On 27 January, I was just under six weeks pregnant. My fertility app – one of several pinned on my phone’s home screen, I am reluctant to admit – told me that the embryo growing inside me was the size of a green pea.
That morning, I felt both elated and nervous. Between Zoom calls and spurts of distracted writing, I thought about spilling the beans to my sister, but resisted. After two miscarriages, I was wary of sharing the news too early.
As noon approached, I started to feel some pangs in my abdomen. At first, I didn’t overthink it: every piece of reproductive literature out there will tell you that cramps, and even light bleeding, are normal during early pregnancy. They subside.
For me, they only got worse. The spotting became heavy bleeding, while mild cramps turned into agonizing stabs of pain on my right side.
“I think you need to come home,” I texted my husband, who was at work. This was not a normal miscarriage.
Mercifully, the nearest emergency department was only a 10-minute drive away. There, the nurse immediately suspected what an ultrasound later confirmed. The pregnancy had been ectopic, meaning it had implanted outside the uterus – in my case, near the opening of my right fallopian tube, which burst.
Because it ruptured so early, my surrounding organs would probably not be damaged. But the pregnancy, as with all ectopic pregnancies, was not viable. It would need to be surgically aborted, and fast, to stop internal bleeding and prevent infection, both of which can be life-threatening.
In simpler terms, I was going to have an abortion and it was going to save my life.
I live in California, where access to legal abortion is not in jeopardy, top-quality medical care is plentiful, and lawmakers understand that an ectopic pregnancy cannot be re-implanted into the uterus to develop into a healthy baby.
My ability to receive the abortion I needed was never in question. But I was not exempt from the fact that in the US, receiving abortion care – or any medical care – can be extremely expensive. At the end of it all, I was billed over $55,000, a number that felt unfathomable for someone who grew up in Canada, where under a publicly funded health system, an emergency abortion (or any abortion, for that matter) would yield no cost to an insured patient.
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As I was wheeled off to the OR, I was overwhelmed with relief that I did not live in one of the 13 states that have banned abortion since the US supreme court ruled to overturn Roe v Wade last June. But as the surgeon explained how they would make a tiny incision in my abdomen to remove my mangled tube and the embryo attached to it, I found myself imagining alternate realities – and was not comforted.
Aborting an ectopic pregnancy is necessary to protect the life of the mother. But in states with abortion bans across the country, exemption clauses that are supposed to reflect those complexities are failing to protect women who need care, often because wording is too vague to ensure that a doctor will not be prosecuted for doing their job.
In Michigan, a woman received a life-saving abortion for an ectopic pregnancy after she was denied one in her home state. Another woman in Tennessee was told that the only way she could legally terminate her rare cesarean scar ectopic pregnancy was with a hysterectomy, which would effectively sterilize her. Unable to travel out of state, she was forced to continue the pregnancy, putting her life in grave danger and risking severe complications for the baby. In California, I retained rights that had been stripped from those women, and that protected me from those unthinkable abuses.
However, my state did not shield me from other brutal features of American healthcare. I received the first bill about a week after the procedure. I was sitting on the couch, wearing the green sweatsuit I had lived in for seven days, with my abdomen still wrapped in gauze, when an email notified me that the surgeon’s charges had come through: $5,922. About 10 days after that, the hospital’s bill arrived, listing additional services adding up to $49,209.20.
I was shocked. I hadn’t even stayed the night, yet, after my private health insurance plan paid its part, I owed over $8,000 for a procedure without which I might have died.
And as it turns out, I’m not alone. One New York woman was charged $80,000 for services related to the termination of an ectopic pregnancy – again, in a state with liberal abortion laws.
Across the board, Americans spend more money per capita on healthcare ($12,318 a head in 2021, to be exact) than their peers in other developed nations, yet experience worse health outcomes. This can be attributed to several factors. For one, US healthcare is profit-motivated, with little stopping providers and pharmaceutical companies from gouging patients. But moreover, its model is made up of a series of disconnected and underregulated systems, leading to high administrative costs that are passed on to patients.
Of course, high costs aren’t exclusive to abortion care. At the hospital I visited, an emergency appendectomy would, in theory, cost the same as my surgery. But a gender bias is baked into the system, especially when it comes to reproductive care.
Studies have shown that women pay significantly more for healthcare than men between their 20s and 40s, largely due to reproductive care and even when they have adequate coverage. This is despite the fact that covering the costs of sexual and reproductive care is known to not only benefit patients’ health, but also save the overall system a good deal of money – as encouraging patients to seek early or preventive care typically reduces complications and lowers costs down the line.
And abortion bans are making it much worse: not only do they force many women to travel long distances for care, which is expensive, but the extra time required to get care also makes it more complex and, as a result, costlier.
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Even in non-emergency situations, abortions in the US are expensive. Typically, where abortion care is legal, it costs between several hundred and several thousand dollars. At a non-profit like Planned Parenthood, abortion costs range from $550-800. At a hospital or private clinic, price tags can be much higher.
“Cost for an abortion has always been a big hurdle for people who are trying to just get the care that they need,” said Dailienis Garcia, senior director of abortion access, funding and navigation for Planned Parenthood. She explained that even in states that are abortion-friendly, requirements pushed by actors hostile to abortion, like multiple in-person appointments or medically unnecessary ultrasounds, have historically driven up prices.
Among the remaining states with unrestricted access, just 16 cover abortion through state Medicaid programs, an enduring legacy of the 1976 Hyde Amendment that blocked the use of federal Medicaid funding for abortion coverage. As a result, many low-income patients have to pay out of pocket.
“The impact … is felt largely by Black, Latino and Indigenous people, immigrants, people living with low incomes and people in rural areas,” Garcia said. “Wealthy individuals will always be able to access abortions.”
That disparity in access extends to other aspects of reproductive care, too. For instance, although federal law requires insurance plans to cover contraception, patients pay high fees for birth control pills or IUD insertions. Fertility care –including fertility testing and assisted reproductive technology like IUI or IVF – is rarely covered by insurance plans and out-of-pocket charges in the US often reach into the tens of thousands of dollars. (In Europe, by way of contrast, most countries heavily subsidize fertility treatments.) In all of these realms, people with lower incomes face barriers to care that do not exist for the wealthy in America.
But reproductive care doesn’t need to – and shouldn’t – cost as much as it does. Across the border, in Canada, physician and hospital services cost a fraction of what they do here in the US.
For a straightforward abortion that takes place before 14 weeks of gestation, a physician in Ontario can bill C$112.40 (US$83). In California, prices start at $250 for patients insured by Medicaid.
Dr Alisha Olsthoorn, an OB-GYN at Toronto’s Mount Sinai hospital, said that she will typically bill C$307 (about US$225) for a laparoscopic salpingectomy – the same surgery that cost me $5,900 in Berkeley.
“If it’s the middle of the night, I’d bill more,” said Olsthoorn, explaining that she would add a 75% surcharge for an after-hours surgery.
At Scarborough Health Network, also in Toronto, hospital costs for an ectopic pregnancy needing a surgical abortion average C$5,608.00 and include an overnight stay (which was not among the amenities provided in my $49k hospital bill).
And even those costs are covered by the government – not the patient.
So why was it that at Sutter, my hospital charges were nearly 10 times that amount?
“They basically make it up,” said Karen Pollitz, senior fellow and co-director of the program on patient and consumer protections in health insurance for Kaiser Family Foundation, who added that “billed amounts are whatever the doc and the hospital feel like billing you”.
As a result, fees in the US can be not only arbitrary, but also grossly inflated, and rarely reflect the actual costs of services – even when certain hospitals are ostensibly non-profit.
Pollitz went on to say that while insurance groups are supposed to act as fiscal gatekeepers that keep tabs on how much a hospital charges subscribers, unfair billing practices often go unnoticed. Most often, patients must shoulder the burden of either paying or fighting for charges to be lowered – something that takes time and energy.
“When you have to deal with this is often when you’re least equipped to do so because you’re going through a scary health crisis … you’re sick or sad because you lost a pregnancy,” said Pollitz. “It’s just not nice to do to sick people.”
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Since 1 January 2021, hospitals across the country have had to comply with the federal government’s hospital price transparency rule, which requires they make their pricing for services offered publicly available. The rule has exposed just how widely costs for a single procedure can vary from place to place, insurer to insurer and patient to patient. The costs for an MRI at Mass General, for example, range from $877 to over $4,000, depending on a patient’s insurance plan.
After digesting the scale of the charges I had received from Sutter Health, a hospital behemoth that has been accused of inflating costs in the past, I began to dig. My hospital listed “All services for surgery related to an ectopic pregnancy” as ranging from $7,500 and nearly $37,000 for people with Blue Shield insurance.
When I asked Pollitz how that squares with my $50,000 in hospital charges, she explained that without any federal oversight, hospitals have no incentive to stick to the charges they post online.
“They’re just a horrible mess,” Pollitz said of the transparency data, explaining that hospitals do not clarify whether listed prices are “comprehensive” or “partial”. Indeed, when I called to contest the cost, a Sutter billing representative said that the “all services” price listed on their website “may just be part of the procedure” and probably didn’t include “pharmacy, layups, IVs, emergency room and anesthesia” charges.
In a statement to the Guardian, Sutter Health seemed to suggest it was impossible to set prices in advance for emergencies. “Sutter and commercial health insurance companies typically do not have set negotiated rates for services provided in emergency care settings. Generally, this is because emergency services and individual patient circumstances can vary widely,” said a spokesperson. “We always listen to patient feedback and continually review our processes to find ways to improve the patient experience and make the billing process more clear.”
But patients do have options for recourse when bills are unjustly high. A person can ask the hospital for charges to be reviewed and for clear descriptions of items listed as “miscellaneous”. (Just note that it doesn’t always work. After formally reviewing my bill, Sutter notified me that the charges were, in their eyes, accurate.)
Contacting one’s insurance plan is another important step, said Pollitz, as lower overall charges also benefit insurers, who are usually responsible for paying a percentage of the bill. But filing a grievance can be frustrating, time-consuming and re-traumatizing. When I called my insurance plan’s customer service line to inquire about the charges, I was told it was my job to research costs before getting surgery, and that it wasn’t their fault that I had failed to do so.
“Did you get the price for your surgery approved in advance?” a representative from Blue Shield California asked me over the phone about my emergency surgical abortion.
The question rang as absurd. Reproductive care is not predictable and if a patient delays seeking emergency care because they are nervous about costs, their condition could become more dangerous and expensive. Prohibitive costs, therefore, not only discourage people from seeking care, but also help contribute to the US’s exceptionally high maternal mortality rates.
“No, I didn’t plan to have an ectopic pregnancy,” I told the representative.
“Then this charge is correct,” she responded. If only I had been able to plan the moment my tube would rupture, I could have saved thousands of dollars.
