Health and Economic Effects of Reduced Access to Abortion (UPDATED)

The Issue:

The Supreme Court’s June 24 decision overturning Roe v. Wade means that states now have the power to prohibit all or almost all abortions. Prior to the ruling, many states had already reduced abortion access through a number of provisions, such as by setting physician and hospital requirements, limiting the use of public funds, and setting limits related to gestational age, among others. These restrictions have enabled economists to study the broad effects of reductions in access to abortion. This emerging research can help us understand the potential impacts of reduced access to abortion on fertility, economic outcomes, and healthcare that could follow the Supreme Court’s decision to overturn Roe v. Wade.

The decision to overturn Roe v. Wade could contribute to lower preventive care for women and impose financial costs on households.

The Facts:

• With Roe v. Wade overturned, the power to make laws about abortion goes back to the states. The 1973 Roe v. Wade and 1992 Planned Parenthood v. Casey Supreme Court decisions established a national constitutional right to abortion access in particular circumstances. Prior to 1973, most U.S. states banned abortions (see here). Roe v. Wade made these bans unconstitutional. Reversing Roe means that state bans on abortion are no longer unconstitutional. Thus, individual states have the legal jurisdiction to limit the right to abortion. 
• In 2011, 45% of pregnancies in the United States were unintended, meaning that they were either unwanted (27% of pregnancies) or the pregnancy occurred earlier than desired (18% of pregnancies). Over half of these unintended pregnancies are carried to term, while 42% of them ended in abortion. Although the United States saw a decline in unintended pregnancies between 2008 and 2011, the rate of unintended pregnancies in the United States was substantially higher than in Western Europe (see here). Abortion rates for women 15 to 44 also declined between 2008 and 2014 (see here). Still, if the 2014 age-specific abortion rates prevail, it is expected that 24% of women aged 15 to 44 will have had an abortion by age 45. 
• Rates of unintended pregnancy are much higher for those of lower socioeconomic status. Women living in households with incomes below the federal poverty level were five times as likely to have an unintended pregnancy than women with household incomes above 200% of the federal poverty level. Rates of unintended pregnancy were also higher for less educated and minority women (see here). 
• But women who have abortions come from a wide variety of backgrounds. Women who have abortions range in ages — the same share are under 20 as over age 34 (12%); about 45% are married or cohabiting; 25% have incomes above 200% of the federal poverty level; and many report a religious affiliation (see here). 
• Clinic closures do lower abortion rates. In the early 2010s, Texas enacted legislation that increased restrictions on abortion clinic operations and shuttered nearly half of the state's abortion clinics. One study showed that an increase in the travel distance to the nearest women’s health clinic from between 0-50 miles to between 50-100 miles reduced abortion rates by 16% and another study showed that abortions fell 17% when a county no longer had an abortion clinic within 50 miles. A similar relationship between greater distances and lower abortion rates was also found in Wisconsin. When legislation regulating abortion providers was enacted in 2011-2013, this ultimately led to the closure of two of five abortion clinics in the state. Researchers determined that the closures increased the average distance to the nearest clinic to 55 miles and distance in some counties to over 100 miles. They found that a 100-mile increase to the nearest clinic reduced abortion rates by 31%. 
• Clinic closures also increase birth rates. In Texas, a 100-mile increase to the nearest women’s health clinic increased the overall fertility rate by 1.2% and increased the fertility rate of unmarried women by 2.4% (see here). In Wisconsin, a 100-mile increase to the nearest abortion clinic increased overall births by 3.2%. 
• Individuals do not increase their retail purchases of condoms and emergency contraception when abortion and family planning clinics close. It is possible that as access to abortion providers becomes more restricted or costly, people adjust their behavior by engaging in more cautious behavior, such as making greater use of condoms or emergency contraceptives. However, this did not appear to be the case in Texas where, in addition to enacting legislation that restricted access to abortion, legislators also reduced funding to family planning clinics. Researchers found no significant change in the purchase of over the counter condoms or emergency contraception as a result of the legislative changes (see here).
• Being unable to get a wanted abortion has negative consequences for a household’s finances. Many clinics have different gestational age cutoffs for an abortion, due to state and local regulations and their particular capabilities and specializations. By looking at women who just made a cutoff compared to otherwise similar women who just missed a cutoff, researchers could compare the effect of being able to have an abortion on other life outcomes. Women who just missed the cutoff have 78% more debt that is 30 days or more past due and have 81% more negative public records inquires (e.g. from bankruptcies and evictions) compared to those women who were able to get an abortion because they made the cutoff (see here). 
• Reduced access to women’s health clinics also reduces preventive care rates. Many women of reproductive age receive preventive healthcare screenings at women’s health clinics. In Texas and Wisconsin, an increase of 100 miles to the nearest women’s health clinic resulted in an 11% decrease in the annual utilization of a clinical breast exam, an 18% decrease in mammograms, and a 14% reduction in Pap tests (see here). These effects are larger for women of lower educational attainment and for Hispanic women in Texas.
• Abortion access will decrease enormously — but disparately by location. Nineteen states had laws in place that prohibit abortion in the absence of Roe v. Wade, including 13 states that  passed preemptive trigger laws, which express legislative intent to ban abortions as soon as it is constitutional to do so. Indeed, within hours of the ruling abortions were banned in seven states (Missouri, Louisiana, Kentucky, South Dakota, Alabama, Arkansas and Utah) with bans in other state expected within weeks. A 2019 study which estimated changes in abortion access in a post-Roe scenario estimated that losing all of the clinics in the 21 states that were most likely to enforce bans if Roe v. Wade were outlawed would mean women in those states would see an average of a 249-mile increase to the nearest clinic and abortion rates would fall by 33%. The authors estimated that such a change would prevent between 93,000 –143,000 women from accessing abortion care. Importantly, states with legislative intent to ban abortion are concentrated in certain parts of the country: the South, the Midwest, and parts of the West.