States already have grappled with insurance coverage of contraceptives before the Obama administration issues rules in 2012 called for under the Affordable Care Act. Twenty-six states have passed laws mandating insurance coverage for contraceptives; another two have administrative rulings requiring coverage. Nineteen states also have included exemption provisions for religious organizations. The Hawaii statute was the model used for the Obama compromise on exemptions.

  Download the brief in PDF

  Download the table: "State Mandates on Contraceptive Coverage by Health Insurance"

• In August 2011, the U.S. Department of Health and Human Services adopted recommendations from the Institute of Medicine identifying eight effective preventive services for women, including contraception services.
• President Obama in January 2012 called for insurance to cover, at no cost to enrollees, any prescribed FDA-approved contraceptive and related services. The rule exempted churches and other houses of worship, but the exemption did not extend to all employers that were religiously affiliated, such as hospitals and universities. 
• After a firestorm of criticism, the president announced a compromise position. The rule would still apply to all plans, but employers with a religious affiliation who object to covering contraception will have a one-year grace period during which they do not have to comply with the rule.¹ Then, under more detailed rules to be published in the next year, religiously affiliated employers will not have to pay for contraception services in their premiums. Employees will receive coverage free of cost, and insurers will directly provide the coverage, and presumably, absorb any costs. 

• Maryland passed the earliest mandate in 1998, closely followed by California, Connecticut, Georgia, Hawaii, Nevada, New Hampshire, Maine, North Carolina and Vermont in 1999.
• Sixteen other states—Arizona, Arkansas, Colorado, Delaware, Illinois, Iowa, Massachusetts, Missouri, New Jersey, New Mexico, New York, Oregon, Rhode Island, Washington, West Virginia, and Wisconsin—have statutorily mandated coverage.
• Michigan’s Civil Rights Commission ruled in 2006 that if an employer’s health insurance plan covered others drugs and services, it also must cover all contraceptive drugs and services.²
• In Montana, a 2006 attorney general opinion found that prescription contraceptives and related medical services must be provided if other prescriptions are covered under both the Montana unisex insurance law and the Montana Human Rights Act.³
• The Guttmacher Institute, a research group focused on sexual and reproductive health, classifies the states’ exemptions for religious or other employers as limited to churches and church associations in four states, broader in another seven states to include religious schools but not hospitals and expansive in eight states. The states with expansive exemptions allow all religious organizations, including at least some hospitals, to exclude insurance coverage of contraception; that includes two states that also exempt secular organizations with moral or religious objections.
• Hawaii’s exemption law⁴, adopted in 1999 at the same time contraception coverage was mandated, is the model for the federal rule adopted in February.⁵

• Senate Majority Leader Harry Reid ruled out of order an amendment to a transportation bill to allow any employer to decline to cover a service that violates their moral or religious convictions.
• Nebraska, joined by the Republican attorneys general of six states, filed suit in federal court to challenge the administration policy. A religious group called Priests for Life has also filed a legal challenge to the new federal rule⁶. 
• Legislation declaring that life begins at conception and giving embryos legal rights—called personhood bills and currently under consideration in several states—could be in conflict with the new federal rule. If contraceptive methods prevent a post-conception egg from development, some would declare the embryo’s rights violated. 
• Legislation filed in Arizona, Idaho and Missouri would allow employers to opt out of any coverage to which they morally object.⁷