Medicaid Helps Americans Afford the Contraceptives They Want—but Access Boils Down to Your Address

Many Americans aren’t using the birth control method they would prefer, and cost is a major reason why. When people can’t afford their preferred method, they’re more likely to stop using contraception altogether, increasing their risk for unintended pregnancy.

Medicaid helps reduce these cost barriers. Family planning services, including contraceptive care, are a mandatory Medicaid benefit, making the program a key source of coverage for people who might otherwise be unable to afford contraception. As the largest public funding source for family planning services in the United States, Medicaid covers more than 70 million people, including one in five women of reproductive age (15 to 49) and four in 10 women of reproductive age with low incomes.

But access to Medicaid and the affordability of contraceptive care differ across states. To date, 40 states and the District of Columbia have adopted the Affordable Care Act’s Medicaid expansion, extending coverage to adults with incomes up to 138% of the federal poverty level. In addition, 30 states and the District of Columbia have expanded eligibility for Medicaid-covered family planning services through waivers, state plan amendments, or state-funded programs, further broadening access for people with low incomes, including men and minors.

New research sheds light on how cost barriers shape unmet contraceptive preference in states with and without Medicaid expansion.

National Study Shows Expanding Medicaid Boosts Contraceptive Access in Resource-Deprived Communities

Much of the research on Medicaid expansion and contraceptive access focuses on differences across states, but this approach can miss important disparities within states. A new study by Alice Cartwright, now of the Guttmacher Institute, and colleagues at the University of North Carolina at Chapel Hill and Tulane University shows how the effects of Medicaid expansion may differ depending on the joint racial and economic conditions of neighborhoods.¹ This approach recognizes that access to care is shaped not only by state policy, but also by the economic and structural conditions of the communities where people live.

Using a large, nationally representative sample collected over nine years, the authors find that the benefits of Medicaid expansion are not evenly distributed across neighborhoods.

In the most resource-deprived communities, Medicaid expansion was associated with a 7.6 percentage-point increase in the use of long-acting reversible contraception (IUDs and implants) and a 17.5 percentage-point decline in the use of no method or less effective barrier or coital methods. The authors used data from the National Survey of Family Growth, comparing the 2011-2013 period (pre-Medicaid expansion) to 2017-2019.

By contrast, the study finds little change in contraceptive use among people in the most advantaged neighborhoods, where access to health insurance was likely already relatively high and Medicaid expansion did not meaningfully alter affordability or coverage for residents.

The authors largely attribute these patterns to reduced costs for contraception following insurance coverage gains. By lowering out-of-pocket costs for provider-dependent methods, Medicaid expansion appears to have made long-acting reversible contraceptives more accessible in these communities.

The findings suggest that Medicaid expansion plays an important role in helping people access their preferred contraceptive methods, especially in the most economically and racially disadvantaged neighborhoods. Yet because many of these neighborhoods are in states that have not yet expanded Medicaid—such as Mississippi—these results raise significant health equity concerns.

In Mississippi, Cost and Insurance Barriers Drive Unmet Contraceptive Preference

Evidence from states that have not expanded Medicaid insurance further illustrates the role of cost and coverage in shaping contraceptive choice. Using data from an online survey of Mississippi residents ages 18 to 45 who were assigned female at birth, Amanda Nagle at the University of Texas at Austin and colleagues examined how structural barriers to contraceptive care are associated with unmet contraceptive preference.²

Mississippi has one of the most restrictive reproductive health care environments in the United States. The state has not expanded Medicaid, 14% of women ages 18 to 64 are uninsured, and 13% report forgoing medical care in the past year due to cost. Among the 462 survey respondents, 37% reported unmet contraceptive preference, and 83% experienced at least one barrier to accessing contraceptive services at clinics and doctors’ offices.

Cost-related barriers—such as being unable to afford a method or insurance denials—were most strongly associated with unmet contraceptive preference. Respondents who encountered any barrier were nearly twice as likely to have unmet contraceptive preference compared with those who reported no barriers, and uninsured respondents were significantly more likely to experience unmet contraceptive preference than those with private or public insurance.

The authors suggest this disparity reflects Mississippi’s decision not to expand Medicaid and the state’s limited investment in safety-net reproductive health services for uninsured and underinsured residents.

Mississippians Want—But Cannot Access—More Effective Contraception

In the Mississippi study, individuals with unmet contraceptive preference most often wanted to switch to more effective methods than the ones they were currently using—methods that typically involve higher upfront costs, particularly when not covered by insurance. Fewer than one in five respondents wanted to switch to a method with comparable effectiveness, suggesting that unmet contraceptive preference reflects barriers to accessing more effective options rather than dissatisfaction with current ones.

The pattern is clear across method types.

• Among respondents using long-acting reversible contraception who wished to change methods, the largest share (44%) desired a permanent method (male or female sterilization).
• Among users of short-acting hormonal methods seeking a different option, half (50%) preferred a long-acting reversible contraceptive (implants or IUDs) and 13% preferred a permanent method.
• Among barrier and coital method users with unmet preference, nearly one-third wanted to switch to short-acting hormonal methods (oral contraceptive pills, injectables, or patches/rings), while 23% preferred a long-acting reversible contraceptive and 29% desired a permanent method. Barrier and coital methods include male and female condoms, emergency contraception, diaphragms/sponges, foams/suppositories/jellies/creams, withdrawal, and calendar and other fertility awareness methods.

These findings suggest that reducing cost and insurance barriers is critical to decreasing unmet contraceptive preference and supporting reproductive autonomy in Mississippi. Expanding Medicaid would increase insurance coverage and remove financial barriers that prevent people from accessing preferred—and often more effective—contraceptive methods. At the same time, higher Medicaid reimbursement rates and reduced administrative burdens could encourage more providers to accept Medicaid, further expanding access to care.

Reducing Cost and Insurance Barriers—Including by Expanding Medicaid—Is Key to Improving Contraceptive Access

Recent federal policy changes threaten to roll back these coverage expansions. The passage of the One Big Beautiful Bill Act (H.R. 1, Pub. L. 119-21) in July 2025 is projected to reduce federal Medicaid funding by approximately $1 trillion and leave an estimated 10 million people without health insurance coverage. These fiscal pressures are expected to force states to reevaluate health care spending, including whether to scale back or eliminate Medicaid expansion programs. In addition, H.R. 1 introduces new administrative requirements—including work reporting and more frequent eligibility redeterminations—that are expected to increase coverage churn, make it harder for eligible individuals to remain enrolled, and discourage provider participation in Medicaid. Compounding these challenges, the expiration of enhanced premium tax credits at the end of 2025 is expected to significantly increase premiums and out-of-pocket costs in the individual market, placing health insurance out of reach for many. Together, these developments raise serious concerns about the future affordability of contraceptive care.

At the same time, research shows that reducing cost and insurance barriers is essential to decreasing unmet contraceptive preference and supporting reproductive autonomy. Medicaid expansion emerges as a particularly powerful policy tool, delivering the greatest gains in communities facing the steepest financial barriers and offering a pathway to more equitable access to effective contraception.

However, these findings also suggest that expanding Medicaid coverage is not enough. States must also encourage provider participation and ensure timely, high-quality care delivery through mechanisms like increasing Medicaid reimbursement rates and reducing administrative burdens. Further, they should address cost and structural barriers through policies that eliminate or reduce out-of-pocket costs and expand the number of providers and facilities offering contraceptive services.

As federal and state policymakers consider changes to Medicaid and health insurance markets, these findings underscore the importance of evaluating how policies affect not just states as a whole, but the communities within them. Ensuring access to the full range of contraceptive options—at no cost and without unnecessary barriers—is fundamental to advancing reproductive autonomy and health equity nationwide.