Contraception Coverage Policy in the United States: History and Current Challenges

Background: State and federal policies have aimed to expand access to contraception by providing coverage of its costs in both public and private health insurance. Yet barriers to contraception coverage remain and are expected to increase after the 2022 U.S. Supreme Court decision in Dobbs v. Jackson Women's Health Organization. This paper describes the history of these policies and current challenges. Methods: We constructed a chronology of federal and state policies providing coverage of the cost of contraception in both public and private health insurance, from establishment of the federal right to contraception through 2024, using published sources and public datasets. We aligned the chronology with the history of the development of contraception technology and practices, as described by historians and social scientists, and with political and legal challenges. Results: Following establishment of a federal right to contraception after nearly a century of restrictions under the 1873 Comstock Act, three waves of contraception coverage policymaking sought to increase access to contraception by making it more affordable to consumers. These waves included options for states to expand coverage for contraception within the Medicaid program; passage of state contraception coverage equity laws to ensure parity for contraceptive coverage in private health plans; and the Affordable Care Act's national contraceptive coverage requirement and its subsequent modifications, clarifications, and codifications. Post-Dobbs, challenges to contraception coverage include efforts to redefine certain contraceptives as abortifacients and to resurrect some of the restrictions of the Comstock Act. The requirement of no-cost coverage of preventive services is also threatened. Conclusion: Contraception coverage policy will be impacted by ongoing challenges to contraception and abortion access, as well as changing contraceptive technology and modes of delivery.