General Methodology
NARAL Pro-Choice America Foundation has supporting documentation for statements of fact made in Who Decides? The Status of Women's Reproductive Rights in the United States. We do not cite all the letters, notes, emails, records of telephone interviews, and faxed information in the publication itself, but we maintain such documentation in NARAL Pro-Choice America Foundation's offices.
Access Facts: The number of abortion providers and analysis of census data was supplied by The Guttmacher Institute (Jones RK and Kooistra K., Abortion Incidence and Access to Services in the United States, 2008, Perspectives on Sexual and Reproductive Health, 2011, 43(1):41-50).
State Legislative Information: This report uses the term “measures enacted” to refer to statutes adopted by the legislature or enacted by ballot measure. "Laws" refers to constitutional provisions, statutes, regulations, court decisions, approved ballot initiatives, opinions of state attorneys general, and implementing policies. In addition to the types of laws that are highlighted on the "Fast Facts" pages of Who Decides?, the anti-choice counts of measures enacted provided on the "Key Findings" pages include but are not limited to measures that propose "Choose Life" license plates; fund anti-choice crisis pregnancy centers; mandate failed “abstinence-only” programs; and grant separate legal status to a pregnancy. The pro-choice counts of measures enacted include but are not limited to measures that ameliorate anti-choice actions (e.g. requiring crisis pregnancy centers to disclose anti-choice bias), improve reproductive health, support healthy childbearing, and require comprehensive sex education. For further information, please contact the Policy Department.
Report Card Methodology
Who Decides? reflects the legal state of women's access to reproductive-health services.
For 14 years, Who Decides? has used a grading system to capture the cumulative burden each state imposes on access to reproductive-health care. Points are subtracted for anti-choice restrictions and added for pro-choice laws. Laws that impose the greatest burdens on women are penalized most heavily. Likewise, demerits fall most heavily on laws that are in force, rather than laws that courts have declared invalid.
For each issue area as listed below, a state receives points in return if the law is held unconstitutional or enjoined. A detailed analysis of the report-card methodology appears below. For the purposes of this publication's methodology, the term "exceptions" may include but is not limited to exceptions for the life or health of the woman; rape and incest; emergency situations; cases of fetal anomaly; situations of child abuse; private employers; and state employees.
The nationwide grade reflects not only state restrictions on the right to choose, but also federal anti-choice measures.
Abortion Ban(s)
(- up to 80 points)
Points were subtracted for each abortion ban based
either on the point in pregnancy when the ban(s) begin,
or on whether the statute bans a specific procedure. Points
were added for certain exceptions included in the ban(s).
Additional points were subtracted for any ban(s) whose
effective dates would be triggered if the Supreme Court
overturns Roe v. Wade.
Biased Counseling & Mandatory Delays
(- up to 25 points)
Points were allocated based on the length of the waiting
period; whether multiple trips are required; whether
a physician is required personally to provide specified
information; whether the woman must receive state-prepared
materials; and whether the woman must receive other material,
oral or written, that contains information beyond risks,
benefits, and alternatives. No points were subtracted if a
state has an abortion-specific informed-consent law that
does not require biased counseling or a mandatory delay.
Contraceptive Equity
(+ up to 20 points)
Points were added if a state requires health-insurance plans
to cover contraceptives to the same extent that they cover
other prescription medication; fewer points were added
if the law has an overly broad refusal clause or requires
an insurer only to offer and make available such coverage
but not include it in every plan.
Counseling Ban/Gag Rule
(- up to 10 points)
Points were subtracted if the ban applies to counseling
and/or referrals and if the ban applies to all or some public
funds or employees. Points were added based on the
exceptions included in the law.
Emergency Contraception
(+ up to 25 points)
Points were added if the state allows sexual-assault
survivors greater access to emergency contraception (EC)
in emergency rooms (ER) (receiving EC in the ER and/or
receiving information about EC in the ER); if the state's
Medicaid program covers over-the-counter EC; and if
pharmacists are allowed to provide EC to a woman without
a prescription through a law specific to EC or one that
permits collaborative-therapy agreements generally
and includes EC. (These laws were in place before the
Food and Drug Administration (FDA) approved EC for
over-the-counter sales and still provide greater access
in some states, particularly for young women who are
excluded from the FDA's ruling.
Freedom of Choice Act
(+ up to 55 points)
Points were added if a state has passed legislation to
codify the protections of Roe v. Wade and provides an
affirmative right to choose abortion prior to viability
without government interference.
Guaranteed Access to Prescriptions
(+ up to 10 points)
Points were added if a state explicitly guarantees a
woman's right to have her birth-control prescription filled.
Insurance Prohibition for Abortion
(- up to 35 points)
Points were subtracted if the law prohibits insurance
coverage of abortion in the private insurance market; if the
law prohibits insurance coverage of abortion in the state
health-insurance exchange; if the law prohibits insurance
coverage of abortion for all or some state and/or municipal
employees; and if the law requires insurers to provide a
policy alternative excluding abortion. Fewer points were
deducted based on exceptions included in the law.
Low-Income Women's Access to Abortion
(and Restrictions on Low-Income Women's Access
to Abortion) (- up to 25 points)
Points were allocated based on the circumstances under
which the state medical assistance program funds abortion
services: only to preserve the woman's life; only in cases of
rape, incest, or life endangerment; or in cases of rape, incest,
life endangerment, and limited health circumstances. If a
state medical assistance program funds abortion care in
all or most circumstances, no points were subtracted.
Low-Income Women's Access to Family Planning
(+ up to 5 points)
Points were added if the state provides increased coverage
for Medicaid-covered reproductive-health-care services
through a federal Medicaid waiver or through a family-planning
state plan amendment (SPA). A state that applies
for and receives a waiver or SPA is generally allowed to
increase eligibility for Medicaid family-planning services
and/or improve the quality of those services for a specific
period of time. The duration, eligibility requirements, and
covered services provided by each state's expanded
coverage program vary from state to state. While pursuant
to the Affordable Care Act it is anticipated that Medicaid
family-planning waivers may be phased out and replaced
with SPAs, NARAL Pro-Choice America Foundation will
continue to include Medicaid waivers as an indicator of
states' commitment to providing essential family-planning
care to low-income women until this is no longer an
available option for states.
Post-Viability Abortion Restriction
(- up to 10 points)
If a post-viability abortion restriction contains adequate
life and health exceptions and does not define viability as
occurring at a particular point in pregnancy, no points were
subtracted. Points were subtracted for the lack or inadequacy
of the health exception and if the state defines viability as
occurring at a particular point in pregnancy.
Protection Against Clinic Violence
(+ up to 15 points)
Points were added if the law prohibits interference with
entry or exit to a facility; physical invasion of the facility
including trespass, property damage, arson, and bombing;
excessive noise, odors, or telephone calls; and threats,
including weapon possession at demonstrations. Points
were also added if the law creates a buffer zone, and/or
permits injunctive relief.
Public Facilities and Public Employees Restriction(s)
(- up to 10 points)
Points were subtracted if all or some public employees
and/or facilities are prohibited from providing abortion
services. Points were added based on the exceptions
included in the law.
Refusal to Provide Medical Services
(- up to 20 points)
Points were subtracted for each area in which individuals
or organizations are permitted to refuse to provide
services: abortion, insurance coverage for contraception,
family planning/birth control, sterilization, individual
health-care instructions, or prescriptions.
Restrictions on Young Women's Access to Abortion
(- up to 25 points)
Points were subtracted based on whether consent or
notice is required before a minor may obtain abortion
services, whose consent or notice is required, whether
there is a physician bypass, whether the judicial-bypass
procedure is adequate, and whether there is a waiting
period. Points were added based on the exceptions
included in the law.
Spousal Consent/Notice has been removed as an issue area.
State Constitutional Protection
(+ up to 20 points)
Points were added if a state constitution protects the right
to choose beyond the U.S. Constitution, and to the degree
that the state constitutional protection prevents imposition
of restrictions on the right to choose.
Targeted Regulation of Abortion Providers (TRAP)
(- up to 30 points)
Points were allocated based on the breadth and severity of
all TRAP laws imposed. Additional points were subtracted
if a state prohibits certain qualified health-care professionals
from providing abortion care. (Because of the breadth of
TRAP laws, we have included in the summaries only select
examples that illustrate the burdens these measures
impose on abortion providers.)
