The Affordable Care Act guarantees coverage for all forms of prescription birth control for women enrolled in most insurance plans, yet inequity in access to birth control persists. As of 2021, 12.9 percent of women of childbearing age did not have health insurance coverage. In Texas, the rate was more than double the national average, with 26.3 percent of women of childbearing age uninsured. For people in twelve states, the Affordable Care Act’s promise of expanded Medicaid coverage to all low-income Americans remains a distant dream.
For women who cannot afford health insurance, the most foolproof methods of birth control come at a very steep price. While most women can afford to pay a few dollars at a time for condoms at a drugstore or can otherwise access them for free through community health initiatives, far fewer can afford to pay $800 or more at once for an intrauterine device (IUD) or birth control implant. Even fewer uninsured women can afford tubal ligation, a common form of sterilization which is effectively permanent.
The effectiveness gap between these methods of birth control is staggering. 18 percent of women using male condoms and 9 percent of women using the birth control pill as their sole method of birth control will get pregnant within one year of typical use. In stark contrast, less than 1 percent of women using the IUD or about 0.05 percent of women using the implant as their sole method of birth control will get pregnant within one year. Uninsured women often have little choice but to use less-effective methods of birth control which place them at substantial risk of unwanted pregnancy.
Restrictive abortion laws compound the issues faced by uninsured women even further. The two states with the highest rates of uninsured women of childbearing age are also the two states with the most restrictive abortion laws in the nation. Texas and Oklahoma share the dubious distinction of being the two states with both the highest rates of uninsured women and the most restrictive abortion laws in the nation. Texas has an active law banning abortion after the detection of embryonic or fetal cardiac activity, which typically happens at around six weeks gestation, before many women learn they are pregnant. Oklahoma has an active near-total abortion ban which applies at all gestational ages, with only narrow exceptions for rape, incest, and endangerment of the pregnant woman’s life.
With the nation currently awaiting an upcoming Supreme Court decision in which the justices will decide whether to overturn the precedent set by Roe v. Wade, which gave women the right to obtain an abortion before fetal viability, the implications of being uninsured are especially dire for women of childbearing age. If the Supreme Court does overturn Roe v. Wade, as a leaked draft opinion suggests it likely will, trigger laws outlawing abortion at various stages in gestation will go into effect in thirteen states. Nine of these thirteen states have above-average rates of uninsured women of childbearing age. While all women in these states will have their reproductive choices limited by these abortion bans, uninsured women will face an even more difficult situation.
A woman who cannot afford health insurance is unlikely to be able to afford more effective forms of birth control and is therefore at a substantially greater risk of unwanted pregnancy than a woman who can afford health insurance. Once pregnant, a woman living in a state with active abortion bans faces difficult choices—does she carry the unwanted pregnancy to term, or does she travel potentially hundreds or even thousands of miles to seek an abortion in another state? For low-income women, the latter option may not be possible at all. If she chooses to carry to term or has no choice but to carry to term, she will struggle to pay for prenatal and antenatal care, hospital delivery, and necessities for the care of her child, such as diapers and infant formula.
All but one state with trigger laws on the books has maternal mortality rates above the national average. For some women, abortion bans will be a death sentence. The women affected by these bans will disproportionately be uninsured, low-income women. Once again, it will be poor women who suffer from the decisions made by predominantly male lawmakers the most. In the coming days, we will see just how far lawmakers are willing to rollback the rights of women.
No matter how the Supreme Court rules, we cannot stop fighting for women and girls.
