Threats to Women’s Reproductive Freedom and Maternal Health

Overview

Access to reproductive health care, including safe abortion care, is essential to ensure that people can make informed decisions about their bodies, their families, and their futures. When such health care is accessible, individuals are better able to pursue education and career goals, fully participate in the economy, and maintain their physical and mental well-being. The OBBB’s health care cuts, Medicaid work requirements, and abortion provider restrictions will have a devastating effect on women’s health and economic security—particularly for women of color, low-income families, and those living in rural communities who are already disproportionately impacted by ongoing reproductive rights restrictions.

Harmful OBBB Provisions

The OBBB threatens the welfare of women, particularly women of color, and the nation’s overall economic stability. Analysis from the Washington Center for Equitable Growth finds that the increasing role of women as breadwinners is essential to supporting family incomes and maintaining US economic security. According to research from Georgetown University economists, Medicaid expansion gave workers—especially women—the stable foundation to move into higher-paying occupations. As a result, the OBBB provisions that threaten to reverse Medicaid expansion or make enrollment more challenging will likely have a greater negative occupational impact on women.

Key OBBB provisions that put the economic security and health of women, families, and the nation at risk include:

• Cutting $1.1 trillion in health care programs threatens access to coverage for more than 14 million people, with women—particularly women of color—making up the majority of those impacted. Despite increasing the deficit by $3.4 trillion over the next 10 years, as projected by the Congressional Budget Office (CBO), the OBBB includes $1.1 trillion in cuts to Medicaid and the Affordable Care Act (ACA). As a result of these cuts, ACA Marketplace rule changes, and the lack of an extension of the ACA’s Marketplace coverage enhanced premium tax credits beyond their current expiration at the end of 2025, the CBO estimates that more than 14 million people could lose their health coverage by 2034. According to KFF analysis, women comprise the majority of adults covered by Medicaid, and Medicaid covers 44 percent of non-elderly women with disabilities and more than 40 percent of births in the United States. Women of color are overrepresented in Medicaid coverage, particularly those of reproductive age. The National Partnership for Women & Families estimates that more than half of the 56 percent of women enrolled in Medicaid aged 19–49 are women of color.
• Expanding Medicaid work requirements will pose additional barriers to care for women and dismantle the ACA’s Medicaid expansion coverage gains. The OBBB implements a federal Medicaid work requirement for adults ages 19–64 in states that have expanded Medicaid under the ACA. The new law requires Medicaid recipients in this ACA expansion group to verify they meet at least 80 hours of work activities or work-related activities per month, and every six months for re-enrollment. As the Center on Budget and Policy Priorities (CBPP) notes, such work requirements impose administrative barriers that will lead to coverage losses among people who are working or are between jobs, likely even among those exempt from the requirement—caregivers of dependent children under the age of 13, people with disabilities, and pregnant people—and do not increase employment.
• Instituting a Medicaid abortion provider “defund” restriction—preventing patients from choosing their own health care provider and threatening health center closures. The OBBB targets nonprofit organizations and community health center providers that offer abortion care by including a one-year prohibition on any federal Medicaid payments for any health service to such providers. The prohibition is in addition to the decades-old Hyde Amendment, which restricts the use of federal funds for abortion coverage (except in cases where the pregnancy endangers the life of the pregnant person, or is a result of rape or incest.)While not explicitly named, and impacting other health care providers as well, the provision aims to “defund” Planned Parenthood and its affiliates. Patients who rely on Planned Parenthood or other such health providers as their access point to a range of preventive care and reproductive health services will bear the brunt of this OBBB provision, undermining a woman’s choice in provider and threatening delayed access to care as she searches for a new one.In addition, forced loss of patients and Medicaid reimbursements has led to health center closures. Planned Parenthood estimates that the provision will block more than 1.1 million patients from accessing care at its health centers and reports having already had to close 20 health centers since the law went into effect on July 4, 2025. On October 31, 2025, Maine Family Planning (MFP), the largest reproductive health network in the state, had to close its primary care practices, according to the Center for Reproductive Rights. As noted by the National Health Law Program, the closure of health centers would be a devastating loss, not only for abortion access but also for sexual and reproductive health care more broadly, as such providers are often the sole source of these services in rural and medically underserved areas. Legal challenges against the US Department of Health and Human Services (HHS) attempting to block implementation of the harmful provision are ongoing—including those led by Planned Parenthood, the Family Planning Association of Maine, and the state of California on behalf of 21 other states and Washington, DC.

The Black Maternal Health Crisis: OBBB Cuts and Consequences

IWPR’s Birthing While Black series concludes that access to high-quality, affordable, and culturally sensitive health care, including contraceptive care, makes it possible for women to care for their physical health, plan the timing and size of their families, advance their education, and become economically mobile and more secure. The OBBB’s Medicaid cuts and hostile abortion provider restrictions will have devastating impacts on the Black maternal health crisis.

• The United States has the highest rate of maternal mortality among wealthy nations. While Centers for Disease Control and Prevention (CDC) data show that rates decreased for White and Latina women in 2023, Black women continue to die from pregnancy-related causes at rates three times higher than White women.
• A range of factors contribute to the high rate of Black maternal mortality in the United States, including social determinants of health and medical racism. Abortion restrictions further reduce access to obstetric and gynecological care, and, as reported by ProPublica and Ms. Magazine, have also led to the denial of emergency care, resulting in the preventable deaths of women in Georgia, Indiana, and Texas.
• According to the CDC, 40 percent of all births in the US are covered by Medicaid, though the percentage is higher for women of color, including Black women, at 64 percent. Medicaid requires all states to provide coverage for low-income women during pregnancy. In addition, as reported by KFF, 48 states and Washington, DC, have implemented a 12-month Medicaid postpartum extension. Further, as tracked by IWPR’s State Policy Action Lab, 14 bills were introduced in 2025 across nine state legislatures to enhance such coverage. Among these, two bills advanced to become law in Illinois and Louisiana, and companion bills were enacted in Virginia—all of which extended or enhanced Medicaid coverage for doula services or implementation.
• The Medicaid cuts and work requirements that impose additional administrative burdens could cause a reversal of states’ progress to enhance postpartum care coverage and force a scaling back or discontinuation of such crucial care, putting the health of new mothers—particularly Black mothers, who are already at elevated risk—under further threat.
• In addition to putting millions of people at risk of losing their health care coverage and access to their provider of choice due to the Medicaid abortion provider restriction, the OBBB may threaten already limited maternal health patient access to providers and facilities as well.
  • While IWPR research shows the critical role Black doulas and midwives play in maternal health outcomes for Black women, affordability has long been a barrier to such provider access. States have been making progress in addressing this issue, with tracking by the National Health Law Program showing that 23 states and Washington, DC, actively provide Medicaid reimbursement, and another 10 states are in the process of implementing reimbursement for doula care. But as Medicaid financing realities hit state budgets, states may be forced to reduce or cut doula coverage.
  • According to the March of Dimes, over a third of US counties are already maternity care deserts, lacking an obstetric clinician or a birthing facility. The Center for Healthcare Quality and Payment Reform estimates that rural communities could face 700 hospital closures due to financial constraints, which will be further exacerbated by the OBBB’s Medicaid cuts, according to analysis by the American Hospital Association. Critically, the CDC has already identified the heightened risk of maternal mortality and morbidity resulting from such a lack of access to maternal health care.
• The OBBB’s harmful dismantling of health care access for more than 14 million people over the next 10 years will amplify several of the leading causes of preventable maternal deaths for women as identified by MMRCs, including the lack of continuity of care, the lack of quality of care, and the lack of financial resources—further compromising the maternal health and well-being of women.

Maternal Health Inequities for AI/AN Women

The US maternal mortality crisis is not isolated to Black women. The CDC reports that historical and ongoing trauma and systemic barriers to care also contribute to the maternal health inequities that American Indian and Alaska Native (AI/AN) people experience. AI/AN women are two times more likely to die of pregnancy-related causes than White women,

 

Tragically, as data published by the CDC shows, among all maternal mortality review committee (MMRC) pregnancy-related death determinations in 2021, 87 percent were preventable. When looking specifically at AI/AN deaths with a preventability determination in the same year, however, the CDC reports 100 percent of such deaths were determined by MMRCs to be preventable.

What the Research Says

• As IWPR highlighted, Medicaid cuts and work requirements disproportionately harm women, particularly women of color and those of reproductive age. A Guttmacher Institute analysis reports that, in 2023, Medicaid covered 21 percent of all women of reproductive age (15–49) in the US, with a higher proportion (24 percent vs. 16 percent) in states that have ACA Medicaid expansion than in states that do not. Guttmacher estimates that 40 percent of those enrolled in such expansion states were women of reproductive age and, therefore, will be most impacted by a loss of Medicaid coverage and associated care. While many factors make coverage loss projections challenging, the analysis further estimates that the new work requirements could threaten to eliminate Medicaid coverage for between 2.1 million and 6 million women of reproductive age by 2034.
• The expansion of Medicaid coverage has yielded reproductive health and economic equity benefits that would be threatened if reversed. Research conducted at the Columbia University School of Social Work shows that the ACA’s Medicaid expansion could be contributing to reduced maternal mortality rates in the United States. Should states eliminate their Medicaid expansions, the Urban Institute estimates that 5.7 million women of reproductive age would be at risk of losing comprehensive, affordable health coverage. Further, studies of Medicaid expansion in Michigan and Ohio, highlighted by Georgetown University’s Center for Children and Families, showed that enrollees reported their Medicaid coverage made it easier to find, keep, and do their jobs better. Additionally, an HHS study found that a higher share (44 percent) of enrollees in states that expanded Medicaid were employed, compared to 37 percent in non-expansion states.
• The ACA enhanced premium tax credits, introduced in 2021 and extended through the end of 2025 by the Inflation Reduction Act of 2022, play a critical role in improving the affordability of ACA Marketplace coverage by helping to lower the monthly cost of health insurance for eligible individuals and families. As KFF reports, these tax credits have contributed to increasing ACA Marketplace insurance enrollment coverage from 11 million to approximately 24 million people. The
  OBBB did not extend the tax credits; should they expire, premium payments are estimated to more than double in 2026.
• The new Medicaid work requirement is a “solution” without a problem, designed as a cost-saving measure to reverse the ACA Medicaid expansion. Research by KFF found that 92 percent of Medicaid adults under age 65 who are not receiving benefits from the Social Security disability programs and are not also covered by Medicare are currently working full- or part-time, or are otherwise not working due to caregiving responsibilities, illness or disability, or school attendance. A joint Commonwealth Fund and George Washington University Milken Institute School of Public Health analysis projects that the work requirements could result in 5.2 million adults nationwide losing Medicaid coverage next year alone. The researchers estimate that this reduction in federal funding to states could result in a loss of as much as $59 billion in state gross domestic product and the elimination of up to 449,000 jobs across multiple industries.
• According to IWPR research, as of 2023, over 24 million women aged 25–54 (considered prime working-age) who are active in the US labor market lived in states with total bans or restrictions on access to abortion care. The impact of these restrictions is especially severe for Black women, with 59 percent of Black women in the same age range residing in states with such restrictions. Among the 11 states with the highest maternal mortality rates from 2020–2022, 8 had abortion bans. Additional IWPR analysis found that the 16 states with the most restrictive abortion policies cost the US economy more than $64 billion annually due to workforce losses and reduced economic contributions from those unable to access abortion care.

Policy Solutions

• As long as the OBBB remains current law, it is critical that advocates and Congress remain committed to continued oversight of its implementation to monitor its impact and mitigate harm where possible. It will be equally crucial to build support for policy solutions that seek to advance economic equity and security for women and families—not undermine these goals. Such data-driven policy solutions include:
  Increasing access to health care coverage and expanding—not restricting—access to social benefit programs such as Medicaid and the Supplemental Nutrition Assistance Program (SNAP).
• Prioritizing health care accessibility and a health care workforce that reflects the patient population, particularly in rural and underserved areas, including expanding access to midwives and doulas.
• Reviving and investing in critical data systems, such as the CDC’s Pregnancy Risk Assessment Monitoring System (PRAMS) and MMRCs, and strengthening data collection and disaggregation efforts.
• Advancing legislation that comprehensively addresses maternal mortality, morbidity, and disparities across the United States by centering those most affected by the crisis— Black women—which will lead to improved health and well-being for all mothers and infants.
• Protecting and expanding access to a full range of reproductive health care and services by supporting the capacity of HSS’s Office of Population Affairs and increasing funding for the Title X family planning program, including removing barriers for immigrants to access public health care services.
• Legislating a nationwide right to abortion and reducing financial barriers to such care.

For more Federal Policy Solutions to Advance Gender Equity, visit iwpr.org/federalpolicyagenda.
For state-level data on women and legislative developments, visit IWPR’s State Policy Action Lab (State PAL) at statepolicyactionlab.org.