Medicare and Medicaid Innovation.

South Dakota is the one state not covering abortions in cases of rape or incest. The 14 states that reported not covering the drug used in medication abortions are shown in the GAO’s map, above.  The GAO reports that the Department of Health and Human Services (HHS) concurred with the recommendation that CMS needs to address state non-compliance with the law. 

“This is suspect when considered in light of other Trump administration rules that make access to contraception as well as abortions for women complex and difficult,” Heinrich says. “Successful litigation takes time and pregnant women don’t have the luxury of that time.”

The report points out that women could face various challenges accessing abortions depending on where they live, and Medicaid beneficiaries may face additional challenges in some states. It identifies seven key factors that could pose challenges to women accessing abortions, based on interviews with providers and review of the literature: gestational limits, mandatory counseling, out-of-pocket costs, parental involvement requirements, provider availability, stigma and harassment, and waiting period requirements. The presence of these factors and their effect on abortion access—such as delays in care or increased costs—varied by state, according to the report.

“A low-income woman already may face barriers to access to health care, with extra barriers to access abortion care - depending on which state she lives in, as documented by the GAO,” said Prof Susan F Wood, PhD, Director of the Jacobs Institute of Women’s Health at the Milken Institute SPH.  “The fact that some states do not follow federal law with regard to Medicaid coverage of abortion is a striking reminder of the challenges women face. The evidence provided in this report should move both Congress and CMS to ensure that the legal minimum of Medicaid coverage for abortion care is available nationwide.”

The report includes three recommendations to CMS to ensure compliance with federal requirements for abortion coverage.

“Medicaid: CMS Action Needed to Ensure Compliance with Abortion Coverage Requirements” (GAO-19-159) is available here.