Methodology & Sources
Many of the barriers to client-centered contraceptive access in the United States are directly or indirectly shaped by federal and state policies. While federal policies provide a broad foundation for contraceptive access, states set their own policies that expand and protect these rights or curtail them.
The patchwork of federal and state policies that govern contraceptive access in the United States creates a tiered system that promotes or inhibits access to affordable, available, and equitable contraceptive care based on a person’s state of residence. Such a chaotic and confusing policy landscape is detrimental to patients seeking information and care and to advocates and policymakers working to expand and protect access to essential contraceptive services.
In creating the State of Access: A Contraceptive Policy Scorecard, PRB provides a tool that easily and comprehensively assesses the extent to which each state’s policy environment enables and supports access to contraceptives, including by minors, and what policy actions states can take as a result. This tool focuses specifically on contraceptive access and is intended to be used by a wide audience—advocates, civil society organizations, journalists, donors, and researchers.
Scorecard Framework
While considering how to structure the State of Access scorecard, PRB explored various conceptual frameworks that define the concept of “access” to health care to guide and organize policies identified in our research. We considered many frameworks, including Roy Penchansky and William Thomas’s “The Concept of Access,” Jean-Frederic Levesque’s “Patient-Centered Access to Health Care,” and Emily Saurman’s “Improving Access: Modifying Penchansky and Thomas’s Theory of Access.” Each of these frameworks conceptualize multiple dimensions of access (ranging from five to six dimensions) that aim to identify relevant determinants that can impact access to health care. Penchansky and Thomas conceptualize access to health care as the degree of fit between patients and the health care system and identify five dimensions of access: availability, accessibility, accommodation, affordability, acceptability. Saurman adds awareness—a sixth dimension—to the Penchansky and Thomas framework since knowledge and information are required for access. Other frameworks were also explored, including Biana Hall, Cynthia Akwatu, and Antoinette Danvers’s “Reproductive Justice Framework” and John Fortney et. al’s “A Re-Conceptualization of Access for 21st Century Healthcare.” These frameworks are used to improve the planning and delivery of equitable health care services, including in underserved communities.
While we initially decided to use Saurman’s “Six A’s” to group policy indicators in the scorecard, our review of Saurman’s dimensions of access and evidence in the literature showed limitations of this framework’s application for our purposes. Some components of the dimensions of access are useful in measuring the community, health system, and interpersonal levels, but they are not as useful for measuring policy because policy is overarching by design. We also felt it was crucial to ground the scorecard in a public-facing nature to make the web feature the most useful tool possible for users. To do so, we’ve sought to avoid jargon (like “accommodation”) and ensure that each category grouping contains at least two policy indicators to make it easier for a wide range of users.
Thus, the scorecard builds on established frameworks and uses a revised conceptual model for grouping contraceptive access policies. While we chose not to replicate all dimensions of Saurman’s Improving Access framework, we did use the dimensions that cover policies implemented at the state level—affordability, availability, and awareness. In addition to these three dimensions, we chose to integrate perspectives from equity-centered frameworks that recognize the unique challenges that young people face when seeking contraceptive care. Our final model looked at three dimensions of access:
Affordability: Affordability policies examine direct costs for patients.
Availability: Availability policies examine policies that support faster access and sufficient services/resources to meet the patients’ needs.
Environment of Care: Environment of care policies include those that cover communications, information (i.e., awareness), and consumer perception (i.e., acceptability).
Comprehensive Literature Review
To identify the policy interventions associated with increased access to contraception in the United States, PRB conducted a comprehensive literature review of high-quality research and evaluation articles, including peer-reviewed literature, gray literature (i.e., research from organizations like nonprofits and think tanks), and technical guidance published by government and multilateral health agencies. We determined key search terms for the literature review on an iterative basis, beginning with broad terms such as “contraception, access, use, barriers, and state policy.” We also used additional search terms based on key words in the literature resulting from broad terms, including “sex education, long-acting reversible contraception, youth, Title X, Medicaid, coverage, privacy, consent, prescription, and dispensing.” Based on the literature review findings, we identified a broad list of policies and interventions that provided evidence in support of increasing access to contraceptives.
Selecting Policy Indicators
The evidence on the effectiveness of interventions on complex behavior such as contraceptive access is varied and at times contradictory. Acknowledging these challenges, we narrowed the broad list of policies down to those for which certain conditions apply:
- The policy is associated with a strong body of evidence supporting impact on contraceptive access, including among minors. Policies around abortion are not included.
- The evidence is from the United States and can be implemented at the state level and compared across most state contexts. Policies primarily implemented at the institutional or clinical level are excluded, as are those that are primarily impacted by federal-level policies.
- The policy has information publicly available.
Policies that overlapped or resulted in duplication with other policies in the scorecard were removed or combined, including policies that appeared as two sides of the same policy coin. For instance, Medicaid Expansion includes policies that increase access to contraception and policies that decrease access.
Technical Expert Review Panel
To assist with validation of our methodology, we formed and consulted a technical expert review panel for guidance. The panel was composed of 16 experts in contraceptive access representing national, state, and local levels and a variety of sectors, including academia, advocacy, and service delivery. See About for more information about the panel. The expert panel guided the framework approach, assisted in narrowing down the indicator list, and contributed to the final weighting of each indicator. While some policies may span more than one category, the project team made collective decisions about how to best place indicators in a single category.
Final Indicators Selected
The final nine indicators identified are:
Medicaid Expansion: Policies that adopt and implement Medicaid expansion under the Affordable Care Act.
Family Planning Medicaid Expansion: Policies that expand Medicaid coverage of family planning services through a waiver, state-plan amendment, or state-funded program.
Contraceptive Coverage: Policies requiring insurers to cover prescription and over-the-counter contraceptive methods without cost sharing.
Extended Contraceptive Supply: Policies requiring extended supplies of contraceptive methods available under private insurance and Medicaid.
Emergency Contraception: Policies that expand access to emergency contraception in emergency rooms or restrict access to emergency contraception in state family planning programs or contraceptive coverage mandates.
Prescriptive Authority: Policies that allow pharmacists, nurse midwives, and nurse practitioners to prescribe contraceptives independently.
Minor Consent: Policies that allow minors to consent to contraceptive care without parental involvement.
Sex Education: Policies that require comprehensive sex education or abstinence-plus education that is medically accurate and has an opt-out policy.
Refusal Clauses: Policies that allow pharmacists, individual providers, and health care facilities to deny contraceptive care to patients for religious or moral reasons.
Policy Indicator Classification and Grading Scale
Each state is evaluated across the nine policy indicators using a four-level classification system: protective, some protections and/or restrictions, restrictive, and no policy. This qualitative grading scale was developed to reflect the relative strength or limitation of each policy in supporting access to contraceptives. Not all indicators align neatly across all four categories. Some policies reflect positive actions only, where the presence of legislation expands or facilitates access, and the absence of such legislation is categorized as “no policy” rather than “restrictive.” For example, Extended Supply of Contraceptives can be considered a positive policy action and does not have a “restrictive” option.
For two affordability indicators, however, the absence of a policy is considered restrictive. This approach is supported by the literature review conducted for the scorecard, which found that lacking specific protections—specifically Medicaid Expansion under the Affordable Care Act (ACA) or Family Planning Medicaid Expansion—creates significant barriers to contraceptive access, particularly for populations with low income. Based on these findings, the scorecard treats the absence of such policies as indicative of a restrictive policy environment.
Other indicators, such as refusal clauses, are inherently restrictive in nature. In these cases, the scorecard only includes a restrictive, some protections and/or restrictions, or no policy designation, as no corresponding legislative action confers a protective effect.
We chose to distinguish “no policy” from “restrictive” or “protective” policies because the absence of legislation can reflect a range of realities: inaction, legal ambiguity, or reliance on federal protections or default practices. By separating these categories, we aim to provide a more accurate and nuanced picture of the policy landscape, especially in states where a policy silence or void may still shape access—intentionally or unintentionally.
Indicator Scoring Rules
Table 1 outlines how states were categorized for each policy indicator based on policies enacted in each state.
Table 1. Policy Indicator Scoring Rules
Medicaid Expansion
State has adopted and implemented full Medicaid Expansion under the Affordable Care Act (ACA), extending eligibility to at least 138% of the federal poverty level.
State has adopted and implemented Medicaid expansion under the ACA, but either has 1) a trigger law in place or 2) implements work requirements for beneficiaries.
State has not adopted Medicaid expansion under the ACA, restricting access to services for a large number of individuals with low income.
N/A
Family Planning Medicaid Expansion
State has expanded Medicaid coverage of family planning services through a waiver or state plan amendment.
State has expanded Medicaid coverage of family planning services through a waiver or state plan amendment but does not extend eligibility to men or minors.
State has not expanded Medicaid coverage of family planning services through a waiver or state plan amendment and is restricting access to services for many individuals with low income.
N/A
Contraceptive Coverage
State policies require insurers to cover the cost of prescription and at least some over-the-counter contraceptives and prohibit insurers from sharing this cost with patients (unless a therapeutically equivalent drug is available with no cost sharing).
While state policies require insurers to cover the cost of prescription contraceptives, they do not prohibit insurers from sharing this cost with patients. In addition, insurers are not required to cover the cost of over-the-counter contraceptives.
Or
State policies require insurers to cover the cost of prescription contraceptives and prohibit insurers from sharing this cost with patients. However, insurers are not required to cover the cost of over-the-counter contraceptives.
N/A
No state policies require insurers to cover the cost of prescription or over-the-counter contraceptives or prohibit insurers from sharing this cost with patients.
Prescriptive Authority
State policy allows pharmacists, nurse midwives, and nurse practitioners to prescribe contraceptives independently (regardless of whether a prescribing period is required).
State policy allows 1 to 2 but not all 3 groups (pharmacists, nurse midwives, and nurse practitioners) to prescribe contraceptives independently (regardless of whether a prescribing period is required).
State policy does not allow pharmacists, nurse midwives, or nurse practitioners to prescribe contraceptives at all or independently.
N/A
Extended Contraceptive Supply
State requires private insurers and public health plans to require coverage for an extended (12-month) supply of contraceptive methods.
State either requires coverage of an extended supply of contraception for 12 months at one time for privately insured or Medicaid beneficiaries, but not both,
Or
Requires that the insured first receives a smaller supply of contraceptives before receiving an extended supply.
Or
Requires coverage of an extended supply of contraception for greater than 3 months but less than 12 months.
N/A
State does not have policies that extend required coverage for supply of contraceptives beyond 3 months.
Emergency Contraception (EC)
State has taken measures to expand access to contraception, including requiring emergency rooms to provide information about EC and dispense upon request. State also does not exclude EC from state family planning programs or the contraceptive coverage mandate.
State requires information and dispensing of EC in emergency rooms and also restricts EC from state family planning programs/contraceptive coverage mandate.
Or
State only requires providing information but does not require dispensing of EC in emergency rooms.
State restricts access to EC from state family planning programs or the contraceptive coverage mandate. State also does not expand access to EC in emergency rooms.
State does not have any policies that expand access to EC in emergency rooms or restrict access to EC in state family planning programs or the contraceptive coverage mandate.
Minor Consent
State allows all minors to consent to contraceptive services without parental involvement and does not allow providers to notify parents when minors access care.
State allows minors of a certain age—but not minors of all ages—to consent to contraceptive services without parental involvement.
Or
State allows all minors to access contraceptive care without consent of their legal guardians but allows providers to notify parents when minors access contraceptive care.
State policies restrict the majority of minors from accessing contraceptive services without the consent of their legal guardians. State law may permit certain groups, such as married minors, minors who are pregnant, minors who are parents, minors who are considered mature minors, and minors with health issues, to consent to contraceptive services.
State does not have laws or policies that permit or restrict minors to consent to contraceptive services.
Sex Education
State requires comprehensive sex education or abstinence-plus education that is medically accurate and has an opt-out policy.
State requires abstinence-plus education (even if not required to be medically accurate) and has an opt-out policy.
State requires abstinence-only-until marriage programs and/or state has an opt-in policy.
State has no sex education standards.
Refusal Clauses
N/A
State policies allow 1 to 2 but not all 3 of the following groups to refuse to provide contraception for religious or moral reasons: pharmacies/pharmacists, health providers, and institutions.
State policies allow pharmacies or pharmacists, health providers, and institutions to refuse to provide contraception for religious or moral reasons.
No state policies allow providers, health facilities, or pharmacists to refuse to provide contraceptive services for religious or moral reasons.
Data Sources
The data used in this scorecard were gathered primarily from publicly available secondary sources, starting with data tracking organizations that monitor contraceptive access and related legislation, such as the Guttmacher Institute and Kaiser Family Foundation. We then cross-referenced this information by reviewing state legislative websites, government databases, and official legislative records to confirm the status of each policy indicator. Because these sources update at different speeds and have varying levels of detail, our data reflect the most current information available at the time of collection. We made efforts to verify and reconcile discrepancies where possible to ensure accuracy and consistency.
Weighting Schema
To calculate an overall score, each policy indicator in the State of Access scorecard was assigned a weight based on feedback from our expert technical review panel and consultations with policy experts. Members of the technical expert review panel ranked the importance of each policy indicator for contraceptive access. There was strong agreement among panelists that the policy indicators in the Affordability category (Medicaid Expansion, Family Planning Medicaid Expansion, and Contraceptive Coverage) were particularly important to improving contraceptive access. Panelists also agreed that indicators affecting a smaller subset of the population (such as access to Emergency Contraception in emergency rooms) or that shape access more indirectly (for instance, Sex Education) should be assigned lower weights due to their narrower or more diffuse impact.
However, the panel had less consensus on the relative importance of indicators such as Minor Consent and Prescriptive Authority. In these cases, we made final weighting decisions based on a combination of expert feedback and internal deliberation, prioritizing consistency with our scoring framework and the scorecard’s intended use.
Weighting decisions considered two main factors: 1) the number of people typically affected by each policy, and 2) the relative importance of the policy in shaping an individual’s ability to access contraception.
Indicators in the affordability category were given greater weight, reflecting the broad impact and critical role of cost-related barriers—an element the expert panel consistently identified as highly influential. The availability and environment of care categories were assigned equal overall weights, ensuring balanced representation across the different dimensions of access. Each policy indicator was scored on a standardized scale from 0 to 100 (see Table 2).
Table 2. Policy Weights for Calculating Overall Score
Medicaid Expansion
20
Family Planning Medicaid Expansion
15
Contraceptive Coverage
15
Prescriptive Authority
10
Extended Coverage Supply
7.5
Emergency Contraception
7.5
Minor Consent
10
Sex Education
7.5
Refusal Clauses
7.5
For each policy indicator, we determined point allocations based on the indicator’s total possible points, as defined by its weight in the composite score. States scored as “restrictive” or “no policy” received zero points, while those classified as “some protections and/or restrictions” received half points proportionate to the indicator’s total.
We applied a unique scoring approach to the Medicaid Expansion indicator, which was the only policy indicator with two partial point options. States that adopted Medicaid expansion under the Affordable Care Act but have eligibility work requirements were assigned 10 points, reflecting reduced access due to policy barriers. States that adopted Medicaid expansion under the Affordable Care Act without work requirements but had a trigger law in place were assigned 17 points, recognizing full implementation of the policy while accounting for the potential instability presented by trigger laws. This approach allowed us to account for both the breadth of coverage and the sustainability of access within a changing policy environment.
Composite Score and Policy Environment Categories
A PRB staff member scored each state across the nine policy indicators using the scoring rules outlined in Table 1. All scores were then independently cross-checked for quality assurance by other PRB staff. In addition, data and scoring decisions from selected states were verified by state-level experts.
After we scored states across each policy indicator, we calculated a weighted composite score to reflect the strength of their contraceptive access landscape. These composite scores provide a basis for comparing how state policies support or hinder contraceptive access.
To generate an overall classification for each state, we categorized composite scores into three groups: 0 to 39.9 as restrictive, 40 to 69.9 as some protections and/or restrictions, and 70 to 100 as protective. These cutoffs were informed by the distribution of scores and reviewed to ensure that they meaningfully differentiate between low, moderate, and strong policy support for contraceptive access.
Limitations
While the State of Access scorecard focuses on state-level policies, it does not capture the role of health system strategies, community-based efforts, or individual-level determinants that also influence access to care.
PRB recognizes that successful public health programs, including those focused on contraception, depend on political commitments to secure resources and implement action. The scorecard reflects only policies and legislation that have been enacted by state legislatures. As a result, it may not fully capture the range of political support or opposition to these policies, nor the broader policy environment—including key actors, events, institutions, and networks—that influences whether supportive legislation advances. The scorecard also does not capture how policies are implemented in practice.
Additionally, our weighting of policy indicators was informed by input from a relatively small panel of experts and did not incorporate a formal Delphi process or assessment of inter-rater reliability. This approach may introduce subjective bias and limit the reproducibility and generalizability of the weights, potentially affecting the robustness and validity of composite scores.
Reality is more complex than can be captured in a scorecard, and the importance of individual policies depends in part on how interdependent policies come together in a particular state. For example, Medicaid expansion is particularly important in states where contraceptive coverage is restrictive, and refusal clauses are less important in states where prescriptive authority is widely distributed among non-physician providers. Further, the decision to avoid assigning a numeric or letter grade—intended to prevent stigmatizing states with more restrictive policies—means some subjectivity remains in the classification of states into restrictive, some protections and/or restrictions, or protective policy environments.
Finally, the data for this scorecard were collected from secondary sources and state legislative websites. Therefore, the accuracy and completeness of the information depend on how quickly and consistently those sources update their records. Delays or gaps in updating may affect the timeliness of the data reflected in the scorecard. Additionally, some important policy indicators—such as authority to dispense contraception—could not be included due to a lack of reliable, comparable data across states. This limitation means the scorecard may not capture the full scope of policies influencing contraceptive access.
Last updated: July 14, 2025 