Featured photo: A Woman’s Choice is Greensboro’s only abortion clinic. (courtesy photo)

This story was initially published by Clarissa Donnelly-DeRoven, North Carolina Health News on June 27, 2022

Anna wasn’t sure if she wanted to be a mom. She was sure that she wasn’t happy with her part-time job — which didn’t offer health insurance — and that she and her partner were in a rough spot in their relationship. A northern transplant to the Triangle in her late twenties, everything felt messy and in flux. 

On top of all that, she’d just missed her period. 

She knew this was a possibility since she’d switched birth control methods: from taking the pill to tracking her ovulation, called the rhythm method. It’s a type of contraception whereby somebody tracks their period to figure out which days of the month their body releases an egg. They then either avoid having sex on those days, or use another form of contraception, such as a condom, to prevent pregnancy. 

Anna read online that everyone ovulates on day 14 of their cycle — turns out that’s not true. Like most other bodily processes, it’s a spectrum. Anna, she later learned, ovulated around day 18.

So, the rhythm method failed for her. Research shows it fails for anywhere between seven to 24 percent of people practicing the method.

She spent days thinking about what this meant for her. She soon realized what she needed to do and made an appointment at a nearby Planned Parenthood to have an abortion. There are 14 abortion clinics in North Carolina, and in the Triangle, Anna had access to four of them. 

As Anna and the clinic went back and forth about appointment times, something else came up: money.

The cost of an abortion varies. It depends how far along someone is in their pregnancy, the location of the procedure, how much their insurance will cover, and other factors. For Anna, the tab would come to about $600. 

She said she groaned when she heard the price. 

“I’m not gonna not afford this,” she thought to herself. She also couldn’t afford to become a parent. Not then, anyway. 

Anna’s partner had a more stable job than her, and he said he would pay. If that hadn’t been the case, Anna doesn’t know how else she would’ve managed. It wasn’t until years later that she learned about, and got involved with, an organization designed to help people in her exact situation: The Carolina Abortion Fund

Insurance barriers to care

Founded in 2011 by a collection of people who wanted to make abortion more accessible, the Carolina Abortion Fund pays for abortions and for the logistics of getting to an abortion clinic. Staff and board members only use their first names or pseudonyms in public for security reasons. Anna is a pseudonym.

The organization is part of the National Network of Abortion Funds, organizations which have existed for years as many states have made abortion increasingly difficult to access even as it remained legal on paper.

Following the Supreme Court’s June 24 decision to overturn Roe v Wade — the landmark 1973 ruling that created a constitutional right to an abortion — abortion regulation will be left entirely up to the states. Millions will find themselves in abortion care deserts. 

Even before the reversal, the cost of getting an abortion often proved to be an insurmountable barrier for many nationwide. 

“​​There’s this saying that the South has always been post-Roe because there’s so many restrictions in the South even with Roe v Wade standing,” Anna said. 

In North Carolina, for example, there are significant restrictions on what kind of insurance can pay for an abortion. 

“North Carolina statutes bar any state money from covering abortion care, except in very limited cases,” said Tara Romano, the executive director of the Pro-Choice North Carolina Foundation

“This includes bans in insurance for state employees and teachers, as well as bans on state Medicaid coverage, in addition to the ban in federal Medicaid, which is part of the Hyde Amendment,” Romano said. “There are also bans on local governments providing abortion coverage for their employees, as well as bans on private insurance bought on the [Affordable Care Act] marketplace from covering abortion care.”

The only insurance plans in North Carolina which are legally allowed to pay for abortions are private health insurance plans obtained through somebody’s private-sector job. Not all of these plans cover abortion, but they’re all legally allowed to. 

Because of all the insurance restrictions, many erroneously think their only option is to pay out of pocket. The Carolina Abortion Fund, and other organizations like it, exist to fill the gap.

How funding works

To get support from the Carolina Abortion Fund, people first need to have a doctor’s appointment. Then, they call the fund’s warm line, which opens on Monday. They’re directed to a voicemail box, where they leave their basic information alongside their appointment time and location. A volunteer or a staff member calls back every person in the following 24-48 hours to tell them if they have funds to help pay for their care or not. The voicemail box also closes on Mondays, because that’s typically when the fund runs out of money. 

In a typical week, the fund receives about 80 calls and uses $5,000 to cover between 15 and 20 patients. They choose who to fund based on whose appointment is the soonest. The organization encourages those who don’t receive support one week (because their appointment is the following week) to call back when their abortion gets closer in order to receive financial support.

If the fund has to turn somebody away, they try to help patients find another source of money. Many clinics have funds they can pull from to help reduce costs for patients who can’t afford their abortion. The Carolina Abortion Fund helps people access this money from the clinic where their procedure is scheduled. 

Planned Parenthood in Charlotte
The Charlotte Planned Parenthood clinic at its 2019 grand opening. It’s one of just 14 abortion clinics in the state, and is likely to see increasing numbers of patients from all over the south seeking care. Photo credit: Yen Duong

For abortions they fund, the Carolina Abortion Fund sends the money to the clinic directly. If it’s for the cost of travel to and from the appointment, or for child care, the money goes to the caller. 

They can also connect people with abortion doulas, who support patients through the emotional aspects of the procedure. Abortion doulas used to be allowed into the clinic with patients, but COVID-19 restrictions changed that rule for some states. 

The only thing the Carolina Abortion Fund generally cannot help with is the ultrasound fee, which North Carolina law requires patients to receive before an abortion.

Cost of abortion goes beyond procedure

Abortions generally increase in price as a pregnancy progresses. According to an amicus brief filed by the American College of Obstetricians and Gynecologists and other medical organizations, almost half of all pregnancies in the U.S. are unplanned. Irregular periods can make it difficult for people to keep track of their cycle and see that they’ve missed a period. 

That means it can take months before someone even realizes they’re pregnant. One study found that more than half of those surveyed who got an abortion after three months did so because they didn’t know they were pregnant before. Even among those who do get an abortion during their first trimester, nearly 40 percent said that not knowing they were pregnant delayed their abortion. 

It’s not only the price of the procedure itself that can be quite hefty. All of the bureaucratic costs add up: time needed to locate a clinic that performs abortions and figure out if their health insurance will cover the procedure (if they have coverage), transportation costs, taking time off work, and for about two-thirds of North Carolinians seeking abortions, finding someone to watch their existing children. 

“The logistics issue of how do you get people to clinics is massive,” said Jonas Swartz, an OB-GYN at Duke Health who provides abortion services. “The funding issue is massive because we already know that abortion is just like other health care services. Abortion is expensive and difficult for people to access.” 

The financial and time commitment were already a huge burden, Swartz said.

“We already know that, prior to this ruling, vast disparities existed based on where you lived, how much money you had, and the color of your skin in terms of the type of reproductive health care access [that you had],” he said. “[The ruling] really makes that much worse.”

‘Folded back into the work’

The Carolina Abortion Fund was previously a volunteer-based organization, but it now has multiple staff members and a board of directors. The staff is paid through grants, while all of the donations the fund receives go to patients. 

Like other funds, the Carolina Abortion Fund raises money from a range of foundations and individual donors. The funds support North and South Carolina residents seeking an abortion in the two states and outside of them, as well as people who live in other states but who come to North or South Carolina for the procedure.

The organization ends up funding more abortions in North Carolina. The state has fewer restrictions, which translates into a higher procedure volume. In South Carolina, about 5,400 abortions were reported to state regulators in 2020, the latest year for data. In North Carolina, that number was around 25,000 in the same year. 

In 2019, according to the Carolina Abortion Fund’s latest available tax forms, the organization raised $419,291 and paid out $321,774 in direct grants. They generally cover just part of the cost of the procedure — about $260 — equating to funding for nearly 1,200 people. 

Their funding has skyrocketed since the draft of the Supreme Court decision to overturn Roe v Wade leaked to Politico in May. In the week after, the organization received more than $100,000 from 1,125 individual donations — an amount of money they can use to support around 400 people’s abortions.

Funding and involvement with the organization tends to follow a similar pattern: policies that restrict abortion access lead to more donations. The way the organization intervenes to support people in these moments of personal crisis leads many of its beneficiaries to circle back. 

That’s how it was for Camille, who spoke at an event the organization held in Durham shortly after the Supreme Court’s draft opinion leaked.

After getting services from the fund she said she was “folded back into the work.”  

“That is what folks are typically doing now when they join reproductive justice orgs,” Camille said. “They are going through their experience, and then they’re coming back to the fight to make sure people don’t go through what they went through.”

That was true for Anna. During her abortion, she didn’t know what to expect. Statistically, she knew she must’ve known people who’d had abortions, “but, like with other things, people don’t talk about it,” she said. 

Getting involved with the Carolina Abortion Fund offered her a space to be with others going through the same thing, and to offer them the same support she received during her own experience. She said she hopes she can help people feel confident in their decisions.

More births, fewer resources

Of the 13 states that make up the southeastern U.S., North Carolina is one of just three where a law to fully or mostly outlaw abortion will not take effect in the coming weeks. Governor Roy Cooper and Attorney General Josh Stein issued statements reaffirming that abortion will remain legal in North Carolina for the foreseeable future. 

But people in other states face increased restrictions or outright bans, and it’ll impact more than just individual families. State bans are expected to increase the number of births exponentially — Rick Shannon, a Duke OB-GYN estimated that between 600,000 and 800,000 more babies could be born each year in the U.S. in the wake of the decision.

State health officials have given Femcare, an abortion clinic in Asheville, 10 days to show is it has met, or plans to meet, licensing requirements. The facility was ordered to close by Wednesday afternoon. Jon Elliston/Carolina Public Press
Femcare was an abortion clinic in Asheville. It closed following increased regulations of abortion clinics. Now, Planned Parenthood – Asheville is the only abortion clinic serving all of western North Carolina. Photo credit: Jon Elliston/Carolina Public Press

“I cannot imagine that our labor and delivery units are prepared for that influx,” said Ashley Navarro, a North Carolina OB-GYN who also trains medical students and residents on abortion care. “We have labor and deliveries closing across our state — especially in more rural western North Carolina areas, they’re not opening. And so I’m not sure how we’re going to handle that volume.”

Justine, a staff member at the Carolina Abortion Fund, said the organization’s call volume “is expected to go up by 5,000 percent.” With Roe v Wade over turned, many expect North Carolina will become a destination for abortions for people from all over the South.

“It feels like a number that sounds fake,” she said. The organization plans to keep its eye on both North and South Carolina’s state legislatures over the coming weeks, namely South Carolina as the state is expected to hold a special legislative session to implement further abortion restrictions. The state previously passed a law banning abortion after six weeks — before many even know they’re pregnant — but an injunction prevented it from being implemented. Now that Roe is no longer the law of the land, it’s likely to take effect.

“People deserve care where they live. It doesn’t matter what your ZIP code is,” Justine said. “The bottom line is, it’s not justice.”

NC Health News editor Rose Hoban contributed reporting for this story.

North Carolina Health News is an independent, non-partisan, not-for-profit, statewide news organization dedicated to covering all things health care in North Carolina. Visit NCHN at northcarolinahealthnews.org.

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