There’s a wonky, long-running and almost entirely under-the-radar hitch that makes it harder for some women in Maryland to get an abortion.

Maryland is one of 17 states that covers the full cost of the procedure for low-income women enrolled in its Medicaid health program — unless the women qualified for the coverage because they were pregnant.

The obscure loophole has persisted in past administrations of both parties and carried over into the administration of Democratic Gov. Wes Moore, even after an attempt by the General Assembly to close the gap after the U.S. Supreme Court decision to overturn Roe v. Wade two years ago.

“They’re able to deny pregnant people an abortion, and it’s not right,” said Abigail Burman, a lawyer with a background in reproductive rights and state health care regulations. Burman said she noticed the loophole almost a decade ago and has struggled to get an explanation on why it still exists.

A spokesperson for Moore said in a statement Monday that the administration is committed to “providing and protecting safe and inclusive abortion care.”

“Since learning about this unfair exclusion only weeks ago, the administration has taken active steps not only to understand the policy’s origin but also to identify what is necessary to correct the exception,” said Moore’s Communications Director David Turner. “We will continue to work with legislators, advocates, and other stakeholder partners to ensure all Marylanders can receive more equitable abortion health care.”

The policy dates to the 1970s, when lawmakers first inserted money for abortions into the state budget. Health department officials then turned out a one-page fact sheet limiting how that money could be spent. It doesn’t appear to be written into law or regulation.

Maryland health officials don’t track how many times the state has denied abortion coverage because of the policy, though abortion providers say they have trouble getting Medicaid to cover abortion care.

Medicaid is a major health care insurer in Maryland, with about 1.7 million enrolled last year. It covered about 30% of the abortions estimated to have been performed last year, based on data from the state and the health policy group KFF.

If Maryland changes the policy, there could be a considerable cost.

The number of pregnant or postpartum women enrolled in the state health program nearly doubled in the past two years to nearly 26,800, likely because Medicaid began allowing women to stay on the insurance for a year after their babies were born. The state also spent about 10% more last year on abortion services, or $7.9 million for about 12,700 abortions, compared with two years earlier.

Maryland pays the full cost because the federal government is legally banned from funding abortions except in cases of rape or incest, or when the life of the woman is at stake.

Women excluded from abortion coverage by Medicaid include those with incomes up to about $36,000 who became eligible for the state health program because they were pregnant. Women with incomes below $20,000 but who happened to be pregnant when they enrolled are also excluded, according to the fact sheet.

The origins of the fact sheet don’t appear widely known inside and outside government. The abortion sheet is one of about a half dozen put out by the state health department to dictate the technicalities of coverage because federal funds can’t be used. Some of the exclusions could have initially been made to avoid interference of federal officials, but otherwise how they were chosen isn’t clear.

Pregnant people denied abortion coverage through the state must cover the costs themselves or through charity.

The average Medicaid bill for an abortion in fiscal 2023 was $617, but the amount can escalate into the thousands as pregnancies advance and become more complicated to terminate. That may be far more than many people can pay out of pocket.

That can be a burden on abortion funds and clinics.

“We do support a number of clients who have Maryland state Medicaid as their primary insurance and have trouble using their plans as intended to cover an abortion,” said Lynn McCann-Yeh, co-executive director of the Baltimore Abortion Fund, a nonprofit that financially supports women in the state or who travel to Maryland for an abortion.

Allison C. is a patient care technician at Partners in Abortion Care, a College Park clinic, and has worked as a billing specialist. She asked that her last name not be used to protect her safety.

She said in an email that clinic staff have noticed a lot of Medicaid claims are “not getting paid for,” and it’s not always clear or consistent.

“I’ve questioned why Maryland states it is a safe haven for abortion care, and yet Maryland Medicaid has multiple issues for coverage in abortion?” she said.

She and McCann-Yeh are among those who expected the post-Roe legislation in Maryland would close loopholes.

The 2022 law permitted advanced practice nurses to perform abortions and created a training program. Its sponsors said the law also aimed to give broad coverage and generally ease the process for women by ensuring they no longer had to say why they needed an abortion.

“On paper, it really seems like a big victory, but in practice it’s a bit patchier who that benefit applies to,” McCann-Yeh said. “The jury is still out if the law is functioning as intended.”

Chase Cook, state health department spokesperson, said the law passed during the administration of former Gov. Larry Hogan, a Republican, which continued using the longstanding exceptions to Medicaid’s abortion coverage.

Mike Ricci, a spokesperson for Hogan, said he was not familiar with the policy but that, typically, if a legal interpretation was needed, it would come from the Office of the Attorney General.

In this case, the health department has no record there was an official interpretation of state abortion law from that office, Cook said. The office offered a letter of support for the 2022 legislation, but it focused on the training program for new abortion providers.

But Cook said it was clear from the department’s own records that Medicaid hadn’t stopped using the exceptions “as the law allows.”

Former state Sen. Ariana Kelly, a Montgomery County Democrat who sponsored the abortion access bill, acknowledged the law didn’t eliminate all barriers as intended.

“If you’re eligible for Medicaid, you should be eligible for services covered by Medicaid,” she said. “That should be how it works.”

Kelly is now executive director of the Maryland Commission for Women, which works with state agencies to expand opportunities for women. She said it’s considering support next year for a bill that could help with funding by tapping leftover fees collected by private health plans, a measure that failed to pass the General Assembly this year.

Kelly said the money, millions already held by private insurers selling plans on the state health exchange, could pay for Medicaid to cover more abortions. The funds could also be used for those who travel to Maryland for an abortion but don’t qualify for the state health program because they don’t live here.

“If the money goes unused,” she said, “why not put it in an abortion fund?”