GRANITE CITY, Ill.— Abortion access in America is narrowing. There are fewer clinics, longer drives and more restrictions earlier in pregnancy.
But something else is different: The women themselves.
Women getting abortions today are far more likely to be poor than those who had the procedure done 20 years ago.
Half of all women who got an abortion in 2014 lived in poverty, double the share from 1994, when only about a quarter of the women who had abortions were low-income, according to the Guttmacher Institute, a research group that supports abortion rights and conducts a national survey of abortion patients every six years.
The abortion rate has declined by nearly 40 percent since the mid-1990s. But the United States still has a higher rate of unplanned pregnancy than many other developed countries, and a growing share of women who respond by having an abortion are impoverished.
“The patient population in abortion clinics is increasingly made up of poor women,” said Diana Greene Foster, a demographer at the Bixby Center for Global Reproductive Health at the University of California, San Francisco.
The result is that as more states pass stringent laws limiting abortion access, it is increasingly poor women who have to grapple with their effects. These are also the women who have the least means to travel to states with freer access.
“Whenever states enact restrictions, the people who are most affected are the ones with the fewest resources,” said Rachel Jones, a researcher at Guttmacher.
There are a number of possible reasons for why this is happening. One is purely demographic: The population of women living below the federal poverty level — around $25,750 for a family of four in 2019 — has grown faster than it has among women living above it, Foster said. That means there are simply more poor women subject to the risk of unwanted pregnancy who may turn to an abortion.
At the same time, women with higher incomes may have better access to highly effective contraception than before, Jones said.
Another possible reason: There are more financial resources for low-income women to pay for abortion. Jones noted that an uptick in charities that offer financial help has made it possible for more women to afford an abortion. Also, Medicaid expanded in several states under the Affordable Care Act, increasing coverage for poor women, and in turn, coverage of abortion in states that allow their Medicaid programs to pay for it.
At Hope Clinic for Women, in Granite City, Ill., just across the Mississippi River from Missouri and a quick drive from downtown St. Louis, more than half of all patients require some financial help. Many call the National Abortion Federation Hotline Fund, a national nonprofit that gives out small grants, often of a few hundred dollars, to help women pay for abortions and sometimes for travel. They also get help from the Gateway Women’s Access Fund, a local charity set up in 2015 to help Missouri patients.
That is what helped a young woman from St. Louis, who arrived at the clinic for an appointment last Friday. She had with her $560, part of which she had saved from her job answering phones on a hospital switchboard. But when she was told she needed another hundred dollars because of her blood type, she began rapidly texting, hoping she could borrow it. She even called her mother, something she said she didn’t want to do.
“I’m short $100, can you lend it to us?” she asked her mother, in a quiet voice.
The crisis passed when a clinic worker, Cali Baublitz, said she could cover it using money from the Gateway fund.
As the number of abortions has declined, the map of abortion access across the country has become uneven, with red states passing ever-stricter laws and blue states moving in the opposite direction.
Missouri is now one of six states with only one clinic left. The others are Kentucky, Mississippi, North Dakota, South Dakota and West Virginia. That has created surges in adjacent states, and at border clinics like Hope, whose patient load was up by 35 percent this June, compared to the same month a year ago, according to Dr. Erin King, the clinic’s executive director.
Part of the growing divide among states is financial. Federal Medicaid funds can only be used for abortion in extremely limited circumstances. But some states, like California and New York, have gone their own way, allowing state funds to cover the procedure. Illinois joined those ranks in 2017, and now the overwhelming majority of Hope Clinic patients calling the National Abortion Federation for funding are residents of Missouri, a state that does not allow Medicaid to cover abortion.
The result is a substantially lighter burden for poor women in states that do allow Medicaid to pay — 16 as of June, when Maine joined the list. Just 25 percent of abortion patients in those states paid out of pocket for care, according to Guttmacher, compared to 75 percent of abortion patients in states where Medicaid does not pay.
In those states, charities have become a significant part of how women pay for abortion.
The National Abortion Federation’s office in Washington, D.C., buzzes with the sound of ringing phones as young people wearing headsets answer calls from abortion patients from around the country.
The hotline, the largest of its kind in the nation, will employ 36 full-time workers by the end of this month, up from 22 in 2011, said Melissa Fowler, a spokeswoman for the organization. Last year, the fund provided financial assistance for approximately 85,000 women seeking abortion care, she said, a figure that was down slightly from 2017, after Illinois, the fifth most-populous state, began covering the procedure through Medicaid.
“The phone is always ringing,” said Charlene Sumter, who answers patients’ first calls into the hotline. “There’s never a moment of silence.”