2024-10
Affordability and Coverage of Reproductive and Transgender Healthcare
Sponsored by
Asm. Jessica González Rojas (NY), Del. Joseline Peña-Melnyk (MD),
Sen. Teresa Ruiz (NJ) and Sen. Cristina Castro (IL)
Reported to the Caucus by the NHCSL Healthcare Task Force
Rep. Alma Hernández (AZ), Chair
Ratified by the Caucus on November 23, 2024
I. Access to comprehensive and affordable sexual, reproductive, and transgender health care is essential and too often inaccessible in our country.
WHEREAS, transgender health care and sexual and reproductive health care encompassing abortion, contraception, and fertility care are essential forms of health care that should be affordable, available, and supported for everyone who needs them; and,
WHEREAS, attacks on these forms of care have risen in catastrophic ways, with 21 states terminating abortion access, 24 states banning best practice medical care for transgender youth, more than 100 bills introduced attacking access to health care for transgender populations this year alone, and multiple states proposing legislation to restrict access to birth control; and,
WHEREAS, these are not just attacks on essential health care but on an individual’s bodily autonomy and the right to determine the course of their life; and,
WHEREAS, a patchwork of access to sexual, reproductive, and transgender health care results in greater costs in obtaining that care, and a lack of affordability impedes individuals’ ability to build the families and futures that they want; and,
WHEREAS, 37% of transgender youth live in a state that bans best practice medical care for transgender youth[1] and 85% of transgender and nonbinary youth said their mental health was negatively affected by these laws;[2] and,
WHEREAS, even in states where this care is legal, the legal right to health care without the ability to access and afford such care negatively impacts too many people working to make ends meet, particularly those who are Black, Indigenous, Asian, Pacific Islander, Latinx, young people, LGBTQ+ people, immigrants, and disabled people; and,
WHEREAS, everyone, regardless of their age, race, sex or gender, sexual orientation, zip code, documentation status, insurance coverage, income, or disability, deserves access to the health care they need; and,
WHEREAS, access exists in name only without comprehensive coverage of health care services; and,
II. Even when such care is not banned or restricted, many people in need of abortion, fertility care, contraception, and/or gender-affirming care do not have access to this care, including due to the cost of that care, which negatively impacts our communities.
WHEREAS, access to abortion and fertility services is a matter of economic justice and critical to ensuring economic security for pregnant people and their families; and,
WHEREAS, roughly half of U.S. adults say it is difficult to afford the health care they need and one in four say they or a family member in their household has struggled to pay for health care or have skipped or postponed getting health care they needed because of the cost;[3] and,
WHEREAS, Americans are often forced to leave their prescriptions unfilled or skip doses of their medications because of the cost;[4] and,
WHEREAS, contraception access is basic preventive health care for women and people who may become pregnant — nine out of 10 women of reproductive age, and more trans and nonbinary people, have used birth control at some point in their lives for a host of health care reasons, including to prevent pregnancy and to treat endometriosis, migraines, pre-menstrual pain, and menstrual regulation;[5] and,
WHEREAS, more than 19 million women of reproductive age face the logistical barrier of living in a contraceptive desert, meaning that they lack reasonable access in their county to a provider or health center that offers the full range of contraceptive methods;[6] and,
WHEREAS, the average cost of an abortion is $500, which is almost half the monthly income for people living below the federal poverty line;[7] and,
WHEREAS, women with incomes less than 200% poverty experience an abortion rate six times higher than those with incomes greater than 200% above the poverty line;[8] and,
WHEREAS, the cost of an abortion does not include the additional costs many pregnant people must undertake in order to access care, including transportation, childcare, lodging, and food; and,
WHEREAS, in the wake of the Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization, data show that requests for economic support from abortion funds and other support organizations have dramatically increased,[9] indicating the growing financial burdens felt by patients seeking abortion care throughout the country; and,
WHEREAS, patients that cannot afford the costs of an abortion or cannot afford the costs associated with travel to access that care will be forced to delay care, increasing the potential risks; and,
WHEREAS, an inability to access abortion has long-lasting negative consequences for pregnant people and their families, as demonstrated by a 2020 longitudinal study by UC San Francisco finding that when a woman is unable to access a needed abortion, she is four times more likely to live in poverty going forward;[10] and,
WHEREAS, the denial of abortion can force individuals to remain pregnant against their will and subject them to a wide range of physical, psychological, social, and economic ramifications, including short-term health problems such as anemia and hypertension;[11] increased risks for depression and anxiety;[12] limitations on educational and professional attainment;[13] workplace discrimination on the basis of pregnancy;[14] and significant medical debt;[15] and,
WHEREAS, fertility services are an essential part of reproductive health care for many people, particularly LGBTQ+ individuals, to build the families they want; and,
WHEREAS, sexual and reproductive health care is interconnected, and as we have seen politicians taking action to restrict or ban abortion, making it harder for abortion providers to remain open and provide services, we have seen a related decline in access to contraception provided at those same health centers[16] and increased threats to fertility care; and,
WHEREAS, the same lawmakers and groups that worked tirelessly to strip away the rights of people to make decisions about their pregnancies are now putting the lives and well-being of transgender people at risk by outlawing best-practice medical care—despite this care being backed by decades of research and supported by the American Medical Association, the American Academy of Pediatrics, and every leading health authority; and,
III. People of color, transgender individuals, people with low-incomes, and immigrant and migrant communities are most impacted by barriers to comprehensive, affordable health care.
WHEREAS, transgender individuals face myriad barriers to health care access, including higher rates of uninsurance, outsize health disparities, discriminatory insurance denials for medically necessary care, bans on Medicaid coverage of gender-affirming care, and pervasive mistreatment from health care providers—the harmful impact of these barriers compounds for individuals sitting at the intersection of multiple marginalized identities, such as transgender people of color, undocumented immigrants, and those with low incomes; and,
WHEREAS, people of color in the United States already face disproportionate risk when compared to their white counterparts as a result of, among other things, a lack of neighborhood health services, lower rates of insurance coverage, and lower access to sexual and reproductive health education; and,
WHEREAS, systemic racism, economic insecurity, ableism, and a dehumanizing immigration system exacerbate the already massive barriers to sensitive health care services; and,
WHEREAS, a lack of availability of quality health care in low-income and other marginalized communities, particularly communities of color, contributes to widespread health care disparities; and,
WHEREAS, gaps in access to care, coverage, and education result in marked disparities in reproductive health outcomes, including lower levels of access to contraception, higher rates of sexually transmitted infections, as well as higher rates of preterm deliveries and maternal morbidity and mortality; and,
WHEREAS, Black women experience higher rates than white women of preeclampsia, eclampsia, embolisms, hypertension, cardiovascular conditions, diabetes, fibroids, endometriosis, and a range of mental health conditions related to pregnancy; and,
WHEREAS, Black women experience higher rates than white women of preeclampsia, eclampsia, embolisms, hypertension, cardiovascular conditions, diabetes, fibroids, endometriosis, and a range of mental health conditions related to pregnancy;[17] and,
WHEREAS, Black women in the United States are three to four times more likely than their white counterparts to die from pregnancy-related causes;[18] and,
WHEREAS, Black, Brown, and low-income women specifically struggle to access birth control, evident by the fact that Black and Latina women are less likely to use long-acting reversible contraceptives (LARCs) in comparison to their white counterparts, in part because providers are often less likely to explain and recommend these options;[19] and,
WHEREAS, people of color are also generally more reluctant to trust healthcare providers because their communities have routinely been mistreated, including via forced sterilization and coerced use of birth control;[20] and,
WHEREAS, as a result of many factors, fewer Black and Hispanic women than white women in the United States report having ever used fertility services to become pregnant;[21] and,
WHEREAS, the lower reliance on fertility services among Black women is despite the fact that research has shown a higher rate of infertility among Black women;[22] and,
WHEREAS, LGBTQ people also face heightened barriers to fertility care, including discrimination based on their gender identity or sexual orientation and an inability to afford fertility services exacerbates barriers to this care;[23] and,
WHEREAS, nearly one in four transgender people report avoiding seeking necessary health care because they fear discrimination or mistreatment due to their gender identity, and transgender people of color experience “deeper and broader” patterns of discrimination;[24] and,
WHEREAS, the transgender community faces massive health disparities impacting sexual and reproductive health, with transgender individuals nearly five times more likely to have HIV as compared to the national average and approximately one in five Black transwomen living with HIV;[25] and,
WHEREAS, transgender individuals are more likely to be low-income, experience housing insecurity, and be reliant on Medicaid, with one-third of transgender individuals and half of undocumented transgender individuals report experiencing homelessness at some point;[26] and,
WHEREAS, being uninsured is associated with substantial delays in seeking care, and over 25% of transgender people of color are uninsured, compared to 11% of cisgender adults in the United States;[27] and,
WHEREAS, transgender populations report high rates of mistreatment from health care providers, among transgender people who visited a health care provider in the last year 29% report that a provider refused to see them because of their actual or perceived gender identity;[28] and,
WHEREAS, access to gender-affirming care is associated with positive health outcomes, one study found that access to gender-affirming health care for transgender youth led to a 60% decrease in the likelihood of developing moderate or severe depression and a 73% decrease in the likelihood of suicidality in transgender and nonbinary youth aged 13 to 20;[29] and,
WHEREAS, access to gender-affirming care is associated with positive health outcomes, one study found that access to gender-affirming health care for transgender youth led to a 60% decrease in the likelihood of developing moderate or severe depression and a 73% decrease in the likelihood of suicidality in transgender and nonbinary youth aged 13 to 20;[30] and,
IV. Public and private insurance coverage for abortion, fertility care, contraception, and gender-affirming care are essential for meaningful access, especially for more vulnerable communities, and currently coverage is insufficient.
WHEREAS, coverage is vital to access because we cannot say we truly have access to any health care service in this country until every insurance program, including Medicaid, covers the full spectrum of health care service options without out-of-pocket expenses for enrollees; and,
WHEREAS, we know that without effective coverage, people have to forgo needed and wanted healthcare services because of cost barriers; and,
WHEREAS, without public coverage for abortion services, people are less likely to be able to afford needed abortions and much more likely to continue living in economic distress, impacting the health and well-being of themselves and their families; and,
WHEREAS, 10 states mandate private insurance coverage for abortion and 16 states provide public coverage for abortion, but still 34 states do not include any coverage for abortion or affirmatively ban such coverage, leaving pregnant people with little financial recourse if they cannot afford out-of-pocket costs for abortion; and,
WHEREAS, many of the same barriers that limit coverage of abortion also exist for fertility care, with the vast majority of states lacking any coverage requirement for fertility services;[31] and,
WHEREAS, most fertility patients pay for care out-of-pocket, which can easily exceed $10,000, putting fertility services out of reach for many people; and,
WHEREAS, bans on insurance coverage of abortion particularly impact immigrant and migrant communities because bans compound barriers to health care access disproportionately experienced by these communities, including logistical barriers like travel costs and distance to clinics, lodging needs, and costs, childcare costs, and availability, limited access to language access services, culturally competent care inclusive of low-literacy services, lost wages, and lack of paid time off for health care appointments, and each of these barriers alone, and together, can delay or obstruct entirely abortion care; that
WHEREAS, Medicaid covers 30% of Black women and 26% of Hispanic women in the United States, compared to 15% of White women covered by Medicaid, meaning that a lack of public coverage for fertility services disproportionately impacts Black and Hispanic women compared to white women;[32] and,
WHEREAS, most people who rely on Medicaid likely cannot afford to pay for fertility services out of pocket; and,
WHEREAS, Medicaid programs in at least ten states explicitly prohibit coverage of transgender-related gender-affirming health care;[33] and,
WHEREAS, insured transgender people encounter frequent challenges with public and private insurers excluding or denying coverage for medically necessary gender-affirming care, with 46% of transgender individuals reporting having a health insurer deny them coverage for such care, including 56% of transgender respondents of color;[34] and,
WHEREAS, even those who are covered by health insurance are not immune to the burden of health care costs, and about half of insured adults still worry about affording their monthly health insurance costs;[35] and,
V. Comprehensive health care coverage should include support for the cost of travel to receive health care when it is inaccessible in a given location.
WHEREAS, there can arise a need for individuals to seek health care services outside of their state of residency and states do not prevent a resident from seeking care outside of its borders, regardless of the reason, including seeking specialized care, a second opinion, or in-patient care; and,
WHEREAS, despite the increased costs and additional burdens, many patients regularly find ways to travel to access necessary health care, including abortion; and,
WHEREAS, people with disabilities are often forced to travel to seek health care for a multitude of reasons, including: a paucity of appropriately trained providers; limited medical facility accessibility; a lack of examination equipment that can be used by people with diverse disabilities; a lack of sign language interpreters; lack of materials in formats that are accessible to people who are blind or have vision impairments; lack of individualized accommodations;[36] and,
WHEREAS, an inability to travel to access necessary reproductive health care, including abortion, will particularly impact, to devastating effect, communities of color, especially Black women in the United States.
THEREFORE BE IT RESOLVED, that the National Hispanic Caucus of State Legislators (NHCSL) recognizes the need to protect, support, and improve access to and coverage for comprehensive, quality health care—particularly for care that has been under attack, such as abortion and gender-affirming care for the transgender community—for all individuals, regardless of race, income, age, disability, sex or gender, ethnicity, or national origin; and,
BE IT FURTHER RESOLVED, that the NHCSL supports the vast majority of medical organizations and the World Health Organization in finding that the right to abortion, contraception and fertility care are essential aspects of sexual and reproductive health and calls on states and the federal government to guarantee the full protection of, and compressive, affordable access to, each; and,
BE IT FURTHER RESOLVED, that the NHCSL recognizes that an inability to afford transgender health care creates an insurmountable barrier to care for many people that can have detrimental and even dangerous impacts on the physical and emotional health and well-being of individuals and their families; and,
BE IT FINALLY RESOLVED, that the NHCSL therefore calls on lawmakers and policymakers to develop, prioritize, and support legislation or regulations that will improve the economic security of individuals, families, and communities by protecting and expanding public and private coverage of reproductive health care, including abortion, contraception, and fertility services and transgender health care.
THE NHCSL HEALTHCARE TASK FORCE, AT ITS MEETING OF JULY 9, 2024, UNANIMOUSLY RECOMMENDED THIS RESOLUTION TO THE EXECUTIVE COMMITTEE FOR APPROVAL.
THE EXECUTIVE COMMITTEE UNANIMOUSLY APPROVED THIS RESOLUTION AT ITS MEETING OF JULY 13, 2024.
THE NATIONAL HISPANIC CAUCUS OF STATE LEGISLATORS AMENDED AND RATIFIED THIS RESOLUTION AT ITS ANNUAL MEETING OF NOVEMBER 23, 2024 IN DENVER, COLORADO.
[1] Movement Advancement Project, Bans on Best Practice Medical Care for Transgender Youth, https://www.lgbtmap.org/equality-maps/healthcare_youth_medical_care_bans (last visited May 28, 2024).
[2] Trevor News, New Poll Illustrates the Impacts of Social & Political Issues on LGBTQ Youth, The Trevor Project (Jan. 10, 2022), https://www.thetrevorproject.org/blog/new-poll-illustrates-the-impacts-of-social-political-issues-on-lgbtq-youth/
[3] Lunna Lopes et al., Americans’ Challenges with Health Care Cost, KFF (Mar. 1, 2024), https://www.kff.org/health-costs/issue-brief/americans-challenges-with-health-care-costs
[4] Id.
[5] Brittni Frederiksen et al., Contraception in the United States: A Closer Look at Experiences, Preferences, and Coverage, KFF (Nov. 3, 2022), https://www.kff.org/womens-health-policy/report/contraception-in-the-united-states-a-closer-look-at-experiences-preferences-and-coverage
[6] Power to Decide, Contraceptive Deserts, https://powertodecide.org/what-we-do/contraceptive-deserts#:~:text=More%20than%2019%20million%20women,full%20range%20of%20contraceptive%20methods (last visited May 28, 2024).
[7] Elizabeth B. Harned & Liza Fuentes, Abortion Out of Reach: The Exacerbation of Wealth Disparities After Dobbs v. Jackson Women's Health Organization, Am. Bar Ass’n (Jan. 6, 2023), https://www.americanbar.org/groups/crsj/publications/human_rights_magazine_home/wealth-disparities-in-civil-rights/abortion-out-of-reach/
[8] Id.
[9] Allie Kelly, Abortions Now Cost Over $450, More Than Double the Price Before Roe Was Overturned, Per a Reproductive Care Nonprofit Director, Bus. Insider (Feb. 29, 2024), https://www.businessinsider.com/costs-abortions-travel-expenses-increase-scotus-roe-v-wade-dobbs-2024-2
[10] Diana Greene Foster, The Turnaway Study: Ten Years, a Thousand Women, and the Consequences of Having―or Being Denied―an Abortion (2020).
[11] Ctrs. for Disease Control & Prevention, Pregnancy Complications (May 15, 2024), https://www.cdc.gov/maternal-infant-health/pregnancy-complications/index.html
[12] MGH Ctr. for Women’s Mental Health, Psychiatric Disorders During Pregnancy, https://womensmentalhealth.org/specialty-clinics/psychiatric-disorders-during-pregnancy/ (last visited May 28, 2024); Ctrs. for Disease Control & Prevention, Symptoms of Depression Among Women (May 15, 2024),
[13] Diana Greene Foster et al., Socioeconomic Outcomes of Women Who Receive and Women Who Are Denied Wanted Abortions in the United States, 108 Am. J. Pub. Health 407, 412 (2018).
[14] Jennifer Bennett Shinall, The Pregnancy Penalty, 103 Minn. L. Rev. 749 (2018); Brief for Nat’l Women’s L. Ctr. et al. as Amici Curiae Supporting Respondents at 11, Dobbs v. Jackson Women’s Health Org., No. 19-1392 (Sept. 20, 2021).
[15] Michelle H. Moniz et al., Out-of-Pocket Spending for Maternity Care Among Women with Employer-Based Insurance, 2008-15, 39 Health Affs. 18, 20 (2020); Jamille Fields Allsbrook & Osub Ahmed, Building on the ACA: Administrative Actions to Improve Maternal Health, Ctr. for Am. Progress (Mar. 25, 2021), https://www.americanprogress.org/article/building-aca-administrative-actions-improve-maternal-health/
[16] Guttmacher Inst., Restrictions on Contraceptive Services Interfere with People’s Ability to Get Care and Use Their Preferred Contraceptive Method (Sept. 20, 2022), https://www.guttmacher.org/news-release/2022/restrictions-contraceptive-services-interfere-peoples-ability-get-care-and-use.
[17] Charmaine N. Scarlett & Angela D. Aina, Issue Brief: Black Maternal Health, Black Mamas Matter Alliance (Sept. 2020), https://blackmamasmatter.org/wp-content/uploads/2022/04/0322_BMHStatisticalBrief_Final.pdf.
[18] Id.
[19] Jenny Higgins et. al., Provider Bias in Long-Acting Reversible Contraception (LARC) Promotion and Removal: Perceptions of Young Adult Women, 106(11) Am. J. Pub. Health (Nov. 2016) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5055778/#bib14.
[20] Deepali Gill, Access Denied: The Startling Struggle for Birth Control Access in Black, Brown, and Low-Income Communities, ICAN (Feb. 8, 2024) https://ican4all.org/access-denied-the-startling-struggle-for-birth-control-access-in-black-brown-and-low-income-communities/.
[21] Gabriela Weigel et al., Coverage and Use of Fertility Services in the U.S., KFF (Sept. 15, 2020), https://www.kff.org/womens-health-policy/issue-brief/coverage-and-use-of-fertility-services-in-the-u-s/.
[22] Id.
[23] Id.
[24] Sandy E. James et al., The report of the 2015 U.S. Transgender Survey 6 (2016).
[25] Id.
[26] Id.
[27] Dickey LM, Budge SL, Katz-Wise SL, Garza MV. Health disparities in the transgender community: Exploring differences in insurance coverage. Psychol Sex Orientat Gend Divers. 2016;3(3):275–282. doi: 10.1037/sgd0000169.
[28] Shabab Ahmed Mirza & Caitlin Rooney, Discrimination Prevents LGBTQ People from Accessing Health Care, Ctr. for Am. Progress (Jan. 18, 2018), https://www.americanprogress.org/issues/lgbtq-rights/news/2018/01/18/445130/discrimination-prevents-lgbtq-people-accessing-health-care.
[29] Em Buyea, The Impact of Banning Gender-Affirming Care in America: A Step Backward for Equality, Tufts University (June 26, 2023), https://sites.tufts.edu/chsp/2023/06/26/the-impact-of-banning-gender-affirming-care-in-america-a-step-backward-for-equality/#:~:text=Health%20and%20Well%2Dbeing%20Consequences,%2C%20and%20self%2Dharm%20tendencies.
[30] Diana M. Tordoff et al., Mental Health Outcomes in Transgender and Nonbinary Youths Receiving Gender-Affirming Care, 5 JAMA 1 (2022).
[31] RESOLVE, Insurance Coverage by State, https://resolve.org/learn/financial-resources-for-family-building/insurance-coverage/insurance-coverage-by-state/ (last visited May, 28, 2024).
[32] Gabriela Weigel et al., Coverage and Use of Fertility Services in the U.S., KFF (Sept. 15, 2020), https://www.kff.org/womens-health-policy/issue-brief/coverage-and-use-of-fertility-services-in-the-u-s/.
[33] Movement Advancement Project, Medicaid Coverage of Transgender-Related Health Care, https://www.lgbtmap.org/equality-maps/medicaid (last visited May 28, 2024).
[34] Caroline Medina, Fact Sheet: Protecting and Advancing Health Care for Transgender Adult Communities, Ctr. for Am. Progress (Aug. 25, 2021), https://www.americanprogress.org/article/fact-sheet-protecting-advancing-health-care-transgender-adult-communities/.
[35] Lunna Lopes et al., Americans’ Challenges with Health Care Cost, KFF (Mar. 1, 2024), https://www.kff.org/health-costs/issue-brief/americans-challenges-with-health-care-costs
[36] Nat'l Council on Disability, The Current State of Health Care for People with Disabilities (Sept. 2009), https://www.ncd.gov/publications/2009/Sept302009#Overview.