An Overview of the Federal Policy Environment for Contraceptive Access

Introduction

Despite broad and consistent public support, the federal foundation for contraceptive access in the United States is ever shifting.

While longstanding federal policies and programs provide a broad foundation for contraceptive access, it is alternately strengthened and weakened as the politics and priorities of Congress, the executive branch, and the courts change over time. It is also affected by the complex interplay of evolving federal and state policy environments.

Today, federal trends toward limiting government spending (especially for social support), expanding religious exemptions, and restricting reproductive health care weaken the federal foundation for contraceptive access. As a result, states have wide latitude to shape access for their populations through funding and legislative decisions.

This reality means that a person’s ability to obtain the care they want depends in part on their state of residence and jeopardizes the health and well-being of millions of Americans, especially those who already face barriers to care.

State Policy Environments for Contraceptive Access

Wide Demand, Uneven Access

Americans widely support contraceptive access, and their use of contraceptives is exceedingly common.

In a 2024 KFF Women’s Health Survey, 82% of U.S. women ages 18 to 49 said they used some form of contraception in the past 12 months. Nearly half (48%) said they used more than one method.

Some evidence suggests that demand for contraceptive care has grown since the overturn of Roe v. Wade in 2022, including more requests for long-acting and permanent methods. Despite these facts, nearly one in five women ages 18 to 49 say it is difficult to obtain contraceptive care in their state.

The State of Access scorecard reveals how the patchwork of policies and practices influences contraceptive access.

The Federal Foundation

The United States has recognized access to contraception as a vital aspect of health care and a core individual right for decades. Landmark rulings in 1965 (Griswold v. Connecticut) and 1972 (Eisenstadt v. Baird) established the right to use contraception under the constitutional right to privacy. This legal protection has been reinforced by a range of federal programs and funding streams that support contraceptive access, particularly for low-income and underserved populations. They include Title X, Medicaid, and the Patient Protection and Affordable Care Act, as well as other programs. These programs’ ability to deliver services could be affected by a series of executive orders issued in 2025.

Title X

The intent

In 1970, federal involvement in contraceptive access began in earnest with the passage of Title X. More than 50 years later, Title X remains the only U.S. federal grant program dedicated solely to providing comprehensive family planning and related health services, such as HPV vaccination and cancer screening.

With Title X funds, community-based health facilities across the United States provide confidential, low-cost or free contraceptive services mostly to individuals who have low income or are uninsured. In 2023, these facilities served nearly 2.8 million clients—a 7% increase from 2022. In that same year, 60% of Title X clients—or nearly 1.7 million people—lived at or below the federal poverty line.

The reality

Title X has faced a long history of challenges, from shifting requirements and regulations to spending restrictions to attempts to repeal the policy entirely. Despite the growing demand for Title X services, it remains chronically underfunded—congressional appropriations have been flat since 2015.

In recent history, the Title X Final Rule (commonly referred to as the “domestic gag rule” and in place from 2019 until its repeal in 2021) banned clinics from using Title X funds for any abortion-related services, including counseling and referrals. In 2020, constrained by both the Title X Final Rule and the COVID pandemic, Title X health facilities served 60% fewer clients than in 2018, and an estimated 1,000 health facilities lost Title X funding.

While funding has been restored to many facilities, in March 2025 nearly one in five Title X grantees received notification that their funding would be withheld, affecting an estimated 879 clinics in 23 states. Should this funding freeze become permanent, 834,000 people could lose access to Title X care over the course of a year, and care could scale down in 15 states and completely disappear in seven states.

Medicaid

The intent

In 1972, Congress amended the Medicaid insurance program to require that states cover family planning services and supplies. Medicaid is the single largest public payer of family planning services in the United States as of today, insuring nearly 17 million women ages 19 to 49. Medicaid generally covers all FDA-approved methods, from pills to intrauterine devices (IUDs) to emergency and permanent contraception at no or low cost.

The reality

Medicaid is jointly funded by states and the federal government, and states administer it in accordance with broad federal rules. This approach creates significant state-level variations in program design, including who’s covered, what services are included, and how care is delivered. For instance, while the federal Affordable Care Act expanded Medicaid eligibility to more adults with low incomes in 2014, 10 states have yet to adopt the expansion, leaving 1.4 million qualifying people in these states without government-sponsored health insurance.

Long politically divisive, Medicaid also faces existential threats. In June 2025, the Supreme Court ruled in Medina v. Planned Parenthood South Atlantic that patients cannot sue when states block Medicaid funding to qualified contraceptive providers. In July 2025, President Trump signed the “One Big Beautiful Bill Act,” a budget reconciliation law that reduces Medicaid spending by over $1 trillion over the next decade. The legislation, along with other policy changes, could result in 17 million Americans losing health care coverage over the next decade, according to estimates from the nonpartisan Congressional Budget Office. These developments directly threaten access for millions of Americans who depend on Medicaid.

The Patient Protection and Affordable Care Act

The intent

Signed into law in 2010, the Patient Protection and Affordable Care Act (commonly referred to as the Affordable Care Act) requires that most health insurance plans cover FDA-approved contraceptives at no cost to the patient. Churches and similar organizations with religious exemptions were exempted from the Act’s contraceptive coverage mandate. The mandate represents a significant expansion of contraceptive access.

The reality

By reducing the cost barrier, the contraceptive mandate has increased contraceptive use and contributed to declines in both pregnancy and abortion rates.

But the mandate is threatened by a string of judicial decisions concerning religious and moral objections. In the 2014 Burwell v. Hobby Lobby Stores, Inc. decision, the U.S. Supreme Court ruled that certain for-profit corporations could refuse to cover contraceptives on religious grounds, citing the 1993 Religious Freedom Restoration Act. In 2017, the first Trump administration expanded these employer exemptions, allowing virtually any employer to claim a religious or moral exemption. The Supreme Court upheld those exemptions in 2020.

Legal challenges to the Affordable Care Act’s preventive care guarantees, including the contraceptive mandate, continue to be heard in the courts. The decisions made in these cases will contribute to further shifts in the foundation for contraceptive access across the country.

Other Federal Programs

Across the United States, other federal programs play a complementary role in supporting contraceptive access for specific populations:

• Temporary Assistance for Needy Families (TANF) allows states to allocate funds for family planning education and services as part of broader goals related to reducing teenage pregnancy.
• Title V Maternal and Child Health Services Block Grants can support access to contraceptive services, particularly for adolescents and women with low income, by funding state and local initiatives focused on improving maternal and child health outcomes.
• The Indian Health Service (IHS), the primary federal agency responsible for providing health care to American Indian and Alaska Native communities, provides contraceptive care as part of its comprehensive reproductive health services.

While these funding streams are often limited in scope and vary in implementation across states and regions, they remain important levers for expanding access and equity for underserved populations.

Recent Developments and Future Outlook

A January 2025 executive order rolled back earlier executive orders that aimed to protect access to reproductive health and abortion in the wake of the 2022 Dobbs v. Jackson Women’s Health Organization ruling. This rollback could fuel policies, programs, and funding decisions that further restrict broad access to contraceptives.

A series of additional executive orders in 2025 related to reproductive health, along with forthcoming legal decisions, create an uncertain federal environment that can fuel ambiguity within and significant differences across states. While some U.S. states may quickly adopt legislation consistent with the priorities identified in federal pronouncements, other states may wait to see how challenges to their legality play out in court.

The tangled maze of contraceptive access across the United States could have far-reaching effects beyond stated priorities—effects like an increased risk of endometrial and ovarian cancer, and increases in cardiovascular disease and transmission of HIV from mother to baby. Contraceptive access constraints, combined with a lack of federal programs that fund or expand the availability and use of comprehensive sex education, leave people without valuable resources to make informed decisions about their health.

Explore the State of Access scorecard to learn more about the policies and programs in each U.S. state.

Sources

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