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Since the passage of the Hyde Amendment in 1976, people on Medicaid cannot generally use their health coverage to obtain abortions. But there is one important exception—when someone wants to terminate a pregnancy that resulted from rape or incest.

But according to a new report from Think Progress, few survivors are actually able to obtain abortions through their states’ Medicaid programs. In 2017, Medicaid programs did not pay for even one survivor’s abortion in nine states, and in four states, only one survivor was successfully able to use Medicaid to pay for an abortion.

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As Think Progress notes, “[T]he intersection of Medicaid and abortion—which are stigmatized as handouts and destroying life, respectively creates a complicated process, perhaps by design, for providers and patients who just want insurance to pay for a health procedure. Sexual assault survivors aren’t exempt from that complicated process.”

Reporting requirements make it even more challenging for some. In a few states, survivors are required to file police reports if they wish to use Medicaid to obtain an abortion, despite explicit guidance from the Department of Health and Human Services, dating from 1998, that “reporting or documentation requirements may not serve to deny or impede coverage for abortions.”

From Think Progress:

Today, a handful of states still do not explicitly waive the requirement that patients report their rape to law enforcement even if they fear for their lives. ThinkProgress found that at least two states (Utah and Wisconsin) and D.C. only pay for abortions if a police report is filed.

If it’s not a police report, it’s another requirement that’s not widely known and therefore not met. In Virginia, for example, survivors also have the option to report to a public health agency instead of law enforcement, but it’s not a well-known option. When ThinkProgress asked the state’s health department about this option, staff admitted that no one has ever asked.

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The difficulties for abortion providers in working with their state’s Medicaid programs is another block:

When providers are able to get public funds to pay for abortion services, reimbursement rates are usually low. Kansas Medicaid, for example, reimbursed a provider $290 for one abortion in 2017, the state health department told ThinkProgress. But abortions in Kansas can cost anywhere between $600 to $1,675, depending on the procedure.

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Arkansas Planned Parenthood provider Dr. Stephanie Ho noted one colleague has stopped even asking Medicaid to cover abortion services.

“More women who need assistance paying for the abortion — they have easier access to the abortion funds than they would through a Medicaid exception,” she said. Arkansas Abortion Support Network, she noted, doesn’t ask many questions beyond income and household size. For this reason, Ho advises low-income patients to use them because many cite privacy and safety concerns.

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Think Progress interviewed Dr. Shanthi Ramesh, an abortion provider at a Planned Parenthood clinic in Virginia, who shared that in the past year, seven of her patients technically should have been able to use Medicaid to pay for their abortions. But four of the seven women did not file police reports. One tried to file a report with local law enforcement, but the police dismissed her claims.

Most survivors are unwilling to go to the police, according to Ramesh. “I would say the majority of women say something to the effect of ‘I’ve already been through enough. I just want to get it done. I don’t want to have anyone else involved,’” she told Think Progress.

Ramesh added: “For some patients, reporting to the police is potentially empowering for them. But I think to say everyone who has experienced rape and who wants to have Medicaid pay for their abortion has to report to the police is not trauma-informed. I think meeting patients where they are is.”