In response to the COVID-19 pandemic, every state has declared a state of emergency. In early May, some states started to lift restrictions on certain types of businesses; however, a majority of residents throughout the country are under stay-at-home orders and directives that affect access to health care. As states continue to extend or modify policies to keep people safe from contracting the coronavirus and protect the health care system, those efforts must also ensure that people can receive high-quality sexual and reproductive health services.
Decisions about sexual and reproductive health are among the most fundamental and personal, and delaying access to services can have substantial consequences for many people and their families. That is why the World Health Organization’s recent guidance on maintaining essential health services includes as a high priority "services related to reproductive health, including care during pregnancy and childbirth."
Yet, even during this pandemic, some of the governors who oppose abortion have attempted to close all abortion clinics in their state. As of early May, litigation had been filed in nine states to ensure that this urgent and vital care remains available; in several instances, court decisions have prevented the closure of clinics.
In other states, governors’ executive orders are protective of reproductive health care, including abortion. The protections in these orders provide a framework, and there is much that state policymakers can do to build on this support. Here are 10 things that states should do to protect and ensure access to sexual and reproductive health care and rights during the pandemic.
1) Ensure that reproductive health care is included within essential health care. As governors seek to reduce coronavirus transmission, they must ensure timely access to reproductive health services. Although most executive orders have not addressed these services specifically, many states are diligently working to ensure continuity of reproductive health care. As of May 8:
- Only two states, Massachusetts and New Jersey, have explicitly exempted abortion services from stay-at-home orders as essential health care. In other states—such as Delaware, Hawaii, New York and Oregon—attorneys general have publicly clarified that their state’s order exempts abortion.
- Some states, such as New Mexico and Washington, are shoring up access to comprehensive family planning services by designating the "full suite of family planning services" as essential.
- Other states, like Illinois and Montana, have designated reproductive health providers more broadly as essential, and California’s Department of Health provided guidance to continue pregnancy-related services for Medi-Cal beneficiaries "during these unprecedented times."
- Nearly every state has adjusted health care provider licensure requirements in response to the pandemic in order to prepare for an increase in demand and the impact it will have on the state’s health care systems.
With nearly a quarter of states specifically addressing access to at least some aspects of reproductive health care in their COVID-19 responses and the extension of stay-at-home orders in some states, policymakers should:
- Include reproductive health services as essential, urgent health care and reproductive health providers as essential workers in stay-at-home orders.
- Include reproductive health providers in efforts to provide financial support, regulatory relief and infrastructure—including personal protective equipment—to health care providers and critical businesses.
- Reject attempts to restrict or undermine reproductive health services and providers.
- Enforce both existing abortion clinic protection laws and new emergency orders to prevent protesters from threatening—and potentially infecting—patients.
2) Ensure that abortion care is accessible and timely by repealing burdensome restrictions. Abortion restrictions in place in many states already prevent timely care and, for some people, make it inaccessible. The logistical barriers created by abortion restrictions are compounded by statewide stay-at-home orders and a worsening economic downturn. State policymakers should:
- Repeal mandatory waiting periods, in-person counseling requirements and telemedicine bans that force patients to make multiple trips to a clinic, putting them and their health care providers at higher risk of coronavirus exposure.
- Increase the number of available abortion providers by lifting physician-only provision requirements and allowing advanced practice clinicians to provide early abortion, so that patients do not have to wait for care or travel long distances during shelter-in-place orders.
- Roll back parental involvement laws, which create barriers particularly for immigrant youth and youth in unstable and abusive homes, and which young people may be unable to have waived using a judicial bypass procedure while state courts are closed.
3) Protect individuals’ autonomy and choices in abortion care, including self-managed abortion. As some abortion clinics close (whether voluntarily or by state order), travel is restricted and risk of exposure to the coronavirus continues, more people may choose to self-manage their abortion. Also, people who experience pregnancy complications at home, including miscarriage or stillbirth, need to be able to seek medical care without fear of arrest for suspicion of having self-managed an abortion. And, others will continue to need abortion care at a clinic later in pregnancy for a number of reasons. Policymakers should:
- Affirm the right to access and obtain an abortion throughout pregnancy without state interference, including during emergency shelter-in-place orders.
- Suspend laws that could be used to prosecute people for their pregnancy outcomes or for self-managing an abortion, along with anyone who assists them.
4) Allow pharmacists to provide contraceptive services. When pharmacists are allowed to prescribe and dispense contraceptives, people can receive their care without having to separately visit a health care provider’s office. Pharmacy access measures can reduce patient interaction with health care locations that are overburdened by COVID-19 cases, which may lower transmission risks and free up capacity of health care providers to handle other needs. To support this service, state policymakers should:
- Authorize pharmacist-provided contraceptive care, including for self-administered hormonal methods (the pill, patch and ring) and injectable contraceptives.
- Encourage all pharmacies to participate in order to maximize access for patients.
- Ensure pharmacists are trained and paid for this care.
5) Increase support for publicly funded clinics. Publicly supported family planning clinics, STI clinics and community health centers provide essential health services that people continue to need during the current crisis. For some people, these providers are their only point of contact for health care. Several states have already appropriated funds so that family planning clinics can remain open in spite of the 2019 federal "gag rule" that slashed the national Title X provider network’s capacity in half. States must provide additional funds for continued support as the COVID-19 pandemic stretches providers’ resources. Policymakers should:
- Provide additional funding to ensure that these essential providers can serve their patients despite federal funding restrictions.
- Repeal state-level restrictions that prevent providers and organizations that perform or refer for abortion services from receiving funds to provide family planning and STI care.
- Enable public health clinics, including family planning providers, to screen and test people for COVID-19 by providing technical assistance and supplies and allowing them to use family planning funds for coronavirus response.
6) Respond to the needs of pregnant and parenting individuals and continue efforts to reduce maternal mortality. Health experts are still learning about the effects of COVID-19 on pregnant individuals. So far, there is no evidence to suggest that people who are pregnant are at greater risk of illness. However, pregnancy suppresses the immune system, making pregnant people especially vulnerable to viral respiratory infections and severe illness. The coronavirus pandemic is unfolding in the midst of a national maternal health crisis in the United States, where black women are dying from pregnancy-related causes at more than three times the rate of white women. COVID-19 will only exacerbate the existing inequities and racism that black women and other women of color experience with the health care system. In order to appropriately support all pregnant individuals during the pandemic, policymakers should:
- Prioritize COVID-19 testing for anyone who is pregnant.
- Require medical facilities to train staff who serve patients during pregnancy, labor and delivery, and postpartum about implicit bias, either virtually or in person.
- Designate health care services throughout pregnancy, delivery and postpartum as essential services, including mental health and substance use treatment.
- Review guidance from the American College of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine and maternal health clinical experts to determine what will be best for pregnant individuals in their state, including how to ensure they receive support during labor and delivery as well as postpartum, whether in person or via telehealth.
- Address the specific needs of incarcerated pregnant individuals, including by mitigating their exposure to the coronavirus; ensuring their access to quality physical and mental health care and appropriate nutrition; prohibiting shackling during pregnancy, labor and delivery, and postpartum; and providing lactation support.
- Ensure funding for state maternal mortality review committees and relevant state agencies to determine how to best track maternal morbidity and mortality related to COVID-19.
- Direct state and federal maternal and child health care funds to support the state’s efforts to respond to the coronavirus pandemic, including through provision of care, research, provider education, and dissemination of accurate and reliable information to parents.
7) Support sex education in remote learning programs. Schools that offer sex education may teach it only once in middle or high school, and students should not miss the opportunity to receive this instruction. High-quality sex education covers communication skills, emotional self-awareness and tools for healthy relationships that can help young people navigate family dynamics and explore their sexuality in healthy ways during the current crisis. To promote this instruction, state policymakers should:
- Require schools to teach comprehensive, inclusive sex education in grades K–12, and encourage inclusion in remote learning curricula to the fullest extent possible.
- Provide school districts with model curricula appropriate for remote learning environments and training for teachers to implement this instruction.
8) Expand public and private insurance coverage of reproductive health services. Insurance coverage of reproductive health services is essential for access to and affordability of health care. Coverage has become even more critical during the coronavirus crisis, when people seeking care must navigate overburdened health care systems in unprecedented circumstances. States can pursue multiple approaches to ensure that people can obtain necessary care, including by expanding coverage under both private health insurance plans and Medicaid.
Experts have recommended suspending all Medicaid copayments; allowing insurance plan enrollees to obtain more than a month’s supply of their prescriptions at one time; requiring insurance coverage, without cost sharing, of COVID-19 testing, treatment and vaccination (once available); and ensuring Medicaid coverage for people who are not currently living in their state of residence. Specifically for sexual and reproductive health, state policymakers should also:
- Require Medicaid and private insurers to cover doula services throughout pregnancy and postpartum; lactation support; postpartum health services, such as physical therapy and mental health services; and related equipment necessary for pregnancy, including glucose and blood pressure monitoring.
- Ensure that both state Medicaid programs and private health insurance plans cover abortion under all circumstances.
- Require private insurers and state Medicaid programs to cover the full range of contraceptives, including over-the-counter methods, and dispensing of a 12-month supply at one time.
- Implement Medicaid family planning expansions to help otherwise uninsured individuals afford contraceptives and related services and supplies.
- Apply for federal permission to expand Medicaid coverage to one year postpartum for all pregnant beneficiaries.
- Extend Medicaid coverage for sexual and reproductive health services to all individuals regardless of immigration or documentation status.
9) Broaden access to sexual and reproductive health care through telehealth. Expanding access to telehealth options allows people to interact with health care providers while practicing social distancing to reduce exposure to the coronavirus. Telehealth can be used to provide many reproductive health services, and state policymakers should permit the full range of these services during the COVID-19 pandemic by taking steps to:
- Require private and public health insurance coverage of telehealth, without cost sharing, for abortion, contraceptive, obstetric, postpartum and other sexual and reproductive health care to mitigate exposure to the coronavirus.
- Eliminate bans on the use of telehealth for medication abortion or requirements for a provider to be in the same room as the patient.
- Provide funding and support so that providers can administer care reliably and effectively and protect patient confidentiality.
10) Protect patients from religious and moral refusals of care. For decades, state laws have allowed organizations and individual health care providers with an expressed religious or moral objection to refuse to provide abortion, contraceptive and sterilization services. In almost all of these refusal clauses, there is no requirement that the refusing provider facilitate patient access to these services elsewhere. These refusal clauses limit the number of available providers for reproductive health care and could be even more burdensome—and perhaps life threatening—during the COVID-19 crisis.
At all times, and especially during a public health emergency, people need to be able to seek care without fear that it will be denied on the basis of their sex, sexual orientation or gender identity, or because the provider has a religious or moral objection to the procedure. State policymakers should:
- Limit the ability of health care providers and institutions to refuse to provide care and enforce laws that prohibit discrimination in health care.
- Require refusing providers to facilitate patient care by another provider.
- Require that care be provided in emergency situations.
Since March, reproductive health care providers and patients have had to navigate a new reality, and many providers have taken innovative approaches to offer care that is both effective and centers the needs of their patients. Policymakers at the state level have the responsibility to support these efforts and use the tools at their disposal to ensure that sexual and reproductive health care is accessible and available to all who need it. These policy recommendations provide a solid foundation for the provision of care now and beyond this pandemic.