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Obamacare, despite its warts, has been a boon for birth control. Thanks to its no-cost contraceptives provision, since the law went into effect the percentage of women who have had to pay out-of-pocket for birth control has fallen sharply, according to the Kaiser Family Foundation. In 2012, 22 percent of all women with health insurance paid out of pocket for birth-control pills, but just 3.7 percent did in 2014.

Out-of-pocket spending on oral contraceptive pills

Share of women ages 15-44 with health coverage from a large employer who spent money out of pocket on oral contraceptive pills from 2004 to 2014. (Kaiser Family Foundation / Truven Health Analytics / Peterson-KaiserHealth Tracker System.)

In recent years I’ve interviewed dozens of teen moms, imprisoned moms of seven, homeless moms, and others who told me, essentially, “I love my kids, but I wish I had better birth control earlier on.” Why didn’t they? Some were afraid to tell their parents they wanted to get on the pill. Others had transportation issues, and still others couldn’t afford it or didn’t know about it.

Even though birth control is now supposed to be free and easy to access, that’s not always the case for poor women, thanks to gaps in insurance coverage, states’ failure to expand Medicaid, and a lack of funding to a federal program that serves as a last-resort option for poor women’s family planning needs. Women’s attainment of the most effective methods—IUDs and implants— is further obstructed by a tangle of regulatory barriers and misconceptions among providers.

The Affordable Care Act required insurance plans to cover all FDA-approved methods of contraception at no cost. But about one in ten women remain uninsured, either because they find coverage unaffordable, are undocumented, or are unaware of the requirement to buy insurance.

Uninsured Rates Among Non-elderly Women in 2015

Kaiser Family Foundation

Medicaid covers birth control, but in 2015 only half of doctors were accepting new Medicaid patients. What’s more, 19 states have still not expanded Medicaid under Obamacare. In those states, many adults fall in a “coverage gap,” earning too much to get Medicaid but too little to qualify for subsidies to buy health insurance.

What Financial Help are Uninsured Women Eligible For?

Women in the coverage gap tend not to qualify for any subsidies, Medicaid, or other insurance assistance. (Kaiser Family Foundation)

Uninsured women can go to publicly funded family-planning clinics to obtain birth control, but in many states these clinics are already few and far between, and they are being further threatened by budget cuts. Some of them are affiliated with Planned Parenthood, which has faced attacks on its funding in many states. After Texas slashed funding to Planned Parenthood in 2011, for example, insurance claims for long-acting birth control in the state fell by more than a third. Researchers at the Texas Policy Evaluation Project performed a study for which they surveyed 800 women in Austin and El Paso, Texas, who had recently given birth to a child. They found that though about a third wanted to be using IUDs or implants, also called LARCs, only about 13 percent were. The most significant predictor of a woman actually getting a LARC? If her family made $75,000 or more per year.

Low-income women can also get birth control from local health departments or at family-planning clinics—such as one I wrote about recently in Amarillo, Texas—that aren’t affiliated with Planned Parenthood or any other abortion provider. Many of these clinics use a sliding, income-based scale to determine how much a woman should pay for, say, a newly inserted IUD. Some get at least part of their funding through a federal program called Title X, which also allows teens to get birth control without their parents’ permission—a crucial element, advocates say, for teens and young adults who don’t share their parents’ religious views. Some counties, such as Midland, Texas, which I wrote about this summer, lack a single Title X clinic despite being home to 9,000 women in need of publicly funded family planning services. The need for publicly funded family planning has increased by 5 percent since 2010, according to the Guttmacher Institute, while funding for Title X has been cut by 10 percent.

Women Who Need Publicly Funded Contraceptives

According to Guttmacher’s measures, poor women have an income less than 100% of the poverty level. Low-income women are between 100 and 250%. (Guttmacher Institute)

The National Campaign to Prevent Teen and Unintended Pregnancy has a database of birth-control providers who will see uninsured women (at a reduced cost) as well as those on Medicaid. When the organization cross-referenced those clinics with the number of low-income women in need of birth control, the resulting map revealed many areas where poor and uninsured women have few or no birth-control options for miles:

Only half of U.S. counties have what the National Campaign calls “reasonable access”—one publicly funded birth control clinic for every 1,000 low-income women. And then there are other areas the group calls “contraceptive deserts,” a term borrowed from the “food desert” concept in health policy. They’re places where low-income women seeking IUDs or implants have few places to turn. (The map uses the best information the National Campaign could obtain, but it might be missing some private providers who accept Medicaid, if they’re not in the National Campaign’s database.)

Meanwhile, not all public or private clinics provide IUDs and implants. These LARCs are credited with contributing to the precipitous recent drop in teen pregnancy rates, and because they require no refills, reminders, or check-ups for years, LARCs are ideal for teenagers and for women in rural areas. After Colorado invested in providing LARCs to low-income women in the state, unintended pregnancies fell by 27,000 each year.

“If you go to the first map, there are clinics present in most places,” said Ginny Ehrlich, the chief executive officer at the National Campaign.This isn’t a matter of building new clinics, it’s a shift in terms of perspective in what providing contraceptive services means, and focusing on most effective methods.”

Not all clinics can afford to staff a doctor who knows how to insert IUDs, said Kinsey Hasstedt, a senior policy manager with the Guttmacher Institute. “If you don’t have funding to pay the provider competitively, it’s hard to bring them in the door,” she added. What’s more, not all doctors are trained to insert LARCs, and the devices, which can cost about $800, are expensive for clinics to stock. A 2012 study found that fewer than half of family physicians were trained to offer IUDs. The numbers aren’t much better for pediatricians, who are supposed to offer the devices to sexually active teens.

Even if providers are trained, “if they don’t do [IUDs] after the training, they might forget how or not have the confidence to offer them,” said Eve Espey, chair of the Department of Obstetrics and Gynecology in the University of New Mexico School of Medicine.

Finally, some doctors still harbor outdated misconceptions about IUDs. Rachel Schulson runs the Step Ahead Foundation in Chattanooga, Tennessee, which connects women seeking LARCs and other birth control with clinics willing to provide it. Some women were told by their doctors that IUDs are only for women who have already had children, Schulson told me. One 28-year-old woman told Schulson, “I asked my doctor about this, and she said I have to be married.”

% of Doctors Who Would Consider IUDs for Various Patients

STI is a sexually transmitted infection; PID is a pelvic inflammatory disease. (Family Medicine, 2012)

That same 2012 study found just 69 percent of family-practice doctors “would consider” IUDs for unmarried women (compared to 87 percent of ob-gyns), and an even smaller number would offer the devices to women who had just delivered or had an abortion—something gynecologist groups recommend.

A common argument among those who oppose a more robust safety net is that the poor should simply “stop having kids they can’t afford.” Many are trying to do just that, but it isn’t always easy.

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