Access to contraceptive care has been shown to have many health and economic benefits. However, some people experience barriers to obtaining contraception, including issues with delivery of care, payment for contraception, and privacy. States have a key role in supporting access to contraceptive care through the administration of state Medicaid and public health policies and programs, as well as regulation of public and private health insurance plans.
Many methods of contraception require continuous renewal of supplies or care on a monthly, annual, or other ongoing basis to be effective. For certain groups of people, access to contraception poses unique risks, including for adolescents and young adults, who may be less likely to access contraceptive services if confidentiality is a concern, and women experiencing interpersonal violence, who may experience coercion and fear of retaliation.
These complexities underscore the need for alignment across programs and sectors to ensure continuous access to contraceptive care, as individuals may move through programs or access different programs to meet their contraception needs. In light of a shifting contraceptive care landscape, including legal considerations and challenges, workforce shortages and health care deserts, innovations in care delivery, and financing constraints, many states have proposed or enacted policy changes around contraceptive care access and are reevaluating their approaches in this area.
Access to contraceptive care in the U.S. is provided through an array of programs, many of which are administered or regulated by states. State Medicaid and Medicaid family planning programs provide coverage for low-income individuals who meet program eligibility criteria, while the Title X Family Planning Program, often but not always administered by states, serves anyone regardless of insurance status or ability to pay, with services provided at no-cost or discounted cost for people with low income.
Other sources of funding, including Title V Maternal and Child Health Block Grants and Temporary Assistance for Needy Families (TANF) funds, are used by some states to support programs that increase access to contraceptive care. States can also provide access to contraceptive care through state-regulated health plans and policy changes to expand provider authority or dispensing requirements.
- The Title X Family Planning Program (Title X), a federal program administered by the Office of Population Affairs in the U.S. Department of Health and Human Services, provides grants to family planning clinics to provide comprehensive family planning and preventive health services for people with low income or who are uninsured, with no charge for people with income at or below 100 percent of the federal poverty level (FPL) and a sliding scale for those with income higher than 100 percent and up to 250 percent FPL. People with income higher than 250 percent FPL are charged fees designed to recover the reasonable cost of providing services. In 2022, Title X served 2.6 million clients through grants to 91 grantees, including state and local health departments, as well as family planning, community health, and other private nonprofit organizations.
- State Medicaid programs provide health coverage to over 83 million Americans who meet eligibility criteria, including low-income adults, children, pregnant people, and people with disabilities. Each state administers its own Medicaid program, and funding comes from states and the federal government. In 2019, approximately two-thirds of womeni with Medicaid coverage were of reproductive age. In 2021, Medicaid was the source of payment for 41 percent of all births nationally, with Medicaid financing over half of all births in some states. Some states have also elected to expand eligibility for coverage of family planning services through Medicaid. Medicaid family planning programs expand eligibility for those who would not otherwise be eligible for Medicaid, often by expanding income eligibility. The expanded income eligibility for Medicaid family programs varies by state, ranging from 138 percent of the FPL to 306 percent of the FPL.
Leading State Strategies to Increase Access to Contraceptive Care
Many states have used a variety of policy and programmatic mechanisms to increase access to contraceptive care to meet the needs of their populations. These include strategies to increase the capacity and impact of the contraceptive care workforce, make contraceptives more conveniently accessible in community settings, create new programs and increase resources for existing family planning services, and safeguard coverage of contraceptives in both public and private health plans.
Supporting the health care workforce to expand access to contraceptive care
Access to contraceptive care from clinical providers is unequally distributed across the U.S. In 2019, over 1,200 counties (over one-third) in the U.S. had no obstetrician, certified nurse-midwife, or certified midwife.ii These gaps in access are uneven across the country, with nearly half as many obstetric providers per 10,000 births in rural counties compared to urban counties.
States have implemented both financing and policy changes to support the contraceptive care workforce. They are using both loan forgiveness and grant programs for contraceptive care providers to increase capacity to deliver care to more patients through equipment upgrades, increased staffing, training, security upgrades, and expanded information technology services, among other supports. For example, New Jersey has issued zero-percent interest forgivable loans for upgrades at reproductive health care facilities and grants for security enhancements for family planning providers seeking to deliver care to more patients. This includes appropriating $10 million in fiscal year 2023 and $5 million in fiscal year 2024. California submitted a Medicaid section 1115 demonstration waiver to the Centers for Medicare and Medicaid Services in June 2023, which requests approval to provide grants to reproductive health providers to be used to increase provider capacity through training, retention and recruitment efforts, expanded hours and services offered, facilities investments, and other patient access supports, with the goal of improving access to care for Medicaid participants and others facing barriers to care.
States have also implemented unique strategies to increase provider capacity and alleviate workforce shortages by providing increased training and implementing supervisory models that support clinical staff to leverage their full scope of practice and provide the highest level of care they are authorized to offer. This allows the workforce to better meet contraceptive care needs by distributing delivery across providers relative to complexity and skills needed. For example, several states, including Michigan, Missouri, and New Hampshire, provide Medicaid reimbursement for certified nurse-midwives to provide family planning and reproductive care. In New Mexico and Oregon, licensed midwives and licensed direct-entry midwives, who typically are not required to have a nursing degree, are reimbursed for family planning services in the states’ Medicaid programs. States are also using Medicaid financing and investing in training and supports to expand access to care through community-based providers, public health workers, and community members. This community-based workforce, including community health workers (CHW), doulas, and peer educators, among others, can help improve access to care as these professionals are often trusted members of the community who work in community- or home-based settings. These frontline public health workers with lived experience in the communities they serve can support clients by providing culturally informed contraceptive counseling and assistance navigating the health system to access contraception.
Twelve states and Washington, DC, cover doula service benefits for Medicaid beneficiaries. Doulas provide postpartum support in addition to the support they provide during pregnancy and childbirth. New Jersey, Virginia, and DC offer a value-based incentive payment to doulas if a postpartum visit is performed and their client is seen by an obstetrician for a postpartum visit, an important access point for contraceptive counseling and care.
Other states are investing in the community-based health workforce to provide health education, coaching, and training. In 2024, approximately 15 states reimburse for CHW services through Medicaid, and others are using 1115 demonstration waivers or Medicaid managed care contracts to support CHW services. Rhode Island included family planning among the approved health promotion and coaching and/or health education and training topics for which CHWs can be reimbursed in the state’s Medicaid program. North Carolina Department of Health and Human Services uses federal Title X funding and state funds for the Title V Maternal and Child Health Services Block Grant to implement its Preconception Peer Educator Program at Historically Black Colleges and Universities and other colleges, community colleges, and universities around the state. College students are trained in preconception health, including reproductive life planning and other wellness areas, and share this information on their college campuses and in surrounding communities.
Best practices in pharmacist prescribing of contraceptives
Over 20 states and DC authorize pharmacists to prescribe certain types of contraceptives. By eliminating the need to visit a doctor’s office for a prescription and then a pharmacy to fill the prescription, pharmacist prescribing policies can help alleviate several barriers to care, including workforce shortages among traditional contraceptive care providers and lack of convenient access to providers in clinical settings. Pharmacies, as existing infrastructure in communities, have increasingly been used to improve population health, through medication management, disease testing and treatment, and delivery of immunizations. Research shows that this strategy may prove effective, with one study finding pharmacists were more likely to prescribe a contraceptive supply of six months or greater compared to traditional clinicians, which may increase continued use and convenience.
State policy actions that allow pharmacists to prescribe contraception include legislation that authorizes pharmacists to independently prescribe contraceptives, statewide standing orders that allow a state health officer to authorize pharmacist prescribing, and collaborative practice agreements that allow pharmacists to prescribe contraception with an authorized prescriber. These policies also differ in the types of contraceptives that pharmacists can prescribe, with policies covering all or some types of contraceptives, including the hormonal birth control pill, patch, ring, and injection. Some state policies contain age restrictions, authorizing pharmacists to prescribe contraceptives only to individuals 18 and older. State policies also differ in payment policies, limitations on charging patients, and training requirements for pharmacists.
Studies indicate interest from both consumers and pharmacists in pharmacist prescribing of contraceptives but also find that pharmacists’ comfort level for prescribing contraception varies and that many identify a need for additional training. Several states have developed partnerships with local pharmacy associations and schools to fill this need, including North Carolina, where the North Carolina Board of Pharmacy collaborated with the North Carolina Association of Pharmacists to offer a training for pharmacists, compliant with the state’s requirements for pharmacists providing hormonal contraceptives. A grant from the North Carolina Board of Pharmacy also allowed the North Carolina Association of Pharmacists to make the training free for the first 6,000 registrants.
Expanding coverage of contraceptive care in state Medicaid programs, including under family planning benefits
While coverage of family planning services and supplies are a mandatory benefit in state Medicaid programs, states have flexibility around how this benefit is designed. A 2021 survey of state Medicaid agencies found variation in contraceptive policies, including utilization controls such as quantity limits and age restrictions and prescription requirements for emergency contraception and over-the-counter (OTC) contraception. Some states have expanded Medicaid coverage of contraceptive care with the goal of expanding access. For example, Washington’s Medicaid program covers OTC contraceptives that are approved by the U.S. Food and Drug Administration (FDA), including internal and external condoms, emergency contraception (OTC and prescribed), and spermicide. Washington is also one of a few states that allow Medicaid beneficiaries to receive these contraceptives directly from a pharmacy, eliminating the requirement to visit a provider with prescriptive authority.
Medicaid family planning programs expand eligibility for those who would not otherwise be eligible for Medicaid, often by expanding income eligibility. This expanded income eligibility varies by state, ranging from 138 percent to 306 percent of the FPL. Some states operate Medicaid family planning programs under waiver authority, while some have implemented state plan amendments (SPAs). While many states operate Medicaid family planning programs, a recent report showed that program enrollment was low for many states, with most states’ programs enrolling less than 50 percent of potentially eligible individuals. Annual utilization of contraceptive services also varied, ranging across states from 7 to 42 percent.
States have implemented a variety of Medicaid payment, coverage, and quality strategies to increase access to contraception during the postpartum period. Most states have extended postpartum coverage in Medicaid beyond the required 60 days, often to one-year postpartum, through section 1115 demonstration waivers and SPAs. This provides an opportunity for postpartum people to receive contraceptive counseling, services, and follow-up care. States have also implemented a variety of Medicaid payment strategies to increase access to contraceptive care. Some states, including South Carolina, have elected to unbundle long-acting reversible contraception (LARC) from the global maternity fee by providing separate payments to providers for immediate postpartum LARC insertion, thereby reimbursing providers for both the insertion procedure and the costs of the LARC device in addition to the costs of the delivery. Following this policy change, a study found that odds of receipt of immediate postpartum LARC increased. Some states, including North Carolina, have also integrated measures of access to postpartum care into their Medicaid managed care quality strategies.
Braiding funds to increase access to quality contraceptive care for the uninsured and those who experience barriers to accessing care through insurance
States fulfill the role of providing contraceptive care to those who are uninsured, have low income, or who are insured but experience barriers to accessing contraception using their insurance. While the Title X Family Planning program is the federal grant program dedicated to family planning and related preventive services, these funds have remained at the same level since 2015 and have not kept up with inflation. States are leveraging an array of state and federal programs and financing mechanisms to meet the contraceptive care needs of their populations, including braiding funds and other support from outside sources. These efforts have typically been focused on LARCs due to the high cost of this contraceptive method relative to others, and additional training needs for providers.
Virginia’s Contraceptive Access Initiative uses funds from the state’s federal Temporary Assistance for Needy Families (TANF) block grants to support increased access to FDA-approved contraceptives in qualifying health centers, with administrative support provided by the state’s Title V Maternal and Child Health Block Grant. The program was launched in 2018, initially focusing on expanding access to LARC for women with income below 250 percent of the FPL. In 2020 the program was expanded to include all FDA-approved contraceptives.
States are also participating in public-private partnerships to expand the reach of state-funded family planning services, as the Delaware Contraceptive Access Now (DelCAN) initiative, a partnership funded by a combination of state Division of Public Health and philanthropic funds. During the partnership, state funding was used to purchase LARC devices, and the nonprofit Upstream USA provided training and technical assistance to clinical and administrative staff to increase their ability to provide same-day access to the full range of contraceptive services. States have also undertaken efforts to lower program costs to increase contraceptive access.
Establishing state contraceptive coverage requirements
The Affordable Care Act (ACA) established federal requirements for most private health care plans to cover at least one form of each of the 18 FDA-approved contraceptive methods and counseling without cost-sharing in 2012, with the exemption of employers with moral or religious objections. Since 2012, some states have enacted legislation to require coverage of other types of contraceptives, including OTC birth control methods or male and/or female sterilization that extends beyond the federal requirements. In states with more comprehensive contraceptive coverage requirements, state-regulated plans must comply with the higher state standard. Enforcement of contraception coverage requirements can be carried out by state divisions of insurance.
At least 29 states and DC have established requirements for the coverage of prescription contraceptives by state-regulated health care plans. These include individual plans and fully insured group plans but not self-funded plans, which are covered by federal law, and represent 60 percent of covered workers. State regulations vary in their cost-sharing requirements, the methods that must be covered, and the exemptions allowed. For example, some states do not allow exemptions for any employers covered by the state requirement, some allow exemptions for religious employers that meet certain definitions, and some allow exemptions for employers with moral exemptions. Over half of the states with contraceptive coverage requirements prohibit cost-sharing for covered plans.
Some states require coverage of at least some OTC contraceptives without a prescription for Medicaid payers, private insurers, or both. Additionally, several states use state-only funds to cover at least some OTC contraception without a prescription in Medicaid. In 2023, the FDA approved Opill, the first OTC daily oral contraceptive available in the U.S. market without a prescription. States will play a role in implementation of policies and programs related to access, payment, and awareness of this new method of contraception.
Improving contraceptive care access through extended supply policies
Half of states (24 and DC) have implemented policies to cover dispensing an extended supply of hormonal birth control pills, which require coverage of a six- to 12-month supply dispensed with one prescription. In the absence of extended supply coverage policies, hormonal birth control pills are often prescribed in 30- or 90-day supplies. These policies vary in scope, with some states requiring extended supply coverage for both state-regulated private plans and Medicaid, and others requiring just private plans or Medicaid to do so. Extended supply policies are a promising strategy for increasing access to contraception, as they can help reduce gaps in contraception use by eliminating the need to frequently visit the pharmacy or clinic. A nationally representative survey found that 36 percent of women taking oral contraceptives reported that they had missed taking their birth control on time because they were not able to get their next supply on time. In one state study, dispensing a 12-month supply of oral contraception pills to women in a Medicaid family planning program was associated with a 30 percent reduction in an unplanned pregnancy compared to those who received one- or three-month supplies.
States with extended supply policies have used a variety of methods to support implementation and reduce barriers to accessing an extended supply for those who are eligible. A 2021 survey of Massachusetts providers found that over half were unaware of the state’s law requiring extended coverage. To support the implementation of the extended supply policy and increase access to contraception, the Massachusetts Department of Health launched a public awareness campaign in 2022 to educate individuals covered by state-regulated plans, alongside training materials for prescribers, pharmacists, and insurers, about the state’s 2017 ACCESS law, which requires coverage of a year’s supply of hormonal birth control, dispensed in one visit to the pharmacy.
States are innovating in a variety of ways to finance and facilitate delivery of contraceptive care against a backdrop of challenges. Many policy and programmatic levers exist at the state level, with state Medicaid and public health programs providing contraceptive care to millions of people every year. States are using financing and policy strategies to support and expand the workforce, develop new programs and care delivery models, and expand coverage requirements for public and private state-regulated plans. Though states are implementing a range of innovative strategies to increase access to contraceptive care, challenges remain. States continue to face a host of issues related to program funding and operating costs, including ensuring sufficient funding to serve Title X patients amid stagnant funding of the program, as well as inflation, increasing provider salaries, and challenges in stocking certain contraceptives due to cost. Program implementation challenges include protecting patient privacy, providing access to care for minors and people without legal documentation, maintaining timely care for patients in states with increasing patient rosters, maximizing utilization of Medicaid family planning benefits, and operationalizing new policies such as pharmacist prescribing. Ongoing legal challenges to the Title X program and other forms of reproductive care remain, creating a shifting contraceptive care landscape for states to navigate. As states continue to grapple with these challenges, sharing best practices and emerging strategies can help optimize access to contraceptive care.
i Kaiser Family Foundation analysis of 2019 TMSIS data
ii Maternity Care Deserts Report, 2022. March of Dimes analysis of U.S. Health Resources and Services Administration, Area Health Resources Files, 2021
This work is made possible through generous support from Arnold Ventures.
