State Choices, Unequal Access: Policies Shaping Reproductive Health Care Across the United States

Context: Access to sexual and reproductive health care varies widely by geography, and state-level policies play a major role in establishing the contours that govern the coverage, provision, availability, and costs of services. The role of state-level policies has been amplified in the wake of the 2022 Supreme Court ruling in Dobbs v. Jackson Women’s Health Organization, which eliminated the federal right to abortion care allowing states to set their own policies to ban or protect abortion. Additionally, states play a major role in shaping Medicaid policies that affect access to contraception and maternity care. This Perspective examines the many ways that state policy choices affects access to three interrelated areas of reproductive health care: contraception, abortion, and maternity care.

Methods: State policy actions and decisions are at the core of reproductive health coverage and access. They are shaped by funding decisions, eligibility, and coverage polices established by the legislative and administrative bodies. This includes state policies related to contraceptive coverage and rights, Medicaid eligibility, telehealth and pharmacy access, scope of Medicaid and private insurance coverage, and efforts related to quality improvement and oversight.

Findings: Affordability, availability, and coverage are still barriers to sexual and reproductive health services in many parts of the nation. Several states have intentionally erected barriers to abortion care, but structural challenges also affect contraception and maternity care access. Financing and regulatory policies treat contraception, abortion, and maternity care as distinct domains, but they are inextricably linked and many women often seek these services from the same clinicians. State level policies related to health coverage, reimbursement levels, workforce supply, and quality of care all overlap and affect the care that women receive and their experiences with the health care system.

Conclusions: State policymakers play an outsize role in developing and implementing approaches to address their resident’s reproductive health needs. The implementation of Medicaid work requirements and other federal cuts to health spending in the next several years is expected to lead to a major increase in people becoming uninsured at the same time that the reproductive health care safety-net faces financial uncertainty. States that take a coordinated, systems-level approach to health care can strengthen access, improve care delivery, and better meet patients’ reproductive health care needs.