Amanda Andrade-Rhoades/AP Photo
Providers don’t need extra, special training to prescribe mifepristone. The pill is exceedingly safe.
Anita Ravi, a family medicine provider in New York City, decided to begin offering abortion services at her clinic, PurpLE Family Health, which serves survivors of gender-based violence such as domestic abuse and sexual assault. She feels like she did everything right from a legal and liability perspective. Despite that, her insurance prices skyrocketed, jeopardizing the entire clinic’s finances.
Ravi’s difficulty as an abortion provider with accessing appropriate, affordable insurance is not unique. Providers across the U.S., especially family medicine practitioners who are interested in adding abortion to their scope of care to make abortion more accessible in their communities, have come across insurance costs or availability as a major barrier.
Ravi, who is the CMO of PurpLE Family Health as well as the CEO and founder of PurpLE Health Foundation, was interested in providing a highly limited scope of abortion care to her patients, with a primary focus on medication abortion. That treatment entails prescribing mifepristone, the medication that induces abortion, and following up with patients after they’ve taken the medication.
When she applied for the malpractice insurance that would allow her to prescribe mifepristone and help her patients navigate miscarriages before 12 weeks of pregnancy, Ravi expected to get a very basic tier of coverage. After all, she was planning to offer some of the safest and most straightforward abortion care available; over half of all abortions are done using medication. Despite that, Ravi found that her insurance company had designated that care as “major surgery,” an objectively incorrect categorization, and was charging her exorbitant prices. After digging into the paperwork, Ravi realized that checking “abortion” as a service she provides on her insurance forms is what caused the miscategorization. Her insurance company didn’t bother to ask what kind of abortion she was planning to offer, and her broker didn’t bother to clarify, despite knowing that Ravi was primarily planning on prescribing mifepristone.
Some insurance companies asked her to provide proof of training in reproductive health services, even though that training was built into Ravi’s family medicine practice. What’s more, providers don’t actually need extra, special training to prescribe mifepristone. The pill is exceedingly safe.
“Malpractice [insurance] companies are effectively limiting the scope of practice for many primary care providers,” Rory Tito, manager of technical assistance at the Reproductive Health Access Project (RHAP), said about barriers like providing proof of unnecessary training.
Ob/gyns have some of the most expensive rates of malpractice insurance in medicine, due to a high likelihood of being sued.
You could be forgiven for assuming that the difficulty doctors face in getting liability coverage for abortion is an issue that emerged after the Supreme Court overturned Roe v. Wade in 2022, allowing states to criminalize abortion and thus making the job of an abortion provider much more dangerous. But, in fact, predatory insurance for abortion providers has a long history in the U.S., and is fundamentally entangled with the history of pre-Dobbs abortion restrictions.
But legal risk, both from the potential of violence and from out-of-state citizens armed with laws in Texas and Idaho and other jurisdictions that allow them to sue anyone who assists in performing an abortion on a resident of one of their states, has increased after Dobbs. And the general wariness to accept this legal risk has made setting up any practice for abortion services that much tougher.
MEDICAL LIABILITY INSURANCE is an essential piece of a physician’s ability to practice, allowing them to provide care without fearing that a single error will bankrupt them and end their career for good. In 18 states, it’s also legally required.
Physicians whose scope of care could include abortions have long had difficulty accessing affordable liability insurance. In particular, ob/gyns have some of the most expensive rates of malpractice insurance in medicine, due to a high likelihood of being sued—two out of three ob/gyns face legal action at some point in their career.
These high prices have disastrous effects: The number of ob/gyns in the U.S. is declining precipitously. The American College of Obstetricians and Gynecologists (ACOG) estimates that by mid-century, the country will be short 22,000 ob/gyns. The problem is already life-threatening: In 2017, ACOG found that half of U.S. counties, representing ten million women, lacked a single ob/gyn. This shortage often affects rural, low-income, and Black patients the most, in a country where the Black maternal mortality rate is already three times that of the rate for white women.
Family medicine providers like Ravi who are considering adding abortion care to their scope of practice face a different, but equally burdensome, set of challenges. Since Dobbs, the number of family medicine and primary care doctors providing abortions in states where it’s legal to do so has grown rapidly. Many of these providers felt the need to do something after Dobbs. Accessing abortion care in a family medicine clinic can be less intimidating for patients than going to Planned Parenthood, clinicians told me. Primary care doctors who provide abortion care also help fill the gaps in counties where there is no ob/gyn.
But when a family medicine provider considers adding abortion care to their scope of practice, they can often find it nearly impossible to parse the legalese of their liability insurance policies to ensure that they are covered. Now, post-Dobbs, bounty hunter laws like Texas’s SB 8, which empower citizens to sue those who “aid and abet” abortions, no matter where they’re located, only heighten the need for abortion providers to have malpractice insurance.
This confusion creates a barrier for many doctors who want to add abortion to their scope of practice, especially those who work for small independent clinics without the legal resources that big hospital systems have.
On the other hand, providers who work in big hospital systems face yet another set of challenges, often cultural, when they seek to expand coverage for abortion care. “These are profit-making institutions, and so they’ll just provide what makes them the most money,” said Carrie Baker, a professor at Smith College. “You have a for-profit medical system that prioritizes profit over people and profit over the health of people.” Also, Baker said, providers have to traverse a long chain of administrators to get permission to add abortion care, and just one dissenting voice can send a provider back to square one.
BAKER SITUATES CURRENT-DAY INSURANCE ISSUES in the larger project of anti-abortion activism in the U.S. “One of the strategies of the anti-abortion movement is to drive up the cost of abortion. It’s first to restrict abortion just to stand-alone abortion clinics by stigmatizing abortion health care.”
Baker argues that this siloing of abortion clinics into discrete, vulnerable locations makes them easy targets for both physical violence and legislative attacks—two distinct but often related forms of repression.
On the violence front, between 1977 and 2022 there have been 11 murders, 200 arsons, and 492 clinic invasions directed at patients and providers of abortions, according to the National Abortion Federation’s 2022 Violence & Disruption Statistics report.
During 2022, the year that the Supreme Court overturned Roe, violence directed at abortion clinics and providers skyrocketed. Stalking of patients and providers increased by 913 percent over the span of one year, bomb threats went up by 133 percent, and assault and battery rose by 29 percent.
This violence in turn ricochets back on clinics and providers through insurance increases or coverage denial. Landlords, concerned about the physical safety of their buildings, might withdraw from lease agreements with the clinics operating within them, as was the case at a soon-to-open Beverly Hills abortion clinic earlier in 2023. Physicians might see their insurance rates skyrocket to untenable levels, like Ravi did.
This confusion creates a barrier for many doctors who want to add abortion to their scope of practice, especially those who work for small independent clinics.
The barrier of expensive liability insurance also echoes the barriers caused by one previously ubiquitous legislative attack: targeted restrictions on abortion providers (TRAP) laws, which anti-abortion legislators passed to functionally ban abortion without doing so in name while Roe stood as the law of the land. TRAP laws placed medically unnecessary requirements on abortion providers and reproductive health centers, such as down-to-the-inch specifications for hallways and exam rooms, or location requirements that forced abortion providers to be a certain distance from schools.
Passed under the guise of protecting patient health, TRAP laws had the opposite effect, functionally making abortion illegal by simply making it too difficult and too expensive to provide. Between 2013 and 2014, restrictions from Texas TRAP laws contributed to the creation of health care deserts: In just that year, the number of patients who lived more than 100 miles from an abortion clinic in the state tripled.
Now that Roe is no longer the law of the land, such complicated maneuvering from anti-abortion activists is hardly necessary: States can simply ban abortion outright. But exorbitantly expensive liability insurance, whether explicitly intended to restrict abortion access or not, has the same repressive effect as TRAP laws.
Mary Ruth Ziegler, a professor at UC Davis Law, sees expensive and inaccessible liability insurance as a direct result of anti-abortion legal strategies pioneered in the ’80s and ’90s. Ziegler cites Mark Crutcher, the founder of the radical anti-abortion organization Life Dynamics, Inc., as a key instigator of anti-abortion strategy that focused more on making care inaccessible than making it illegal.
“His argument essentially was that it doesn’t matter if abortion is legal if it’s inaccessible,” Ziegler explains. “It didn’t matter if there actually was liability if insurance rates were high.”
Crutcher encouraged lawsuits against abortion providers and clinics, almost all of which failed. “But, you know, there’s … some reason to think that certainly, the goal was to drive insurance rates up,” Ziegler said. “The prospect of either being unable to get insurance or being unable to afford insurance had a chilling effect on people’s willingness to get training.”
RAVI WAS ABLE TO NEGOTIATE with her insurance provider to move her out of the “major surgery” price category, but it wasn’t easy. She relied on the help of the team at RHAP, which helped her identify the issue and communicate with her insurance company. RHAP even brought the issue up to the New York state attorney general on her behalf.
To Ravi, the excessive cost of insurance for abortion care and the administrative labor required to apply for it damaged her trust in the systems that are supposed to work together to provide care for vulnerable patients and protect physicians.
“All of this is rooted in implicit trust. You’re trusting the systems to understand. You’re trusting that your broker, in some way, is advocating a little bit on behalf of you, [and] we realized it’s not the case,” she said.
In many ways, Ravi is lucky: She noticed that she was being overcharged for insurance, was able to investigate why, and eventually fixed the issue. Not every family medicine clinician has the energy and resources to dig into the administrative and legal mess of their liability insurance. Some physicians who see only a low volume of patients seeking abortions might decide that the cost and logistical burden of malpractice insurance isn’t worth it, and could discontinue that care. Small family medicine clinics are often at the forefront of abortion access, and are also most likely to be unable to stand up to their malpractice insurance companies.
When I asked doctors, professors, and pro-choice advocates about potential solutions to this issue, they cited a number of policy changes that could help. Tito suggested requiring the insurance industry to standardize their terms and risk categorizations, so providers like Ravi who only want to prescribe mifepristone won’t be slotted into a “major surgery” price category for checking a box that says “abortion.” Tito noted, though, that brokers are “making commission off of the cost of the premium. So there’s not really an incentive there to get good or fair pricing,” or for companies to properly define their terms.
Shield laws, which 24 blue states have passed to protect abortion providers in the wake of Dobbs, can also provide a level of protection from insurance spikes. Half of the states that have shield laws on the books include provisions related to liability insurance, such as protections against increases in premiums or denials of coverage. While shield laws are a promising defense for abortion providers, they also remain untested by the courts, though lawsuits are surely on their way.
Silpa Srinivasulu, of RHAP, wondered if alternatives to typical malpractice insurance companies could be part of the solution. According to Srinivasulu, the National Abortion Federation (NAF) offers good liability insurance to its member clinics, but the majority of its members are reproductive care–focused clinics like Planned Parenthoods that have a high volume of patients seeking abortion care. Small family medicine clinics, Srinivasulu explained, don’t have the same funding resources and thus aren’t able to reap the benefits of insurance from NAF. She hopes NAF looks into providing discounts for low-volume family medicine clinics.
At the end of the day, the underlying problem is the stigmatization of abortion, which has only increased after Dobbs. Insurance companies are benefiting from what Baker calls “abortion exceptionalism”—the incorrect idea that abortion is a uniquely dangerous medical procedure that requires extra regulation.
“The fact of the matter is, this medication is safer than Tylenol,” Baker said. “So the reason that insurance companies are doing this is because they think they can, and because everybody’s so scared of abortion. Everybody just thinks, ‘Oh, abortion: danger, liability! I’m going to charge you a lot for that.’”
