As federal funding cuts loom in Delaware, Maryland pioneers the use of Affordable Care Act reserves to support abortion access for out-of-state and uninsured patients.
On July 4, 2025, the passage of President Donald Trump’s so-called “Big Beautiful Bill” sent shockwaves through the realm of reproductive health care. While the sweeping legislation included a raft of federal funding cuts across various sectors, it was a particular provision affecting reproductive health services that set off alarm bells among providers in Delaware. As reported by Bay to Bay News, there is growing concern that Medicaid users in Delaware could soon see significant changes—or even reductions—in their access to reproductive health care, depending on how the bill’s provisions are implemented at the state level.
Meanwhile, just next door, Maryland is charting a very different course. As of August 17, 2025, Maryland became the first state in the nation to unlock a little-known fund connected to the Affordable Care Act (ACA) to help pay the costs for patients who travel to Maryland seeking abortion care. With abortion now restricted or outright illegal in 22 states, Maryland has become a destination for patients from as close by as West Virginia and as far away as Texas, according to reporting from NPR and WYPR.
The Baltimore Abortion Fund, a nonprofit with a lean staff of six, has found itself on the front lines of this new reality. The group spends about $1 million a year helping patients cover the costs of bus or plane tickets, lodging, and even meals while they’re in Maryland. The demand is staggering: since the Supreme Court overturned Roe v. Wade in 2022, calls to the fund’s confidential helpline have jumped by 50% to 60% every year. “Sometimes that means that our helpline is closing within 24 to 48 hours at the start of the week, because there’s just too much demand for the amount of resources that we have,” said Lynn McCann-Yeh, the fund’s co-director. “There are many, many more dozens of callers each week that are just getting a voicemail message saying that we’ve run out of support.”
So where does Maryland’s new money come from? The answer lies in a little-known provision of the 2010 ACA. Under the law, states could require insurance plans sold on the ACA “marketplaces” to cover abortion, but federal restrictions—specifically the Hyde Amendment—prohibit the U.S. government from paying for abortions except in the narrowest of circumstances. To get around this, commercial insurers were required to collect a $1 monthly fee from every policyholder and deposit it into a segregated account, strictly reserved for abortion care. Over time, these accounts quietly grew. “Insurers have quietly complied with the ACA special rules resulting in these segregated accounts that have millions of dollars in them intended for abortion coverage,” explained Cat Duffy, a policy analyst for the National Health Law Program.
Maryland’s account now holds a whopping $25 million and brings in about $3 million every year. This spring, the Maryland Legislature passed a law allowing the state’s health department to tap these funds, allocating up to $2.5 million annually in grants to organizations operating in Maryland that provide abortion assistance. The law took effect July 1, 2025, and the first transfer of funds is expected by fall. These grants can be used not just for Maryland residents, but for anyone traveling to Maryland who needs help paying for an abortion, including uninsured and low-income patients.
For clinics, this new funding could be a lifeline. Diane Horvath, an OB-GYN at Partners in Abortion Care in College Park, Maryland, described the typical patient: “I would say a typical patient that we see probably every week is somebody who’s already got at least one child, they’re working a job that doesn’t offer substantial leave for medical care, it may not offer health insurance, or the insurance it offers doesn’t cover abortion, particularly when they’re coming from out of state and they’re struggling and living paycheck to paycheck.” More than 90% of the patients at Partners in Abortion Care receive financial assistance through various abortion funds. Unlike many other clinics, Partners in Abortion Care can provide abortions later in pregnancy, which are more complex and expensive.
Ramsie Monk, director of development at the Women’s Health Center of Maryland near the West Virginia border, expressed confidence in the new system: “We know that we will be able to use those funds wisely and to make sure that we’re not turning away any patient due to their inability to pay.” Without such assistance, Monk and others say, many patients simply couldn’t afford the care they need.
The numbers underscore the scale of the challenge. According to the Guttmacher Institute, Maryland clinics performed about 39,000 abortions in 2024—a 28% increase from 2020. The influx is largely attributed to patients crossing state lines, seeking care they can no longer access at home. As more abortion funds exhaust their resources, clinics feel the financial and logistical strain of serving not only local patients but also those traveling from states where abortion is now out of reach.
Maryland’s legislative move is being closely watched by other states with similar ACA funds. “This bill is super important for Maryland; we’re making sure our clinics stay open,” said Maryland state Delegate Lesley Lopez, who sponsored the bill. “Maryland has been a leader on a lot of reproductive bills for the past 30 years, and so in that way, this bill fits into that legacy. It’s also nationally significant, because there’s 25 or 26 other states that can take this model and run with it. We’re looking for California, Illinois, New York, those bigger states that are sitting on potentially hundreds of millions of dollars to take what we’ve done here in Maryland and implement it there.”
Not everyone is on board with the new law. Anti-abortion groups in Maryland have voiced strong opposition, arguing that the policy forces some insurance consumers to subsidize procedures they may morally oppose. “This bill uses insurance premiums from insured women to abort the children of uninsured women,” Laura Bogley, executive director of Maryland Right to Life, told the state legislature in March. “Many of those uninsured women are non-Maryland residents who are trafficked into the state for late-term abortions that are restricted by other states.” Supporters of the law push back, insisting that patients are traveling by choice, not coercion, and are seeking care unavailable elsewhere.
As Delaware providers brace for possible funding cuts and Maryland clinics prepare for another surge in out-of-state patients, the patchwork of abortion access across the United States grows ever more complex. What’s clear is that the fight over reproductive health care—its costs, its availability, and who pays for it—is far from over, and the next chapter is being written in statehouses and clinics across the country.