For 21-year-old Scierra Hill, her community’s disapproval of contraceptives for girls nearly discouraged her from accessing birth control during high school.

A resident of Wheeling, a city in West Virginia’s Northern Panhandle, Hill said: “We’re a small town with very narrow-minded people who tend to make girls more afraid to look for those resources and go to them …. That’s how I felt when I started [using birth control]. I felt like everyone was looking at me like I was a prostitute or something.”

Young people in West Virginia are not guaranteed to learn about reproductive health at school. West Virginia middle school and high school health classes are required to teach sexual education, but their only mandatory topic is HIV. Upon the advice of her mother, Hill went to the local Wheeling-Ohio County Health Department, to get birth control at age 16.

The health department was one of the limited places where Hill could find information and receive a birth control prescription as a minor with Medicaid. According to The Intelligencer, the local newspaper, West Virginia Medicaid insured 30 percent of West Virginians as of January 2017. Hill’s family is one of thousands who utilize the insurance, and she said her family has been on Medicaid for as long as she can remember. Both her parents work—her father in health care and her mother at a produce market—but Hill never remembers her parents ever having private insurance.

Hill began to see how difficult it is to access birth control in a state where Advocates for Youth reports teens are contracting sexually transmitted diseases at a high rate and giving birth at a rate above the national average. West Virginia is in the thick of a health crisis, which extends to reproductive health. Stigma, distance, and state Medicaid policies that presume birth control can be found elsewhere or force “new” adults to seek other care make getting contraception an unnecessarily difficult task for many young West Virginians.

Hill was able to obtain birth control pills at the health department for two years. However, when she turned 18, health department workers told Hill she had to find a new doctor because she was now technically an insured adult. Her health insurance plan, however, had not changed.

She was confused by the need to switch. “Even though I have health insurance, it’s health insurance for lower-income people, and [the health department is] a place that’s supposed to help lower-income people,” she said.

But her county health department states that individuals must be “uninsured or underinsured” to receive birth control pills from their office. Medicaid has covered at least some forms of prescription birth control since before the Affordable Care Act (ACA), which means that individuals utilizing Medicaid are not always eligible to receive birth control prescriptions through the health department. Individuals with Medicaid can access other services through the health department, such as STD testing. With her mother’s assistance, Hill was finally able to find one of the few OB-GYNs in the Wheeling area who accept Medicaid.

Another option for Hill would have been to obtain her prescription from Planned Parenthood, but West Virginia has only one clinic in the entire state. Located in Vienna, it’s nearly a two-hour drive from Wheeling. Hill’s closest Planned Parenthood is actually located an hour away across state lines in Pittsburgh.

Despite the notion that Hill seemingly had a variety of options through which she could obtain birth control, in reality, her choices were limited due to unexplained stipulations on where her Medicaid would be accepted. While little information can be found online in regard to how many OB-GYNs in West Virginia accept Medicaid, doctors are increasingly unwilling to accept the insurance due to “administrative hassles” and a low reimbursement rate.

Wheeling resident Jessica Broverman, 24, used Medicaid until she was 18 but has not yet felt the need to reapply. “I don’t want to do it unless I have to, and I’ve thought about doing it for food stamps or housing or health care, but there’s a lot more people who have it a lot harder than me,” she said.

Like Broverman, some West Virginia residents forego health insurance altogether—a decision that further limits the health care they can access and puts them at risk for having to pay a tax penalty for not having coverage. In 2016, 8.9 percent of adults were believed to be uninsured in West Virginia, an all-time low for the state, with the ACA largely credited for the drop in uninsured individuals across Appalachia.

Broverman, who recently completed her undergraduate degree from West Liberty University and works as a server, is uninsured partly due to finances. Broverman said she is searching for a job that can offer her comprehensive health insurance, but it is not simple to find a position that would provide her with a livable wage after the cost of health insurance has been deducted from her paycheck.

Without health insurance, however, Broverman claims she is unable to visit the doctor for most health issues because the costs would be debilitating.

“If I think about it too much, I get really upset,” Broverman said. “My back will hurt a lot or something will be going on down there and I think, ‘I should really go get a checkup or have this or that done,’ but I can’t. So I just try and figure it out.”

Unlike Hill, Broverman is not currently using contraceptives. She tried the NuvaRing and implant methods in the past, but disliked both. Broverman said she would like to continue searching for a form of birth control that works well with her body, but due to staggering costs associated with doctor visits and prescriptions, she is not able to do so without insurance.

“[If I had insurance] I’d just be trying different kinds to see what my body would be best with,” she said.

While she occasionally visits walk-in clinics like MedExpress Urgent Care for issues she cannot manage herself, Broverman often finds herself looking for cheaper solutions to pacify potentially serious health conditions. “I’ve tried all kinds of home remedies and DIY to fix actual medical issues,” she said. “This is what people in Third World countries do, and I’m an hour away from Pittsburgh.”

From black lung disease to opioid overdoses, West Virginia is not known for producing healthy residents. A national comparison of general health rates and the percentage of individuals who utilize health care services currently ranks West Virginia 46th.

Even with two MedExpress centers and the health department nearby, Broverman knows the difference between being close to care and having the financial means to actually access it.

She said: “We all have access to get into a hospital or to meet Matthew McConaughey, but that doesn’t mean we’re going to be able to meet him.”