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Table 2 Illustrative quotes by themes

From: Provider and community stakeholder perspectives of expanding Medicaid coverage of abortion in Illinois

Themes

Illustrative quotes

Positive impacts of HB-40 on abortion access

Reduced financial stress

"I can say that a patient that–and before the passage of the bill, would’ve had to find multiple resources, if any, to come up with some portion of the fee. And then, they would’ve had to kind of work with other funding agencies to see if they qualify, based upon the funding agencies requirements or qualifications, to see if they can get any financial assistance. And if they made it through all those hoops, they would get the services. But if not, they would not be able to seek abortion care."(SH, abortion provision)

“The vast majority of people are just incredibly grateful that they […] are able to access [abortion] services without a significant amount of difficulty in terms of the cost.” (YV, abortion provision)

"No out-of-pocket, no having to coordinate care with anything. You just have to have your active Medicaid, and the patients can just have their abortion paid for by their Medicaid, which is the right way to do it. But previously they could get some funding, but they generally – unless their situation was very extreme – had to come up with some on their own. And they had to figure it out, usually in advance, and do a little extra legwork, et cetera, and now it’s better" (ED, abortion provision)

“It's more like an indirect benefit because […] we'll be able to give a fund to somebody who's undocumented if they didn't have to also give that fund to somebody who could use Medicaid […] so I think there's […] now more resources for people who have less access.” (LV, policy involvement)

R: So we started definitely funding a lot more out-of-state folks. Yeah. But they had always been calling. And also, with the increased barriers in surrounding states – I don’t want to leave that out. You know Indiana is a mess, so the surrounding states have really – they’re stricter so –

I: Right. So it wasn’t like there were more calls, it was just like you could –

R: Yeah, I want to say it was like – yeah, because you couldn’t come and use your Medicaid here. You couldn’t use your form of insurance, your Medicaid insurance in Illinois, so they weren’t coming because of HB 40, it’s just it changed the dynamics in how we funded (NH, resource provision) R: So we started definitely funding a lot more out-of-state folks. Yeah. But they had always been calling. And also, with the increased barriers in surrounding states – I don’t want to leave that out. You know Indiana is a mess, so the surrounding states have really – they’re stricter so –

I: Right. So it wasn’t like there were more calls, it was just like you could –

R: Yeah, I want to say it was like – yeah, because you couldn’t come and use your Medicaid here. You couldn’t use your form of insurance, your Medicaid insurance in Illinois, so they weren’t coming because of HB 40, it’s just it changed the dynamics in how we funded (NH, resource provision) R: So we started definitely funding a lot more out-of-state folks. Yeah. But they had always been calling. And also, with the increased barriers in surrounding states – I don’t want to leave that out. You know Indiana is a mess, so the surrounding states have really – they’re stricter so –

I: Right. So it wasn’t like there were more calls, it was just like you could –

R: Yeah, I want to say it was like – yeah, because you couldn’t come and use your Medicaid here. You couldn’t use your form of insurance, your Medicaid insurance in Illinois, so they weren’t coming because of HB 40, it’s just it changed the dynamics in how we funded (NH, resource provision) R: So we started definitely funding a lot more out-of-state folks. Yeah. But they had always been calling. And also, with the increased barriers in surrounding states – I don’t want to leave that out. You know Indiana is a mess, so the surrounding states have really – they’re stricter so –

I: Right. So it wasn’t like there were more calls, it was just like you could –

R: Yeah, I want to say it was like – yeah, because you couldn’t come and use your Medicaid here. You couldn’t use your form of insurance, your Medicaid insurance in Illinois, so they weren’t coming because of HB 40, it’s just it changed the dynamics in how we funded (NH, resource provision)

“In the beginning for the first three or four months women would show up because they’d already been scheduled before HB-40 and so they would have their money ready to pay. And we got to tell them that we didn’t need that money. That it was now gonna be covered by their insurance. And so we definitely had people crying and saying how happy they were. And how now they could pay their rent or buy food for their kids.” (OZ, abortion provision)

“I think the perception, say, from the public – the public’s perception and from lots of people is that everything’s just great. And from the patients’ perspective, as well, which that is great that patients feel like it’s fixed and they can come get their abortion and they don’t have to worry about taking money away from the other necessities of life.” (YV, abortion provision)

TF: Yeah. And people are shocked when they call, email, come in. They’re like, wait, how much do I have to pay? I’m like, no, nothing. They’re like, wait a minute, how much?

MD: Yeah. It’s like, no, no, no, your copay is zero. Wait, what? We’re –

TF: They’re literally sitting and like –

[...]

TF: Oh, my god, it’s how it should be.

MD: I mean, people cry about that. I mean, they get very –

TF: Oh, my – they’re like, thank you, so much. (MD and TF, abortion provision)

TF: Yeah. And people are shocked when they call, email, come in. They’re like, wait, how much do I have to pay? I’m like, no, nothing. They’re like, wait a minute, how much?

MD: Yeah. It’s like, no, no, no, your copay is zero. Wait, what? We’re –

TF: They’re literally sitting and like –

[...]

TF: Oh, my god, it’s how it should be.

MD: I mean, people cry about that. I mean, they get very –

TF: Oh, my – they’re like, thank you, so much. (MD and TF, abortion provision)

TF: Yeah. And people are shocked when they call, email, come in. They’re like, wait, how much do I have to pay? I’m like, no, nothing. They’re like, wait a minute, how much?

MD: Yeah. It’s like, no, no, no, your copay is zero. Wait, what? We’re –

TF: They’re literally sitting and like –

[...]

TF: Oh, my god, it’s how it should be.

MD: I mean, people cry about that. I mean, they get very –

TF: Oh, my – they’re like, thank you, so much. (MD and TF, abortion provision)

TF: Yeah. And people are shocked when they call, email, come in. They’re like, wait, how much do I have to pay? I’m like, no, nothing. They’re like, wait a minute, how much?

MD: Yeah. It’s like, no, no, no, your copay is zero. Wait, what? We’re –

TF: They’re literally sitting and like –

[...]

TF: Oh, my god, it’s how it should be.

MD: I mean, people cry about that. I mean, they get very –

TF: Oh, my – they’re like, thank you, so much. (MD and TF, abortion provision)

I think it's great that Medicaid is treating abortion like other services that are part of the spectrum of reproductive health care [...] Knowing that pregnancies that are unplanned can be very harmful to a woman's course of life in what she wants to be doing. And particularly, for low-income women, that can be something that could be financially devastating. And especially if they're not ready to have a child or have another child or for whatever reason." (FK, abortion provision)

" I was happy, because it will help a lot of people. [...] It would make it less stressful on the patient, less stressful on the physician, and less stressful on the facility because we know we can provide good care for them. They’re getting what they need, so they’re gonna leave happy." (KK, abortion provision)

Patient-driven care (choice of abortion method)

I'm sure over time you'll see people who are getting abortions earlier, they just don't have to delay it as long in order to get them." (HW, policy involvement)

But we are definitely seeing patients – we are seeing a huge increase in the medical abortions. I think part of that is because we’re seeing patients at much earlier gestational ages. And I don’t have the exact numbers on the gestational ages, but I could get you numbers on the percent changes in medical versus surgical abortions. But we’re seeing patients earlier. [...] “I think it’s because of Medicaid. They’re not waiting to get money […] they find out they’re pregnant and they go get the abortion, rather than, ‘I didn’t get my abortion yet because I’m saving money or waiting for a paycheck’, or whatever. It’s like, oh, ‘I wanna have my abortion, I’m gonna go have it now, it’s free’.” (TF, abortion provision)

I know that [clinic name] has felt that they’ve seen earlier patients, because they could have it done earlier. I don’t know if we’ve seen the same thing. (ED, abortion provision)

I think the other effect that we saw that we were really excited about – again, because it ties back to why we wanted to pass HB 40 – is that we saw a surge in women coming in earlier in the pregnancy, [...]. And I think that’s just proof well, how financial hardships were preventing women from seeking care early on. (DK, abortion provision)

Patient-driven care (choice of facility)

"Well, I hope that patients have more access to abortion care in their home institutions and will not have to rely on any place like our county hospital which provided a noble service but it was kind of an assembly line and not very patient-centered." (CL, abortion provision)

“Now patients with Medicaid are going to have the choice of going to a really private clinic that they can spend the whole hour with just the doctor, or they can have the choice to go to one of the other clinics. But the point being that they have the choice to go and have the service be covered under their own insurance.” (BK, abortion provision)

“Now patients with Medicaid are going to have the choice of going to a really private clinic that they can spend the whole hour with just the doctor, or they can have the choice to go to one of the other clinics. But the point being that they have the choice to go and have the service be covered under their own insurance.” (BK, abortion provision)

“Now patients with Medicaid are going to have the choice of going to a really private clinic that they can spend the whole hour with just the doctor, or they can have the choice to go to one of the other clinics. But the point being that they have the choice to go and have the service be covered under their own insurance.” (BK, abortion provision)

“HB 40 has allowed us to provide elective abortion services for people within our system that we hadn’t been able to serve in the past. We have, for example, our resident clinic that sees predominantly Medicaid patients, and a lot of those patients in the past wanted elective terminations and we couldn’t do them, and now all those patients we’re getting in and we take care of them ourselves.” (SP, abortion provision)

Before House Bill 4, for patients that were self-pay they didn’t have the option of going to the operating room [and getting sedated] for their procedure because the out-of-pocket cost was exponentially higher. But for patients who had Medicaid coverage after HB 40, those patients did have the option of having their procedure in the operating room. (AD, abortion provision)

Patient-focused care

Yeah. So that’s actually – I would say in providing – other than the satisfaction which is the top thing – the next best thing – and it’s a good thing – is that I’m more likely now to refer someone for hospital-based care […]: So either in an operating room, or at [names of facilities], where they have a clinic that’s based in the hospital. So if someone coded, or someone couldn’t breathe, you could make a call, and within three minutes have a team of anesthesiologists there, as opposed to at [facility not based at hospital] where we’d have to call 911 (ED, abortion provision)

“It is completely changing the way that we provide abortions. It’s treating it as just a medical service. It’s not [a] herd of patients showing up at one time [for counseling] [...] So I think in a lot of ways, it’s a very patient-focused style of medicine, and most patients on Medicaid otherwise would not be able to have that service. (BK, abortion provision)

I mean, the biggest part – the most exciting thing about HB40 was that we could finally see our own patients. We didn’t have to send them off for abortion like it was some dirty thing that we don’t do here at [facility] because we do do it. And this clinic right where we are, where I’m sitting, is the resident clinic, so it’s majority Medicaid patients [...] and we don’t have to turn them away and they get the continuity of care and everything. (GM, abortion provision)

I would hope that we were doing everything that we could to engage them in ongoing care to get them connected with family planning methods that they would be interested in to prevent subsequent unplanned pregnancies. Or just get them in a primary care. (FK, abortion provision)

"Now that we take all these Medicaids, we're able to fill those vacancies quicker. So, like say if three people cancel, we're able to find three people who are in need, and we already know that we take their Medicaid. So, I would say because of that and having access to all these Medicaids, our clinic has been able to be a lot more full, a lot more productive, a lot more efficient. So, I would say that's definitely been a plus in that. (BG, abortion provision)

Removal of discriminatory insurance policy

“I think that by allowing for Medicaid reimbursement for abortion services, it allows individuals who earn low incomes to have the same access to life-saving services that someone with private insurance would have.” (RA, policy involvement)

“So, I think it's great that Medicaid is treating abortion like other services that are part of the spectrum of reproductive health care, and not singling it out […] I see this […] coverage as equalizing the program even more.” (FK, abortion provision)

I think the idea that Illinois would expand its state Medicaid coverage to include abortion care is really important from an equity lens so, that a wide array of people can have access to abortion care regardless of their income. (JN, resource provision)

Decreased abortion stigma

I think that the passage of HB40 definitely- definitely moves the needle on the stigma around abortion care, around the rules of who can access abortion and who can't. I think it, it was a huge win, a huge win. (RA, policy involvement)

No, I think for patients specifically with Medicaid, it definitely – the stigma has reduced, right? Because just knowing that your procedure is covered by your insurance and it’s recognized as part of normal reproductive healthcare that you can go to your reproductive healthcare provider. (GM, abortion provision)

"I just think it helps with de-stigmatizing it. It's weird that every other reproductive health service is covered under Medicaid and not abortion, you know? Like that sends a really big message right away as to whether or not somebody is allowed to get one, whether its safe, whether - you know? And so I think there's just a lot there as well. (HW, policy implementation)

“I do see it as a victory because it’s so rare that there’s good public discussion on how abortion should be part of regular medicine. (VS, abortion provision)

Gaps in patient access to abortion

Uninsured populations and populations ineligible for Medicaid

“I think with HB40 it would be really nice if it wasn’t just limited to people on Medicaid. I think it should be anyone who has any insurance or anyone who doesn’t have any insurance, because we know that there’s so many people that are uninsured so that means they’re not on Medicaid or anything.” (RD, resource provision)

I think documented immigrants, immigrant folks who have access to Medicaid, for sure, they have benefits from it but folks who are undocumented and then also with the new public charge rules, there are a lot of people who are just afraid of what they're allowed to have and are just not enrolling in any support services. So that's the fear - it's like, even if it was covered, I think people wouldn't be keeping it under the shelf like potential public charge later on. (LV, policy implementation)

“Even if we have Medicaid-funded abortion services, many in our community don’t qualify for Medicaid because of the five-year bar. [...] So even if we repealed Hyde and Hyde was never a thing anymore or not a thing anymore, there’s a significant number of Asian Americans and other immigrants who still would not have affordable access to abortion care because they do not qualify for Medicaid because of the five-year ban.” (HH, policy involvement)

I mean, always folks that should be eligible but aren’t for Medicaid, mostly undocumented folks, but I think there’s still people that fall through the cracks. So how do you deal with that? And then also like it’s great and this helps a huge number of people, but you look – somebody that’s just over this income limit still doesn’t have that kind of money to cover procedures like that. So I think looking forward to how you get the rest of the folks that are struggling for access still. So a huge step in the right direction, but I think there are still things within the system to improve and then what about the people that fall through the cracks of that system. (FR, policy involvement)

Minors

“If you are a young person who is now pregnant, who does not have Medicaid […] you can’t go and just get it on your own and use that to pay for an abortion. Your family needs to do the application for you and with you. And if you don’t want your parents to know that you’re pregnant, you can’t do that.” (HR, policy implementation)

Rural Populations

“And so I know that the experience that women who live in this region have in accessing services is much different than somebody in Central or Southern Illinois, where transportation might be a bigger barrier or just finding a willing provider that is within a reasonable distance of where you can get to […] Having a service covered doesn't mean automatically mean access.” (FK, abortion provision)

But we know in a kind of more general sense that there’s lack of providers and there’s a lack of providers that go all the way to 23.3 weeks in Illinois, outside of Chicago (RD, resource provision)

"What does it mean, for people, for example, who are living in rural Illinois in the area that used to be served by the [clinic] that's now closed down? Partially as a result of-of reimbursement rates being very low and not being able to, kind of, stem the tide, you know? So in the short term [...] they've lost access, essentially. Whether or not that actually is gonna be a long-term impact now that rates are better and the reimbursement processes are better, I don't know." (HW, policy involvement)

"What does it mean, for people, for example, who are living in rural Illinois in the area that used to be served by the [clinic] that's now closed down? Partially as a result of-of reimbursement rates being very low and not being able to, kind of, stem the tide, you know? So in the short term [...] they've lost access, essentially. Whether or not that actually is gonna be a long-term impact now that rates are better and the reimbursement processes are better, I don't know." (HW, policy involvement)

Factors diminishing the impact of HB-40 on individuals seeking abortion care

Lack of public knowledge about the law

"Also think probably that’s partially related to the information not being totally disseminated in the whole system, so – in the whole county really, and everyone knowing that for a long time it was 75 bucks at [facility name] and we haven’t gone – we don’t do any publicity or anything. So no one knows, unless you call and ask specifically that it’s changed, most people come probably expecting that it’s $75, and then are sort of pleasantly surprised that it’s not." (AM, abortion provision)

“I feel like now it's just like the fact that so many people still don't know […] even if people like are told that their Medicaid was covered [...] they wouldn't believe that [...] because abortion is still stigmatized and politicized that they would expect for it to not be covered [...] It doesn't seem like there are like a lot of resources or like energy behind uh, like spreading awareness rather. Like it's something that [organization name] is trying to do but um, outside of that, it's not like a priority of like the government, you know.” (CJ, resource provision)

" I think there could be many, many, many more people who could benefit from it if there was more education around it (LV, policy implementation)

"So again – and then it passed, and then even around implementation and like community education – there’s been no community education done about it. People don’t know about it at all, and all of this talk about implementation has been very insider, like policymakers and insurance experts and Medicaid experts sitting around talking rather than like actually involving community – again, like actually involving people that are impacted by it." (HH, policy implementation)

  […] people would call the help line who have Medicaid and they're like asking funding and then we tell them if they can just- they go to a different clinic, they can use their Medicaid. But like clinics weren't giving that information to people because they wanted that business essentially.  And that was frustrating because, I understand the business, but like our priority is people. Like care and it seemed dishonest and like frankly messed up to like not tell somebody that they could get coverage if they went somewhere else. So-- and that was difficult for us to navigate as funders as well cause we want to maintain relationships with the clinics. (CJ, resource provision)

“Are there ways to reach out to other providers, like primary care, other OB-GYNs to let them know? Because they don’t even know, in a lot of cases. So it may be that that’s what comes next.” (FR, policy involvement)

Insurance-related logistical hurdles

“So there are pregnant women who come in for prenatal care and they’re not enrolled in Medicaid, there’s a presumptive eligibility clause that says okay we’re going to presume you’re going to be paid for this service to provide you early prenatal care, because it might take you a couple of months to get on Medicaid. So they know they will retroactively be paid, so they’re more likely to provide the service [...] if you come in [seeking abortion] and you’re in an early pregnancy stage and you don’t have the money to pay for [the abortion] we say “Well, you have to enroll in Medicaid. Come back in three months after you’re enrolled.” Yeah. I mean so that is ridiculous, right? So it reduces–it increases the risk for the mom. […] It’s just – it’s not okay.” [WW, policy implementation)

After HB 40, there was some patients we kind of had to sort out insurance information with. So for instance – there were patients that came that thought that they had Medicaid and when we looked them up in the system it was no longer active. There were patients who didn’t think they had Medicaid and it turns out that they did. So there was that component of trying to figure out what their status was – became incorporated into the clinic flow. (AD, abortion provision)

“The issue of what is often called, in the public benefits field, ‘churning’ is a whole separate issue that affects a lot of low-income people. Which is this concept that we make applying for and remaining on public benefits programs way too complicated, so people are constantly churning on and off these. They’re eligible, then they’re not eligible, then they have to reapply. And so, people are constantly losing eligibility. And that applies in TANF, SNAP, Medicaid, all sorts of public benefit programs.” (HR, policy implementation)

"But the bottom line of HB-40-it was a major legislative victory but behind the scenes has really not provided the reimbursement necessary for clinics to actually stay open if they start immediately taking Medicaid." (YV, abortion provision)