Federal health officials are not enforcing requirements for Medicaid coverage of abortion in the limited circumstances where it is legal, congressional investigators have found.
At least 13 states are flouting a requirement to cover abortion-inducing pills, and one state, South Dakota, has for 25 years failed to provide the required coverage for abortion in cases of rape or incest, the Government Accountability Office, a nonpartisan investigative arm of Congress, said in a report made public this month.
The report underlines the wide range of restrictions that states impose on abortion access and Medicaid coverage of it.
Trump administration officials, like many of their predecessors, “have not taken any actions to address states’ noncompliance,” the report said.
The federal law known as the Hyde Amendment generally prohibits federal funding for abortions. But state Medicaid programs are required to cover an abortion if the pregnancy is a result of rape or incest, or if the life of the pregnant woman would be endangered without an abortion.
States are also supposed to cover the pill that induces abortion, Mifeprex, when an abortion is available under Medicaid. But in a survey by the Government Accountability Office, 13 states said they do not cover the drug.
“Without such coverage,” the report said, “Medicaid beneficiaries seeking abortions in these states would have to find another way to pay for the drug or undergo a surgical abortion instead.”
Federal officials at the Centers for Medicare and Medicaid Services “were not aware that these states did not cover Mifeprex, and thus the agency had not sought to address states’ noncompliance,” the report said.
The drug, also known as RU-486, is approved for use through the first 10 weeks of pregnancy and is usually taken in combination with another medicine.
The number of abortions in the United States has declined in the last 30 years, the report said, but medication abortions, which involve the use of prescription drugs rather than a surgical procedure, have increased and may now account for one-third of abortions.
Representative Diana DeGette, Democrat of Colorado, who requested the investigation, expressed dismay at the findings.
“States are supposed to be covering a limited number of abortions under Medicaid, but are not even doing that,” Ms. DeGette said. “A poor woman who has been raped or raped by a relative or whose life might be endangered by carrying a pregnancy cannot afford to go to another state to get these services. That’s why we have Medicaid covering services like this.”
South Dakota told the Government Accountability Office that it does not cover abortions in cases of rape or incest. Federal health officials sent a letter to South Dakota in 1994 observing that its Medicaid coverage did not comply with federal law.
The federal Centers for Medicare and Medicaid Services is aware that South Dakota “does not cover abortions in cases of rape or incest, as required by federal law, but has not taken any action in 25 years to ensure the state’s compliance,” the report said.
“As a result,” it said, “Medicaid beneficiaries in South Dakota do not have Medicaid coverage for abortions in cases of rape or incest.”
The findings lead to a paradoxical conclusion: The Trump administration, which is firmly opposed to abortion, may now have to work with states to make sure they provide Medicaid coverage for the surgical procedure and for the abortion pill in certain circumstances.
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After seeing a draft of the report, the Trump administration said it would urge states to comply because they must operate their Medicaid programs “in accordance with federal laws and guidance.” Neither South Dakota nor the 13 states were in compliance with federal requirements, the administration said.
Representative Frank Pallone Jr., Democrat of New Jersey and the chairman of the Energy and Commerce Committee, which is responsible for Medicaid, said the administration’s response had been “woefully inadequate.” He asked the top federal Medicaid official, Seema Verma, to explain what steps she was taking to bring states into compliance.
Federal law does not explicitly require Medicaid coverage of the prescription drugs used to terminate a pregnancy. But states are generally required to cover the drugs of any companies that agree to give deep discounts to Medicaid through its drug rebate program, and the manufacturer of Mifeprex, Danco Laboratories, is among those companies. So states are supposed to cover the drug when it is used in abortions eligible for federal funding under the Hyde Amendment.
The report by the Government Accountability Office found that 28 states cover abortions only when the federal government will help pay for them. Other states use their own funds to provide broader coverage.
In 14 states, women must report rape or incest to the police or another government agency before Medicaid will cover an abortion to terminate the resulting pregnancy.
Federal officials do not know how many women are receiving abortions under the Medicaid program. Most Medicaid beneficiaries are in managed care plans, but states do not regularly collect information on how many abortions they receive. States are supposed to report abortions in the traditional fee-for-service Medicaid program, but the reports are often inaccurate, the Government Accountability Office said.
In its survey, the office identified nearly 5,000 abortions for which states claimed federal funds from 2013 to 2016 — nearly 10 times the number reported to Congress by the federal Medicaid agency. And even the higher number is incomplete, the report said, because some states were unable to provide any information on the number of Medicaid abortions.