Lessons learned: Illinois providers’ perspectives on implementation of Medicaid coverage for abortion

Objective: On January 1, 2018, Illinois became the first Midwestern state to cover abortion care for Medicaid enrollees. This study describes state implementation of the policy, the impact on abortion providers, and lessons learned.

Study design: We documented abortion providers’ perspectives on the service delivery consequences of Medicaid coverage for abortion in Illinois. We conducted in-depth interviews with clinicians and administrators (N=23) from 15 Illinois clinics, including clinics that provided other services and those primarily providing abortion. We conducted interviews in person or by phone between April and October 2019. They lasted ≤100 minutes, were audio-recorded, transcribed, and coded in Dedoose. We developed code summaries to identify salient themes across interviews.

Results: All participants supported the law and expected benefits to patients. Many struggled to implement the policy because of difficulties obtaining certification to bill the state Medicaid program, confusing and cumbersome paperwork requirements, reimbursement delays, confusing claim denials, and uncertain protocols for Medicaid patients covered under the exceptions defined by the Hyde Amendment. Nearly all participants expressed concern that low reimbursement rates were insufficient to cover costs. Implementation was easier for multiservice clinics and those nested in larger institutions. Several clinics closed during implementation; one clinic opened. Clinics leveraged internal resources, external funding, and technical assistance to ensure that Medicaid enrollees could receive care without costs.

Conclusions: Implementing Medicaid coverage for abortion requires proactive and responsive state institutions, improvements to reimbursement processes, and adequate reimbursement rates. In Illinois, successful implementation depended on clinic adaptability, external support, and advocacy.

Implications: Our research suggests that successful, sustainable implementation of Medicaid coverage for abortion depends on state policies that allow clinics to enroll patients, process claims in 30-90 days, and receive reimbursements covering the cost of care. Without these measures, ensuring immediate patient access may depend upon clinics mobilizing resources and external transitional support.