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“We know that even small amounts of cost-sharing for birth control can make the difference for folks being able to get it or not, particularly given the financial struggles people have had over the last few years,” says Mara Gandal-Powers, senior counsel and director of birth control access at the law center who is among those calling for tougher federal enforcement.

The Food and Drug Administration is also facing increasing pressure to approve two applications for over-the-counter birth control pills that have been pending before the agency for years. Several other countries allow the pills, and mainstream medical groups like the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists and the American Medical Association have endorsed doing so in the United States.

“I hear about so many barriers young people in particular face when a prescription is required – from long wait times for appointments to health care providers refusing to prescribe birth control because of their religious or moral beliefs,” says Angela Maske, who works with the group Advocates for Youth and manages the #FreeThePill Youth Council that led a recent demonstration outside the White House, complete with a mock pharmacy counter stocked with faux boxes of birth control pills alongside things like cough syrup.

HHS marked Roe’s 49th anniversary earlier this year by setting up a reproductive task force to review policies that could protect access to contraception. The White House set up its own Gender Policy Council to make a similar effort. Neither group has proposed specific policy changes yet.

The Center for Medicare and Medicaid Services has been pushing for coverage expansion, which could help millions of patients afford birth control as well as other services. But top priorities such as extending Obamacare subsidies and expanding Medicaid in a dozen hold-out states have been sidelined since Biden’s Build Back Better legislation found last fall.

Advocates also argue the federal government could also do more to preserve Medicaid’s long-standing provision letting patients go to any qualified provider of their choice in light of Texas kicking Planned Parenthood out of Medicaid and other states making similar moves.

Asked by POLITICO at a health journalism conference if the administration is planning to put out new guidance or ramp up enforcement of Medicaid’s “Free Choice of Provider” provision, CMS Administrator Chiquita Brooks-LaSure said only that her agency continues to monitor what is going on in the states when it comes to access and making sure that coverage is meaningful. ”

Meanwhile, Congress is not expected to act on the issue any time soon, even as Democrats’ narrow majorities look increasingly threatened in November’s midterms. House Democrats have pushed some legislation to expand contraception access for veterans and active-duty service members who are not covered by the ACA’s free contraception policy, but the proposals have died in the Senate. Maloney’s “Access to Birth Control Act,” which would crack down on pharmacists refusing to fill birth control prescriptions, has not received a hearing this Congress, let alone a floor vote.

One possible opportunity for supporters of access to contraception: Many states, including some conservative ones, are now focusing more on addressing high maternal mortality rates, particularly among Black women, and extending Medicaid coverage after a woman gives birth. Spacing out pregnancies can help, and policymakers and advocates are pushing to boost contraception right around the time of childbirth – and to modify insurance payment policies to make it easier.

Advocates are also looking toward individual states to broaden contraception access by modifying telemedicine regulations and allowing more pharmacists to prescribe contraception as well as making sure they have the training to do so and stepping up outreach, so people know it’s an option. But, Guttmacher interim associate director of state issues Elizabeth Nash notes “Getting state legislators to support additional funding is difficult, even in more progressive states.”

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