Mixed Contraceptive Access Exposes Regional Reproductive Health Disparities

Varied contraceptive access in the United States, driven by divergent state-level Medicaid coverage, has resulted in significant reproductive health disparities, according to a recent study by Oregon Health & Science University published in Health Affairs.

As the primary source of publicly funded contraception, Medicaid supports care access for millions of American women by covering a broad range of reproductive health services, including contraception costs. In 2019, adult women made up 36 percent of the overall Medicaid population, according to Kaiser Family Foundation (KFF) data.

Federal regulations mandate that state Medicaid programs provide coverage for reproductive health services to low-income individuals, but states have the discretion to broaden this coverage and offer additional care. Even more, the Dobbs ruling in June 2022 further increased state control over reproductive health services, experts stated.

While contraception is defined as a core benefit within Medicaid, access and use vary substantially across the nation and within states, and there is little data to explain these differences.

“States differ considerably in the services their Medicaid programs cover, and to whom care is provided, and this has significant implications on patients,” lead author Maria Rodriguez, MD, MPH, professor of obstetrics and gynecology in the OHSU School of Medicine and director of the Center for Reproductive Health Equity, said in the press release.

“Reproductive health is a fundamental right, yet so many Americans do not have equal access to care. I hope that the data revealed in this study will encourage providers and policymakers to address the gaps in our systems so we can improve the health of millions of women who are enrolled in Medicaid.”

In collaboration with OHSU's Center for Health Systems Effectiveness, the study analyzed data from over 8.5 million female Medicaid beneficiaries aged 15 to 44 across 40 states and nearly 3,000 counties. The research employed national Medicaid claims to evaluate county-level variations in providing the most or moderately effective contraception methods and long-acting reversible contraception (LARC).

The study findings revealed significant geographic disparities in reproductive health services, specifically in the rates of effective contraceptive use, which ranged from a low of 10 percent to a high of 44 percent across states.

The disparities were even greater when looking at long-acting contraceptive options like intrauterine devices (IUDs) and implants, spanning from a low of 1.0 percent to a high of 9.6 percent. In the aftermath of Roe v. Wade’s overturning in June 2022, researchers stated that various forms of contraception could face increased restrictions, potentially exacerbating the gaps identified in this study.

“Unfortunately, many of the legal efforts being made to restrict reproductive healthcare will only exacerbate these inequities,” Rodriguez said. “It’s crucial that we continue to fight for policies and practices that expand contraceptive access to ensure that all women — no matter where they live — can make informed decisions about their health.”

The researchers concluded that a variety of factors at the individual, state, and federal levels might contribute to these variations, including differences in state policies, provider networks and practices, individual preferences, and pregnancy intention.

These findings emerge as separate research highlights how state policies governing reproductive healthcare providers limit patient access to reproductive healthcare. For instance, a 2017 Iowa law chose to forgo the federal Medicaid family planning program, opting to establish a state-run family planning program instead. This state-run program excluded clinics associated with abortion care from participating, resulting in limited patient access to contraceptive care.