The Big Beautiful Bill, a tax and spending package signed into law by President Donald Trump on July 4, is expected to slash federal spending on Medicaid by 15% in the next 10 years. According to experts with the Population Reference Bureau, any level of funding cuts could be problematic for a state like Texas that already struggles to guarantee access to contraceptives like birth control pills, condoms and the morning after pill.
The organization released a “Contraceptive Policy Scorecard” on Wednesday, which rates each state’s access to contraceptives as either protective, some protections and some restrictions, or restrictive. Scoring was done by examining state-level policies, or lack thereof, in nine indicator areas. Texas was one of 16 “restrictive” states and sixth-worst overall in the country for guaranteeing access to contraception, the scorecard found.
Any state that declined to expand Medicaid access under the 2010 Affordable Care Act automatically landed a “restrictive” ranking, Christine Power, senior policy advisor at the Population Reference Bureau (PRB), told reporters Tuesday. Texas has routinely declined to expand Medicaid access, although legislators recently voted to broaden coverage for family planning through 2030. The limited expansion provides some access to contraceptive services for low-income Texans, but those protections are limited when it comes to younger people and men.
With only 16 states receiving a protective label for contraceptive access, the national landscape is already looking bleak, and it could soon get worse, Power said. She described the Big Beautiful Bill's Medicaid cuts as “a major setback” for advocates in the reproductive healthcare space. In states like Texas, where guarantees of coverage for contraceptives are already weak, the “deep cuts” to Medicaid could be felt sooner rather than later.“State policies are really shaping the reality of contraceptive access on the ground, especially because the federal protections are crumbling." - Cathryn Streifel, senior program director at the Population Reference Bureau
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“These aren't abstract budget changes. It means that fewer people are going to be able to consistently get contraceptive care and counseling,” Power said. “On top of that, the bill does include some harmful Medicaid work requirements that are proven to push people out of coverage. And so our overall concern is that, especially in states with already limited contraceptive protections, but in all states, this bill will make it even harder for people to access basic essential care.”
Family planning in Texas may already be taking a hit. Last year, a study found that the passage of Texas’ strict abortion ban coincided with a steep drop in the number of people utilizing contraceptives. Birth control pill prescription refills fell by a third, the study found, and emergency contraceptive purchases fell by half. Experts believe these drops may have occurred because family planning clinics, which provided these medications in addition to abortions, were forced to close.
The Reality of Family Planning in Texas
The nine policy areas measured by the scorecard fall under the umbrellas of affordability, availability and environment of care. Out of the nine scoring categories, Texas did not log a single “protective” status.The first category in the affordability indicator is Medicaid expansion, which scored “restrictive” in Texas. For the two other affordability indicators, providers offering financial coverage of contraceptives and Medicaid expansion for family planning, Texas had some protections and/or some restrictions.
While the Lone Star State does require insurance companies to cover prescription contraceptives, such as birth control pills, there is no restriction on that cost being turned over to the policyholder. The PRB warns this could limit access for lower-income Texans, “worsening income-based inequities in reproductive health.”
Texas also does not require insurance companies to cover the cost of over-the-counter contraceptives, such as Plan B. According to the Kaiser Family Foundation (KFF), 13 states require insurance companies to cover the cost of over-the-counter family planning medications.
“State policies are really shaping the reality of contraceptive access on the ground, especially because the federal protections are crumbling,” Cathryn Streifel, senior program director at the PRB, said. “The reality that your access to reproductive healthcare currently depends on where you live is really unfortunate."
The availability indicator includes three categories: prescriptive authority, extended supply and emergency contraception. Texas ranked restrictive in the first category, because of limitations barring nurse midwives, nurse practitioners and pharmacists from prescribing contraceptives, and “protections and/or some restrictions” in the second two categories.
Packed house tonight as Fort Worth ISD’s school board is voting on whether to bring back sex ed to classrooms.
— Keenan Willard (@KeenanNBC5) February 28, 2024
The program up for discussion is Choosing The Best, an abstinence-centered program. Texas law requires that sex ed programs emphasize abstinence.
Parents and students… pic.twitter.com/9GVbjDT96A
Texas received the most restrictive rankings in the “environment of care” category, which includes the right of minors to consent to contraceptive services, sex education in schools and the right of pharmacists to refuse providing a medication on religious grounds.
The scorecard only took passed legislation into consideration when grading states’ stance on contraceptives, which means some of Texas’s more conservative swings at family planning that failed to make it through the legislative session weren't taken into account.
For instance, a series of proposed bills this past legislative session would have cleared a path for doctors to morally object to prescribing contraceptives on religious grounds, and another proposed law would have called for sewage water to be monitored for traces of birth control or abortion pills.
Power said Texas stood out to her in the study because none of the nine areas surveyed resulted in a “policy void,” or an area where lawmakers have chosen not to weigh in on an issue.
“That to me reflects active policymaking,” Power said. “About half of [Texas’] policies are restrictive, and half of them are marked as some protections or some restrictions, which I think shows that there are some efforts to improve access. But Texas does have significant room for improvement.”
