Twelve-Year Trends in US State-Level Contraceptive Access Policies
Unfettered access to contraception is a critical component of reproductive autonomy. Allowing people to control choices related to their own childbearing and to independently plan their families results in improved economic, social, and health outcomes for people capable of pregnancy and their families, such as improved mental health and well-being, increased educational attainment and workforce participation, and financial stability. Efforts to expand access to contraception include the federal contraceptive coverage mandate included in the landmark Affordable Care Act Medicaid family planning expansions, which offer coverage for family planning services to people previously ineligible for Medicaid. Another effort is guidance from the Centers of Disease Control and Prevention encouraging providers to offer contraception and family planning services via telemedicine during the COVID-19 pandemic. Lawmakers continue to push for increased access to contraceptive services, such as in the Access to Contraception for Servicemembers and Dependents Act, which seeks to ensure non–active duty military service members and their dependents have access to contraceptive coverage without copayments, a benefit presently only offered to active-duty service members.
Despite these efforts, challenges and barriers to contraceptive coverage and access in the United States remain. For instance, the Affordable Care Act contraceptive coverage mandate endured repeated challenges to its legality and viability. These challenges resulted in multiple US Supreme Court cases primarily regarding religious objections to contraceptive coverage on behalf of for-profit religious organizations, such as Burwell v. Hobby Lobby Stores in 2014, Zubik v. Burwell in 2016, and Little Sisters of the Poor Saints Peter and Paul Home v. Pennsylvania in 2020. Legislative attacks on contraceptive access were prolific under the prior presidential administration, which issued new regulations allowing any employer to refuse to comply with the contraceptive coverage mandate on religious or moral grounds. The previous administration also enacted a “domestic gag rule” that excluded health care providers performing abortions from receiving Title X funding. The fallout from these restrictive policies and regulations has been devastating; because of the domestic gag rule, Title X network capacity to provide contraceptive services has reduced by 46 percent, or 1.6 million patients.
Contraceptive policy in the US has a long and sordid history with disparate implications across populations. Government practice and policy have enabled historic and ongoing reproductive abuse of people of color, people with lower incomes and people with disabilities via forced sterilizations and contraceptive testing, and coercive incentivization of contraceptive use in public assistance programs. Simultaneously, policies expanding access to contraceptives have vast potential to benefit the health and well-being of birthing people of color and birthing people with low incomes, who, because of structural determinants, face higher rates of unplanned pregnancies and poor maternal health outcomes associated with childbearing, including maternal mortality. Additionally, access to contraceptive services and the implementation of policies restricting access to comprehensive sexual and reproductive health services vary by geographic region in the US. According to Status of Women in the States, nearly all states in the Midwest and South maintain a grade of C or lower (on an A to F scale) with respect to reproductive rights. The data include measures around abortion access, Medicaid expansion, state Medicaid family planning eligibility expansions, coverage of infertility treatments, sex education, and same-sex marriage and adoption.
Given the historical and current sociopolitical context and the dynamic environment surrounding contraceptive access policies, we document changes in some state-level policies regulating access to contraceptive services over 12 years (2006–17). We sought to understand geographic and time-trend patterns in the shifting contraceptive policy environment and to inform future policy change evaluation. To do so, we collected data on 23 policies across 51 jurisdictions (all states and Washington, DC) from sources including the Guttmacher Institute, the National Conference of State Legislatures, the National Health Law Program, and Nexis Uni. We examined 20 expansive and 3 restrictive policies regulating contraceptive education, insurance coverage, minor confidentiality and consent, prescribing and dispensing authority, bans on family planning funding, and provider refusal clauses. We find the following:
- As of 2017, most enacted policies expanded contraceptive access. These policies include Medicaid expansion (n = 32 jurisdictions, or 63 percent of jurisdictions) and prescribing authority for nurse practitioners (n = 50, or 98 percent), certified nurse-midwives (n = 50, or 98 percent), and clinical nurse specialists (n = 37, or 73 percent).
- The average number of expansive policies enacted per jurisdiction increased from 6.0 in 2006 to 8.3 in 2017.
- States in the West and Northeast had the highest average numbers of expansive policies (9.1 and 7.6) and increases in the average number of expansive policies (about 3 each).
- Most of the restrictive policies enacted were clauses permitting providers to refuse to provide contraceptive services to patients (n = 27 jurisdictions, or 53 percent of jurisdictions).
- States in the Midwest and West had the highest average numbers of restrictive policies (0.9 and 0.8).
In summary, our findings, recently published as an abstract in the October 2021 issue of Contraception, demonstrate that regions with the least restrictive sexual and reproductive health policy environments further expanded contraceptive access, whereas more restrictive contraceptive policy environments were maintained. More nuanced understanding of how contraceptive policy diffusion affects health outcomes and equity is needed to inform public health advocacy and lawmaking. Following the full publication of this study, our team will use these policy data to examine these contraceptive access policies’ implications for preventive health service use, outcomes, and equity.