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The political environment has shifted under the Trump-Pence administration and the anti-choice majority in Congress. Reproductive health and rights are under full attack through efforts to repeal the Affordable Care Act, restrict access to abortion, and confirm an anti-choice U.S. Supreme Court justice.

It is all the more important therefore to articulate the complex nature of women’s lives today and their role as key contributors to American society. Women’s economic contributions often depend on having access to comprehensive reproductive health services, as well as to education, jobs with livable wages, and workplace supports. In the U.S. political and public discourse, connections between women’s health and family economic stability are often obscured, ignored, or dismissed. The political debate is regularly reduced to either family planning or abortion, but reproductive health and rights encompasses a continuum of health services and legal protections that bolster all areas of their lives.

This report argues that reproductive health, rights, and justice must be integral to a successful, 21st-century economic agenda. The United States must acknowledge and focus on the mutually reinforcing ways in which reproductive health and economic empowerment help both women and the economy thrive. This report proposes policy recommendations for federal and state policymakers to help women achieve economic security and reproductive justice in tandem.

Current laws and public perceptions perpetuate stigma about reproductive health and rights. The country must change the conversation so that abortion is seen as an option—not just an exception—family planning is recognized as ineffective as a sole strategy for reducing poverty, and so that policy debates address solutions that consider both women’s economic and health needs. A new framework is needed that values reproductive health, responds to women’s economic challenges, and increases workplace opportunities for the modern woman and her family.

Reproductive health and rights are inextricably linked with reproductive justice. The five key pillars that should be at the core of an economic agenda to address the needs of women and their families are:

• Self-determination
• Access to comprehensive reproductive health services
• Affordability of care
• Parenting with respect and dignity
• Workplace and caregiving supports

Each pillar represents a key component that all women need to thrive and be healthy. These pillars are valuable individually but are also mutually reinforcing to anchor a policy agenda that meets the intersectional needs of working women.

This report argues that reproductive health, rights, and justice must be integral to an economic agenda that works for all. Rather than focusing solely on a narrow argument that access to contraception and abortion ensure economic opportunity for women, this report takes a broader, more comprehensive look at the mutually reinforcing ways in which reproductive health and economic empowerment help families and the economy thrive. This analysis is followed by a discussion focused on the five key principles listed above. Finally, this report proposes a policy agenda aimed at rejecting rollbacks that would reverse concrete progress in an environment hostile to women’s health and rights. The proposed policy agenda includes progressive measures at the intersection of economic justice and reproductive justice. These policy tools can be deployed at the federal or state level and include the following.

• Protect the Affordable Care Act, or ACA, so that millions of women can continue to benefit from no-cost access to well women’s care and other preventive services, such as contraception; breast feeding support and supplies; screening and testing for sexually transmitted infections, or STIs; and breast cancer screenings.
• Prevent roll backs of progress on reproductive rights, ensuring that abortion remains part of the full continuum of safe, legal medical care.
• Support the Title X Family Planning Program and ensure access to affordable health care for low-income, uninsured, and young people, as well as communities of color, across the country.
• Reject efforts that deny health care based on religious or moral objections.
• Expand Medicaid in order to help fill the coverage gap of approximately 3 million women who are currently eligible but uninsured.
• Pass the Equal Access to Abortion Coverage in Health Insurance, or EACH Woman Act, which would repeal the Hyde Amendment and other abortion funding restrictions passed through the appropriations process. It would also prohibit restrictions on private insurance coverage for abortion services.
• Pass the Women’s Health Protection Act, or WHPA, which would prohibit states from enacting dangerous restrictions on abortion care and interfering with the patient-doctor relationship.
• Pass the Health Equity and Access Under the Law, or HEAL, Immigrant Women and Families Act, which would restore Medicaid and Children’s Health Insurance Program, CHIP, coverage to immigrant women and families residing lawfully within the United States.
• Adopt strong workplace standards to improve job quality and give workers the resources and tools they need to live healthy lives. These include raising the minimum wage, guaranteeing all workers have access to paid family and medical leave and paid sick days, and promoting and ensuring pay equity.
• Promote affordable high quality child care that meets the needs of families and doesn’t jeopardize their economic security.
• Commission a study examining unequal access to women’s health care in order to connect health indicators with economic indicators and help address disparities in care.

Comprehensive state and federal policies, like those listed above, will ensure equitable opportunity for all.

Ensuring women’s full participation in the workplace and throughout society is crucial to the economic stability of women and working families, as well as to the efficient functioning of the economy.

In the United States, however, there has been a longstanding, deeply divisive struggle surrounding reproductive health.. Reproductive health care, particularly abortion access, is often omitted from the broader conversation about women’s economic needs. But women know that their lives cannot be broken into silos. Recent polling shows that voters viewed health care, the economy, and jobs as equally important during the 2016 elections.¹ In fact, health care is one of the top five issues for voters among jobs, government spending, terrorism, income inequality, and immigration.² In short, reproductive health and economic security go hand-in-hand, whether policymakers acknowledge it or not.

Many women struggle to maintain their economic security to the detriment of their health. Women make up the majority of workers in low-wage jobs, which are less likely to offer health insurance or workplace supports such as paid family and medical leave.³ But even when women have decent paying jobs with health insurance, they often struggle to find the time to take their leave and make use of their coverage. Additionally, increased restrictions on reproductive health at the state level interfere with the relationship between patients and their doctors.⁴ For instance, many states require abortion providers to counsel patients with inaccurate information, to perform medically unnecessary procedures, or to delay care.⁵ Worse, many of the states that severely restrict abortion access do not offer any additional workplace protections for pregnant women or new parents such as paid family leave, paid sick days, or pregnancy accommodations.⁶

An ambitious economic agenda must encompass reproductive rights, health services, and institutional supports in a broad way. It must protect their health, as well as their ability to plan their childbearing, support their families, and participate in the workforce. This comprehensive approach reflects the complexity of women’s lives and is essential for them to achieve their full potential. Reproductive health services help women and LGBT individuals become independent and control their own destinies. 

Reproductive health and rights have long played a role in women’s economic security and social advancement. Expanded accessibility of the birth control pill has helped millions of women chart their own course by being able to plan a pregnancy, determine their personal timetable for marriage, pursue an education, and embark on a career.

Comprehensive reproductive health services have improved women’s health broadly and increased the economic stability of countless families. Yet, in the political and public discourse, the connections between women’s health and family economic stability often have been obscured, ignored, or dismissed. This has occurred in three key ways:

• Policymakers have long singled out and treated reproductive health differently—and often more harshly—than the broader topic of health due to the abortion debate, regardless of the potential economic consequences
• Policymakers have used family planning ineffectively as part of a so-called strategy to reduce poverty without requiring a deeper investment in policies to promote economic stability
• Economists who advise lawmakers on policy solutions often view health differently from consumer of health care products.

These challenges are reflected in new laws and in public perceptions and stigma about reproductive health and rights.

Abortion as an exception

Reproductive health services include family planning, maternal health, preventive care—such as cancer screening—and abortion care.⁷ The public battles over reproductive rights, however, have historically centered on abortion access. As a result, there is a common misperception that reproductive rights are only about abortion access. Organizations and advocates alike have struggled for decades in this environment to balance their efforts pushing back against relentless attacks on abortion access, while also advocating more broadly for affordable contraception and the right to pursue motherhood on their own terms.

This has been most apparent in the legal arena where court cases have not just shaped reproductive health law but have changed the health care experience itself. In myriad cases, from the U.S. Supreme Court to the lower courts, reproductive health care options and patients’ ability to interact freely with their health care professionals have been altered because of special rules governing abortion care. For example, in Webster v. Reproductive Health Services,⁸ the Court ruled that states were allowed to restrict the use of state funds, public employees, and facilities from providing abortions. In Planned Parenthood v. Casey, the Court ruled that governments are allowed to impose restrictions on abortion services that do not pose an “undue burden” on those seeking care.⁹ These rulings not only contributed to the physical separation of abortion services from other kinds of reproductive  health services, particularly family planning services, but also meant that abortion care became more stigmatized and vulnerable to political attacks. Moreover, these and other cases reinforced the misperception that reproductive health care could be segmented into different components and dispensed in piecemeal fashion through legislative restrictions, rather than through consultation with doctors and health professionals.

These federal rulings and 30 years of state restrictions have shaped attitudes about abortion care. As a result, in 2016 many voters did not see restrictions on abortion services—such as the 24-hour waiting period, mandatory counseling, regulation of medication abortion, and parental notification—as unusual.¹⁰ But these policies actually harm the ability of people to receive all kinds of care. Treating abortion services differently from the broader range of reproductive health services puts all reproductive health at risk. An impact study conducted by Ibis Reproductive Health and the Center for Reproductive Rights found that states with the most abortion-related restrictions are also the worst at ensuring sexual and reproductive health in a broad range of areas, including STIs and HIV, domestic and intimate partner violence, cervical cancer, maternal health, and mental health.¹¹ Women can better control their lives when they have unfettered access to comprehensive reproductive health services, including abortion care.

Family planning as an ineffective solo strategy to reduce poverty

The first federal appropriation for family planning was made in 1965 to help low-income families as a part of President Lyndon Johnson’s War on Poverty program.¹² In 1970, Congress passed Title X of the Public Service Health Act, the only program to pay for family planning for low-income women.¹³ It was eventually expanded to other programs such as Medicaid, the State Children’s Health Insurance Program, or SCHIP, and block grants that support a network of family planning clinics across the nation.¹⁴ These programs successfully helped reduce unintended pregnancies, improve maternal health, and expand preventive care for low-income families. They did not stand alone, however, to resolve other systemic barriers—such as poverty, housing discrimination, and racism—that undermine low-income women’s economic opportunity.

More than a half-century later, Title X too often continues to be burdened by unrealistic expectations.¹⁵ Heralded for its cost savings to states and the federal government, the program is treated as a cure-all for the challenges that low-income women face. But research shows that contraceptive coverage alone does not alleviate poverty or lack of economic opportunities. For example, one 30-year study of 300 young mothers on the causes of generational poverty and teenage pregnancy found that contraception alone did not change their low socioeconomic status, the lack of educational and job opportunities beyond high school, or their social supports.¹⁶ As a result, when low-income women of color delayed pregnancy, for example, they often remained low-income.¹⁷

Policies that solely targeted teen pregnancy, such as comprehensive sex education, did increase access to contraception, but strategies focused on actually improving economic opportunities helped reduce poverty and teen childbearing rates.¹⁸ Thus, while investments in family planning services and Medicaid programs have made some inroads, complementary policies such as early childhood education programs, increased financial aid for higher education, efforts to raise wages, workplace supports, and addressing social inequalities are critical.¹⁹

Conflicting economic perspectives

Another challenge to crafting an economic agenda that embraces reproductive health, rights, and justice includes a basic understanding of how health affects economic outcomes. The discussion of health in the economic context often occurs in two ways: 1) health care as a contributor to the long-term growth of the economy because healthier people are more productive at their jobs, live longer lives, and work longer and 2) health care as an independent market with products, consumers, and profit.²⁰ But beyond these two concepts, health care also is essential to the quality of labor market opportunities for individuals, not just quantity of working hours and years. Employees and future workers must have comprehensive health care and good health in order to pursue education, have greater job mobility, build skills and different careers, and access job opportunities that make sense for them and their families. Yet the cost and availability of the full range of health care services for women rarely factor into the publicly discussed equation of what makes a fairer and more just economy.

For workers, the costs and availability of health care, namely reproductive health care, are critical to being able to make sound decisions about work, education, and their lives overall. Their ability to take advantage of workplace opportunities is directly linked to their ability to access reproductive health services and plan their families. Women’s early career choices, which often take place during their peak reproductive health years, affect their lifetime earnings and retirement security. A small body of economics research, for example, has looked at how access to reproductive health care—such as the availability of the pill—increased women’s economic opportunities when women were granted legal access to birth control at different times across states. Women were better able to invest in their careers, access higher education across more fields, and increase their labor force participation over the course of their lives.²¹

But too often economic policy is viewed as gender-neutral and, as it relates the interaction between economics and health factors, does not take into consideration gender differences such as the variation in the rates of particular diseases or the types of health services that are needed.²² As a result, the unique health needs of women are often omitted from essential conversations driving the economic policy decisions that will affect them well into the future.

Women lead complex lives and need access to policies that can help them respond to demands at home and at work and achieve economic stability for themselves and their families. Women frequently are still the primary caregivers for children and are more likely to have gaps in employment as a result.²³ Having the freedom to decide whether, when, and how to start a family affects their investments in education, career choice, career timeline, lifetime earnings, and retirement security differently than it affects men.

While access to reproductive health services alone does not guarantee positive outcomes, it is necessary to empower women to become economically secure. But more intentional efforts are needed to avoid oversimplifying women’s experiences, and to help ensure that any positive economic outcomes correlated with reproductive health care access actually translate into actions with broader effects, such as reducing health care costs and health disparities for low-income women.

Supporting access to reproductive health must be considered as an investment in the nation’s economic future. As such, federal and state policymakers should produce a framework that prioritizes reproductive health as a critical component of women’s economic challenges as well as their opportunities. 

Women’s lives are composed of intersecting factors that shape their ability to fully participate in society and have economically secure lives. The current political environment fails to reflect this nuanced understanding. Reproductive health services and legal protections are important, but they cannot resolve these economic challenges alone. As families struggle to make ends meet in today’s economy, women need the full range of economic supports such as paid leave, affordable child care, fair pay, and comprehensive reproductive health services.

What is needed is a shift to a reproductive justice agenda. Economic security is interconnected with reproductive justice, which is defined as the economic, social, and political power and resources for women to make healthy decisions about their bodies; sexuality and reproduction; families; and communities.²⁴ The phrase “reproductive justice” was coined by African American women in 1994.²⁵ It is rooted in the belief that systemic inequality shapes women’s decision-making around childbearing and parenting, particularly vulnerable women. Institutional forces such as racism, sexism, and poverty, influence women’s individual freedoms in society. Other factors—such as immigration status, gender identity, sexual orientation, and age—can also affect whether or not women get the appropriate care they need. All women deserve access to health services, but some people need supports beyond policy change and legal services. Justice, in this case, refers to cultural norms that value everyone and every community as human and worthy of respect.

The five pillars

Women’s health is not simply about the accessibility and availability of direct services, but also the social and economic conditions that allow women to be healthy and autonomous. These conditions are mutually reinforcing: Reproductive health, rights, and justice are necessary to ensuring economic empowerment. But just as importantly, economic empowerment is necessary for ensuring access to reproductive freedom for all women.

There are five pillars essential to an economic framework that fully integrates reproductive health:

• Self-determination
• Access to comprehensive reproductive health services
• Affordability of care
• Parenting with respect and dignity
• Workplace and caregiving supports

These pillars collectively represent a holistic approach to ensuring that all women have what they need to thrive and be healthy. Each pillar is valuable individually, but, taken as a group, the pillars are also mutually reinforcing to anchor a policy agenda that meets the intersectional needs of working women. This policy agenda centers on women’s health, not as the absence of disease or disparity, but as a driving force to ensure economic security.

Self-determination

Self-determination refers to a person’s ability to control her body, health, and resources in order to pursue opportunity free from violence or coercion.²⁶ It also refers to a woman’s ability to decide the number of children she will have, her family structure, and how she will parent.²⁷ Bodily autonomy is not simply a matter of biological reproduction but of one’s ability to work and form a family regardless of one’s gender or sexual orientation. A woman’s ability to work ultimately shapes her ability to take advantage of opportunities and seek economic mobility.

Reproductive and sexual health undergird a person’s ability to access other freedoms. A rights-based approach ensures that all people receive information about family planning, abortion, childbearing and sexual health education in a way that meets their unique needs. More importantly, when an individual receives information and services free from discrimination, coercion, or violence, it creates a ripple effect in their families and communities. The result is that all people can control their own lives, have healthier relationships, increase their self-esteem, and teach their children about health and wellness. Finally, self-determination is key to health equity. It places vulnerable people at the center of the allocation of resources as well as policymaking to ensure that everyone benefits. 

Access to comprehensive reproductive health services, including abortion care

Comprehensive reproductive health services include breast and cervical cancer screening; sexually transmitted infections, or STI, and HIV testing; pregnancy tests; birth control; abortion services; infertility specialties; mental health services; maternity care; addiction counseling; sex education; and counseling for victims of domestic and sexual violence.²⁸ These services are pivotal for women to be healthy throughout their lifetime, to control their fertility, and to increase their economic mobility. But the care must be available, accessible, timely, and affordable. Preventive care is considered the bedrock of women’s health, shaping women’s relationships with medical professionals for a lifetime.

Overwhelmingly, family planning is the primary reason women seek reproductive health care. Contraception is currently used by 62 percent of U.S. women of reproductive age.²⁹ The most common methods include the birth control pill and tubal ligation, but long-acting reversible contraceptives, or LARCs, are growing in popularity, as they are more than 99 percent effective.³⁰ While primarily used to plan and space pregnancy, contraception is also used for other health benefits such as menstrual pain and regulation, and to treat endometriosis.³¹

Pregnant women who want to bear children benefit from maternal health care, which refers to care provided during the pregnancy, childbirth, and post-partum.³² Prenatal care helps women reduce complications, protect fetal health, and plan for childbirth.³³ It also helps prevent negative health outcomes such as maternal morbidity, which has been on the rise for the past 25 years despite health advancements.³⁴

Low-income women and women of color are less likely to receive early prenatal care,³⁵ and a lack of care is associated with a higher rate of newborn death.³⁶ African American women are three times more likely than white women not to receive prenatal care.³⁷ But American Indian and Alaska Native women are the most likely to