State legislative activity in the first half of 2024 included attacks on reproductive care for young people, restrictions on contraceptive access and criminalization of pregnancy outcomes. The harms caused by these attacks are compounded by the total abortion bans enforced in 14 states and the early gestational bans enforced in seven states that would have been unconstitutional under Roe v. Wade. Such harms fall particularly hard on those with lower incomes, so in our analysis below, we highlight how restrictions on sexual and reproductive health care perpetuate economic inequality.

Legislators in many states also demonstrated how far they are willing to go to deny people their right to reproductive care, as they sought to advance legislation that would restrict in vitro fertilization (IVF) and divert increasing amounts of state funding to anti-abortion centers. The first six months of 2024 also saw anti-LGBTQ legislation passing in dozens of states.

At the same time, states seeking to protect access to reproductive health care enacted policies supporting more economically just access to services, such as increased contraceptive coverage, improvements to telehealth and increased provision of doula care.

Attacks on Sexual and Reproductive Health Care

Limiting Young People’s Access

Lawmakers in many states focused on curtailing youth access to sexual and reproductive health care. These types of laws affect youth regardless of income status, but youth with the fewest resources will be the most affected.

Abortion support bans

Abortion support bans assign civil or criminal liability to adults who help a minor obtain abortion care. This new type of legislation makes it difficult for many young people who need financial or logistic support to access care. The bans also increase a general climate of hostility and confusion for providers and patients, as well as fear among those who provide practical support to those seeking an abortion.

One recent Guttmacher analysis, which draws from data collected before Roe was overturned, found that 54% of adolescents reported paying out of pocket for their abortions, at an average cost of $499. In addition, 54% of adolescents delayed expenses or sold something to help cover the costs of their abortion, as opposed to 46% of adults aged 25 or older. Financial strain related to getting an abortion has likely increased with the large number of bans and restrictions enacted since the US Supreme Court’s Dobbs v. Jackson Women’s Health Organization decision in June 2022.

• Tennessee enacted an abortion support ban in late May. The law is scheduled to take effect in July, although a legal challenge is expected.

• In the 2024 legislative session, three other states introduced similar bills—Alabama, Mississippi and Oklahoma.

• Another abortion support ban was enacted in Idaho in 2023 but was blocked by a federal judge as litigation proceeds.

Requiring parental consent

Requiring parental consent for contraceptive and STI care is another way lawmakers limit youth access to reproductive health care. In a recent decision, the 5th Circuit Court of Appeals upheld a lower court ruling from 2022 that blocked clinics in Texas receiving federal Title X funding from providing prescription contraceptives to minors without parental consent. In addition, an Idaho law that was signed into law in March requires minors to get parental consent to access health care such as STI treatment.

Eight bills introduced in six states would require young people to obtain parental notification or consent to obtain contraceptives. These proposed requirements mirror prior efforts to normalize parental consent and involvement laws for abortion access. Research has shown that parental involvement laws for abortion can lead to concerns among the minors involved that they will be kicked out of their homes. As attempts to require parental involvement for minors’ contraceptive access grows, it is likely that a similar pattern will emerge.

Gender-affirming care bans

Four states—Idaho, Ohio, South Carolina and Wyoming—have enacted gender-affirming care bans so far this year. The Idaho law bans public funding of this care; the state already banned gender-affirming care for young people in 2023. Added to the 19 bans enacted in 2023, nearly half of all states now restrict gender-affirming care for people younger than 18, although the Florida ban was recently blocked. Some states have also introduced bills that would restrict care for people up to age 21. In addition, Tennessee adopted a new law that applies the concepts of abortion support bans to gender-affirming care, creating civil liability for nonparent adults who help a minor obtain this type of care.

These bans follow a similar pattern to abortion bans: By making care unavailable for individuals in particular states, states force people to either travel for care, find care through another mechanism or forgo the care altogether. This legislative attack on transgender youth has also forced families to consider moving to another state. Those who cannot afford to do this are denied care because of their economic status.

Restricting sex education

More than 50 bills have been introduced across 28 states this year that would interfere with the ability of students to receive comprehensive sex education. Sex education is not required in every state, and when provided, sex education is required to be medically accurate in only 20 states. In addition, the majority of states require sex education curricula to emphasize abstinence.

While interfering in sex education has long been the focus of the anti-reproductive rights movement, “Baby Olivia” laws are a new effort aimed at perpetuating abortion stigma by increasing misinformation in the school curriculum. This year, Tennessee passed this type of law, which mandates the viewing during sexual education classes of misleading, medically inaccurate videos produced by an anti-abortion group. Legislators in Georgia, Hawaii, Iowa, Kentucky, Michigan, Missouri, Pennsylvania, South Carolina, Virginia and West Virginia introduced similar sex education bills, but all of these failed to become law.

Preventing Access to Infertility Care

In February, the Alabama Supreme Court ruled in an unprecedented decision that embryos created through IVF are considered children under the state’s Wrongful Death of a Minor law, demonstrating a push toward embryonic and fetal personhood. Given the implications of the ruling, many clinics in the state halted IVF treatments, leaving patients without time-sensitive care and threatening their chances of becoming pregnant.

Following public backlash, 12 states, including Alabama, introduced bills that either explicitly protect providers from criminal or civil liability or clarify that fertilized embryos outside of a human body are not human beings; however, many patients in Alabama were still harmed in the process. For example, one patient described how she was left without any options to use her own fertilized embryos in Alabama, and her only option at the time was to restart the entire process in another state and spend another $30,000. Even with Alabama’s new protective law in effect, certain clinics are terminating their services in anticipation of ongoing litigation and legal confusion.

Infertility care can be cost prohibitive, in part because it is often not covered by health insurance. In recognition of this fact, state legislatures considered 68 bills in 27 states to improve coverage for infertility care in 2024.

Attacks on Contraceptive Access

So far in 2024, eight states have enacted or proposed attacks on contraceptive access. These attacks are attempts to push contraception further out of reach for many people, particularly those with lower incomes. In one state, anti-abortion legislators, with support from activists, amended a bill to include the false notion that certain types of contraceptives can cause an abortion.

• A law passed in Indiana focuses on providing long-acting contraceptives after birth to those with Medicaid coverage. However, during the legislative process, the bill was amended to provide for only subdermal contraceptives, based on the false claim by anti-abortion groups that IUDs cause abortions. The law limits the options and types of care available to those utilizing Medicaid based purely on misinformation from anti-abortion groups and perpetuates stereotypes about individuals with lower incomes not being able to manage certain types of birth control.

• A bill proposed in Oklahoma sought to enact a number of restrictions on both abortion and contraception. The bill purposefully conflated abortion care and certain types of contraceptives, with the stated intention of banning IUDs and emergency contraception.

Expanding the Harms of Anti-Abortion Centers

There are over 2,500 anti-abortion centers in the United States, also known as crisis pregnancy centers. Anti-abortion centers aim to prevent pregnant people from obtaining abortion care and contraception. They often pose as abortion clinics, use coercive and deceptive counseling, and target people with lower incomes: young people, immigrants and people who live in rural areas with limited access to health care.

In 2024, anti-abortion politicians sought to increase the scope and reach of these centers. Several states directly fund the centers through their annual budgets.

• Texas funneled more than $140 million into these centers for fiscal year 2024–2025.

• Kansas increased funding in 2024, awarding $2 million directly to the Kansas Pregnancy Care Network, an anti-abortion nonprofit.

• Iowa removed requirements that the state’s health department had to post the criteria for its alternatives to abortion program providers online, further obscuring the entities receiving state funding.

These centers collect extensive personal data on pregnant people and are not required to adhere to HIPAA or protect private health information. Therefore, these centers may provide an extensive network of surveillance for states seeking to criminalize pregnancy outcomes. A bill in Kansas, for example, would require abortion patients to document if they had gone to one of these centers in the last 30 days.

Criminalizing Pregnancy Outcomes

Individuals have long experienced criminalization for the outcome of their pregnancies. At its most extreme, criminalization can involve arrests and pressing charges, but it can also include investigations, involvement of the family regulation system, often referred to as the child welfare system, and questioning by and other types of interaction with law enforcement. Individuals may be criminalized for perceived substance use, suspicion of self-managing a pregnancy or an adverse birth outcome.

Income status is a key predictor of those charged with pregnancy criminalization. A study looking at criminal arrests of individuals for issues related to pregnancy criminalization found that both Black and White pregnant people with lower incomes bear a disproportionate share of pregnancy criminalization.

In the 2024 legislative session so far, eight bills have been introduced in 11 states that would have intensified criminalization of pregnancy. By contrast, 42 bills in 20 states sought to improve maternal health by allocating funding or resources to provide better care to pregnant individuals coping with substance use.

Protections for Sexual and Reproductive Health

Protecting Contraceptive Access

In an effort to protect access to reproductive health care, 14 states and the District of Columbia have codified legal protections for contraception. In 2024, several states with abortion restrictions—Alabama, Arizona and Virginia—introduced bills to protect access to birth control. Only Virginia was able to pass legislation through both houses. However, Virginia’s governor vetoed the bill.

Two states with severe abortion restrictions or complete abortion bans also passed laws protecting six- and 12-month supplies of birth control under health insurance plans.

• Tennessee passed a law protecting a 12-month supply of birth control.

• Idaho passed a law requiring coverage of a six-month supply of birth control by a margin of only one vote in the Idaho House.

Increasing Digital Privacy

Three states enacted legislative solutions to protect the privacy of people who can get pregnant or seek reproductive care.

• Maryland enshrined a right to online data privacy, with the goal of protecting consumers who search for or access reproductive health care services.

• Virginia prohibited search warrants or subpoenas from being issued for menstrual data that is stored on third-party apps and other digital services.

• Hawaii introduced a privacy bill on the collection, use and sharing of consumer health data.

Other states that introduced bills focused on this type of protection include Alaska, Georgia, Massachusetts, North Carolina, New Jersey, New York, Ohio and Vermont.

Shield Laws

Efforts to expand or introduce shield laws, which seek to minimize legal risks for people providing and individuals accessing abortion, and, in some cases, gender-affirming care, are continuing in 2024.

• Maine passed a shield law to protect health care providers who offer abortion and gender-affirming care.

• Washington introduced a bill that would allow physicians to use an ID number, rather than their name, when prescribing medication abortion pills.

• However, in Virginia, the governor vetoed a bill that would have prohibited the governor’s participation in extraditing people who receive, provide or assist with reproductive health care services, including abortion, in Virginia to states where these services are banned.

Support for Telemedicine

During the COVID-19 public health emergency, telemedicine access was greatly expanded across the United States and was especially helpful in improving abortion access. Telemedicine is often a lower-cost option for abortions than in-person care, improving access for those with lower incomes. Now that federal COVID-19 protections have ended, several states adopted laws this year to continue ensuring telemedicine options for patients, including medication abortion obtained through telehealth.

• Washington passed a law that includes asynchronous services as part of telehealth, which means that communications between the patient and the health care provider can happen at different times.

• California introduced a bill to extend coverage of asynchronous care by Medi-Cal, the state Medicaid program, to include telehealth communication initiated by patients, including via mobile apps.

Improving Maternal and Infant Health

The United States has the highest maternal mortality rate of any high-income nation, and the rate among Black women is more than twice as high as the overall rate. In the first half of 2024, four states passed laws that improve support for both mothers and infants.

• Kentucky expanded psychiatric support for mothers and insurance coverage of maternity and prenatal services.

• Tennessee expanded its maternal mortality review board to include community members.

• In Oklahoma, the state legislature removed some licensure requirements for birth centers and allowed them to cover postpartum care.

• Virginia enacted legislation requiring Medicaid to cover doula care, joining the majority of states that do so or are moving in that direction.

Anti-abortion politicians are now supporting postpartum Medicaid expansion bills, likely in response to the public backlash against abortion bans and rising maternal and infant mortality rates. However, some of these politicians attempted to co-opt some of these bills, which historically have been advocated for by reproductive justice groups. In Iowa, for example, anti-abortion lawmakers added severe income restrictions, leaving some pregnant people and their families in an insurance coverage gap.

Passing Ballot Initiatives

Four states—Colorado, Florida, Maryland and South Dakota—have already certified ballot initiatives that would protect abortion access for the November election. Another five states—Arizona, Missouri, Montana, Nebraska and Nevada—have ballot initiatives underway that would be protective of abortion access. However, not all states allow citizen-led ballot initiatives, including several of the states with total abortion bans. In addition, some ballot initiatives prevent abortion care later in pregnancy, which pushes care out of reach for some patients, especially those with low incomes.

Anti-abortion lawmakers are also aware that abortion rights are a winning issue at the ballot box and therefore are waging attacks on attempts to bring these initiatives to voters. For example, a law passed in South Dakota in March allows people to withdraw their signatures from petitions for ballot measures, referendums and constitutional amendment questions. Anti-abortion activists used this law in an attempt to undermine the ballot initiative in that state.

Conclusion

State legislative actions in 2024 demonstrate that access to reproductive health care is divided in the United States across both geographic and economic fault lines. Guttmacher’s Monthly Abortion Provision Study has found that nearly one in five patients are now traveling out of state for abortion care, a number that has doubled in recent years. Whether people can access sexual and reproductive health care remains largely dependent on their zip code and socioeconomic status. While some states seek to close that divide by supporting the right to travel and provide care across state lines, increase contraceptive coverage and improve telehealth, others continue to roll back access and criminalize both pregnant people and those who support their decisions.