How State and National Policies Affect Access to Reproductive Health Care for Low-Income Women

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.

Study Overview: Access in Five Communities

In order to understand what is happening at the local level, KFF, working with Health Management Associates, conducted interviews with local clinicians, social service providers, community-based organizations, researchers, and health care advocates as well as a focus group with low-income women in five different communities: Selma and Dallas County, AL; Tulare County, CA; St. Louis, MO; Crow Tribal Reservation, MT; and Erie County, PA. Based on the interviews and focus groups, the study addresses how national, state, and local policies, as well as cultural factors, shape access to reproductive health care.

Key Findings and Cross-Cutting Themes

The report identifies themes that cut across all five “medically underserved” communities, but play out in different ways depending on the policy, political, and social environments in each place:

• Cultural and Social Determinants of Health: In each of the communities, poverty, cultural factors, and social determinants were identified as having a considerable impact on women’s ability to prioritize, afford, and get to family planning or abortion services. In addition, the residual effects of historical abuses by the medical establishment result in persistent mistrust of providers in some communities.
• Coverage and Medicaid Expansion: Interviewees identified lack of coverage options for basic health care services as a prominent challenge in states that did not adopt the ACA’s Medicaid expansion. They also identified ways to strengthen Medicaid to improve services, such as elimination of pre-authorization for certain contraceptive methods and improving systems to connect uninsured women to Medicaid-funded family planning programs.
• Provider Supply and Distribution: There are provider shortages in many communities, especially in large, rural areas. Interviewees said that challenges with recruitment and retention of clinical staff create access barriers for women, alongside a shortage of female clinicians and gaps in consistent language translation services.
• Sex Education: The importance of comprehensive sex and STI education was raised across communities. A lack of information was said to leave many girls and women uninformed or misinformed about their reproductive health care, contraceptive options, and how to access services.
• Abortion Environment: Abortion was difficult to access in all of the communities. Stigma, anti-abortion beliefs, and policy restrictions at the state and/or community level shape the availability of legal abortion services and women’s ability to access them.

Policy Impacts on the Reproductive Health Safety Net

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, and underlying social determinants of health all shape access at the community level. Shifting federal policies and priorities, such as new federal rules related to the Title X family planning program, add to already complex state and local dynamics.

Comparison of Community Research Focus Areas

The following list details the specific areas of focus and findings for each community based on the KFF case studies:

• Dallas County (Selma), AL: Focused on Medicaid coverage and continuity, provider distribution, social determinants of health, and access to abortion counseling and services.
• Tulare County, CA: Examined Medicaid coverage, sex education and STIs, and access for special populations.
• St. Louis, MO: Analyzed provider distribution, religious health systems, and contraceptive provision and use.
• Crow Tribal Reservation, MT: Investigated Indian Health Service and Medicaid coverage, sex education policy, and provider distribution.
• Erie County, PA: Highlighted specialized services for refugee communities, cost and coverage, and Ob-Gyn consolidation.