Beyond the Numbers: Access to Reproductive Health Care for Low-Income Women in Five Communities
In Washington, DC, and in state capitols across the nation, policy debates over the future of access to reproductive and sexual health services are shaping the range of services and providers available to low-income women. Access to these services, including contraceptive care, sexually transmitted infection (STI) prevention and treatment, obstetrical care, and abortion services, have a profound impact on women’s lives. While instructive, national statistics can mask wide regional and local variation, as well as disparities across socioeconomic, racial, and ethnic groups.
The Role of National and State Policies
Service availability and policies related to health care, contraception, and abortion vary significantly across and within states. State policymakers determine whether to expand Medicaid coverage to low-income adults under the Affordable Care Act (ACA), establish and fund family planning programs for uninsured residents, and adopt rules that regulate abortion services. These state policies also intersect with local factors; the number and distribution of family planning and safety net providers, the content of school-based sex education, cultural traditions of local populations, and underlying social determinants of health all shape access to reproductive health care at the community level. Shifting federal policies and priorities add to already complex state and local dynamics. New federal rules related to the Title X family planning program, for example, directly affect which organizations receive funding.
Community Perspectives and Case Studies
In the spring and summer of 2019, KFF, working with Health Management Associates, conducted interviews with clinicians, social service providers, community-based organizations, researchers, and health care advocates, as well as a focus group with low-income women in five “medically underserved” communities. The following table highlights the specific areas of focus within these five diverse communities across the United States:
| Community Location | Key Focus Areas |
|---|---|
| Dallas County (Selma), Alabama | Medicaid Coverage and Continuity, Provider Distribution, Social Determinants of Health, and Contraceptive Provision. |
| Tulare County, California | Medicaid Coverage, Provider Distribution, Sex Education and STIs, and Access for Special Populations. |
| St. Louis, Missouri | Provider Distribution and Religious Health Systems, Contraceptive Provision, Access, and Use. |
| Crow Tribal Reservation, Montana | Indian Health Service and Medicaid Coverage, Provider Distribution, and Sex Education Policy. |
| Erie County, Pennsylvania | Contraceptive Provision, Specialized Services for Refugee Communities, and Ob-Gyn Consolidation. |
Mobile Clinics and Rural Access Challenges
Rural areas have disproportionately fewer doctors, including OB-GYNs, than urban areas. Mobile clinics help shrink that gap in rural care, but they can be challenging to operate. Money is the greatest obstacle; a 2020 study of 173 mobile clinics found they cost an average of more than $630,000 a year. While many programs launch with the help of grants, they can be difficult to sustain, especially with over a decade of decreased or stagnant funding to Title X, a federal money stream that helps low-income people receive family planning services.
There is a small but growing number of mobile programs aimed at increasing rural access to women’s health services, including long-acting reversible contraception (LARC). There are two kinds of these highly effective methods: intrauterine devices, known as IUDs, and hormonal implants inserted into the upper arm. These birth control options can be especially difficult to obtain — or have removed — in rural areas. Rural providers may not be able to afford to stock long-acting birth control devices or may not be trained in administering them.
Cost and Practical Barriers for Patients
IUDs and hormonal implants are highly effective and can last up to 10 years. But they’re also expensive — devices can cost more than $1,000 without insurance — and inserting an IUD can be painful. Organizations that can’t afford mobile programs can consider setting up “pop-up clinics” at existing health and community sites in rural areas to bridge the gap in service provision.