Last year, reproductive rights in the United States received a devastating blow when the Supreme Court decided to overturn Roe v. Wade in the Dobbs v. Jackson Women’s Health Organization case, undoing nearly fifty years of precedent for legal abortion access. Despite the urgency of the moment for sexual and reproductive health, progress for contraceptive access has unfortunately been slow since the Dobbs decision. The Title X grant program received no increase in funding in the 2023 fiscal year spending bill for the ninth year in a row. The U.S. Food and Drug Administration (FDA) also postponed the advisory committee meeting (previously scheduled for November 2022) that was designed to weigh the approval for an over-the-counter (OTC) oral contraceptive pill.

However, there are still some signs of progress that advocates hope to build upon as we start the 118th Congress. This report will outline key policy priorities and recommendations to focus on this year that will further contraceptive equity.

The Title X Program

Title X serves as our nation’s only federally funded family planning program.1 First signed into law over fifty years ago as an amendment to the Public Health Service Act, Title X provides affordable birth control and sexual health care services, such as testing for sexually transmitted infections and cancer screenings, to millions of low-income people across the country. This program is also critical to contraceptive equity: data from 2021 indicate that approximately one-fourth of Title X patients self-identified as Black and nearly two-thirds self-identified as Hispanic or Latino.2

Title X is still recovering from the damage caused to the program during the Trump administration, primarily by a regulation known as domestic gag rule. The gag rule prohibited abortion referrals by Title X clinics and required an unnecessary physical and financial separation of Title X-funded activities from abortion-related activities (Title X already does not pay for abortion care).3 Fortunately, the Biden–Harris administration ended the Title X gag rule in 2021, restoring the program back to its pre-Trump regulatory framework with modifications to strengthen the program.4 However, one in four Title X service sites were forced out of the network due to the gag rule prior to the Biden–Harris administration rule changes, resulting in a staggering 46 percent reduction in network capacity, the negative effects of which are still being felt nationwide.5

Following the Dobbs decision, the Biden–Harris administration provided additional supplementary allocations of funding to Title X. Unfortunately, in another loss for reproductive health and rights, the Title X program was flat funded at $286.5 million for the ninth year in a row in the 2023 omnibus spending bill—and this is in spite of requests from research and advocacy organizations to increase investments in the program to at least $737 million, as well as of President Biden’s FY 2024 budget proposal to increase Title X investments to $512 million.6 This leaves Title X funding levels stagnant in Congress. And, when taking inflation into consideration, these levels are actually significant decreases.

Meanwhile, certain elements of the program have recently been contested in the courts under baseless claims. In December 2022, a Trump-appointed federal judge in Texas issued an opinion in Deanda v. Becerra claiming that “the Title X program violates the constitutional right of parents to direct the upbringing of their children.” This opinion not only contained a number of legal errors and ignored legal precedent, it also completely disregarded the fact that federal law requires the Title X program to include health care services for adolescents, including voluntary and confidential family planning services.7 However, it indicated something that reproductive rights advocates have been sounding the alarm on for years, but especially in the wake of the Dobbs decision: there are forces within the U.S. judiciary system with a strong desire to chip away at not just the right to abortion, but also the right to contraception. Young people’s access to non-coercive, affordable, and confidential contraception is a major part of contraceptive equity. Research shows that adolescents who are concerned about the confidentiality of their contraceptive care are 45 percent less likely to obtain it.8 What’s more, many young people rely on Title X. In 2021, 15 percent (over 250,000 people) of all Title X patients were under the age of 20.9

There are forces within the U.S. judiciary system with a strong desire to chip away at not just the right to abortion, but also the right to contraception.

It is also important to note that preventing pregnancy is not the only reason why people seek birth control, and that the Title X program provides services beyond birth control. Fibroids, polycystic ovary syndrome, and other reproductive health challenges that disproportionately impact Black women and birthing people are additional reasons why someone might seek birth control.10 With the current STD crisis in the United States, ensuring equitable access to STD testing and ovarian cancer screening (two other health care services offered through the Title X program) is essential.11 When reproductive health care providers lose access to Title X funding and can’t stay open as a result, communities across the country are losing access to these essential services as well.

While increasing next year’s funding levels for the Title X program may prove challenging due to the current split of power in the 118th Congress, advocacy for the evidence-based, research supported increase to $737 million is necessary to continue garnering support for the critical services that the Title X program provides. Contraception is by no means a replacement for abortion care, but with the current patchwork legal landscape surrounding abortion access across different states, it is more important than ever that everyone—especially low-income folks who rely on Title X—has access to a range of birth control options that work for them in the absence of Roe.

Over-the-Counter Oral Contraceptive Pills

Globally, over 100 countries have already made birth control pills available over-the-counter.12 It is long past time for the United States to join them. In this country, hormonal contraceptives are currently the most common forms of reversible contraception.13 Research shows that a majority (over three-quarters) of reproductive aged women support making birth control pills available over-the-counter without a prescription, and nearly 60 percent state “convenience” as the leading reason why they would be very likely to use OTC birth control pills.14 More than 19 million women of reproductive age in the United States currently live in contraceptive deserts, meaning that they live in a county lacking a health center with the full range of contraceptive options.15

More than 19 million women of reproductive age in the United States currently live in contraceptive deserts, meaning that they live in a county lacking a health center with the full range of contraceptive options.

Not only do OTC oral contraceptive pills have the potential to fill some of the gaps in access seen across the United States by eliminating the need for a prescription to be filled, but they are also safe and effective. The American College of Obstetricians and Gynecologists (ACOG) supports over-the-counter access to hormonal contraception without age restrictions, citing data that supports the safety and efficacy of progestin-only hormonal methods.16 The American Medical Association (AMA) has also urged the FDA to make oral contraceptives available over-the-counter.17

Unfortunately, in November 2022, the FDA postponed the advisory committee meeting, during which they planned to weigh the approval for a progestin-only OTC oral contraceptive pill, called OPILL. The evidence is clear that OPILL would not only be supported by and popular amongst the general public, but that it is also safe and effective. The FDA must act with urgency to reschedule their review and approve this method of hormonal oral contraception for over-the-counter use.

Protecting Contraceptive Coverage

Moving birth control pills to OTC status is a great tool to remove barriers and expand access to care, but it should be considered in tandem with other important contraceptive policy priorities. Without health insurance, one year’s supply of birth control pills can cost up to $600.18 What’s more, while an OTC oral contraceptive option would be a major step in improving access to reproductive health care, the pill is just one of many different birth control options. Research indicates that uninsured patients were significantly less likely than insured patients to be unable to access contraceptives due to cost.19

Thanks to the Affordable Care Act (ACA) and the Biden–Harris administration, most private insurance is required to cover one form in all eighteen different birth control categories approved by the FDA, and private insurers must cover contraception without cost-sharing measures.20 However, the ACA’s birth control benefit has faced challenges with religious refusals in the courts, and many insurers are not enforcing the rule properly.21 Women and birthing people of color in the United States are more likely to be uninsured or enrolled in Medicaid compared to their white counterparts.22 Protecting contraceptive coverage for a full range of options regardless of one’s health insurance status is essential to contraceptive equity.

The Families First Coronavirus Response Act was effective at maintaining continuous Medicaid coverage for those who needed it until the end of the COVID-19 Public Health Emergency (PHE).23 Medicaid enrollment grew to unprecedented levels during the PHE.24 Now, the Biden–Harris administration plans to end the PHE in May, and even before that, Congress severed the PHE from the Medicaid continuous coverage requirement in the 2023 omnibus.25 States will be able to disenroll Medicaid enrollees for the first time since early 2020 beginning on April 1, 2023 and millions of low-income people and people of color may experience disruptions in their health coverage due to administrative barriers.

This disenrollment could have a damaging impact on contraceptive access for some of the most vulnerable populations. One of the main causes for unintended pregnancy in the United States is gaps in contraceptive use, and one in four women of reproductive age who are Medicaid enrollees obtain contraception through Medicaid.26 As the Medicaid unwinding process looms ahead, states should be proactively working to prevent people from falling through the cracks, including by ensuring that eligible people renew their Medicaid and others are directed to other coverage sources.

Emergency Contraception

Emergency contraception (EC) is a form of birth control that, if taken shortly after unprotected sex, can prevent pregnancy.27 Roughly one-quarter of sexually active women in the United States have used EC.28 One popular form of EC, commonly known as “Plan B,” is currently available over-the-counter in all U.S. states.

However, a concerning recent poll shows that roughly one-third of all adults in the United States, and half of all women living in states where abortion is banned, are unsure of the legality of Plan B in their state, and a majority of adults are under the false impression that EC can end a pregnancy.29 This lack of public awareness is even more worrisome when prior and current political attacks on reproductive health care access are taken into account. Conservative lawmakers in Missouri, for example, have tried (and failed) to prevent their state’s Medicaid agency from paying for specific forms of contraception, including EC and intrauterine devices (IUDs).30 The states most likely to make an attempt to ban EC are also the states that have already banned abortion and are disproportionately harming women and birthing people of color.31

In December of 2022, the FDA changed the labeling on EC pills to clarify that they are not, in fact, abortifacients.32 This was a major step forward. Policymakers at all levels must be clear in their definitions of contraception, and ensure that the classification of EC does not fall under the umbrella of abortifacients. While the Biden–Harris administration has taken a number of important steps towards protecting reproductive rights since the Dobbs decision, including the FDA EC labeling change, more public messaging on the safety, efficacy, and legality of EC as well as emphasizing the distinction between EC and medication abortion is necessary in order to quell confusion and misinformation campaigns.33

It’s Time to Meet the Urgency with Action

As the state of sexual and reproductive rights in the United States continues to deteriorate due to constant attacks from conservative lawmakers, it is critical that the affordability of contraception, as well as access to the full range of contraceptive methods, is prioritized through policy. Increasing Title X funding, approving OTC oral contraception, protecting insurance coverage of contraception, and improving public awareness of emergency contraception should all be priorities for anyone seeking to advance contraceptive equity.

Notes

  1. Vina Smith-Ramakrishnan, “How to Advance Health Equity and Build a Stable Future for Title X,” The Century Foundation, February 17, 2022, https://tcf.org/content/commentary/advance-health-equity-build-stable-future-title-x/.
  2. Christina Fowler, Julia Gable, and Beth Lasater, “Family Planning Annual Report: 2021 National Summary,” Office of Population Affairs, Office of the Assistant Secretary for Health, Department of Health and Human Services, September, 2022, https://opa.hhs.gov/sites/default/files/2022-09/2021-fpar-national-final-508.pdf.
  3. “What is Title X? An Explainer,” Physicians for Reproductive Health, https://prh.org/what-is-title-x-an-explainer/.
  4. “Memorandum on Protecting Women’s Health at Home and Abroad,” The White House, January 28, 2021, https://www.whitehouse.gov/briefing-room/presidential-actions/2021/01/28/memorandum-on-protecting-womens-health-at-home-and-abroad/
  5. Ruth Dawson, “Trump Administration’s Domestic Gag Rule Has Slashed the Title X Network’s Capacity by Half,” Guttmacher Institute, February 5, 2020, https://www.guttmacher.org/article/2020/02/trump-administrations-domestic-gag-rule-has-slashed-title-x-networks-capacity-half
  6. “Blueprint for Sexual and Reproductive Health, Rights, and Justice,” July 2019, https://reproblueprint.org/wp-content/uploads/2019/07/BlueprintPolicyAgenda-v14-PR-All-1.pdf; “Budget of the U.S. Government Fiscal Year 2024,” Office of Management and Budget,The White House, March 9, 2023, https://www.whitehouse.gov/wp-content/uploads/2023/03/budget_fy2024.pdf
  7. Kinsey Hasstedt, “Ensuring Adolescents’ Ability to Obtain Confidential Family Planning Services in Title X,” Guttmacher Institute, November 15, 2018, https://www.guttmacher.org/gpr/2018/11/ensuring-adolescents-ability-obtain-confidential-family-planning-services-title-x
  8. Kinsey Hasstedt, “Ensuring Adolescents’ Ability to Obtain Confidential Family Planning Services in Title X,” Guttmacher Institute, November 15, 2018, https://www.guttmacher.org/gpr/2018/11/ensuring-adolescents-ability-obtain-confidential-family-planning-services-title-x
  9. Christina Fowler, Julia Gable, and Beth Lasater, “Family Planning Annual Report: 2021 National Summary,” Office of Population Affairs, Office of the Assistant Secretary for Health, Department of Health and Human Services, September, 2022, https://opa.hhs.gov/sites/default/files/2022-09/2021-fpar-national-final-508.pdf.
  10. Chloe A. Mondesir, “New Fibroids Policy Must Be Part of the Black Maternal Health Agenda,” The Century Foundation, May 6, 2022, https://tcf.org/content/commentary/new-fibroids-policy-must-be-part-of-the-black-maternal-health-agenda/
  11. “New data suggests STDs continued to increase during first year of the COVID-19 pandemic,” Centers for Disease Control and Prevention, April 12, 2022, https://www.cdc.gov/media/releases/2022/p0412-STD-Increase.html
  12. “OTC Access World Map,” Free the Pill, July 12, 2022, https://freethepill.org/otc-access-world-map
  13. “Contraceptive Use in the United States by Method,” Guttmacher Institute, May 2021, https://www.guttmacher.org/fact-sheet/contraceptive-method-use-united-states
  14. Michelle Long, Brittni Frederiksen, Usha Ranji, Karen Diep, and Alina Salganicoff, “Interest in Using Over-the-Counter Oral Contraceptive Pills: Findings from the 2022 KFF Women’s Health Survey,” KFF, November 3, 2022, https://www.kff.org/womens-health-policy/issue-brief/interest-using-over-the-counter-oral-contraceptive-pills-findings-2022-kff-womens-health-survey/
  15. “Contraceptive Deserts,” Power to Decide, 2023, https://powertodecide.org/what-we-do/access/contraceptive-deserts
  16. “Over-the-Counter Access to Hormonal Contraception,” The American College of Obstetricians and Gynecologists, October 2019, https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2019/10/over-the-counter-access-to-hormonal-contraception#
  17. “AMA urges FDA to make oral contraceptive available over-the-counter,” The American Medical Association, June 15, 2022, https://www.ama-assn.org/press-center/press-releases/ama-urges-fda-make-oral-contraceptive-available-over-counter
  18. “How much do birth control pills cost?” Planned Parenthood, June 29, 2022, https://www.plannedparenthood.org/learn/ask-experts/how-much-do-birth-control-pills-cost
  19. Megan L. Kavanaugh and Rubina Hussain, “Associations between unfulfilled contraceptive preferences due to cost and low-income patients’ access to and experiences of contraceptive care in the United States, 2015-2019,” Guttmacher Institute, May 2022, https://www.guttmacher.org/article/2022/05/associations-between-unfulfilled-contraceptive-preferences-due-cost-and-low-income
  20. “HHS, DOL, and Treasury Issue Guidance Regarding Birth Control Coverage,” Department of Health and Human Services, July 28, 2022, https://www.hhs.gov/about/news/2022/07/28/hhs-dol-treasury-issue-guidance-regarding-birth-control-coverage.html#:~:text=Under%20the%20ACA%2C%20most%20private,including%20access%20to%20emergency%20contraceptives.3
  21. Adam Sonfield, “The ACA’s Birth Control Benefit is Back Before the Supreme Court,” Guttmacher Institute, January 2020, ​​https://www.guttmacher.org/article/2020/01/acas-birth-control-benefit-back-supreme-court#:~:text=On%20July%208%2C%20the%20U.S.,Care%20Act’s%20contraceptive%20coverage%20guarantee.;  “Access to Birth Control Without Out-of-Pocket Costs: Improving and Expanding the Affordable Care Act’s Contraceptive Coverage Requirement,” National Women’s Law Center, November 16, 2021, https://nwlc.org/resource/access-to-birth-control-without-out-of-pocket-costs-improving-and-expanding-the-affordable-care-acts-contraceptive-coverage-requirement/
  22. “Women of Color More Likely to be Uninsured or Covered by Medicaid,” KFF, https://www.kff.org/women-of-color-more-likely-to-be-uninsured-or-covered-by-medicaid-womenshealth/
  23. Kellie Moss, Lindsey Dawson, Michelle Long, Jennifer Kates, Marybeth Musumeci, Juliette Cubanski, and Karen Pollitz, “The Families First Coronavirus Response Act: Summary of Key Provisions,” KFF, March 23, 2020, https://www.kff.org/coronavirus-covid-19/issue-brief/the-families-first-coronavirus-response-act-summary-of-key-provisions/
  24. Bradley Corallo and Sophia Moreno, “Analysis of Recent National Trends in Medicaid and CHIP Enrollment,” KFF, February 6, 2023, https://www.kff.org/coronavirus-covid-19/issue-brief/analysis-of-recent-national-trends-in-medicaid-and-chip-enrollment/
  25. Sharon LaFraniere and Noah Weiland, “U.S. Plans to End Public Health Emergency for Covid in May,” New York Times, January 30, 2023, https://www.nytimes.com/2023/01/30/us/politics/biden-covid-public-health-emergency.html; Jennifer Tolbert and Meghana Ammula, “10 Things to Know About the Unwinding of the Medicaid Continuous Enrollment Provision,” KFF, February 22, 2023, https://www.kff.org/medicaid/issue-brief/10-things-to-know-about-the-unwinding-of-the-medicaid-continuous-enrollment-provision/#:~:text=The%20Consolidated%20Appropriations%20Act%2C%202023,states%20can%20resume%20Medicaid%20disenrollments.
  26. “Access to Contraception,” The American College of Obstetrics and Gynecology, January 2015, https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2015/01/access-to-contraception;  Brittni Frederiksen, Usha Ranji, and Alina Salganicoff, “Family Planning and Contraceptive Provision Among Females Enrolled in Medicaid,” February 17, 2022, https://www.kff.org/womens-health-policy/issue-brief/family-planning-and-contraceptive-provision-among-females-enrolled-in-medicaid/
  27. “Emergency Contraception,” Guttmacher Institute, February 1, 2023, https://www.guttmacher.org/state-policy/explore/emergency-contraception
  28. “Use of Emergency Contraception in the United States,” Guttmacher Institute, September 2021, https://www.guttmacher.org/fact-sheet/use-emergency-contraception-united-states
  29. Grace Sparks, Shannon Schumacher, Marley Presiado, Ashley Kirzinger, and Mollyann Brodie, “KFF Health Tracking Poll: Early 2023 Update on Public Awareness On Abortion and Emergency Contraception,” KFF, February 1, 2023, https://www.kff.org/womens-health-policy/poll-finding/kff-health-tracking-poll-early-2023/?utm_campaign=KFF-2023-Womens-Health-Policy-WHP&utm_medium=email&_hsmi=244022061&_hsenc=p2ANqtz-_HjKMIQRsqccSfByw8JKF4WGJv-ZUV_yjbRwzQT9T_GPR41qFbX6A457epEuBCO7g2QgWLVm2BcDDdNdTyLxpoxDaBvHCwuQm5fLOunVK9n5DDK_M&utm_content=244022061&utm_source=hs_email
  30. Sheryl Gay Stolbert, “In Missouri, Battles Over Birth Control Foreshadow a Post-Roe World,” The New York Times, June 25, 2022, https://www.nytimes.com/2022/06/13/us/politics/birth-control-roe-v-wade.html
  31. Aria Bendix, “Birth control restrictions could follow abortion bans, experts say.” NBC News, June 24, 2022, https://www.nbcnews.com/health/health-news/birth-control-restrictions-may-follow-abortion-bans-roe-rcna35289; Anne Branigin and Samantha Chery, “Women of color will be most impacted by the end of Roe, experts say,” The Washington Post, June 24, 2022, https://www.washingtonpost.com/nation/2022/06/24/women-of-color-end-of-roe/
  32. Laurie McGinley and Lenny Bernstein, “‘Morning after’ pill label changed to clarify it does not cause abortion,” The Washington Post, December 23, 2022, https://www.washingtonpost.com/health/2022/12/23/morning-after-pill-label-change-fda/
  33. Jamila Taylor and Anna Bernstein, “How the Biden-Harris Administration Is Supporting Access to Abortion,” The Century Foundation, November 16, 2022, https://tcf.org/content/commentary/how-the-biden-harris-administration-is-supporting-access-to-abortion/

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