Since December 2020, the US has fully vaccinated over 1.4 million residents in long-term care facilities (LTCF) and over 1 million LTCF staff. Since then, weekly deaths in nursing homes have continued to fall, much of which has been attributed to the high rates of vaccination among nursing home residents. LTCFs include a range of facilities, including nursing homes, assisted living facilities, and other congregate care facilities for people with disabilities or older adults. This data note looks at state-reported LTCF data from 41 states plus Washington DC to assess what has happened to new deaths and cases in LTCFs in the four months since vaccinations began on December 21^st, 2020. We also examine how recent changes in deaths and cases in LTCFs have shifted the nature of the pandemic outside of LTCFs. Data in this analysis is as of the week of April 11^th, 2021. See methods for more details.

COVID-19 Deaths in Long-Term Care Facilities

Of the 39 states (38 states plus DC) for which we can trend COVID-19 deaths in LTCFs, 21 states reported an all-time low death rate in April 2021. Five states reported zero LTCF deaths per 100,000 state residents in April 2021, a rounded value that represents a very small number of LTCF deaths in those states (Table 1 and Appendix Table 1). Across all states analyzed, LTCF deaths per 100,000 state residents hit an all-time low of 0.2 deaths per 100,000 state residents in April 2021, a steep decrease from the peak of 2.8 deaths per 100,000 US residents in April 2020 and a rate of 1.9 per 100,000 as vaccinations were being rolled out in January 2021. California, Colorado, Mississippi, Tennessee, and Montana reported zero LTCF deaths per 100,000 state residents in April 2021. This is a rounded value that represents a small number of LTCF deaths in those states. Of the 17 states that did not report the lowest number of LTCFs deaths per 100,000 in April 2021 over the course of the pandemic, 13 reported the lowest rate in April since vaccinations began in December 2020. These 17 states reported an average rate of 2.1 deaths per 100,000 in January 2021, which declined to 0.3 deaths per 100,000 in April 2021. See Appendix Table 1 for detailed data.

Since vaccinations began in mid-December 2020, the number of COVID-19 deaths in LTCFs across all states in this analysis has declined by 89% as of April 2021, from 1.7 deaths per 100,000 state residents to 0.2 deaths per 100,000 state residents (Table 1 and Appendix Table 1). Percent decline is calculated by taking the difference between average weekly deaths in December 2020 and average weekly deaths in April 2021 and dividing that difference by the average weekly deaths in December 2020.  Among the 39 states for which we can trend COVID-19 deaths between December 2020 and April 2021, 38 states reported a decline in deaths per 100,000 state residents, ranging from a decline of 68% in Virginia to 100% in Kentucky, with an average drop of 84%. Iowa was the only state that reported higher average weekly LTCF deaths in April 2021 than December 2020 (24% increase). It is possible that this number reflects unknown reporting changes or data reconciliation, especially because the trend in Iowa has been unstable, with increases and decreases reported since October 2020. Notably, Iowa’s LTCF deaths per 100,000 was lower in April 2021 than January and February 2021.

Both nationally and in most states, the share of deaths attributed to LTCFs has dropped since the start of vaccinations in December 2020 (Table 1), indicating a faster decline in death rates in LTCFs than in the community. To a large extent, deaths due to COVID-19 have been concentrated in LTCFs throughout the pandemic.  Previous analysis indicates that the share of COVID-19 deaths attributed to LTCFs peaked in June 2020, when about 49% of all COVID-19 deaths in the US were in LTCFs. Since then, the share of deaths attributed to LTCFs dropped slowly to 42% for the week of December 20^th, 2020, when LTCF residents began receiving vaccines. By mid-April, 2021, LTCFs accounted for 34% of total, cumulative COVID-19 deaths, an eight-percentage point drop since the start of vaccinations. This pattern held in most states. However, four states reported a higher share of deaths in LTCFs in April 2021 compared to December 2020 (CO, IN, OK, OR). Increases in these states were modest, ranging from one to four percentage points, reflecting a slightly faster decrease in community deaths than LTCF deaths.

COVID-19 Cases in Long-Term Care Facilities

Similar to LTCF deaths, average new weekly cases in LTCFs hit an all-time low in April 2021, with two states (Kansas and Mississippi) reporting zero new LTCF cases per 100,000 state residents that month (Table 2 and Appendix Table 2). Across the 39 states (38 states plus DC) included in this analysis, average new weekly cases in LTCFs were just 1.6 per 100,000 in April 2021, compared to a peak of 20.3 in December 2020. Of the 39 states, 28 states reported the lowest average weekly new case rate in April 2021 since the start of the pandemic. Of the remaining 11 states, 3 reported the lowest average weekly rate in April 2021 since vaccinations began in December 2020. See Appendix Table 2 for detailed data.

New cases in LTCFs dropped by 92% between December 2020 and April 2021, a pattern that is reflected in state-level data as well (Table 2 and Appendix Table 2). Nearly all states (36 of 39 states) included in the analysis reported a greater than 80% drop in LTCF cases in this time period. The remaining three states reported a drop of greater than 50%.

Reflecting a potentially troubling trend of increasing community spread, eight states reported increases in LTCF cases from March to April 2021 (Table 2 and Appendix Table 2). These increases ranged from a 6% increase in New Hampshire to over 150% in Connecticut and Michigan. The other five states that saw increases from March to April 2021 were Idaho (9%), Louisiana (31%), New Jersey (36%), Ohio (78%), and Alabama (81%). These increases may be a result of increased cases in the state overall, which has been attributed to rising infections among younger people due to “pandemic fatigue” and the rise of the B.1.1.7 variant. Research suggests a strong connection between increased cases in the community and increased cases in LTCFs. None of the states reported both an increase in LTCF cases and deaths between March and April 2021, so it remains to be seen whether these increased LTCF cases will lead to increased LTCF deaths.

Key Takeaways

• About two-thirds of women who work for pay say that their employer offers them paid sick leave (66%), paid vacation (68%) and a retirement plan (66%), and just over four in ten report that they are offered paid parental leave or paid family and medical leave.
• Among women with school age children, more than six in ten report that they are the ones who usually take charge of health care responsibilities such as choosing their children’s provider (68%), taking them to appointments (70%), and following through with recommended care (67%). Fathers are more likely than mothers to say they share responsibility for these tasks equally with a partner.
• Among employed parents, mothers are more likely than fathers to report they care for children when they are sick and cannot attend school. Nearly half (46%) of mothers say they are not paid when they take time off to care for children who cannot go to school.
• Mothers who are low-income or in part-time jobs are more likely than those with higher incomes and full-time jobs to report missing work when their children are sick and less likely to have paid sick leave benefits.

Introduction

The persistent challenges that working mothers face in balancing family and work responsibilities came into clear focus during the COVID pandemic. These challenges were intensified by a huge increase in caregiving needs, a shift to homeschooling, a dearth of childcare options, and widespread social isolation.  Many women who were considered essential workers did not have the opportunity to work from home and many, particularly women of color, also bore the impact of a sharp rise in unemployment that was exacerbated by decades of structural racism. For many working women, economic security is intertwined with health issues, including workplace benefits such as insurance coverage, paid sick leave, and paid family leave. It is also related to women’s roles as mothers and primary managers of their children’s health care.

This brief provides new data from the KFF Women’s Health Survey, a nationally representative survey of 3,661 women and 1,144 men ages 18-64 (Methodology) conducted November 19, 2020 – December 17, 2020. Among several topics related to women’s health and well-being, we asked respondents about employment and family health care needs. In this brief, we highlight how workplace benefits and caring for children’s health care differ by gender and among different subpopulations of women.

Workplace Benefits

The majority of women who are employed for pay say their employer offers them health insurance, paid sick leave, paid vacation, and a retirement plan. Most, however, are not offered paid parental leave or family and medical leave. Three in four employed women (75%) say their employers offer health insurance (Table 1). About two-thirds report that their employer offers them paid sick leave (66%), paid vacation (68%) and a retirement plan (66%). However, most report that they are not offered paid parental leave or paid family and medical leave. Just over four in ten women workers say they are offered these benefits.

Men report receiving most of these same benefits in similar rates, except that a higher share of men report they are offered paid vacation (74%) and paid family and medical leave (46%). Across the board, low-income women and those with part-time employment are less likely to be offered any of these benefits compared to their higher income and full-time counterparts.

There are also consistent gaps in workplace benefits by educational attainment and geography with lower rates among women in rural areas compared to urban and suburban areas. Among women of color, Asian women report the highest offer rates of several benefits, including health insurance, paid vacation, paid sick leave, and paid parental leave (Appendix Table 1).

Awareness of Paid Parental Leave

Unlike most high-income countries, there is no federal requirement for employers to offer paid leave to workers after the birth or adoption of a child in the US, although this benefit is required in a few states. The federal Family and Medical Leave Act (FMLA) requires some employers to provide unpaid leave as well as job protection to eligible employees who take time off for the arrival of a child or to care for ill family members, but does not require employers to pay for this time.  Despite the fact that few employers offer parental leave to their workers, only three in ten women (29%) are aware that the US does not have a national requirement to provide paid parental leave to workers. About a third of women think (erroneously) that there is a national paid parental leave policy and almost four in ten say that they do not know if there is one (Figure 1).  People may not know about the lack of a benefit unless they try to use it and realize they don’t have one.

Parental Roles for Children’s Health

Mothers and fathers have very different perspectives about who takes the lead in managing family health. In most households, women say they are the managers of their families’ health care needs, with fathers playing a lesser role. Many fathers, however, say they share responsibility with a partner jointly. Among women with children under 18, more than six in ten report that they are the ones who usually take charge of health care responsibilities such as choosing their children’s provider (68%), taking them to appointments (70%), and following through with recommended care (67%), compared to less than a fifth of fathers who report they take care of these tasks (Figure 2). Mothers and fathers differ somewhat on their assessment of their involvement in children’s health care. While fathers are more likely to report that their partners take care of their children’s health needs than themselves, they are also more likely than mothers to report that it is a joint responsibility. About half of fathers say they share health care responsibilities equally with a partner or other parent, compared to about a quarter of mothers.

There are some variations in children’s health care responsibilities between groups of women by race/ethnicity, income, marital status, and education level (Appendix Tables 2, 3, 4). Black women are more likely to say that they attend to children’s health care needs and are less likely to share the work with a partner compared to White women. Single mothers and low-income mothers are also more likely than partnered and higher income mothers to say that they are typically responsible for managing their children’s health care.

Impact of Children’s Health Needs on Working Parents

Among working parents, mothers report they are more likely than fathers to care for children when they are sick and cannot attend school. Six in ten working mothers (61%) say they are usually the one to take care of children who are sick and cannot got to school, more than six times the share of working fathers (9%) who say this is the case (Figure 3). However, this is another topic where men are more likely to say that they share in the work equally. A quarter of mothers and 45% fathers say they share responsibility for this jointly.

Caring for children’s health can have tangible economic consequences for parents, but especially for women. When mothers care for children because they are sick and cannot go to school, 46% are not paid for time off, as is the case for 38% of men (Figure 4). Considering that nearly one-fifth of children miss at least three school days a year due to illness or injury, missing work to care for sick kids is a common occurrence with negative economic implications for many employed parents. Furthermore, as schools re-open, there could be a rise in parents missing work to stay home with children due to COVID concerns.

Mothers in part-time jobs, those who are low-income, and who are single parents are more likely to report they are the ones to care for children when they are sick compared to their full-time, higher income, and partnered counterparts. Low-income mothers who must miss work when their child is sick are also far more likely to lose pay (75%) compared to higher income mothers (33%) (Figure 5). Additionally, there is a large disparity in workplace benefits, with offer rates of paid sick leave and paid vacation significantly lower among mothers who are low-income or part-time employees (Table 2).

Conclusion

Women now comprise at least half of the nation’s workforce, yet median earnings for women are 81% of men’s earnings, a gap that has persisted for years and is even larger for women of color. Roughly seven in ten women with children under age 18 are in the labor force, but can face challenges without access to paid parental leave. The United States remains one of the few industrialized nations that does not require paid leave for major health events, such as the birth or adoption of a child, to care for an aging relative, or for routine sick leave that most workers will need at some point. For many women, even a month of leave after childbirth is unaffordable and unattainable without paid time off. Additionally, missing work when their children are sick, including with COVID-19, has an economic cost, as nearly half are not paid when they take a sick day.

Women continue to be the primary health care managers for their families, although some share the work for children’s health care with partners, and perceptions of responsibility for caregiving differ substantially between mothers and fathers. Mothers will play a significant role in the nation’s pandemic recovery, as they are likely to take the lead on getting kids vaccinated once vaccines are available for children. This survey finds that many working women, particularly those with lower incomes or in part-time jobs, do not have workplace protections such as paid sick days or paid family leave. This past year, this gap has been amplified by the lack of in person education for school aged children and childcare closures, along with an unparalleled national health crisis that has disproportionately affected low-income communities of color across the nation. While federal policymakers have addressed some of these gaps through the various federal COVID relief laws passed by Congress, these measures are restricted to certain industries and employer sizes, and time-limited. For some women, the system is largely working. But, for many others, including those who are in low-wage jobs or work part-time hours, the financial consequences of taking time off to care for their children can force them to make difficult tradeoffs between their financial wellbeing or their families’ health.

The 2020 KFF Women’s Health Survey was designed and analyzed by researchers at the Kaiser Family Foundation (KFF) of a representative sample of 4,805 adults, ages 18-64 years old (3,661 women and 1,144 men). The survey was conducted online and telephone using AmeriSpeak®, the probability-based panel of NORC at the University of Chicago. U.S. households are recruited for participation using address-based sampling methodology and initial invitations for participation are sent by mail, telephone, and in-person interviews. Interviews were conducted in English and Spanish online (4,636) and via the telephone (169). Our previous Women's Health Surveys were conducted exclusively by telephone, so trend data are not included in our 2020 survey. Interviews for this survey were conducted between November 19 and December 17, 2020, among adults living in the United States. KFF paid for all costs associated with the survey.

The sample for this study was stratified by age, race/ethnicity, education, and gender as well as disproportionate stratification aimed at reaching uninsured women, women who identify as LGBT, Asian women, and women 18-49 years old. The sampling also took into consideration differential survey completion rates by demographic groups so that the set of panel members with a completed interview for a study is a representative sample of the target population. This survey includes people who self-identified as 'female' or 'male’ regardless of their sex at birth. While our goal was to be as inclusive as possible, we were not able to obtain a large enough sample to support a separate questionnaire that addresses the unique health concerns and experiences of non-binary or gender-fluid people to include them in this survey. We recognize that additional study is needed to better understand the health and access issues faced by non-binary people.

A series of data quality checks were run and cases determined to be poor-quality, as defined by surveys with a length of interview of less than 33% of the mean length of interview and with high levels of question refusal (>50%) were removed from the final data (n=96). Weighting involved multiple stages. First, the sample was weighted to match estimates for the national population from the 2020 Current Population Survey on age, gender, census division, race/ethnicity, and education. The second round of weights adjusted for the study’s sampling design. All statistical tests of significance account for the effect of weighting.

The margin of sampling error including the design effect for the full sample of women is plus or minus 2 percentage points. Numbers of respondents and margins of sampling error for key subgroups are shown in the table below. For results based on other subgroups, the margin of sampling error may be higher. Sample sizes and margins of sampling error for other subgroups are available by request. Note that sampling error is only one of many potential sources of error in this or any other public opinion poll.

Key Takeaways

Use of Contraceptives

• Six in ten (60%) women aged 18 to 49 years say it is very important to avoid becoming pregnant in the next month; one in four women (25%) say avoiding pregnancy is not a priority. One in seven (14%) sexually active women report they are not using any form of contraception and the leading reason is concern and dislike of side effects.
• More than four in ten (44%) women have been worried they were pregnant when they did not want to be and the main reason was because they did not use birth control.
• Oral contraceptives and condoms are the leading forms of reversible contraception women use, and almost a quarter say they use an intrauterine device (IUD).
• Most women (72%) use more than one type of contraception in their lifetime and on average, women use 3.4 different contraceptive methods throughout their lifetime.
• Nearly one in five women (18%) use contraception solely for a reason not related to preventing pregnancy such as managing a medical condition or preventing STIs.

Contraceptive Coverage

• One in five women (18%) are not using their preferred method of contraception and a quarter (25%) say it is because they can’t afford it.
• Almost two-thirds of privately insured women have full contraceptive coverage through their plans where all FDA-approved contraceptive methods and contraceptive counseling and education are covered without cost-sharing, but one in five women (21%) with private insurance are still paying some out-of-pocket costs for their contraceptive care.
• Nearly one-third (31%) of oral contraceptive users say they have missed taking their birth control because they were not able to get their next supply in time.

Access to Quality Sexual and Reproductive Health Care

• Publicly funded clinics provide contraceptive care for one in five low-income and uninsured women (21%). The majority of women rely on office-based providers for their birth control.
• Four in ten women (44%) rate their provider’s contraceptive counseling as excellent, but the share rating counseling as excellent is lower among Black (36%) and Hispanic (38%) women, as well as low-income (35%) and uninsured (28%) women.
• The majority of reproductive-aged women (65%) are comfortable with pharmacists prescribing birth control and support making birth control available over the counter without a prescription (70%).
• Most reproductive-aged women have discussed contraception with their providers (68%), but a much smaller shared were asked about sexually transmitted infections (26%-28%) and domestic violence (38%). Only about 1 in 10 (11%) of women of reproductive age say they have discussed HIV pre-exposure prophylaxis (PrEP) with their provider.
• Most reproductive-aged women (58%) know someone who has had an abortion with 68% of those women knowing more than one person and just over half of women have heard of a medication abortion (57%).

Introduction

Sexual and reproductive health is an integral part of women’s overall health. Access to these services is shaped by a broad range of factors including coverage and affordability, national and state policies, availability of care, health provider characteristics, as well as individual preferences and experiences. For many women, the Affordable Care Act (ACA) improved access to sexual and reproductive health care by expanding pathways to Medicaid eligibility and making private insurance more affordable. The ACA also required private health insurance plans to cover many recommended preventive services without any patient cost-sharing, such as sexually transmitted infection counseling and screening and all 18 FDA-approved contraceptive methods. While the ACA has expanded sexual and reproductive health care, state and federal policy actions in recent years have resulted in more limited access to comprehensive sexual and reproductive health care, including abortion referrals and services, particularly for women who depend on publicly supported health care providers and clinics.

Access in the past year has also been undoubtedly affected by the COVID-19 pandemic, which has forced providers to find ways to make contraceptive and STI services available via telehealth or through minimal contact, like no-test medication abortions. There is increasing interest in expanding efforts to allow pharmacists to prescribe birth control, gain FDA approval for over-the-counter oral contraception without a prescription, and expanding access to contraception through smartphone apps or online platforms that no longer require a visit to a brick-and-mortar clinic or doctor’s office.

While the system is undergoing constant change, the perspectives and experiences of women in obtaining sexual and reproductive health care can help to shape the next generation of policies and programs. This brief provides a window into some of those voices and perspectives by presenting selected findings from the 2020 KFF Women’s Health Survey, a nationally representative survey of women conducted in November/December of 2020 (Methodology). The survey covered a wide range of topics related to women’s coverage, use, access, and experiences with the health care system. This brief presents survey findings on coverage and use of reproductive and sexual health services among different subgroups of 2,695 women ages 18 to 49.

Use of Contraceptives

WHILE MOST REPRODUCTIVE AGE WOMEN SAY IT IS IMPORTANT TO THEM TO PREVENT PREGNANCY, ONE IN FOUR WOMEN SAY AVOIDING PREGNANCY IS NOT A PRIORITY.

Among women ages 18-49 who are not currently trying to get pregnant, the majority say it is very important (60%) or somewhat important (10%) for them to avoid becoming pregnant in the next month, but a quarter of women (25%) say it is not very important or not important at all (Figure 1). More than half (57%) of women who are not using contraception say that it is very important or somewhat important for them to avoid pregnancy compared to 81% of women using contraception. These data speak to the fact that even though women are not necessarily trying to get pregnant, they may be open to having a pregnancy and may not want to use contraception.

WOMEN ARE NEARLY TWICE AS LIKELY TO HAVE BEEN CONCERNED ABOUT AN UNWANTED PREGNANCY COMPARED TO MEN.

Over four in ten (44%) women have thought they were pregnant when they did not want to be, compared to one in four (27%) men who said this with regard to a partner (Figure 2). Nearly half (47%) of women and over half of men (57%) said it was because they did not use birth control. About a quarter of women (23%) and men (27%) said they or their partner had missed a pill or they had used their birth control incorrectly, 19% of women and 16% of men said their birth control failed like a condom breaking, and 18% of women and 22% of men weren’t sure the contraceptive method they were using worked.

A MINORITY OF WOMEN AND MEN USED CONDOMS THE LAST TIME THEY HAD SEX.

Six in ten sexually active women report using a method of contraception the last time they had sex compared to four in ten men, regardless of current partner status (Figure 3). Condom use at last sex was lower. Overall, 16% of women say their partner used a condom the last time they had sex, and 26% of men report using a condom. This differed significantly by whether someone was married or living with their partner compared to not. Condoms are not only used as contraceptives but are effective in reducing the risk of transmission of sexually transmitted infections. Men who are married or living with a partner are 2.5 times more likely to use a condom than men who are widowed, divorced, separated, or never married (40% vs. 16%). Thirteen percent of women who are married or living with a partner say their partner used a condom the last time they had sex compared to 23% of women who are widowed, divorced, separated, or never married. When asked if they had discussed birth control or condom use with their most recent sexual partner, the majority of men and women, regardless of partner status, said they had discussed with their partner.

ONE IN SEVEN SEXUALLY ACTIVE WOMEN DO NOT USE CONTRACEPTION. CONTRACEPTIVE NON-USE IS HIGHER AMONG ASIAN WOMEN AND WOMEN WHO ARE UNINSURED OR LOW-INCOME.

Over six in ten sexually active women of reproductive age report using at least one method of contraception in the past 12 months, while one in seven (14%) report that they did not use contraception and are not trying to conceive (Figure 4). One in four (25%) uninsured women report not using contraception compared to 13% of women with Medicaid and private insurance. Similarly, almost a quarter of sexually active Asian women report not using contraception compared to 13% of Black and White women and 15% of Hispanic women, while a lower share of Asian women report they or their partner are unable to conceive (3% vs. 11% of Hispanic women, 14% of Black women, and 19% of White women). Low-income women are also more likely to report not using contraception compared to higher-income women (18% vs. 13%) (Figure 5).

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When asked about the reason for not using birth control, the number one reason was being worried about or disliking the side effects of birth control (29%), followed by not minding if they got pregnant (23%) and not wanting to use birth control (23%) (Figure 6). Over 1 in 5 women cited another reason that was not included in the survey.

CONDOMS, ORAL CONTRACEPTION, AND IUDS ARE THE MOST COMMONLY USED FORMS OF CONTRACEPTION.

Reproductive-aged women were most likely to have used male condoms in the past 12 months (39%), followed by oral contraceptives (37%), and IUDs (23%) (Table 1). Compared to all women of reproductive age, younger women ages 18-35 were more likely to have used oral contraceptives (50% vs. 37%), the contraceptive patch (4% vs. 2%), a contraceptive implant (11% vs. 7%), male condoms (47% vs. 39%), and emergency contraception (15% vs. 9%). Women ages 26-35 were more likely to use fertility awareness-based methods (11%) compared to all women of reproductive age (8%). Women ages 36-49 were most likely to have used an IUD in the past 12 months (28%) compared to all women of reproductive age (23%).

MOST WOMEN USE MORE THAN ONE CONTRACEPTIVE METHOD IN THEIR LIFETIME.

Eighty-seven percent of women report using contraception at some point in their lifetime and on average, women report using 3.4 methods of contraception throughout their lifetime. Seven in ten women (70%) ages 18-64 say they have used oral contraceptives, including a larger share of women ages 36-64. Male condoms were the second most frequently used contraceptive among women ages 18-64 (66%). Younger women ages 18-35 have higher shares that have used implants and emergency contraception compared to women overall (Table 2). Nearly three-fourths of women (72%) have used more than one type of contraception in their lifetime, four in ten women have used more than two types of contraception in their lifetime (42%), and one in five women have used more than three types of contraception in their lifetime (22%). Contraceptive switching is common and it is important that women have access to the full range of contraceptive methods without cost-sharing, so they can find the contraceptive method that works best for them if they want to use contraception. Also, women’s contraceptive needs can change over their reproductive lifespan, what works when they are in their twenties may not be what is best for them in their thirties or forties. Shared-decision making with a provider can allow a patient to communicate their values and preferences for contraception and the provider can share their medical knowledge to help the patient find a contraceptive method that is most consistent with their preferences.

NEARLY ONE IN FIVE WOMEN USE CONTRACEPTION FOR A REASON NOT RELATED TO PREVENTING PREGNANCY.

While many women have used more than one contraceptive in their lifetime, they also use contraception for more than just preventing pregnancy. Over six in 10 women (61%) say they use contraception only to prevent pregnancy (Figure 7). Over one in five (22%) women use contraception to prevent pregnancy and some other reason. Nearly one in five women (18%) use contraception solely for a reason not related to preventing pregnancy such as managing a medical condition or preventing STIs.

ONE IN FOUR UNINSURED AND LOW-INCOME WOMEN ARE NOT USING THEIR PREFERRED CONTRACEPTIVE METHOD.

While many women try and use multiple contraceptive methods throughout their lives for various reasons, nearly one in five women (18%) say they are not currently using their preferred method of birth control (Figure 8). This share is higher among uninsured and low-income women who may not have affordable access to the full range of contraceptive methods or be aware of public programs that provide those services. The primary reason women say they are not using their preferred method of contraception is because they cannot afford it (Figure 9). The goal of publicly supported programs like Title X and Medicaid is to provide access to family planning services to individuals who need family planning services but may not be able to afford services because of lack of insurance or low income. Most Title X clinics provide the full range of contraceptive methods to their uninsured and low-income clients. The fact that such a sizable share of women still report affordability barriers to care may speak to the role of public programs and the need for outreach to expand awareness of and access to sexual and reproductive health care services to low-income and uninsured women.

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Among women who are not using their preferred method, one in five women (20%) say it is because their provider recommended a different method. There is increasing consensus about the importance of high-quality, client-centered contraceptive counseling to ensure that provider care is respectful of, and responsive to, individual patient preferences, needs, and values and importantly, that the patient guides all clinical decisions. Ensuring that patients have autonomy in their contraceptive decision-making is of high value and leads to greater satisfaction with their care and continued use of their method of choice.

Contraceptive Coverage

ONE IN FIVE WOMEN STILL REPORTS PAYING OUT-OF-POCKET FOR CONTRACEPTIVE CARE NEARLY 10 YEARS AFTER THE ACA WENT INTO EFFECT.

The ACA requires that most private plans cover contraceptive services which include patient education and counseling for contraceptive services and all of the 18 FDA- approved methods of contraception without cost-sharing. This provision has drastically reduced cost-sharing for contraception among women with employer or individual insurance plans. The majority of privately insured women report that their insurance covers the full cost of their contraceptive care (64%), but one in five (21%) women say their insurance only covered part of the cost and they paid the rest (Figure 10). There are a number of reasons that women could be responsible for some or all of those payments. For example, a woman could be using a brand-name contraceptive that is not in her plan’s formulary or she is unaware of or not offered a generic alternative. Some women paying out-of-pocket could also be receiving care out-of-network or still be enrolled in a grandfathered health insurance plan (which is exempt from the requirement). Some 13% of covered workers are enrolled in a grandfathered plan in 2019. An unknown number of women are also either employed by or dependents of a worker employed by an organization that has a religious objection to contraception. Those employers are not obligated to provide no-cost contraceptive coverage to their employees. Only 5% of women said they have had problems getting their insurance to pay for a prescribed birth control, such as an IUD, implant, injection, patch, pill, or ring.

In recent years, there has been a move to expand the supply of contraceptives dispensed to women since some women miss their pill (and are at risk of an unplanned or unwanted pregnancy) because they have run out of their supply. The majority of women ages 18-49 (59%) who used oral contraceptives in the past 12 months, received 3-5 months’ supply (Figure 11). However, twice as many low-income women compared to women with incomes ≥ 200% FPL only received 1–2-month supply (43% vs. 20%). Women with Medicaid also received a 1–2 months' supply at twice the rate of women with private insurance (42% vs. 22%). A much larger share of uninsured women (15%) reported receiving 6-11 months of supply compared to women with Medicaid and private insurance (1%). Laws have been passed in at least 17 states and DC that require coverage for 12 months of oral contraceptives to allow women continuous contraceptive coverage for at least a year. However, these laws typically only apply to fully insured plans. Many Medicaid programs can and do limit supply of hormonal contraception to 1-3 month periods; self-funded employer plans are also permitted to do this. Shorter supplies can result in women missing their pills due to delays in receiving their next supply.

Nearly one-third (31%) of hormonal contraceptive users say they have missed taking their birth control because they were not able to get their next supply of pills. This share is higher among younger women ages 18-25 and 26-35 compared to women ages 36-49 (38% and 34% vs. 16%) and among low-income women <200% FPL compared to women with incomes ≥200% FPL (36% vs. 26%) (Figure 12).

Access to Quality Sexual and Reproductive Health Care

THE MAJORITY OF WOMEN GET THEIR CONTRACEPTIVE CARE FROM OFFICE-BASED PHYSICIANS FOLLOWED BY CLINICS.

Three in four reproductive-age women who use contraception report receiving it from a doctor’s office (Figure 13). Many women, particularly about one-fifth of those who are Hispanic (20%), low-income (21%), covered by Medicaid (18%), or uninsured (21%), also use clinics such as federally qualified health centers (FQHC) or freestanding family planning clinics such as Planned Parenthood. Notably, about one in five women who are uninsured said they obtained their most recent contraception at another site, such as a pharmacy or drugstore. And, while there has been growing interest in telehealth, just 5% of women reported that they obtained contraception via a phone or video visit, website, or app.

LESS THAN HALF OF WOMEN REPORT RECEIVING THE HIGHEST QUALITY PERSON-CENTERED COUNSELING.

Women’s interactions with providers play an important role in the quality of their contraceptive care. While there has been a lot of emphasis on access to the most effective methods, there is also growing interest in ensuring that patient-provider relationships are patient-centered and support patient decision making. Approximately four in ten women (44%) rate their most recent contraceptive care provider as “excellent” on all four items of person-centered contraceptive counseling (Figure 14): respecting them as a person, letting them say what mattered to them about their birth control method, taking their preferences about their birth control seriously, and giving them enough information to make the best decision about their birth control. It is particularly concerning that Black, Hispanic, low-income, and uninsured women are less likely to receive this level of high-quality client-centered care. There is a long history of poor reproductive health care for these same groups. It is important to note that there were no significant differences by the type of setting in which the counseling was received, signaling that these groups may be receiving less client-centered care because of their race/ethnicity, income, or insurance regardless of the setting.

Currently, prescription contraceptives require a visit with a clinician in most states. In recent years though, there have been efforts to expand the availability of contraceptives through different avenues, including allowing pharmacists to prescribe and provide some hormonal methods and, applications to the FDA to make oral contraceptive pills (OCPs) available over-the-counter (OTC) without a prescription. Our survey finds that most women are in favor of these changes (Table 3). These approaches appear to be attractive to the majority of reproductive-age women: two-thirds (65%) say they are comfortable with pharmacists prescribing contraceptives and 70% support making pills available OTC if the FDA says it is safe and effective. There are differences in acceptability between different subgroups of women with higher levels of acceptability found among White women, women with a college degree, women living in urban/suburban areas, and Democratic women.

ONE-THIRD OF 18-25 YEAR OLD WOMEN HAVE NEVER SEEN A DOCTOR OR NURSE FOR A GYNECOLOGICAL EXAM.  PRIVATELY INSURED WOMEN WERE THE MOST LIKELY TO HAVE A HAD A GYN VISIT IN THE PAST 12 MONTHS AND UNINSURED THE LEAST LIKELY. 

Nearly three in four reproductive age women report that they have had a gynecological exam in the past three years (Figure 15).  However, that is the case for only half of uninsured women (49%). More than one in ten uninsured women (14%) say that they have never had a gynecological exam, higher than the share of privately insured women (8%). Receipt of gynecological exam increases with age. While 30% of women ages 18-25 say they have never had an exam, that share drops to 4% among women ages 26-35. A gynecological exam usually includes cervical and breast cancer screening, education, and counseling that can prevent future negative health outcomes.

Screening Tests

ASIAN, UNINSURED AND RURAL WOMEN WERE THE LEAST LIKELY TO REPORT HAVING A PAP TEST WITHIN THE PAST TWO YEARS.

A number of federal bodies and professional organizations recommend that women receive sexual health screening tests. These tests are covered without any out-of-pocket charges for women with private insurance and under Medicaid expansion per the ACA’s preventive services requirement. The USPSTF recommends that women receive a Pap smear at least every three years beginning at age 21 depending on their personal risk factors for developing cervical cancer. More than two-thirds (68%) of women ages 21-49 say they have received one in the past two years. However, that is the case for only half of uninsured women (50%) (Figure 16). Pap testing rates are higher among Black women (79%) and lower among Asian women (58%), compared to women who are White (68%). Women who live in rural areas are also less likely than those living in urban areas to have had a Pap test in the prior two years. Many rural communities suffer from a dearth of reproductive health care providers, which may contribute to the lower rates of screening.

DESPITE RECOMMENDATIONS FOR ROUTINE STI AND HIV TESTING, FEW WOMEN HAD HAD A RECENT TEST.

One in four women (26%) report they had an HIV test in the past 2 years and one in three women (33%) who had a recent provider visit say they have had a test for an STI other than HIV in the past two years (Table 4). Knowing one’s status is important for receiving early treatment and preventing transmission to sexual partners. STI and HIV tests are covered without cost-sharing in private plans under the ACA’s preventive services coverage requirements and are typically covered by Medicaid programs. Screening rates are higher among women who are younger and low-income, as well as Black and Hispanic women compared to White women.

However, the actual screening rate is likely lower than the share of women who report being tested, as some assume (erroneously) that STI and HIV tests are routine components of a clinical visit. About one-quarter of women who said they were tested for HIV (26%) recently were under the impression that it is routine, which is not the case (Figure 17). This is also true for about a quarter of women who said they had been tested for other STIs (23%). This may cause women to believe they do not have HIV or another STI when in fact they have not actually been tested.

Sexual and Reproductive Health Counseling and Education

An important part of the gynecological exam and well-woman visit is counseling and education around sexual and reproductive health care, including discussions around contraception, sexual history or relationships, and sexually transmitted infections (STIs). The ACA also covers contraceptive counseling, as well as HIV and STI counseling without cost-sharing.

WOMEN ARE MUCH MORE LIKELY TO HAVE DISCUSSIONS WITH PROVIDERS ABOUT CONTRACEPTION THAN ABOUT STIs, HIV OR PrEP.

Among these sexual and reproductive health topics, the largest share of women ages 18-49 say they have been asked about or discussed contraception with their provider in the past two years (68%) (Table 5). Black women were significantly less likely to have discussed contraception with their provider compared to White women (60% vs. 70%). The majority of women (63%) also say they have discussed their sexual history with a provider.

Less than one-third of women of reproductive age say they were asked by a provider about HIV or another STI (26% and 28%, respectively). Women with Medicaid were more likely to have a discussion with their provider about HIV (31%) compared to women with private insurance (26%). A larger share of Black (32%) and Hispanic (31%) women were also asked about HIV compared to White women (22%). STI rates continue to rise, with younger women and Black and Hispanic women being disproportionately affected. STI counseling for all people of reproductive age is recommended to help individuals reduce their risk for STI transmission.

Only about 1 in 10 (11%) women of reproductive age say they have discussed HIV pre-exposure prophylaxis (PrEP) with their provider and this was higher among Asian (18%) and Hispanic (15%) women compared to White women (8%). Women with Medicaid (14%) were more likely to discuss PrEP compared to women with private insurance (10%) and low-income women (15%) compared to women with incomes ≥ 200% FPL (10%).

Across all the sexual and reproductive health topics, younger women ages 18-35 compared to women ages 36-49 and women living in urban areas compared to rural areas were more likely to be asked about these topics or discuss them with their doctor or health care provider. Roughly one-third of women ages 40-64 (32%) say a provider has discussed menopause with them recently.

FEW WOMEN ARE SCREENED FOR INTIMATE PARTNER VIOLENCE, DESPITE THE PRESENCE OF RECOMMENDATIONS FROM THE US PREVENTIVE SERVICES TASKFORCE AND THE WOMEN’S PREVENTIVE SERVICES INITIATIVE FOR SCREENING. 

Another important topic that the US Preventive Services Task Force recommends providers to screen women of reproductive age for is intimate partner violence (IPV). However, only 38% of women ages 18-49 say a provider has asked them about domestic violence or dating violence in the past two years (Figure 18). This is higher among women ages 26-35 (44%) compared to women ages 36-49 (36%) and women with Medicaid (46%) compared to women with private insurance (38%). However, only 1 in 4 (26%) uninsured women were asked about it. Smaller shares of Asian women (25%) and Black women (33%) report discussing IPV compared to 40% of White women. There were no statistical differences by income and location.

Abortion

A HIGHER SHARE OF WOMEN THAN MEN SAY THEY PERSONALLY KNOW SOMEONE WHO HAS HAD AN ABORTION.

Abortion services are a significant component of sexual and reproductive health care, given that one in four women have had an abortion, making it a relatively common health care service. Nearly six in ten women (58%) and four in ten men (39%) say that they know somebody who has had an abortion (Figure 19). Of that group, most (68%) know more than one woman who has had an abortion (Figure 20). Rates are higher among those who are older, higher income, higher educational attainment (Table 6). Most know one or two women who have had an abortion and on average, women know 2.8 women and men know 2.5 women who have had an abortion.

KNOWLEDGE OF MEDICATION ABORTION IS STILL RELATIVELY LOW. ROUGHLY HALF OF WOMEN AND MEN HAVE HEARD OF MEDICATION ABORTION EVEN THOUGH IT WAS APPROVED BY THE FDA 20 YEARS AGO.

Medication abortion is a pregnancy termination protocol that can be used up to the first 10 weeks of pregnancy that involves taking two different drugs, Mifepristone and Misoprostol. It has been available in the United States for more than 20 years and now accounts for approximately half of all early abortions. However, there are many restrictions on its availability, including an FDA REMS requirement, bans on telemedicine, and requirements for in-person counseling visits and other tests that are not medically recommended for safety. The COVID-19 pandemic has brought many of these restrictions to the forefront as providers have tried to implement no-test and telehealth medication abortion protocols that allow women to pick up medication abortion pills or have them mailed directly to their home with phone or video follow-up without requiring any testing or pre-abortion ultrasounds.

Over half of reproductive-aged women (57%) and almost half of men (48%) say that they have heard of medication abortion (Figure 21). Rates are lower though among Hispanic women, those with lower incomes, and those living in rural areas.

Conclusion

Sexual and reproductive health is multi-faceted and an integral part of a person’s overall health. In recent years, state and federal policies have had a major impact on access to sexual and reproductive health care across the nation, in some cases limiting access and in other broadening availability of care. The Affordable Care Act (ACA) enabled more women to obtain sexual and reproductive health care by expanding access to Medicaid and private insurance coverage and strengthening the scope of that coverage. While it made several preventive sexual and reproductive health services and counseling available without cost-sharing, many women are still saying that affordability is a barrier to contraceptive care, are not using the contraceptive of their choice, and are not getting the recommended levels of preventive sexual and reproductive health care services to which they are entitled under federal law.

Federal support for the family planning safety-net, the types of clinics that may participate in federal programs like Medicaid and Title X as well as state choices regarding Medicaid expansion all have an effect on the ability of low-income and uninsured women to gain access to reproductive care. While the COVID-19 pandemic has challenged providers to find new ways to make contraceptives, STI services, and in some cases abortion care, available via telehealth, it has brought the long-standing structural inequities in the health system into stark focus. Understanding how women use reproductive and sexual health care and the challenges they face could help leaders at the federal, state, and community level make such care more accessible and equitable.

The 2020 KFF Women’s Health Survey was designed and analyzed by researchers at the Kaiser Family Foundation (KFF) of a representative sample of 4,805 adults, ages 18-64 years old (3,661 women and 1,144 men). The survey was conducted online and telephone using AmeriSpeak®, the probability-based panel of NORC at the University of Chicago. U.S. households are recruited for participation using address-based sampling methodology and initial invitations for participation are sent by mail, telephone, and in-person interviews. Interviews were conducted in English and Spanish online (4,636) and via the telephone (169). Our previous Women's Health Surveys were conducted exclusively by telephone, so trend data are not included in our 2020 survey. Interviews for this survey were conducted between November 19 and December 17, 2020, among adults living in the United States. KFF paid for all costs associated with the survey.

The sample for this study was stratified by age, race/ethnicity, education, and gender as well as disproportionate stratification aimed at reaching uninsured women, women who identify as LGBT, Asian women, and women 18-49 years old. The sampling also took into consideration differential survey completion rates by demographic groups so that the set of panel members with a completed interview for a study is a representative sample of the target population. This survey includes people who self-identified as 'female' or 'male’ regardless of their sex at birth. While our goal was to be as inclusive as possible, we were not able to obtain a large enough sample to support a separate questionnaire that addresses the unique health concerns and experiences of non-binary or gender-fluid people to include them in this survey. We recognize that additional study is needed to better understand the health and access issues faced by non-binary people.

A series of data quality checks were run and cases determined to be poor-quality, as defined by surveys with a length of interview of less than 33% of the mean length of interview and with high levels of question refusal (>50%) were removed from the final data (n=96). Weighting involved multiple stages. First, the sample was weighted to match estimates for the national population from the 2020 Current Population Survey on age, gender, census division, race/ethnicity, and education. The second round of weights adjusted for the study’s sampling design. All statistical tests of significance account for the effect of weighting.

The margin of sampling error including the design effect for the full sample of women is plus or minus 2 percentage points. Numbers of respondents and margins of sampling error for key subgroups are shown in the table below. For results based on other subgroups, the margin of sampling error may be higher. Sample sizes and margins of sampling error for other subgroups are available by request. Note that sampling error is only one of many potential sources of error in this or any other public opinion poll.

Key Takeaways

Health Status

• Large shares of lower-income women and women with Medicaid report being in fair or poor health. One in five Black (20%) and Hispanic (19%) women report being in fair or poor health compared to 12% of White women and 9% of Asian women.  
• Six in ten (61%) women ages 50-64 and almost half of White women (48%) and women with Medicaid (47%) report having a chronic health condition that requires regular monitoring, medical care, or medication.

Health Care Utilization

• More than nine in ten (93%) women have seen a doctor or health care provider in the past two years, but a smaller share has had a general check-up or well-woman visit (73%).
• One in ten (10%) women with an ongoing health condition do not have a regular doctor or health care provider.
• Most women obtain their care at doctors’ offices, but many uninsured women, those with Medicaid, and Black and Hispanic women visit health centers or clinics. 
• Nearly half (46%) of women who usually visit a health center or clinic for their care go to a walk-in clinic such as an urgent care facility or clinic inside a store or pharmacy. One-third (34%) visit a community health center or health department.
• Women with Medicaid coverage are more likely than women with employer-sponsored insurance to report experiencing health insurance coverage limitations. Nearly three in ten women with Medicaid (29%) and individual insurance (28%) say a doctor they wanted to see was not covered by their plan, compared to 15% of women with employer-sponsored insurance.

Health Care Experiences

• Among women who have been to the doctor in the past two years (93%), uninsured women (55%) are significantly less likely to have discussed mental health issues with their health care provider than women with health insurance (70%). Black (61%) and Asian (60%) women are less likely to have had this discussion with their provider than White women (72%).
• Among people who have visited a doctor in the past two years, women are more likely than men to say a health care provider has dismissed their concerns (21% vs. 12%) or didn’t believe they were telling the truth (10% vs. 7%). One in three (30%) women who had a negative provider experience say they were treated this way because of their age and one in five (20%) say it was because of their gender. Nearly four in ten (38%) Black women say they were treated this way because of their race/ethnicity.

Health Care Costs

• One in four (24%) women report having had problems paying medical bills in the past 12 months, over half (57%) of whom say this was due, at least in part, to the COVID-19 pandemic.
• Among women experiencing problems with medical bills in the past year, nearly half (48%) have had difficulty paying for basic necessities like food, heat, or housing because of the bills, as have six in ten (61%) low-income women.

Introduction

Women’s access to health care depends greatly on the availability of high-quality providers in their communities as well as their own knowledge about maintaining their health through routine checkups, screenings, and provider counseling. Social determinants of health, structural racism, and experiences with health care providers shape health outcomes and health equity.

While the Affordable Care Act (ACA) expanded pathways to affordable coverage to millions of women, coverage and affordability barriers persist for many. Women with health insurance may experience difficulty affording health care. Many insured women face health care costs in the form of cost sharing or balance billing resulting from receiving care from an out-of-network provider or hospital, which can also impact their financial well-being. The ACA contains provisions aimed at alleviating some of the financial barriers to health care access; however, many women still face challenges with health care costs and medical bills, particularly those who are uninsured or low-income.

This brief presents findings from the 2020 KFF Women’s Health Survey on women’s use of health care services, costs, and experiences accessing health care. The 2020 survey is a nationally representative survey of 3,661 women ages 18 to 64, conducted between November 19 and December 17, 2020. See the Methodology section for more details.

Health Status and Use of Prescription Medications

The majority of women ages 18-64 report being in good or excellent health, but higher shares of older and lower-income women, as well as Black and Hispanic women and those with Medicaid, report being in poorer health.

Most women (85%) rate their health as excellent, very good, or good; however, 15% of women describe their health as fair or poor, similar to other national estimates.¹  As women age, they are more likely to rate their health as fair or poor (Figure 1). Nearly one in four (24%) low-income women, women with Medicaid (24%), and uninsured women (21%) rate their health as fair or poor.²  Black (20%) and Hispanic (19%) women are more likely than White (12%) and Asian (9%) women to report being in fair or poor health.³ 

Many women are managing chronic conditions or living with disabilities that impact daily life.

Just under half of women (44%) report that they have a chronic health condition that requires regular monitoring, medical care, or medication (Figure 2). This rate increases steadily with age, from about one in four (24%) women ages 18-25 to six in ten (61%) women ages 55-64. Almost half of White (48%) and Black (45%) women report having a chronic health condition compared to just over one-third of Hispanic (35%) and Asian (34%) women. Insured women with Medicaid coverage (47%) and private coverage (45%) report higher rates of chronic health conditions requiring regular maintenance than do uninsured women (31%).

Fifteen percent of women report having a disability or chronic disease that keeps them from participating fully in work, school, housework, or other activities (Figure 3). Women with Medicaid (29%), low-income women (24%), and older women (21%) are more likely than their counterparts to report having a disability or chronic disease.

More than half of women are taking at least one prescription medication on a regular basis.

Women may take prescription medications to treat or manage chronic conditions and acute illnesses or to prevent pregnancy. More than half (57%) of women report taking at least one prescription medicine on a regular basis, including oral contraceptives (Figure 4). Prescription medication use increases with age, with about four in ten (42%) women ages 18-49 taking at least one on a regular basis compared to about seven in ten (72%) women ages 50-64. Women in poorer health (71%) are more likely than women in better health (55%) to report taking a prescription medication regularly.⁴  Low-income women (52%) are less likely than women with higher incomes (61%) to take a prescription medication regularly and uninsured women (36%) are less likely than insured women (60%). White women (63%) are more likely than Asian (47%), Hispanic (48%), and Black (51%) women to take a prescription medication.

Health Care Utilization

Sites of Care

Most women obtain their care at doctors’ offices, but clinics are common sites of care for underserved communities, particularly for uninsured women and those with Medicaid.

Eighty-four percent of women report that they have a place they usually go when they are sick or need advice about their health. Eight in ten (81%) women with a usual place of care report that they obtain their care at a doctor’s office (Figure 5). Seventeen percent obtain care at a clinic, such as a health center, urgent care clinic, or clinic inside a store or pharmacy. A very small share (2%) cites the emergency room as their usual site of care and 1% go to some other place.

The share of women with private health insurance (85%), higher-income women (85%), and White (84%) and Asian (85%) women who visit a doctor’s office is higher than those of their counterparts (Figure 6). Approximately one-quarter of women with Medicaid (23%) and one in three (30%) uninsured women usually visit a health center, urgent care clinic, or clinic inside a store or pharmacy. Hispanic (21%) and Black (22%) women are more likely to visit one of these clinics than White (14%) women or Asian (11) women.

Among women who obtain care at a health center or clinic, more than half of women with private insurance visit a walk-in clinic while uninsured women and women with Medicaid are more likely to visit a community or public health center for care.

Among women who usually visit a clinic, almost half (46%) use a walk-in clinic such as an urgent care center clinic inside a store or pharmacy (Figure 7). These clinics are often staffed by advanced practice clinicians and treat minor illnesses and injuries and provide some preventive care. Women with employer-sponsored insurance (59%) are far likelier to use one of these clinics than are women with individual insurance (30%) or Medicaid coverage (37%) and uninsured women (35%) (Table 1). About one-third (34%) of women who usually visit a health clinic go to a community health center or health department. Community health centers and health departments are common among women with Medicaid (46%) and uninsured women (41%), Hispanic (47%) and Black women (41%), and low-income women (47%).

Sources of Care

While the vast majority of women have a regular provider they turn to for routine care, only half of uninsured women have a usual source of care.

Having a usual source of health care is associated with increased use of preventive care and better health outcomes. Seventy-nine percent of women have a regular doctor or health care provider they see when they are sick or need routine care. The likelihood of having a regular provider increases with age (Figure 8). Women who live in a state that expanded Medicaid are more likely to have a usual source of care than women in states that have not expanded Medicaid (82% vs. 74%). Fewer uninsured (51%) and low-income (74%) women report having a usual source of care than their counterparts. Hispanic women (76%) are less likely than White women (81%) to have a usual source of care. Ten percent of women with an ongoing health condition do not have a regular doctor or health care provider (data not shown in figure).

Nearly three-quarters (73%) of women with a regular doctor or health care provider describe their primary provider as a family medicine or internal medicine doctor (Figure 9). Fourteen percent of women with a regular provider go to an advanced practice clinician such as a nurse practitioner or physician assistant, and 7% see an OBGYN.

About three-quarters (77%) of women with private insurance and low-income women report having a family or internal medicine doctor as their primary provider (Table 2). Women who live in rural areas are more likely than women in urban/suburban areas to say their primary provider is an advanced practice clinician (21% vs. 12%). OBGYNs are the primary type of provider for more uninsured (12%) than insured (7%) women and Black women (12%) than White women (6%) (data not shown in table).

Health Insurance

Many insured women report that their plan didn’t always cover all their needed medical care, or that it paid less than they expected.

One in five women (20%) with health insurance report that a doctor they wanted to see was not covered by their plan (out-of-network) and 14% said their plan would not cover a test or scan their doctor recommended (Table 3). More than one in five insured women (23%) said their plan would not cover a prescription medication, or charged high cost sharing for it, and one in ten (10%) said their plan stopped covering a medication they were taking. Nearly one-quarter (24%) of women with health insurance (through either individual or employer plans or Medicaid) reported that their plan did not cover a medical bill for services they thought were covered, or that it paid less for that service than they expected. About one-quarter (23%) of these women said this was due to the provider being out-of-network, 43% believed it was for some other reason, and one-third (33%) said they did not know why this happened.

Some of these problems vary by type of insurance coverage. For example, one in four (25%) women with employer-sponsored insurance say their plan didn’t cover medical care they thought was covered, or paid less than expected, compared to 15% of women with Medicaid. Women with Medicaid (29%) or individual market coverage (28%) are nearly twice as likely as women with employer-sponsored insurance (15%) to report that a particular doctor they wanted to see not covered by their plan. Nearly twice as many women with Medicaid (14%) as with private insurance (8%) reported their plan stopped covering a prescription medication they were taking.

General Check-ups and Provider-Patient Counseling

While most women have visited a doctor in the past two years and had a check-up, rates are lower among younger women and uninsured women.

Regular provider visits give women an opportunity to talk with clinicians about a broad range of issues, including preventing illness, the role of lifestyle factors on health, and management of chronic illnesses. Under the ACA, most health plans must cover at least one annual check-up or well-woman visit, which can include assessments of diet and physical activity, preconception care, and cancer screenings. The majority of women have seen a medical provider in the past two years, but fewer have had a well-woman visit or general check-up.

More than nine in ten (93%) women have seen a doctor or health care provider in the past two years (Table 4). However, fewer young women ages 18-25 (88%), uninsured women (75%), and low-income women (89%) have visited a doctor than the average.

About three-quarters of women (73%) have had a general check-up or “well-woman visit” in the past two years. However, uninsured women (41%), low-income women (64%), and women in poorer health (66%) are less likely to have had a recent checkup. Hispanic women (67%) are less likely than White women (76%) to have had a check-up in the past two years.

More than half (51%) of women who have had a check-up or well-woman in the past two years report that they went to a general practice or internal medicine doctor for their visit (Table 5). About two-thirds (35%) went to an OBGYN. Older women ages 50-64 (62%) are more likely to visit a general practice doctor than younger women ages 18-25 (44%), while younger women (42%) are more likely to visit an OBGYN than older women (22%). About one in ten (11%) women who have had a check-up in the past two years report that they saw a nurse practitioner or physician assistant for their visit; this share is higher among women ages 50-64 (13%) than women ages 18-35 (7%).

Overall, women have more connections to the health care system than men. Higher shares of women than men report having a usual source of care and a visit to a health provider in the past two years.

Women are slightly more likely than men to report having a regular place of care (84% vs. 80%) and a regular doctor or provider (79% vs. 75%) (Table 6). Ninety-three percent of women have visited a health care provider in the past two years and 73% have had a check-up, compared to 88% and 69% of men, respectively. Even within genders, there are differences by age, with older people more likely than younger people to report having each of these regular connections. For example, nine in ten (90%) women ages 50-64 have a regular doctor or health care provider compared to three-quarters (74%) of women ages 18-49. For men, nine in ten (90%) men ages 50-64 have a regular doctor or provider compared to seven in ten (69%) men ages 50-64.

Most women report that they have spoken with a health care provider about health behaviors such as diet, exercise, and nutrition as well as smoking and alcohol or drug use.

Counseling on health-related behaviors such as diet, smoking, and alcohol use is an important component of women’s primary care. More than three in four (77%) women who have seen a provider in the past two years report their provider asking about or discussing diet, exercise, and nutrition with them.

Slightly fewer (72%) have discussed smoking and approximately two-thirds (67%) have discussed alcohol or drug use with a provider in the past two years. Older women ages 50-64 (81%), higher-income women (81%), and those with private insurance (80%) are more likely than their counterparts to have discussed diet, exercise, and nutrition with their provider. Younger women ages 18-49 are more likely than older women ages 50-64 to have discussed smoking (75% vs. 68%) or alcohol or drug use (71% vs. 60%). Across the board, insured women have higher rates of counseling on these issues than uninsured women (Table 7).⁵ 

Smaller shares of Asian and Black women than White women report that a provider has asked about or discussed mental health issues such as anxiety and depression with them.

Most plans must cover treatment for mental health care and other medical conditions equally. Depression and anxiety affect a higher share of women than men over their lifetimes. The U.S. Preventive Services Task Force (USPSTF) recommends women receive depression screenings, though it does not have a recommendation for frequency. The Women’s Preventive Services Initiative (WPSI) now recommends that women and teens also receive anxiety screenings. The ACA requires health plans to cover both of these screenings without cost sharing.

Among women who have seen a health care provider in the past two years, nearly seven in ten (69%) report that their provider asked about or discussed mental health issues, such as anxiety or depression (Figure 10). More White women (72%) than Black (61%) and Asian (60%) women are asked about mental health issues. Younger women and women covered by Medicaid (76%) are more likely than their counterparts to have discussed mental health issues with their provider. Women with health insurance (70%) and those in poorer health (76%) are more likely than uninsured women (55%) and women in better health (67%) to have had this discussion with their health care provider.

Social Determinants of Health

Few women report that their health care providers have asked them about issues such as their ability to afford food, their housing situation, and access to reliable transportation.

In recent years, the social determinants of health have been recognized as critical factors that shape health outcomes. These factors include housing, transportation, nutrition, and financial well-being. Although there are no formal recommendations for routine screening for social determinants of health, there is increasing awareness among the medical community that better tools are needed to help target assistance to patients to improve health. Health care providers who ask their patients about these factors may be able to help connect patients who are experiencing challenges to local assistance and resources.

More than half of women who have visited a doctor in the past two years were asked about the kind of work they do while only 13% were asked about their access to reliable transportation or ability to afford food. Three in ten women with Medicaid were asked about their housing situation.

Over half (56%) of women who have seen their health care provider in the past two years report that their provider asked about what kind of work they do, with higher shares among women ages 26-35 (65%) and women with a college degree (67%) (Table 8). Two in ten (19%) women who have seen a health care provider in the past two years report having been asked about their housing situation, with higher shares among women with Medicaid coverage (30%) and low-income women (27%). Fewer women (13%) report that their provider asked them about their access to reliable transportation or their ability to afford food. Women with Medicaid or who are lower-income are more likely than their counterparts to have been asked about these two topics with their health care provider in the past two years.

Screening Tests

Use of preventive services can lead to early identification of conditions when they are more responsive to medical interventions. This is especially true for certain types of cancers and cardiovascular conditions. For example, the USPSTF recommends routine mammograms every two years for women ages 50-74 to identify breast cancer as well as colorectal cancer screenings for women ages 50-75, though the recommended frequency varies by type of screening test. These services are covered in full by most private plans under the ACA’s preventive services coverage requirements and by most state Medicaid programs.⁶ 

Most women ages 50-64 say they have had a mammogram in the past two years; fewer have had a recent colon cancer screening.

Most (78%) women ages 50-64 have had a mammogram in the past two years (Figure 11). Insured women ages 50-64 (78%) are more likely than uninsured women (49%) to have had a mammogram in the past two years. Low-income women (66%) are less likely than higher-income women (79%) to have received a mammogram in the past two years. The survey found no statistically significant differences in mammogram screening rates by race/ethnicity.

Less than half (45%) of women ages 50-64 report having had a colon cancer screening in the past two years (Figure 12). Women with insurance (47%) are more likely than uninsured women (33%) to have had a colon cancer screening in the past two years. The survey did not find any statistically significant differences in recent colon cancer screening rates by race/ethnicity, insurance type, or income.

Health Care Experiences

Negative experiences with the health care system can contribute to poorer health outcomes, distrust of the health care system, and health disparities. Two in ten women who have seen a health care provider in the past two years say that their provider dismissed their concerns and 13% report that their provider assumed something about them without asking. These shares are higher among younger women, women with Medicaid, and women in poorer health.

The impact of bias in health care, including implicit bias, has garnered increased attention in recent years and is recognized as having detrimental effects on women’s health. To gain greater insight into women's experiences with health care providers, our survey asked whether they had encountered any of four negative experiences when visiting their provider in the past two years.

Among women and men who have visited a health care provider in the past two years, 21% of women report that their doctor had dismissed their concerns, compared to 13% of men (Figure 13). Thirteen percent of women and 11% of men who have been to a doctor in the past two years say their doctor assumed something about them without asking. Ten percent of women who have visited a provider in the past two years have had a provider who didn’t believe they were telling the truth, compared to 7% of men. Nine percent of women and 7% of men report that a provider suggested they were personally to blame for a health problem. Women are more likely than men to have had at least one of these negative experiences with their provider in the past two years  (27% vs. 20%).

Women who are younger, covered by Medicaid, or in poorer health are more likely than their counterparts to have had each of these four experiences with their provider in the past two years (Table 9). Hispanic (14%) and Black (13%) women are more likely than White women (9%) to say their doctor did not believe they were telling the truth. Thirteen percent of unemployed women who have visited a health care provider in the past two years report that their doctor did not believe they were telling the truth, compared to 8% of employed women. Nearly four in ten (38%) women ages 18-25 and women in poorer health have had at least one of these four experiences.

Among women who have been treated in at least one of these ways, many say it was because of their age and/or gender. Black and Hispanic women are more likely than White women to say they were treated this way because of their race/ethnicity.

Among women who had at least one of these four types of experiences with their provider, 30% believe they were treated this way because of their age; 20% say it was because of their gender; 13% think it was because of their insurance type; 11% believe it was due to their race or ethnicity; 8% think it was because of their ability to pay, and 22% do not know (Figure 14). Notably, 32% of women who had one these negative experiences with their provider said that it happened for 'none of these reasons.'

Among women who have had one of these experiences with their provider in the past two years, younger women ages 18-25 (47%) and 26-35 (35%) are more likely than women ages 36-49 (17%) and 50-64 (24%) to say they experienced this because of their age. Women are almost twice as likely as men to say they were treated this way because of their gender (20% vs. 12%). Women with Medicaid are nearly four times more likely than women with private insurance to say they were treated this way because of the type of insurance they had (30% vs. 8%). Black women (38%) and Hispanic women (16%) are more likely than White women (2%) to say they were treated this way by their provider because of their race/ethnicity.⁷  Low-income women are almost three times more likely than higher-income women to say they experienced this treatment because of their ability to pay (14% vs. 5%).

Health Care Costs

Out-of-Pocket Costs for Preventive Care

When it comes to annual check-ups or well-woman visits, more than four in ten women report having at least some out-of-pocket costs associated with these preventive visits.  

The ACA and most state Medicaid programs require plans to cover preventive health care without cost sharing (deductibles, coinsurance, and copayments). This includes an annual check-up or well-woman visit. Despite this requirement, many women still have at least some out-of-pocket expenses for their check-up or well-woman visit. Among women who have had a check-up or well-woman visit in the past two years, more than four in ten (43%) women report having to pay at least some out-of-pocket costs for their annual check-up or well-woman visit.

Nearly half (47%) of women with private insurance and one in five (20%) women with Medicaid had out-of-pocket spending for their check-ups or well-woman visits.

Among women with private insurance plans, most of which are prohibited from charging cost sharing for check-ups/well-woman visits and many preventive services, almost half (47%) report that they had out-of-pocket expenses for their check-up or well-woman visit (Figure 15). It is possible that some respondents may have mistaken another type of visit as a check-up or well-woman visit. There are several reasons why some women are still being exposed to cost sharing for these visits. While many preventive services are provided in the context of a check-up/well-woman visit, additional health services received during that visit, such as diagnostic tests or labs, may be subject to cost sharing. In addition, some women may be enrolled in a grandfathered health plan, which is not subject to the requirement to cover an annual check-up without cost sharing, though there are relatively few people still enrolled in one of these plans. Finally, the requirement to cover preventive care without cost sharing applies to care received in-network, so if a woman goes to an out-of-network provider for their check-up, they will likely be exposed to out-of-pocket costs.

While cost sharing is routine in the private insurance market, it is less common, though not prohibited, in the traditional Medicaid program. Women who are enrolled through the ACA’s Medicaid expansion option are entitled to no-cost preventive care. One in five women with Medicaid (20%), whether traditional or expansion, paid at least some out-of-pocket costs for their check-up. The requirement to cover an annual check-up is not applicable to those without health insurance. About two-thirds (64%) of uninsured women have incurred out-of-pocket costs for their visit. It should be noted that while this question asked about cost sharing for a check-up in the past two years, data on insurance coverage reflects coverage at the time the respondent completed the survey and may have changed during the prior two years.

Medical Bills

While the ACA has helped alleviate some of the financial barriers to accessing health care, many women, including those with insurance, still report problems paying medical bills. Some women incur significant medical expenses because of an unexpected diagnosis such as cancer, or an illness or injury that limits their ability to work and earn income to pay off bills. Costly medical bills can also arise after receiving care from an out-of-network provider, commonly referred to as surprise medical bills.

One in four women report having had problems paying medical bills in the past year, with higher rates among uninsured women and women in poorer health.

Twenty-four percent of women report that they or a household family member has had problems paying medical bills in the past year. Problems paying medical bills are more common among women than men (17%). While more women with children (27%) report problems paying medical bills than do women without children (22%), the share of men with children (19%) and men without children (16%) that have problems paying medical bills is statistically similar.

Outstanding medical bills are more common among uninsured and lower-income women and those in poorer health (Figure 16). This includes nearly four in ten uninsured women (39%) and women in poorer health (38%), and one-third of low-income women (33%). About three in ten Black women (29%), women who live in states that did not expand Medicaid (29%), and those without a college degree (28%) also report having trouble paying medical bills in the past year.

The financial turmoil many people have experienced because of the COVID-19 pandemic has compounded the challenges some women face in their ability to pay medical bills.

Among women who report having had problems paying medical bills in the past year, one-quarter (26%) say it was because of the coronavirus and its impact on their financial situation. This could be due to financial impacts from job loss or furlough, health-related consequences, or other reasons related to coronavirus. About four in ten (42%) women who have had problems paying medical bills in the past year say they were having problems paying medical bills before the pandemic and three in ten (31%) say it was a combination of both (Figure 17).

Medical bills can have serious consequences for women’s financial well-being and ability to afford basic necessities.

Among women who report trouble paying medical bills in the past year, two-thirds (66%) had to set up a payment plan with a doctor or hospital and/or used up all or most of their savings (Figure 18). About six in ten (59%) have been contacted by a collection agency, nearly half (48%) have had difficulty paying for basic necessities like food, heat, or housing, and four in ten (40%) borrowed money from family or friends. These shares are similar between women and men.

Low-income women who have had problems paying medical bills in the past year are more likely than higher-income women to report having had difficulty paying for basic necessities such as food, heat, or housing (61% vs. 37%), having been contacted by a collection agency (64% vs. 58%), or borrowing money from family or friends (49% vs. 33%). Higher-income women with problems paying medical bills in the past year are more likely than low-income women to have set up a payment plan with a doctor or hospital (73% vs. 60%).

Conclusion

Women’s access to and use of health care services has an impact on their health outcomes. Most women report having a regular source of care and having had a recent doctor’s visit. However, connections to the delivery system are more tenuous for low-income and uninsured women, who are less likely to report a recent visit or regular place of care. The ACA prioritized prevention by requiring insurance plans to cover routine check-ups and several screening tests without any out-of-pocket costs. Most women report they have had a general check-up or well-woman visit in the past two years, but similar to other measures, rates are lower among low-income and uninsured women. While a large share of women receive provider counseling on health issues like nutrition, exercise, and alcohol or drug use, a small share report that a provider has asked them about or discussed their mental health in the past two years.

Health insurance coverage helps link women to care and reduces patients’ financial risks when they need routine care, get sick, or need to be hospitalized. However, even women with insurance report having problems using their insurance, such as receiving health care they thought was covered but wasn’t and not being able to see the doctor of their choice because the doctor was out-of-network.

Health care costs continue to be a challenge for a significant share of the population, with many women reporting they have had to pay cost sharing for a preventive care visit or that they have had trouble paying medical bills. This is particularly true for low-income and uninsured women. For many women, the COVID-19 pandemic has added to their health-related financial burdens.

Finally, the importance of the social determinants on health outcomes has gained recognition in recent years but it seems few providers are discussing important factors such as food insecurity and transportation challenges with their patients. Gender bias and racial discrimination in the health care system can contribute to health disparities and poorer health outcomes. Women are more likely than men to report having experienced some type of health care bias, particularly those who are in poorer health, younger, or low-income.

The COVID-19 pandemic has further exposed many of the long-standing weaknesses in the health care system that have disproportionately impacted women, especially those who are low-income, women of color, or who are uninsured. For many women, the ACA helped strengthen access to coverage and protected them from many out-of-pocket costs. However, there is still much that can be done to make health care and coverage more affordable, expand equitable access to care, improve the quality and content of that care, and address the bias and discrimination that many women still experience when they seek care.

The 2020 KFF Women’s Health Survey was designed and analyzed by researchers at the Kaiser Family Foundation (KFF) of a representative sample of 4,805 adults, ages 18-64 years old (3,661 women and 1,144 men). The survey was conducted online and telephone using AmeriSpeak®, the probability-based panel of NORC at the University of Chicago. U.S. households are recruited for participation using address-based sampling methodology and initial invitations for participation are sent by mail, telephone, and in-person interviews. Interviews were conducted in English and Spanish online (4,636) and via the telephone (169). Our previous Women's Health Surveys were conducted exclusively by telephone, so trend data are not included in our 2020 survey. Interviews for this survey were conducted between November 19 and December 17, 2020, among adults living in the United States. KFF paid for all costs associated with the survey.

The sample for this study was stratified by age, race/ethnicity, education, and gender as well as disproportionate stratification aimed at reaching uninsured women, women who identify as LGBT, Asian women, and women 18-49 years old. The sampling also took into consideration differential survey completion rates by demographic groups so that the set of panel members with a completed interview for a study is a representative sample of the target population. This survey includes people who self-identified as 'female' or 'male’ regardless of their sex at birth. While our goal was to be as inclusive as possible, we were not able to obtain a large enough sample to support a separate questionnaire that addresses the unique health concerns and experiences of non-binary or gender-fluid people to include them in this survey. We recognize that additional study is needed to better understand the health and access issues faced by non-binary people.

A series of data quality checks were run and cases determined to be poor-quality, as defined by surveys with a length of interview of less than 33% of the mean length of interview and with high levels of question refusal (>50%) were removed from the final data (n=96). Weighting involved multiple stages. First, the sample was weighted to match estimates for the national population from the 2020 Current Population Survey on age, gender, census division, race/ethnicity, and education. The second round of weights adjusted for the study’s sampling design. All statistical tests of significance account for the effect of weighting.

The margin of sampling error including the design effect for the full sample of women is plus or minus 2 percentage points. Numbers of respondents and margins of sampling error for key subgroups are shown in the table below. For results based on other subgroups, the margin of sampling error may be higher. Sample sizes and margins of sampling error for other subgroups are available by request. Note that sampling error is only one of many potential sources of error in this or any other public opinion poll.

1. This survey includes women ages 18-64. Hereafter, we use the word u2018womenu2019 to refer to women ages 18-64 unless otherwise indicated. ↩︎
2. This survey defines low-income as household income under 200% of the federal poverty level (FPL); higher-income is 200% or more of the FPL. The FPL for a family of four in 2020 was $26,200. ↩︎
3. Persons of Hispanic origin may be of any race; other groups are non-Hispanic. ↩︎
4. Those in poorer health describe their health as fair or poor and those in better health describe their health as good, very good, or excellent health. ↩︎
5. For survey data on sexual and reproductive health-related counseling, including contraception and sexual history, see the Sexual and Reproductive Health Services section. ↩︎
6. For survey data on preventive sexual and reproductive health-related screenings such as pap smears and STI and HIV testing, see the Sexual and Reproductive Health Services section. ↩︎
7. Not sufficient data to report on Asian women. Caution should be used when comparing race/ethnicity data here as there are few observations for White women. ↩︎