General Methodology
NARAL Pro-Choice America and NARAL Pro-Choice America Foundation have 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 We do not cite all the letters, notes, emails, records of telephone interviews, and faxed information in the publication itself, but we maintain such documentation in NARAL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 and 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 "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. require crisis pregnancy centers to disclose anti-choice bias); improve reproductive health; support healthy childbearing; and provide young people with 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 15 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 weighted 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 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 stateprepared 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 informedconsent 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. Points were added based on the 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 deducted 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 and 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 has 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.
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.)
