State Variations in the Role of the Reproductive Health Safety Net for Contraceptive Care Among Medicaid Enrollees – KFF

Report on Contraceptive Care Access for U.S. Medicaid Enrollees and Implications for Sustainable Development Goals

Executive Summary

This report analyzes the delivery of contraceptive care to female Medicaid enrollees in the United States, based on 2023 data. It examines the critical role of the healthcare safety net in providing these services, highlighting significant state-level variations. The findings are contextualized within the framework of the United Nations Sustainable Development Goals (SDGs), particularly SDG 3 (Good Health and Well-being), SDG 5 (Gender Equality), and SDG 10 (Reduced Inequalities). The analysis indicates that recent policy and funding changes pose a substantial threat to the progress on these goals by potentially limiting access to essential reproductive healthcare for low-income populations.

The Role of Safety Net Providers in Achieving Health and Equality Goals (SDG 3, 5, 10)

Medicaid is a cornerstone for financing family planning services, directly supporting the achievement of SDG 3, Target 3.7, which calls for universal access to sexual and reproductive healthcare services. The network of safety net providers is instrumental in delivering this care to millions of low-income individuals, thereby advancing SDG 10 by reducing health disparities.

• Nationally, 43% of female Medicaid enrollees received their last contraceptive visit of 2023 at a safety net provider.
• This reliance underscores the system’s importance for SDG 5, as access to contraception is fundamental to gender equality and women’s empowerment.
• However, a majority (54%) of enrollees received care at office-based providers or outpatient clinics, highlighting a dual system of access.

The composition and efficacy of this safety net vary significantly by state, creating an uneven landscape for achieving universal health coverage and equality.

Analysis of Service Delivery and Contribution to SDGs

The distribution of patients across different provider types reveals distinct patterns that impact the equitable delivery of healthcare. Each provider type plays a unique role in addressing the SDGs, but also faces specific vulnerabilities.

Community Health Centers (CHCs)

CHCs are a key component of the primary care infrastructure for underserved communities, contributing to SDG 3.

1. Accounted for 18% of recent contraceptive visits nationally.
2. Demonstrated significant state-level disparity, challenging the goal of uniform access under SDG 10. For example:
   • High Utilization: 46% in Washington D.C. and 38% in Rhode Island.
   • Low Utilization: 4% in Wisconsin and 6% in Utah, North Dakota, North Carolina, and Minnesota.

Planned Parenthood

As specialized reproductive health providers, Planned Parenthood clinics make a substantial contribution to SDG 3 and SDG 5 by offering a full range of contraceptive methods.

1. Served 18% of female Medicaid enrollees seeking contraception nationally in 2023.
2. State-level reliance varied dramatically, from 47% in California to 0% in states like Arkansas, Mississippi, and Texas, where participation in Medicaid is banned. This disparity directly undermines SDG 10 by creating vast inequalities in access to care.

State and Local Health Departments

Public health departments are vital institutions (SDG 16) for delivering care in certain regions, particularly to marginalized populations.

1. Nationally, they accounted for 6% of contraceptive visits.
2. Their role is disproportionately important in some states, exemplifying a localized approach to SDG 10. For instance, 39% of female Medicaid enrollees in Alabama received their last contraceptive service at a health department.

Indian Health Services (IHS)

IHS is crucial for fulfilling the mandate of SDG 10 to reduce inequalities by providing targeted healthcare to American Indian and Alaska Native populations.

1. While accounting for only 1% of visits nationally, its impact is highly concentrated.
2. In Alaska, 37% of female Medicaid enrollees received care through IHS, and 16% in South Dakota, demonstrating its indispensable role in ensuring healthcare access for indigenous communities.

Office-Based Providers and Outpatient Clinics

These providers deliver care to the majority (54%) of Medicaid enrollees, forming the backbone of the system. However, access to these sites is contingent on maintaining insurance coverage, a vulnerability that threatens progress on SDG 1 (No Poverty) and SDG 3.

Policy Challenges and Threats to Sustainable Development

Recent legislative actions, judicial rulings, and administrative policies are creating significant instability within the reproductive health safety net, jeopardizing progress toward key SDGs.

• Funding Restrictions: The 2025 Federal Budget Reconciliation Law and the Supreme Court ruling in Medina v. Planned Parenthood have enabled states to exclude certain providers from Medicaid and have imposed a federal funding ban. These actions directly threaten the institutional stability (SDG 16) required to deliver on SDG 3 and SDG 5.
• Increased Uninsured Population: The same 2025 law is projected to increase the number of uninsured individuals by millions due to new work requirements for Medicaid eligibility. This development represents a significant setback for universal health coverage (SDG 3) and efforts to reduce poverty (SDG 1) and inequality (SDG 10).
• Uncertainty for Title X: The federal Title X family planning program faces an uncertain future, further destabilizing the funding environment for clinics that serve low-income and uninsured patients.

Conclusion: Future Outlook

The reproductive health safety net in the United States is at a critical juncture. While it has been instrumental in advancing health, gender equality, and equity goals, it now faces unprecedented challenges from policy and funding shifts. The reduction in federal support and the exclusion of key providers are likely to weaken the healthcare infrastructure, particularly for the most vulnerable populations. These changes risk reversing progress on SDGs 3, 5, and 10, leading to increased health disparities, a greater number of unintended pregnancies, and diminished opportunities for women and low-income families. Sustained investment and supportive policies are essential to ensure the continued delivery of these vital services and uphold commitments to sustainable development.

Analysis of Sustainable Development Goals in the Article

1. Which SDGs are addressed or connected to the issues highlighted in the article?

• SDG 3: Good Health and Well-being: The article’s central theme is access to contraceptive care, which is a critical component of public health and individual well-being. It discusses how policy changes and funding cuts affect the availability of essential reproductive health services for millions of people, directly impacting their health outcomes.
• SDG 5: Gender Equality: The analysis focuses specifically on “female Medicaid enrollees” and their access to contraceptive services. Access to family planning is fundamental to gender equality, empowering women to make informed decisions about their reproductive health, which in turn affects their educational and economic opportunities. The article highlights how barriers to these services disproportionately affect women.
• SDG 10: Reduced Inequalities: The article underscores inequalities in healthcare access based on socioeconomic status and geography. It focuses on “low-income people” covered by Medicaid and highlights the significant variations in service availability from state to state. It also points to disparities affecting specific populations, such as American Indian and Alaska Natives who rely on Indian Health Services, thereby addressing inequality within and among countries (in this case, states).

2. What specific targets under those SDGs can be identified based on the article’s content?

1. Under SDG 3 (Good Health and Well-being):
   • Target 3.7: “By 2030, ensure universal access to sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes.” The entire article is an analysis of the provision of and barriers to “family planning” and “contraceptive care” through various safety net providers, which directly relates to this target of ensuring universal access.
   • Target 3.8: “Achieve universal health coverage, including financial risk protection, access to quality essential health-care services…” The article discusses Medicaid as a “major source of coverage” for contraceptive care, which is an essential health service. The threats to Medicaid funding and provider participation, as detailed in the article, represent a direct challenge to achieving universal health coverage for low-income populations.
2. Under SDG 5 (Gender Equality):
   • Target 5.6: “Ensure universal access to sexual and reproductive health and reproductive rights…” This target is directly addressed by the article’s focus on the accessibility of contraceptive services for women. The discussion of funding cuts, clinic closures, and legal challenges that limit access to providers like Planned Parenthood is a discussion of the erosion of practical access to reproductive health services and rights.
3. Under SDG 10 (Reduced Inequalities):
   • Target 10.2: “By 2030, empower and promote the social, economic and political inclusion of all, irrespective of… economic or other status.” The article highlights how policy changes disproportionately affect “low-income people” and specific ethnic groups (American Indian and Alaska Native populations), potentially hindering their social and economic inclusion by limiting their control over reproductive health.
   • Target 10.3: “Ensure equal opportunity and reduce inequalities of outcome, including by eliminating discriminatory laws, policies and practices…” The article analyzes policies like the “2025 Federal Budget Reconciliation Law” and Supreme Court rulings that create unequal access to healthcare for low-income women, effectively reducing equal opportunity for health outcomes based on socioeconomic status and location.

3. Are there any indicators mentioned or implied in the article that can be used to measure progress towards the identified targets?

Yes, the article is rich with quantitative data that can serve as indicators to measure progress:

• Indicators for Access to Family Planning (Targets 3.7 & 5.6):
  • Share of population served by provider type: The article provides precise figures, such as “Over four in ten (43%) received their last contraceptive visit of 2023 at a safety net provider.” It breaks this down further: 18% at Community Health Centers, 18% at Planned Parenthood, 6% at Health Departments, and 1% at Indian Health Services. These percentages are direct measures of service access.
  • State-level disparities in access: The article provides numerous examples of state-level data that indicate unequal access. For instance, the share of female Medicaid recipients using Planned Parenthood “ranged from 0% in states that… ban Planned Parenthood… to almost half (47%) of California female Medicaid recipients.” This variation is a key indicator of geographic inequality.
  • Impact of cost on access: The article cites a survey finding that “20% of uninsured females reported that they had to stop using a method of birth control because of cost,” which is a direct indicator of economic barriers to contraceptive access.
• Indicators for Universal Health Coverage (Target 3.8):
  • Health insurance coverage rates: The article mentions that the “2025 Federal Budget Reconciliation Law is also projected to increase the number of individuals without insurance by 10 million over the next 10 years.” This projection is a critical indicator of a decline in health coverage.
• Indicators for Reduced Inequalities (Targets 10.2 & 10.3):
  • Disparities in service utilization by specific populations: The article highlights that in Alaska, “more than one in three (37%) female Medicaid enrollees received their last contraceptive visit of 2023 at an Indian Health Services site.” This demonstrates the crucial role of specific providers for certain ethnic groups and serves as an indicator of their reliance on a potentially vulnerable part of the safety net.
  • Geographic disparities in provider networks: The data showing that health departments play a much larger role in Southeastern states (e.g., 39% of female Medicaid enrollees in Alabama) compared to other parts of the country is an indicator of regional inequality in the structure of healthcare delivery.

4. Create a table with three columns titled ‘SDGs, Targets and Indicators” to present the findings from analyzing the article.

Source: kff.org