WASHINGTON — Many Republicans hailed the Supreme Court’s Dobbs decision as a victory for one of their highest-profile priorities: ending abortion. But it comes with a string attached — more federal spending, which Republicans usually hate.
More than 4 in 10 births in the United States — 42% in 2019 — are paid for by Medicaid, the government insurance program for the poor whose costs are split between the federal government and individual states. At an average of $18,865 per birth and with one estimate that there will be more than 150,000 extra births annually because of Dobbs, there will almost certainly be more spending.
House Budget Chairman John Yarmuth (D-Ky.) said he’d like to see Congress’ fiscal umpire, the nonpartisan Congressional Budget Office, put pen to paper on the impact of Dobbs.
“I would welcome a CBO score as another way to qualify the damage the Dobbs decision will do to women across the country,” the Kentucky Democrat told HuffPost.
To be clear, there are far more pressing concerns about forcing people to have babies. And even just looking at cost, Medicaid doesn’t cover all the many, many costs that come with having a baby who will become a toddler and then a child and then a teenager, and so forth.
But for a party that has been so quick to raise the alarm on federal spending over programs like expanding the child tax credit, Republicans are noticeably quiet about the financial cost that outlawing abortion will have.
Exactly how much more Medicaid spending Dobbs will entail is unclear. In the past, the CBO has estimated that bills restricting access to abortion would increase births and boost Medicaid spending.
Those increases, though, have been relatively small compared to the program’s overall outlays. A House Republican bill in 2015 to defund Planned Parenthood would have increased Medicaid spending by $650 million over 10 years. A 2017 bill GOP bill to restrict abortions after 20 weeks would have increased Medicaid spending by $175 million over 10 years, but the boost in spending could have been as much as $335 million if more people than projected carried their pregnancies to term instead of ending them before 20 weeks.
Dobbs’ impact may be several orders of magnitude higher. Taking the Kaiser estimate of $18,865 in birth costs, multiplying that by consulting firm Sg2′s high estimate of extra births and assuming the proportion of Medicaid deliveries stayed the same, the annual tab would be about $1.3 billion a year, or $13 billion over 10 years.
“We don’t know how much to expect, but we know that there are going to be women who are not going to be able to gain access to abortions, they’re not going to be able to travel distances to get abortions they seek. And those births are going to be funded by Medicaid,” said Alina Salganicoff, senior vice president with the Kaiser Family Foundation.
“Now, the extent to which that’s going to be something that’s noticeable in the budget, I really don’t know. A lot of it will depend on how successful women are going to be at getting abortions out of state or through self-managed means,” she said.
“We don’t know how much to expect, but we know that there are going to be women who are not going to be able to gain access to abortions, they’re not going to be able to travel distances to get abortions they seek.”
Medicaid is a $600 billion-plus a year program, with almost 88 million Americans enrolled in it or its companion CHIP program for kids, and usually one of the top budget line items for states. It has long been a target of anti-spending conservatives who balk at both its costs and the mandates it places on states.
Few Republicans this week wanted to talk about the potential cost of Dobbs. A request for comment to Rep. Jason Smith (Mo.), Yarmuth’s GOP counterpart on the House Budget Committee, was not answered. Sen. Ted Cruz (R-Texas) ignored the question as he got on an elevator during a Senate vote. Even the National Taxpayers Union did not respond to a request for comment.
Lindsey Graham, the South Carolina Republican who would likely become the chairman of the Senate Budget Committee if Republicans take the Senate, gave a muted response when questioned.
“I’m not trying to reduce the deficit by denying birth,” he said after a Senate vote. “I don’t see denying birth as a deficit reduction plan that anybody supports, OK?”
The budget impact will vary by state, as some provide abortions out of their state share of Medicaid money and others have banned or restricted abortions almost completely in the wake of Dobbs.
States that have the most Medicaid births would probably see the biggest impact, and many of them have restricted abortion since the ruling. According to Kaiser, six states as of 2020 had half or more of their births paid for by Medicaid: Louisiana, Mississippi, New Mexico, Oklahoma, Alabama and Texas. The highest proportion was seen in Louisiana, at 61%, while Alabama and Texas both saw half of their births paid for by Medicaid.
Kaiser’s Salganicoff said there would be “downstream” impacts on Medicaid for years in addition to the costs of increased births.
Salganicoff said as recently as 2014 that about 75% of women having abortions were low-income and that over 60% were women of color, with many already having had at least one child.
“Honestly, a lot of it’s going to depend on how successful women are going to be getting abortions and how many of them will be having children,” she said.
“We do know that they’re likely going to be low-income children that are going to be covered by Medicaid. And Medicaid pays for a broad range of services in addition to their health coverage, a wide range of services that are going to be important to them if they have also special health care needs as well,” she said.