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Economic opportunity is a central tenet of the American dream and a mainstay of American political discourse. But when embracing this core economic aspiration, the ways in which people’s complex lives affect their ability to fully engage in the economy are often overlooked . The Center for American Progress report, “The Pillars of Equity: A Vision for Economic Security and Reproductive Justice,”¹ explored the diverse factors that affect the ability of women to determine the level and nature of their participation in the labor force and the economy. The report concluded, “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.” Understanding the connections between these economic and health issues is particularly important when determining the mix of policies necessary to place women on firm economic ground, as well as to empower women to make the decisions that make sense for them. Such analysis also requires moving beyond the issue silos that often isolate discussions about the economy, health care, and employment, as well as digging deeper into the growing body of research that reveals how these issues mutually reinforce each other.

Far too often, any discussions about reproductive justice, reproductive rights, and reproductive health care access are considered special interest matters in political debates, separate from a broader policy agenda aimed at economic empowerment. The data findings in this report show that these issues are correlated, however, and that states with policies affording women more control over their bodies are also the states where women have more opportunity in the labor market. These findings help demonstrate that, in order to encourage a dynamic economy replete with opportunity across the country, it is critical to foster both access to reproductive choices as well as economic opportunities for all women and their families.

Gaining a more in-depth understanding of the multiple factors shaping women’s economic stability and overall health and well-being is particularly important in this current political climate. Phrases such as “women’s empowerment” are often deployed rhetorically by policymakers without any real commitment to concrete actions that help move women forward. The Trump administration has touted first daughter Ivanka Trump as spearheading a women’s empowerment initiative—yet she has virtually no results to show.² At the same time, the administration has pursued a series of measures that erode women’s economic standing and access to health care, both of which are essential to women’s empowerment. For example, while claiming to be in support of equal pay for women, the Trump administration has done practically nothing to improve pay practices, bolster equal pay protections, or support more robust enforcement of anti-discrimination laws.³ Quite the opposite—Ivanka Trump supported the administration’s decision to halt implementation of a critical pay data collection tool⁴ that would have provided enforcement officials with much-needed information about employer pay practices.

Moreover, the administration has also initiated an all-out assault on women’s reproductive rights domestically and internationally—for example, the administration has reinstituted the Global Gag Rule,⁹ supported congressional efforts to maintain the Hyde Amendment,¹⁰ endorsed restrictive measures as part of the effort to repeal the Affordable Care Act (ACA),¹¹ as well as issued guidance to expand religious and moral exemptions that restrict insurance from covering certain reproductive health costs.¹² Each of these efforts separately has negative consequences for women, but together—along with too many other examples—they comprise a regressive, anti-woman agenda wrapped in a cynical, false narrative about women’s empowerment. The administration’s shallow claims to support women’s equality coupled with attacks by congressional opponents of pro-women policies have shown a complete ignorance of the complex ways in which women’s economic opportunities are linked to their reproductive rights and health care access.

This report shows that women’s economic empowerment, as measured by women’s labor force participation, earnings, and mobility, is correlated with stronger measures of upholding reproductive rights and health care access. Specifically, states with the best conditions for women to exercise bodily autonomy—through laws that empower women to make their own reproductive health decisions without interference—are the same states where women have greater economic opportunity. When women have secure control over planning whether and how to have a family, they are also able to invest in their own careers and take risks in the labor market that lead to better economic outcomes.

Key findings

To understand the ways in which women’s reproductive autonomy and economic opportunity are linked, the authors analyzed economic outcomes for women who face varying degrees of reproductive health care access and found that:

• Women living in states with a better reproductive health care climate—including insurance coverage of contraceptive drugs and services; expanded Medicaid eligibility for family-planning services; insurance coverage of infertility treatments; and the availability of state-supported public funding for medically necessary abortions—have higher earnings and face less occupational segregation compared with women living in states that have more limited reproductive health care access.
• Women in states with robust reproductive health care climates also are less likely to work part time,¹³ giving them more opportunity for higher earnings; nonwage benefits such as access to paid sick days and paid leave; and greater promotion opportunities.¹⁴
• Reproductive rights and health care access also reduce job lock, or the lack of labor mobility between jobs. Women who live in states with positive indicators of reproductive health care access, as measured by publicly available funding for abortion, are more likely to transition between occupations and from unemployment into employment. On the other hand, women in states with more limited abortion access, as measured by the presence of targeted regulation of abortion providers (TRAP) laws, are less likely to make these transitions.

Together, these findings start to paint a picture that shows how certain economic outcomes are connected to a woman’s ability to access the full range of reproductive health care services. Furthermore, the findings help clarify that women cannot achieve economic progress without securing greater autonomy to direct their futures.

In the last several months, reproductive health care access has come under increased threat under the Trump administration and a Republican-majority Congress. In March, President Donald Trump signed a bill spearheaded by anti-abortion rights members of Congress that rolls back Obama-era protections for Title X providers who offer family-planning services.¹⁵ In May, President Trump signed an executive order that allows employers to deny women health insurance coverage for preventative care—including contraception—on the basis of religious or moral objection.¹⁶ And in early October, the Trump administration issued rules that give insurers, employers, schools, or even individuals leeway to deny contraceptive coverage on the basis of religious or moral objection—essentially undermining the contraceptive coverage mandate under the ACA.¹⁷ Trump has also appointed numerous anti-abortion rights individuals to positions within the executive branch and the federal courts, which will threaten reproductive health care access for years to come.¹⁸ Most recently, the administration decided to stop making payments to insurance companies for cost-sharing reductions (CSR), which reduce low-income enrollees’ out-of-pocket costs;¹⁹ additionally, the administration’s support for Congress’ repeated failed attempts to repeal the ACA put health insurance coverage for millions of women at risk.²⁰

While the Trump administration poses dramatic new threats, the onslaught on women’s reproductive health access is by no means a new phenomenon. Since the U.S. Supreme Court granted women the legal right to an abortion in the landmark 1973 case Roe v. Wade, states have enacted 1,142 abortion restrictions.²¹ This has led to differing degrees of access to abortion, specifically, and reproductive health care, generally, across the United States based on a woman’s ZIP code.

Nearly one-third, or 30 percent, of these restrictions have been enacted since 2010, when abortion opponents gained seats in state legislatures and governors’ mansions after the midterm elections that year.²² In 2016 alone, 50 new abortion restrictions were enacted in 18 states.²³ Restrictions—most of which lack rigorous scientific basis²⁴—include banning all abortions 20 weeks post-fertilization; imposing medically unnecessary restrictions on abortion facilities and providers; and requiring women to receive counseling or to undergo waiting periods before having an abortion.²⁵ The final result of all these restrictions is the same, however. In states that impose restrictions, it is significantly more difficult for women to make choices in terms of when and under what circumstances to proceed with a pregnancy.

These laws have had a significant impact on abortion providers. At least 162 abortion clinics have closed or stopped offering the procedure since 2011, while just 21 clinics opened during the same time period.²⁶ As a result, access to abortion services has been limited in many parts of the country. For example, the Guttmacher Institute estimates that 93 percent of reproductive-age women in the South and 68 percent in the Midwest live in a state that is hostile or extremely hostile to abortion.²⁷

Barriers to accessing reproductive health services extend beyond abortion. Approximately one-half of U.S. counties do not have a OB-GYN. These are mostly rural counties, where more than 10 million women, or 8.2 percent of all U.S. women, live.²⁸ As a result, women in rural areas often have to travel longer distances—with the associated higher costs that entails—to access health care services.²⁹ For example, one-half of reproductive-age rural women live within a 30-minute drive of a hospital offering perinatal services.³⁰ For many women, geographic location is the primary determinant of ability to plan for their family.

The growing number of religiously affiliated hospitals further limits women’s reproductive health care access.³¹ These institutions may use religious guidance—known as Ethical and Religious Directives³²—rather than medical standards when determining care, meaning that in areas with already-limited access to medical services, women may have no choice but to see a provider who does not offer contraception, sterilization, infertility treatments, or abortion services.³³ In five states—Alaska, Iowa, Washington, Wisconsin, and South Dakota—more than 40 percent of acute care hospital beds are in hospitals operating under Catholic health care directives. In another five states—Nebraska, Colorado, Missouri, Oregon, and Kentucky—between 30 percent and 39 percent of acute care hospital beds are in facilities operating under these directives.³⁴

Due to structural inequality based on race, gender, and sexuality, barriers to comprehensive health care persist, particularly for women of color and LGBTQ individuals. These communities are more likely to experience additional barriers to accessing reproductive health care.³⁵ Women of color may experience disparate access to health information; lack of reliable transportation or insurance; communication barriers for nonnative English speakers with medical professionals; and a historical distrust of the health care system.³⁶ Communities of color face worse health outcomes on average, and for women of color, this includes higher rates of mortality from cancer,³⁷ of maternal mortality,³⁸ and of pre-existing conditions such as asthma,³⁹ hepatitis,⁴⁰ diabetes, HIV, and AIDS.⁴¹ While overall rates of unintended pregnancy have declined, they remain significantly higher for Latinas and black women.⁴² For immigrant women, language barriers and concern about immigration policies can be a deterrent to seeking care.⁴³ Teens and LGBTQ individuals may face barriers in accessing health care, with both groups more likely to face stigma, discrimination related to stigma, and even denial of care.⁴⁴ LGBTQ communities are also among those who significantly benefited from the ACA—since they are more likely to live in poverty—and have benefited from both the expansion of Medicaid as well as the health insurance marketplace.⁴⁵

While the legal right to abortion is one aspect of autonomy over reproduction choices, affordability of all reproductive health care services is necessary to ensuring that women have the ability to control their own bodies and plan for their families if they so choose. The ACA has been instrumental in increasing access to reproductive health services for women by making these services more affordable. In addition to increasing access to health insurance through establishing the health insurance exchanges, which include financial help, and through providing increased funding for states to expand Medicaid, the ACA also includes no-cost preventive services, allowing millions of women to access several preventative reproductive health services. These services include contraception; well-woman visits; breastfeeding counseling and supplies; and screening and treatment for sexually transmitted infections (STIs). Women can also no longer be charged higher premiums due to their gender.⁴⁶

As a result of the ACA, approximately 9.5 million women who were previously uninsured now have coverage.⁴⁷ From 2013 through 2015, the uninsured rate for women ages 19 through 64 fell from 17 percent to 11 percent,⁴⁸ and since the passage of the ACA, the number of women who report that they delayed or went without care due to cost has also fallen.⁴⁹ Insurance coverage for women of color ages 18 through 64 increased at nearly twice the rate of women overall between 2013 and 2015, demonstrating both the importance of the ACA for these women—including the law’s Medicaid expansion—and the risks associated with Congress’ threats to repeal.⁵⁰ In addition, 62.4 million women now have access to contraception at no cost.⁵¹ Due to the ACA’s contraceptive mandate, women and families saved $1.4 billion in out-of-pocket costs for contraceptive pills in 2013 alone.⁵²

These gains, however, were not distributed evenly across the country. Uninsured rates generally dropped more in states that expanded Medicaid.⁵³ In fact, one analysis found that the strongest indicator in determining whether an individual who did not have insurance in 2013 gained coverage under the ACA was whether they lived in a state that expanded its Medicaid program in 2014.⁵⁴

Access to family-planning services and other reproductive health care services also remains uneven. Prior to the passage of the ACA, 28 states already required insurers to cover prescription contraceptive drugs and devices.⁵⁵ Some of these states expanded or amended their policies to match the federal standard, while others went beyond the federal mandate by requiring coverage of more types of contraceptives. Of these 28 states, 20 now allow certain employers and insurers to refuse to comply with the ACA’s contraception coverage mandate, while eight states do not allow any employers or insurers to refuse compliance.⁵⁶ Title X of the Public Service Health Act focuses on providing critical family-planning health services, including physical exams; prescriptions; contraceptive coverage; referrals; and educational and counseling services.⁵⁷ Title X providers, such as Planned Parenthood, serve about 4 million clients every year, helping fill the gap in services for low-income families.⁵⁸ Additionally, 28 states have Medicaid family-planning programs, and 17 of these states also expanded Medicaid under the ACA—meaning that women in these states have access to a full range of services compared with women in states without Medicaid family planning or Medicaid expansion.⁵⁹ Additionally, Medicaid expansion increased eligibility for Medicaid to all individuals with incomes up to 138 percent of the federal poverty level; thus, more people qualified for the program, expanding coverage for women.

As a result of differing state policies, an individual’s access to care varies significantly depending on the state where she resides. Continuing gaps in coverage mean that more than 1 in 10 women remains uninsured.⁶⁰ The recent decision to stop CSR payments to insurance providers,⁶¹ as well as congressional proposals to repeal the ACA, further threaten women’s health coverage. Recently, proposed bills in the House of Representatives and Senate range from causing an estimated 16 million to 32 million people to lose their health insurance.⁶² Congressional Republican leaders have also attempted to further limit abortion access by proposing restrictions on private insurance coverage of the procedure,⁶³ and congressional proposals have included prohibiting federal Medicaid payments to Planned Parenthood for one year, which would harm the approximately two-thirds of Planned Parenthood patients that rely on federal funding for health care coverage.⁶⁴

Access to contraception is one type of reproductive health care access that has been integral to women’s increased economic opportunity. An estimated 62 percent of women of reproductive age use contraception.⁶⁵ While abortion is less common—an estimated 30 percent of women will have had an abortion by age 45⁶⁶—it is another economically important aspect of reproductive health care since it has both direct costs, including paying for services out of pocket, and long-term costs for women. Furthermore, like contraceptive access, abortion access constitutes an aspect of bodily autonomy. Being able to guarantee and expect control over one’s body, including reproductive decisions, is a necessary condition of the ability to fully engage in the labor market and face a lower likelihood of financial precarity.⁶⁷

Unfortunately, abortion is not accessible for many women. According to research from the Guttmacher Institute, in 2008, one-third of the women who obtained an abortion had no insurance and another 31 percent were covered by state Medicaid.⁶⁸ Seventeen states have a policy that directs state Medicaid to provide funding for medically necessary abortions.⁶⁹ But because of the Hyde Amendment—which prevents federal funds from paying for abortion care except for in cases of rape, incest, or to save the mother’s life—without additional state funding, women covered by Medicaid seeking abortions must cover the direct costs of the procedure without insurance coverage.⁷⁰ The median cost of a surgical abortion at 10 weeks gestation without insurance was $470 in 2009,⁷¹ which is already more money than many Americans would be able to come up with in the case of an emergency. ⁷²

In addition to direct costs of the medical procedure, these women must bear the practical costs imposed by state restrictions, such as multiple doctor’s office visits and unnecessary waiting periods. A low-income single mother who needs to pay for travel to the nearest clinic; a night at a hotel while she completes a mandatory waiting period; child care; and lost earnings from missing work, could end up paying an additional $1,380, according to one estimate by ThinkProgress for a typical woman in Wisconsin, a state with mandatory waiting periods.⁷³ The same estimates found that a middle-income woman living in a city would pay less, at $593. This means that state restrictions affect those who already have the least resources and face the most barriers to receiving medical care, exacerbating economic inequality.

Women who want an abortion but cannot afford the out-of-pocket costs inflicted by the Hyde Amendment face major consequences during the course of their careers. The most thorough study of how women’s lives have been affected by restricted access to abortion is the Turnaway Study, which followed women who wanted to have an abortion but did not obtain one.⁷⁴ Research done with the findings of the Turnaway Study found that cost was the primary reason for not obtaining the procedure for 85 percent of the women who considered an abortion.⁷⁵ Subsequently, these women faced worse economic outcomes, were more likely to live in poverty, and often carried unwanted pregnancies to term.⁷⁶ 

Equitable access to reproductive health care is not only important to help all women have bodily autonomy; it is also vital to allowing women to fully engage in the economy. Research has shown that access to contraception and abortion has serious economic consequences for women, in both immediate costs as well as long-term effects on economic stability and progress. Deciding if, when, and how to raise a family is closely connected with labor force attachment and career development, determining both w