Reproductive & Sexual Health

As the country’s public health insurance program for people with low incomes, Medicaid is a cornerstone of reproductive and sexual health coverage in the United States. Medicaid finances almost half of all births and nearly three-quarters of all publicly funded family planning services nationwide. Nearly one-third of Black women of reproductive age are enrolled in Medicaid, over one-quarter of Latinas, and nearly one-fifth of Asian and Pacific Islander women.

For decades, the National Health Law Program has advocated to protect, advance, and enforce the reproductive and sexual health care rights of Medicaid beneficiaries and low-income populations unjustly excluded from the program. We are leaders in federal and state advocacy efforts to strengthen Medicaid coverage of the full spectrum of reproductive and sexual health services, such as abortion, doula care, contraceptives, sexual health services, assisted reproduction, and gender-affirming care. We pressure Medicaid, marketplace, and other private health care delivery systems to provide truly comprehensive health coverage, including reproductive and sexual health services, free from discrimination. We shape and fight for federal health care reforms that address reproductive and sexual health care needs instead of marginalizing them, and close the various coverage gaps that withhold access to care from millions of immigrants, postpartum people, and Black, Latine, and other uninsured people with low incomes in states that have refused to expand Medicaid.

Abortions are extremely safe and common – approximately one in four people capable of getting pregnant will have an abortion in their lifetime. Despite the undeniable need, state and federal restrictions have created a landscape where access to abortion is largely determined by where a person lives, how much money they make, and what kind of insurance they have (if any). The Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization exacerbated the existing abortion access crisis, opening the floodgates to extreme state bans and restrictions.

At the federal level, a budget rider called the Hyde Amendment functions as a de facto abortion ban for many of the 13.5 million women of reproductive age (15 to 49 years old) enrolled in Medicaid who live in states that do not use their own funding to cover abortions. Multiple studies indicate that the inability to afford abortion care places pregnant individuals further into poverty and harms their health as well as the wellbeing of their current and future children. Comprehensive insurance coverage of abortion is a crucial component of establishing an equitable abortion access landscape.

Please see https://healthlaw.org/abortion-is-health-care/ for more information. 

Affordable family planning services are essential to a person’s health and well-being, yet it remains a challenge for millions of people to obtain. Of the approximately 38 million women in need of contraceptive care in the U.S. each year, 15.5 million are low-income adults and 4.5 million are uninsured. The National Health Law Program is actively working with states to develop laws and policies, such as Contraceptive Equity legislation, to improve access to family planning in public and private health insurance. “Contraceptive Equity” means that every person can make their own decisions about pregnancy prevention, and contraceptive care is easily accessible and covered at no cost in all health programs. 

Prompt access to high-quality reproductive and sexual health care is critical to ensuring the health of birthing people and their babies. While the Affordable Care Act mandated maternity care as an essential health benefit and Medicaid continues to provide coverage for almost half of all births across the country, people still struggle to access adequate health care during their pregnancies. The National Health Law Program works with advocates at the state and federal level to push for high-quality prenatal and postpartum care, labor and delivery services, and for seamless health coverage during transitions for people who become pregnant and after their pregnancies. We also work with state and federal advocates to support laws and policies to advance health equity, address racial disparities in health, and improve maternal and infant health outcomes through culturally congruent, patient-centered care. For example, our Doula Medicaid Project seeks to improve health outcomes for pregnant Medicaid enrollees by ensuring that all pregnant and postpartum people enrolled in Medicaid who want access to a doula can have one. 

Due to intersecting sexism, ableism, racism, and other mutually reinforcing systems of oppression, people with disabilities experience a myriad of barriers to sexual and reproductive health care. For example, they endure accessibility barriers, such as inaccessible provider settings or lack of culturally or linguistically appropriate care. People with disabilities who are of reproductive age enrolled in Medicare or dually eligible for Medicare and Medicaid also encounter specific reproductive health barriers as they navigate a Medicare system that is largely designed for older adults. 

The Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization not only deepened existing barriers to abortions for people with disabilities, but it also provoked some health insurers and pharmacies to deny and erect new limitations to medications and treatments that can prevent, cause complications to, or end pregnancies. These new barriers to care specifically discriminate against people with chronic conditions who may be capable of pregnancy. 

To this end, the National Health Law Program works to create a health care system where people with disabilities have equitable access to the health care一including reproductive, sexual, and related health services一that they need, delivered in an accessible and linguistically and culturally appropriate manner, free from reproductive coercion, violence, or other discrimination.

Health care refusals are laws, policies, and regulations that allow institutions and individual providers to use their religious or moral beliefs to deny care to patients including health care services, information, and coverage that would otherwise be required under evidence-based, medical standards of care. These refusals have historically focused on abortion services, contraception, and sterilization. Health care refusals disproportionately harm women, Black, Indigenous, and other people of color, people with low incomes, people living with disabilities, and LGBTQ people, all communities that often already struggle to access care. The National Health Law Program develops strategies in partnership with state and federal advocates, providers, researchers, and policymakers to respond to health care refusals, and provides technical and legal analysis to stakeholders to ensure that all persons receive the care they need without the interference or religious or moral ideology undermining medical decision-making and standard of care.

Medicaid is a vital health care lifeline for millions of LGBTQ individuals and families in the United States. LGBTQ people who have low incomes and who are from communities of color disproportionately lack access to care and coverage, and experience negative health outcomes at higher rates than the general public. 

To help combat these inequities, the National Health Law Program has led multiple efforts to ensure access to various forms of health care for LGTBQ populations. For instance, we sponsored the first-in-the-nation law that will set quality standards for transgender, gender diverse, and intersex (TGI) patients and ensure curriculum is relevant to TGI patients’ health needs. Along with reproductive justice partners, we created the “Medicaid as an LGBTQ Reproductive Justice Issue: A Primer,” an educational resource for advocates and policy makers with information about the importance of Medicaid for LGBTQ people. Through various forms of advocacy, we have argued that gender-affirming procedures are safe, effective, and medically necessary for many transgender individuals, that should therefore receive coverage in Medicaid and private plans.

The World Health Organization defines sexual health as “a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity.” Far from having obtained a state of sexual well-being, the United States in in the midst of a sexually transmitted infection (STI) epidemic. More than half of all Americans will contract an STI in their lifetime. If untreated, STIs can lead to serious pelvic infections, infertility, and even death. Medicaid is the largest public payer of STI-related care, and the Affordable Care Act guarantees no-cost coverage for most STI screening. Nonetheless, screening rates for high-risk Medicaid enrollees remain low, and a number of barriers hinder access to care, particularly for low-income people. 

NHeLP’s work aims to increase coverage, screening, preventive care, and treatment for people at risk of, or living with, STIs, including HIV. We leverage administrative, legislative, and judicial advocacy to make policy gains such as: a judicial decision decrying the illegal practice of adverse tiering for HIV drugs; administrative inclusion of PrEP and external condoms as no-cost preventive services under the ACA; and passage of state bills allowing pharmacists to prescribe STI medication.

Assisted reproduction (AR) refers to treatments, interventions, or procedures that are intended to cause or assist in causing pregnancy through means other than by sexual intercourse. Assisted reproduction is important to the National Health Law Program because it stands at the intersection of many different facets of our work: reproductive rights, health and justice, disability rights, LGBTQ+ issues, and health equity. Those who will most benefit from comprehensive, rights-based AR policies or laws are low-income, Black, Indigenous and other people of color, LGTBQ, and other historically oppressed communities. As such, NHeLP has developed a set of principles to guide its advocacy work on assisted reproduction. Our staff responds to individual requests for technical assistance and support from state advocates who provide direct services to people around the country. We also receive technical assistance requests related to potential legislation that would mandate coverage of certain AR interventions in various states and in the United States Congress.