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10 facts that explain how America regulates abortion

The abortion rate has fallen steadily for years, decreasing nearly every year since 1981. In 2012, it was at the lowest level recorded since 1973, when the Supreme Court legalized abortion in its Roe v. Wade ruling.

America's abortion rate has steadily declined since the 1980s

In 2012, the most recent year for which the Centers for Disease Control and Prevention has data, there were 699,202 legal, induced abortions in the United States. The abortion rate for 2012 was 13.2 abortions per 1,000 women between the ages of 15 and 44.

The federal government tracks both the number of abortions and abortion rate and, since the 1980s, their data has shown a steep decline. The 2012 numbers mark the lowest abortion rate since 1973, the year that the Supreme Court's Roe v. Wade decision created a legal right to abortion access.

Meanwhile, the national trend has moved in favor of more aggressive abortion regulation. Legislatures across the country passed more restrictions between 2011 and 2013 than they did in the prior decade. These restrictions have led to some abortion clinics closing because they found it too onerous to come into compliance.

Those new regulations have catalyzed new lawsuits: most recently, the fight centers over state requirements that abortion doctors have admitting privileges at local hospitals. These new restrictions have forced courts to dive back into a controversial issue, and further clarify what type of abortion regulation is legal in America.

Abortion patients are disproportionately young, nonwhite, and poor

Women obtaining abortions are disproportionately young, minority, unmarried, and likely to already have at least one child.

The majority of women obtaining abortions — 58 percent — are in their 20s, according to a 2010 report from the Guttmacher Institute, a nonprofit that conducts research on reproductive health. The same report found that non-Hispanic white women account for 36 percent of abortions, black women for 30 percent, and Hispanic women for 25 percent.

Forty-two percent of women who got abortions in 2008 lived below the poverty line (for an individual, this would mean earning less than about $11,000). In 2000, the last time the survey was conducted, only 27 percent of abortion patients were beneath the poverty line — suggesting that abortion services are becoming more concentrated among poorer women.

The same report found that 85 percent of abortion patients are unmarried (though 29 percent were cohabiting with their partner). About 60 percent of women receiving abortions already have one child — that includes 34 percent who already had two or more children.

A first-trimester abortion costs about $500. Most women pay that out-of-pocket.

The average first-trimester abortion cost $470 in 2009, the most recent year for which data is available. Most patients pay for their abortions out-of-pocket, although some use Medicaid or private insurance coverage.

abortion payment

Another 20 percent use Medicaid, a federal-state program that provides health coverage to low-income Americans (32 states and the District of Columbia cover abortion procedures; the rest do not). States have a choice of whether to include abortion as a covered benefit, and if they do, a federal law known as the Hyde Amendment requires they do so with state, rather than federal, funds.

Twelve percent of abortion patients use private insurance coverage to pay for their procedure. This number could drop, as many states have recently passed laws restricting insurance coverage of abortion. Thirteen percent of abortion patients use some type of financial assistance, typically a privately run fund dedicated to helping women who can't afford the procedure.

Abortion clinics are closing, and the number of providers is rapidly declining

In the late 1970s, nearly 3,000 doctors performed abortions. But that number has shrunk significantly, hitting 1,720 doctors performing at least one abortion in 2011. That's a small sliver of the 834,000 licensed doctors in the United States.

The number of abortion providers in the United States decreased by 38 percent between 1982 and 2005, according to the Guttmacher Institute.

Abortion_providers1_medium

(The Guttmacher Institute)

As to why the numbers declined, a number of factors are likely at play. Especially notable are the increases in state-level restrictions and a wave of violence against abortion providers in the 1990s, when five were killed. Being an abortion provider often isn't like being another type of doctor; it requires more risk and concern for safety. Some wear bulletproof vests to work after experiencing direct threats of violence.

"I'm mindful of my circumstances," says Willie Parker, a physician who runs Mississippi's only abortion clinic. "I lock my car. I have contact with law enforcement, in terms of reaching out if I need to. I don't carry a gun, but I'm prepared to defend myself."

Clinics close in the face of new regulation

Abortion Texas maps full width

As the number of abortion providers has declined, so has the number of abortion clinics. There are now four states — Mississippi, North Dakota, South Dakota, and Wyoming — that have only a single facility licensed to perform abortions.

This means that, increasingly, it is harder for women to terminate pregnancies. Just over one-third of American women of reproductive age now live in counties that do not have abortion clinics. One study from the Guttmacher Institute found that, on average, American women travel 30 miles to access abortion services. Seventeen percent of women traveled more than 50 miles to terminate a pregnancy. Abortion services tend to be more accessible in the Northeast and the West and less accessible in the South and the Midwest. In some areas of North Dakota and South Dakota, women live more than 350 miles from an abortion clinic.

State laws have increasingly passed laws that regulate abortion clinics more aggressively, like requiring doctors to have admitting privileges at a local hospital, for example, or adopting stricter building requirements. And in some places, you see this resulting in many clinic closures. After Texas passed these types of regulations, for example the number of clinics dropped from 43 in August 2013 to eight in October 2014.

Roe v. Wade guarantees a legal right to abortion

Roe v Wade telegram

The telegram notifying attorney Sarah Weddington that the Supreme Court had ruled in favor of legal abortion. Read more here.

Roe v. Wade, the landmark 1973 Supreme Court decision, declared a legal right to some, but not all, abortions. At the time of the Roe decision, abortion was illegal in most states except for cases where the woman's life would be endangered by carrying the pregnancy to term.

In the Roe decision, the Supreme Court found that a constitutional right to privacy protected a woman's decision to terminate a pregnancy. The court also ruled that that right must be weighed against two legitimate interests of states: protecting prenatal life and women's health.

To balance those two factors, Roe set forth a viability standard, which tethered states' abortion-regulation rights to the gestational point in a woman's pregnancy. According to Roe, states cannot bar abortions before a fetus is able to live outside the womb (usually thought to be between 24 and 28 weeks after conception). But Roe gives states the authority to ban abortions after this viability point, so long as such restrictions include exceptions for the health or life of the mother.

Roe did not offer legal protection to all instances of abortion. Instead, it gave states the authority to ban abortions after a fetus is viable (usually thought to be around 25 or 26 weeks) if they include an exception for procedures that preserve the life or health of the woman. Forty-one states now ban abortion after a certain point in pregnancy.

And in further decisions, the Supreme Court has specifically ruled in favor of restrictions earlier in the pregnancy, too. Those are now subject to an "undue burden" standard: namely, that these types of laws cannot place an "undue burden" on the patient. In the mid-1990s, the Supreme Court defined this type of burden as a "substantial obstacle in the path of a woman seeking an abortion before the fetus attains viability."

Still, many abortion lawsuits now center on the question of what counts as an "undue burden." In one landmark 1996 case, Planned Parenthood v. Casey, the Supreme Court ruled that a spousal notification requirement — where a woman wanting to have an abortion would have to give prior notice to her husband — violated the undue burden standard. Other restrictions, like a 24-hour waiting period and parental consent for minors, were not found to violate the standard — and now exist in many other states.

States passed 231 abortion restrictions between 2011 and 2014

abortion restrictions

(Guttmacher Institute)

Over the past five years — particularly 2011 and 2012 — there has been a massive spike in state abortion regulations. States passed 231 restrictions between 2011 and 2014 — more than the prior three decades combined. In that same time, only one state has expanded access to abortion: California passed a law in 2013 that allows more medical professionals, like nurse practitioners, to perform abortions.

20-week bans, targeted regulations of clinic have spread across the country

20 week ban

(Think Progress)

Abortion restrictions often come in waves; one state will pass a new type of law and then others follow. Nebraska, for example, passed the first 20-week abortion in 2010. Eight more states have since gone on to pass similar legislation. Another case: between 2011 and 2014, the number of states requiring abortion providers to have admitting privileges at a local hospital jumped from two to 11.

The wave of new abortion restrictions tend to cluster around specific approaches to regulation. About half of those enacted since 2011 fall into four categories: bans on abortion at 20 weeks, limitations on insurance coverage of abortion, limitations on medical abortions, and targeted regulations of abortion providers (like the admitting privilege laws).

There are two factors that likely contribute to the rise in abortion restrictions. The national debate over health care reform catalyzed a separate battle over whether health insurance plans should cover abortions as part of their benefits package.

A few months after Obamacare passed, Republicans took control of more state legislatures, giving them an easier path to passing bills that restricted abortion access. By the end of 2010, abortion had become a prominent political issue — and Republicans had more political clout to take action.

Abortion restrictions appear to lead to fewer abortions, though the evidence is mixed

A 1995 study of states that didn't cover abortions in their Medicaid programs found that those places had lower abortion rates, suggesting that the restriction did limit the termination of pregnancies. Another study, published in 1996, found that parental notification laws — which require minors to get a parent's consent prior to obtaining an abortion — reduced minors' demand for abortion by 13 percent to 24 percent.

Abortion restrictions may have an effect on when women terminate pregnancies, too. A paper in the Journal of Health Economics found that parental notification laws and waiting periods are associated with an increase in the proportion of abortions that occur after the first trimester.

But one 2011 study in the Lancet showed, somewhat counterintuitively, that countries with fewer abortion restrictions tend to have a lower rate of abortion than those with more restrictions. The authors of this paper suggest that the lower abortion rate in less restrictive countries may have to do with more frequent contraceptive use among women.

Abortion_by_country_medium

(New England Journal of Medicine)

Obamacare does not fund abortions

One of the last sticking points to get resolved in the national health reform debate was whether the plans offered on the exchanges would pay for abortions. In response, President Obama issued an executive order that prohibits tax subsidies from paying for abortions, except in cases of rape and incest. Instead, insurers would need to use the part of the premium paid by individuals to cover pregnancy terminations.

Enough anti-abortion legislators were won over by this executive order to pass Obamacare. Many pro-life groups, however, still contend there isn't a strict enough firewall between tax subsidies insurers receive and the abortion claims they pay out.

Since Obamacare passed, many states have taken steps to restrict insurers' ability to cover abortion in their health plans. Twenty-three states restrict or ban abortion coverage on the health insurance exchanges; eight states have laws that restrict abortion coverage for all private plans.

Abortion often gets framed as a divisive issue; Americans either support a woman's legal right to terminate a pregnancy, or they don't. And it is true, when you ask Americans to identify as "pro-life" or "pro-choice" — as Gallup does in its regular polling — there is a stark divide.

pro life pro choice

(Gallup)

But its not totally clear whether this is the right way to ask the question — and whether it captures the nuance to how Americans think about a difficult and personal policy issue.

In a recent Vox poll, we found that 21 percent of Americans identify as "both" pro-choice and pro-life if given the option of that response. Another 18 percent identify as neither. This means that about four in ten Americans don't subscribe exclusively to either of the labels we think of as defining the abortion issue. You can read more about the Vox poll, and how Americans think about abortion, here.

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