The report found that state-level policies typically fall into three categories of access:

• Affordability. The scorecard tracked whether states have expanded Medicaid or enacted policies that require insurers to fully cover contraception. Medicaid is the main source of funding for family planning services for low-income people, according to KFF, a nonprofit health policy research group. Previous research has indicated that in states that expanded access to Medicaid, the number of prescriptions for birth control increased.
• Availability. The researchers looked into whether states allow qualified health care workers who are not doctors, such as pharmacists, to provide birth control and whether they’ve expanded access to emergency contraception, as well as requiring health insurers to cover longer supplies of contraceptives for several months or up to a year.
• Health care environment. The scorecard measured whether public schools in the state teach medically accurate, comprehensive sex education and whether parents can opt-out of the classes for their children. Restrictions to birth control include whether minors are able to get birth control without parental permission and whether doctors or pharmacists are allowed to refuse birth control prescriptions based on personal beliefs.

“Affordability policies had the biggest weight on access, that was bigger than the access policies,” Power said. Power said she was surprised by how many states scored poorly, not necessarily because they’re highly restrictive toward family planning care, but because they “simply haven’t acted at all.”

Power and her team evaluated how state-level policies altered access in each state, both on their own and when they were layered with others. They found that 16 states and Washington, D.C. made birth control easily accessible and affordable. Sixteen restricted access and 18 fell in the middle.

All 16 protective states had one thing in common: they had adopted Medicaid expansion through the Affordable Care Act, which has allowed states to extend Medicaid coverage to more adults with low incomes. None of the 16 restrictive states — including Alabama, Florida, Kansas, Mississippi and Wyoming, which ranked the highest — expanded Medicaid.

States with the most favorable environment for birth control are California, Connecticut, Maryland, New Mexico, New York, Oregon and Washington.

The 18 states that fell in the middle category spanned the political spectrum, from reliably red states like West Virginia to liberal strongholds like Massachusetts.

“Your state-level context really does matter a lot for what your access to contraception looks like. That is especially true for vulnerable people, for people who are on state or public health insurance and for minors who don’t have as much say in their health care,” said Leslie Root, an associate director of the CU Population Center at the University of Colorado Boulder, who was not involved with the report.

Root said the report offers a good synthesis of the layers of legal barriers that play into whether or not a person can get birth control. It can range from what students are taught about contraception in school, to whether they can get a 12-month supply of birth control or whether they can get the type of birth control that works best for them.

“People can really be living in two different Americas,” Root said. “This is a very stark illustration of that.”