Private employers and their health insurers have come to occupy a central role in access to reproductive care for the majority of Americans through a complex legal infrastructure that effectuates employers’ choices in their employee benefit plans. While some aspects of state insurance law, the Employee Retirement Income Security Act of 1974 (ERISA), the Affordable Care Act (ACA), and anti-discrimination laws encourage employers to cover reproductive care, this web of laws is very porous and predominantly supports employers’ choices. Sometimes, this validation of employer choices expands access to reproductive care services, as in the case of Walmart extending its benefits to cover abortion-related travel expenses in the wake of Dobbs v. Jackson Women’s Health. But employers who wish to restrict access to reproductive care also find their preferences validated by law, as illustrated in Hobby Lobby’s successful bid to refuse coverage for certain contraceptive drugs, despite the ACA’s mandate to cover them. The additional deregulation that employers’ “self-insured” plans enjoy under ERISA preemption, combined with the prevalence of these plans, amplifies these effects. In essence, the availability of funding for reproductive care for the majority of Americans of reproductive age is left to the promises enshrined in employers’ health benefit plans and the incentives that these entities pursue in designing their plans. This chapter untangles the legal web that gives private sector employers this gatekeeper role, and explores the implications of our reliance on employers for individuals’ reproductive freedom.

This chapter discusses the four main reasons to measure outcomes: 1. measuring the change in outcomes tells you how you are doing with respect to providing health care; 2. with outcome data you can identify opportunities for learning and improvement; 3. outcome data give patients and their families critical information about what to expect when they seek care from you or your organization (or, if you work for a payer organization or employer, from the health care providers within your network); and 4. you have an ethical obligation to understand whether the care you provide is helping or harming.