Access to OB-GYNs: Evaluating Workforce Supply and ACA Marketplace Networks

OB-GYNs provide a range of care for women throughout their lifespan, including diagnosis and treatment of gynecological conditions such as endometriosis, polycystic ovary syndrome, and cervical cancer; contraceptive care; prenatal and postpartum care; and menopause management. Access to care depends on several factors, including the availability of providers and, for people with insurance, whether the provider is in their plan’s network. When there are few providers in an area, local providers are not taking new patients, or a patient needs to see a provider who is not in their plan’s network, their ability to get care, how long they have to wait for an appointment, and potentially how much they have to pay out-of-pocket can all be impacted.

This brief examines the supply of OB-GYNs in the U.S. and the share of OB-GYNs participating in the provider networks of Qualified Health Plans (QHPs) offered in the individual market in the federal and state Affordable Care Act (ACA) Marketplaces in 2021. This analysis uses multiple data sources; see the Methods section for details. While many more women are covered by employer-sponsored health plans than ACA Marketplace plans, there is no publicly available data to analyze the networks for employer plans.

Key Takeaways

• There were 38 practicing OB-GYNs per 100,000 women in the United States, with higher ratios in metro counties (41) than in rural counties (13) in 2021-2022. 38 practicing OB-GYNs per 100,000 women is equivalent to one OB-GYN per about 2,600 women.
• Nearly half (48%) of counties did not have any practicing OB-GYNs and 7% of women lived in a county with no OB-GYN. The share of women with no OB-GYN in their county was substantially higher in rural counties than in metro counties (58% vs. 3%).
• In 2021, enrollees in ACA Marketplace plans had in-network access to 55% of practicing OB-GYNs in their area on average. By comparison, Marketplace enrollees had in-network access to 43% of primary care physicians.
• Marketplace enrollees in metro counties, on average, had in-network access to 53% of the OB-GYNs near their home compared to 70% in rural counties. However, as noted above, there are relatively few OB-GYNs practicing in rural counties.
• On average, Marketplace enrollees in counties with the highest shares of people of color had in-network access to 43% of area OB-GYNs while those in counties with the lowest shares of people of color had in-network access to 69%.

OB-GYN Workforce

OB-GYNs play an important role in ensuring women have access to comprehensive health care. There are many factors that can create barriers to accessing obstetric and gynecological care, including the size of the OB-GYN workforce and the ratio of OB-GYNs to patients. Although there is no established “adequacy” ratio of OB-GYNs to patients, OB-GYN shortages could be considered in the context of longer appointment wait times and increased travel distances, among others. The U.S. Department of Health and Human Services projects a shortage of 7,980 OB-GYNs by 2037 based on the supply of OB-GYNs in the workforce and the demand for OB-GYNs (based on the population of adolescent girls and women).

According to KFF analysis of the HRSA Area Health Resource Files for 2021-2022, there were 38 OB-GYNs per 100,000 women ages 15-64 (hereafter collectively referred to as “women”) in the United States, with wide variation by county (Figure 1). The workforce data analyzed here is from the year that Roe v. Wade was overturned (and the year before), so that decision’s specific impacts on the OB-GYN workforce are largely not reflected in this data.

In 2021-2022, nearly half (48%) of U.S. counties did not have any OB-GYNs, and 7% of women lived in a county with no OB-GYN. Three-quarters (74%) of all counties had fewer than five OB-GYNs, and 17% of women lived in a county with fewer than five OB-GYNs.

The number of OB-GYNs per 100,000 women was higher than the national average in 28 of the top 30 Core-Based Statistical Areas (CBSAs) with the largest number of women (Figure 2). Among these 30 CBSAs, the CBSAs with the highest ratios were San Francisco-Oakland-Berkeley, CA; Baltimore-Columbia-Towson, MD; and Portland-Vancouver-Hillsboro, OR-WA, with 61, 53, and 53 OB-GYNs per 100,000 women, respectively. The CBSAs with the lowest ratios were Columbus, OH; Los Angeles-Long Beach-Anaheim, CA; and Virginia Beach-Norfolk-Newport News, VA-NC, with 39, 38, and 33 OB-GYNs per 100,000 women, respectively.

CBSA is the umbrella term for Metropolitan and Micropolitan Statistical Areas as defined by the Office of Management and Budget (OMB). CBSAs consist of the county or counties or equivalent entities associated with at least one urban core (urbanized area or urban cluster) of at least 10,000 population, plus adjacent counties having a high degree of social and economic integration with the core as measured through commuting ties with the counties containing the core.

County Classification Differences in Provider Availability

In 2021-2022, eight in ten (79%) rural counties had no OB-GYNs and nearly six in ten (58%) women in rural counties lived in a county without an OB-GYN (Table 1). There were approximately three times more OB-GYNs per 100,000 women in metro counties (42) than in rural counties (13).

County classifications are based on USDA’s 2013 Rural-Urban Continuum Codes and KFF categorized these classifications into metro counties, small urban counties, and rural counties. See the Methods section for more details. Using this taxonomy, 85% of women lived in metro counties, 11% lived in small urban counties, and 4% lived in rural counties.

Race/Ethnicity Differences in Provider Availability

Counties with an above-average share of White non-Hispanic people had almost half the number of OB-GYNs per 100,000 women as counties with an above-average share of Black non-Hispanic people (24 vs. 46). There were 41 OB-GYNs per 100,000 women in counties with an above-average share of Hispanic people of any race. On average, about 58% of the U.S. population was White non-Hispanic, 12% was Black non-Hispanic, and 19% was Hispanic (any race) during that timeframe.

Other Implications

Provider shortages can also play a role in hospital and clinic staffing. For example, one study found that more than 35% of counties are considered “maternity care deserts,” meaning that there is no access to birthing hospitals, birth centers offering obstetric care, or obstetric providers. Maternity care deserts affected maternity care for more than 2.3 million women of reproductive age in 2022, resulting in poorer health outcomes, less prenatal care, and higher rates of pre-term births. Additionally, another study found that the share of hospitals in the U.S. without obstetric services increased from approximately 35% in 2010 to 42% in 2022, with even higher percentages for rural hospitals. Studies have identified that workforce challenges are one of the primary reasons for labor and delivery units closing in rural hospitals.

Although it is not clear how, precisely, OB-GYN workforce shortages impact the use of obstetric and gynecological care, the overall disparities in maternal and infant health for women of color are well-documented. While increased attention to these disparities has contributed to a range of federal and state efforts to reduce disparities in maternal and infant health, it is unclear how, or if, these efforts will continue in a political landscape characterized by rolling back efforts aimed at identifying and addressing disparities in historically marginalized groups and eliminating agencies and committees that lead these efforts. Additionally, state abortion bans and restrictions may exacerbate poor maternal and infant health outcomes, especially for people of color.

Additionally, it is reported that 1.2 million reproductive-age women live in a county without a single health center offering the full range of contraceptive methods, referred to as a “contraceptive desert.” A 2023 KFF survey of OB-GYNs following the overturning of Roe v. Wade found that just three in ten (29%) OB-GYNs provide all contraceptive methods, and that share is substantially lower in states that had banned abortion (13%). Although most OB-GYNs do not provide abortion services, abortion bans could also exacerbate provider shortages in some areas and impact access to other types of care that OB-GYNs provide.

OB-GYN Provider Networks in Marketplace Plans

The breadth of provider networks in the Affordable Care Act (ACA) Marketplaces has been the subject of significant policy interest. As insurers seek to offer lower-premium plans, one mechanism for controlling costs is to limit their physician networks to providers with lower payment rates. While the Centers for Medicare and Medicaid Services (CMS) establishes minimum standards for the adequacy of physicians, including OB-GYNs, in Marketplace plan networks, insurers retain considerable flexibility in how they design networks.

While many more women are covered by employer-sponsored health plans than ACA Marketplace plans, there is no publicly-available data to analyze the networks for employer plans.

The 2023 KFF Survey of Consumer Experiences with Health Insurance found that 24% of adult women with Marketplace coverage said that in the past year, a particular doctor (not specific to obstetric or gynecological care) or hospital they needed was not covered by their insurance. Among women Marketplace enrollees who experienced this problem, 32% said that needed care was delayed, and 42% said they ended up paying more out of pocket for care than expected as a result of problems they had with their health insurance.

This section analyzes OB-GYN provider networks of Qualified Health Plans (QHPs) offered in the individual health insurance Marketplaces in 2021. (At the time of analysis, 2021 was the most recent data available for calculating the total number of active OB-GYNs. See the Methods section for more details.) In total, 12 million consumers selected a plan for the 2021 plan year, roughly 55% of whom were women. Due to missing or incomplete demographic data for some states, this analysis presents data for Marketplace enrollees of all genders.

On average, Marketplace enrollees had in-network access to more than half (55%) of the practicing OB-GYNs near their homes in 2021 (Figure 3). By comparison, Marketplace enrollees had in-network access to 43% of primary care physicians and 37% of psychiatrists near their homes. One-quarter of enrollees were enrolled in plans with fewer than 34% of the local OB-GYNs in-network, while another quarter were in plans with at least 78% of local OB-GYNs in-network.

Geographic Differences in Marketplace Provider Networks

While metro counties had more practicing OB-GYNs overall, smaller shares of them participated in Marketplace plan networks compared to OB-GYNs in small urban and rural counties (Figure 4). Eighty-eight percent of Marketplace enrollees lived in a metro county. Marketplace enrollees in metro counties, on average, had access to 53% of the OB-GYNs within five to ten miles of their county through their plan networks, with one-quarter enrolled in a plan whose network included no more than 33% of local OB-GYNs.

Marketplace enrollees in rural counties (e.g., Knox County, ME; Anderson County, TX; Macon County, NC), on average, had access to 70% of OB-GYNs in their local area (within 30 miles) through their plan networks. The higher OB-GYN participation rates in these counties, however, should be considered in the context of the small number of OB-GYNs practicing in these areas. For example, 98% of rural counties had fewer than five practicing OB-GYNs. It is possible that not all of these providers are accepting new patients, and an enrollee’s choice may be even more limited than the number of OB-GYNs who participate in the plan network. (See the OB-GYN Workforce section for county classification definitions.)

The 30 counties with the highest enrollment in the Marketplaces in 2021 collectively represented 34% of all Marketplace enrollees and 21% of the U.S. population. Most of them are urban and some are home to large cities (e.g., Seattle in King County, WA). On average, Marketplace enrollees in almost all of these counties were in plans that included fewer than half of local OB-GYNs, though there was significant variation across these 30 counties (Figure 5). For example, Marketplace enrollees in Cook County, IL (Chicago) had access to fewer than two in ten (20%) OB-GYNs in their area on average. In contrast, enrollees in Gwinette County, GA (outside Atlanta) had in-network access to seven in ten (71%) practicing OB-GYNs on average.

Race/Ethnicity Differences in Marketplace Provider Networks

On average, Marketplace enrollees living in counties with a higher share of people of color were in networks that included a smaller share of OB-GYNs than counties with a smaller share of people of color (Figure 6). The quarter of Marketplace enrollees living in the counties with the highest share of people of color had access to 43% of OB-GYNs in-network, on average, compared to 69% in counties with the smallest share of people of color. These differences may reflect the higher concentrations of these people of color in large metro counties, where plans typically had narrower provider networks. ‘People of color’ include those who identify as Hispanic (of any race), multi-racial (Hispanic or non-Hispanic), or a race other than White (Hispanic or non-Hispanic).

Numbers of Practicing and In-Network OB-GYNs

The share of providers participating in a network is just one component of access and may not always gauge how well enrollees are served. High network participation rates matter little if there are few local providers to begin with. For example, in 2021, about one-quarter (23%) of Marketplace enrollees lived in a county with fewer than 25 practicing OB-GYNs in the local area (Figure 7). One in ten (10%) Marketplace enrollees had fewer than 10 practicing OB-GYNs in the local area, and 4% lived in a county with fewer than five OB-GYNs in the area (0% of Marketplace enrollees lived in a county with no local OB-GYNs). Sixty-three percent of Marketplace enrollees live in a county with 25 or more practicing OB-GYNs.

When it comes to network breadth, more than one-third (36%) of Marketplace enrollees were in a plan that included fewer than 25 local OB-GYNs, either because there weren’t 25 OB-GYNs in the market, or because available OB-GYNs were not included in the network. Nearly two in ten (18%) were in a plan that included fewer than ten OB-GYNs and one in ten (10%) were in a plan that had fewer than five local OB-GYNs (including 1% who were in a plan with no OB-GYNs). Thirty-five percent of Marketplace enrollees were in a plan with 25 or more OB-GYNs.

Although this OB-GYN network analysis is just among ACA Marketplace plans, employer-sponsored plans, which cover more people than Marketplace plans, also have provider networks. While many employers describe their plan’s provider networks as “very broad” or “somewhat broad,” nearly 1-in-5 (18%) firms with 5,000 or more workers characterize their plan as “somewhat narrow” or “very narrow.” The extent to which provider networks reduce the availability of OB-GYN services for those with employer coverage, and for which enrollees, remains unclear.

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Methods

OB-GYN Workforce Analysis:

Information on the OB-GYN workforce is available in HRSA Area Health Resource File (AHRF) for 2021-2022. Data on the OB-GYN workforce is derived from the American Medical Association Physician Masterfiles. Data on the share of the population that is Black non-Hispanic, White non-Hispanic, or Hispanic is based on the 2010 Census Redistricting Data. Data on the share of the population that is foreign-born or that has limited English proficiency is based on the American Community Survey 2016-2020.

County classifications are based on USDA’s 2013 Rural-Urban Continuum Codes, which was the version in use for the 2021-2022 AHRF. This analysis defines metro counties as those in metro areas with any size population; small urban counties as those with a population of 20,000 or more, adjacent or not adjacent to a metro area or that have a population of 2,500-19,999 adjacent to a metro area; and rural counties as those with populations of 2,500-19,999 not adjacent to a metro area or that have a population of less than 2,500, adjacent or not adjacent to a metro area.

It should be noted that clinicians other than OB-GYNs, such as nurse practitioners, physician assistants, and midwives, also provide obstetric and gynecological care and are included in this dataset. However, the dataset does not indicate the specific field in which they practice, so we are unable to include them in this analysis. Doulas, who provide non-clinical support to pregnant and postpartum people, are not generally included in the dataset and so are also not represented in this analysis.

Provider Network Analysis:

This analysis of ACA Marketplace plan networks uses similar methodology as a 2024 KFF analysis. In total, 12 million enrollees selected or were automatically re-enrolled in a plan on either HealthCare.gov (8.3 million) or a state-based Marketplace (3.8 million) during open enrollment for the 2021 plan year. Approximately 55% of enrollees were female and 45% were male. Gender counts for some state-based Marketplaces are incomplete due to unknown or missing gender data; therefore, the data presented in this analysis is representative of Marketplace enrollees of all genders. This analysis estimates the share of OB-GYNs included in individual Marketplace plans in 2021. The data include only physicians (which includes OB-GYNs) and not other providers of obstetric and gynecological care.

Information on plan provider directories was compiled by Ideon through an API with insurers as well as other data including the National Plan and Provider Enumeration System (NPPES). Data for carriers not participating in the Ideon API were supplemented with carriers’ public filings.

Local OB-GYNs are defined as those who practice within the same county as an enrollee or are within the distance thresholds specified as part of CMS’s network adequacy standards for HealthCare.gov plans. See mileage thresholds in Table 1 here for defining “local” areas.  While the mileage standards in network adequacy regulations are based on the proximity to plan enrollees, this analysis measures the distance from the population-weighted center of the county. County classifications (e.g., rural, small urban, metro) were derived from the data source and approach listed in the OB-GYN Workforce Analysis methods section above.

To estimate the total number of OB-GYNs who are in active practice, we relied on Medicare Data on Provider Practice and Specialty (MD-PPAS), a federal database of physicians who submitted at least one Medicare Part B claim in 2021 and therefore saw at least one Medicare patient in the year. Virtually all OB-GYNs participate in Medicare, with only about 1% formally opting out altogether. In total, 34,945 OB-GYNs were included in MD-PPAS in 2021.

Although MD-PPAS provides a list of physicians known to be working, one concern is that a disproportionate share of OB-GYNs may not have treated a Medicare patient in 2021. To assess the representativeness of OB-GYNs in MD-PPAS compared to other physician types, we examined the share of individual providers by specialty in the National Plan and Provider Enumeration System, a federal registry that assigns health care providers unique National Provider Identifiers (but that is not intended to serve as a census of the active health care workforce), who also filed a Medicare Part B claim in MD-PPAS. On average, 61% of OB-GYNs filed a Part B claim—a rate comparable to adult primary care physicians (57%) and all designated physician specialties (58%).

A central challenge in analyzing provider networks is determining the size of the physician workforce. While the vast majority of physicians engaged in active practice accept Medicare, some physicians may be inadvertently missed, including those in closed-network HMOs serving exclusively commercial populations or those specializing in services not typically used by Medicare enrollees. Telehealth providers whose addresses are not within the local market are also excluded. Further, this analysis only considers individual-level physicians enumerated in the plan directory. In some cases, plans may include group health practices in their networks and not individually list providers.

Conversely, this analysis may exaggerate the breadth of provider networks. “Phantom providers,” or physicians who are listed in the plan directory but no longer accept the plan, may artificially increase the breadth of some plans.

Click here to read the full methodology, scope, and limitations of this analysis.