Fertility Rates Down In U.S. But Iowa Among States With Highest Rates

The Institute for Family Studies recently released “The Demographic Dead End: 2026 State of Fertility Report” by demographer Lyman Stone and researcher Peter Foreshaw Brookes.

The report details U.S. fertility rates back to 1917 and highlights the stark contrast between past high-fertility growth and America’s current fertility trajectory.

The numbers are startling. The U.S. total fertility rate (TFR) has fallen below 1.6 children per woman (replacement level is 2.1). America has experienced two previous extended periods of low fertility after the Great Depression and between 1972-1989. The report finds if current trends continue, the U.S. population is projected to peak around 351 million in the 2050s and then decline.

An interesting finding is the gap between the desired number of children and the actual number of children Americans are having. Americans still want more children hoping for a family size of between 2.4 and 2.7 depending on various survey data. But that is not what is happening.

The question is why?

A survey of almost 4,800 Americans between ages 18-50 found peer and social influences stronger than economic ones. For example, friends matter enormously. For people under 30, those with the most supportive friends – meaning those who would help with things like childcare, meals, transportation, etc. – the numbers diverge. Those with supportive friends boost the desired number of children to 2.8 while those without a supportive friend groups desire just 1.7. The survey also found having friends with kids strongly predicts wanting more yourself.

Does it matter where you live? Turns out it does. The seven states with highest fertility rates are all Republican states: Nebraska, South Dakota, Idaho, North Dakota, Iowa, Kentucky, Utah.

The seven states with the lowest fertility rates? All Democrat states: Vermont, Rhode Island, New Hampshire, Oregon, Maine, Massachusetts, California, Illinois.

Granted New Hampshire has a Republican governor, but it has voted Democrat in seven of the last eight presidential elections.

https://www.demographyunplugged.com/p/chart-of-the-week-americas-fertility

What are the major influences? The report brings up two points.

Celebrity influence is real. Each additional child of an admired celebrity predicted 0.15 more desired children (stronger for young women). However, celebrities shape aspirations more than actual behavior. The authors of the study write, “that paying Taylor Swift a billion dollars to have children might produce more children in society than spending the same money on child tax credits, if her choice sways her wide fanbase.”

City Journal’s Rob Henderson analyzed the study and says economic fixes like housing or money help but aren’t enough without the social and cultural impacts changing. He says reviving births requires rebuilding ordinary social structures like friendship, community support and visible family life. He also argues that the fertility rate decline is a reversible choice. It is not just about costs but eroded social fabric. Families live in different states and the friends you grew up with scatter to various places. Policy innovation isn’t the only thing that is needed but a renewed cultural emphasis on the awesomeness of having children and real-world relationships.

Mental Health

During this year’s general assembly, the legislature has passed many bills to expand access to mental health care in the state and to remove barriers to establishing all levels of care from inpatient psychiatry to subacute to outpatient care. Mental health care plays an important role in public safety, which also received significant attention from the legislature this general assembly as well. The below bills have been signed by the Governor this general assembly:

HF 2523 – Minor Commitments - This bill removes the ability for a minor to refuse mental health or substance abuse treatment if the parent is seeking treatment for their minor and a mental health professional agrees the child is in need of care.

HF 2543 – Subacute Mental Health - This bill makes the following changes based on the subacute mental health facility interim committee:

· Removes the 10 day limit

· Requires subacute Medicaid prior authorization requests to be approved within 48 hours, 5 days or 10 days depending on the urgency of the request.

· Establishes a PMIC bed tracking system

· Requires DHHS to review the state’s capability to establish subacute mental health services and additional inpatient services at Independence MHI beginning in July 2027. This review shall include costs/staffing/infrastructure, the ability to partner with private operators, and submit a report to the chairs of HHS and appropriations in both chambers by January 4, 2027. Allows DHHS to provide subacute services at Independence MHI if can be done within their appropriation.

· Requires DHHS and DIAL to review rules to remove barriers to subacute care.

HF 2782 – IMD Waiver – The FY27 HHS Budget requires DHHS to apply for a waiver of the federal IMD exclusion, allowing additional federal funds to be used for inpatient psychiatric care in Iowa. Recently, the U.S. Department of Justice has issued guidance allowing for additional state institutions for psychiatric care, and this wavier request builds on this work. Additionally, this bill requires annual reporting of state behavioral health spending. Iowa’s annual spending exceeds $1.2 billion and will be discussed in the next newsletter.

HF 2507 – AI Chatbot - This bill provides for disclaimers, prohibitions on certain communications with minors, and allows parental access to minor accounts with AI. This bill also prohibits AI from providing professional behavioral health services and must have protocols in place when a user discusses self-harm. This bill includes enforcement mechanisms and penalties with the attorney general.

SF 474 - High Acuity Youth - This bill came from the Department of Health and Human Services to do the following:

· Allow for protective locked environments

· Allows for a residential facility to not be licensed as a children’s residential facility if it provides live-in care to waiver individuals 16 years of age and older.

· Transfers administrative authority of juvenile court services from the chief judges to the JCS director

· Suspends hawk-i coverage for incarcerated youth

· Creates a workgroup to review Iowa’s commitment, juvenile delinquency and CINA laws during the legislative interim and to make recommendations to the legislature

HF 2635 - Community Mental Health Facilities - This bill makes many changes related to prior authorizations for health insurance, which will be helpful to mental health providers. Additionally, this bill removes the requirement for a certificate of need to be obtained for a community mental health center which will help new mental health facilities be established without additional barriers.

HF 2256 –Child Abuse and Mental Health Treatment - This bill revises the definition of “child abuse” to make clear that a parent that has exhausted all mental health treatment options has not committed child abuse for lack of treatment.

It should be noted, that not all bills that affect Iowans mental health are above. House File 2676, the Iowa Make American Healthy Again bill, is a great example of improving mental health care of Iowa’s children by reducing screen-time in schools and ensuring additional physical activity which improves behaviors.

Another example is Senate File 615 on Medicaid expansion work requirements for able-bodied adults. There is dignity that comes from work and accomplishing something that helps your overall self-esteem as well as having a community of support, rather than isolation.

Legislature Ensures Parents Have Access to Child’s Health Care

Over the last few years, the legislature has prioritized ensuring that parents have access to their child’s health care information and also have the ability to make important decisions regarding the care their child receives.

· Parent Access to Minor Health Records – In 2024, the Governor signed Senate File 477 which required parents to have access to the health care records of their minor children unless the minor has the legal ability to consent to the health care service or prohibited by state or federal law. Prior to this bill, the legislature would often hear complaints from constituents saying that once their child turned 13, health care providers would remove their access to their own minor child’s electronic health care records. This bill ensured that if EHR access was not provided, that the parent would get physical copies of their health records at no charge.

· Parental Consent Mental Health Commitments – This year, the Governor signed House File 2523, which removed the ability for a minor to refuse mental health treatment if the parent is seeking voluntary treatment for their minor. Oddly, prior to this bill, the law allowed a suicidal minor to refuse psychiatric care even if their parents and mental health provider agree they are in need of treatment. The majority of House Democrats voted against this bill.

· Parental Consent Vaccines – This year, the Governor signed Senate File 304. Iowa code allows for minors to consent to very few medical treatments without parental consent. One of those is for the prevention, diagnosis and treatment of sexually transmitted diseases. This code section has been construed to include the ability for a minor to consent to the Hepatitis B vaccine and the HPV vaccine. All other vaccines, including those for whooping cough, measles, mumps, pneumococcal, require parental consent, just like 99% of health care services. Senate File 304 simply removed the ability for a 9 year-old to consent to the HPV vaccine without their parent being involved in the discussion. Strangely, all House Democrats opposed this bill.