By Jeffrey T. Jensen, MD, MPH, Editor

SYNOPSIS: Data from the latest release of the National Survey of Family Growth supports that the contraception coverage mandate of the Affordable Care Act has resulted in a decrease in the incidence of unintended pregnancy, particularly among women with government coverage.

SOURCE: MacCallum-Bridges CL, Margerison CE. The Affordable Care Act contraception mandate & unintended pregnancy in women of reproductive age: An analysis of the National Survey of Family Growth, 2008-2010 v. 2013-2015. Contraception 2019 Oct. 23; doi: 10.1016/j.contraception.2019.09.003. [Online ahead of print].

Although unintended pregnancy has declined in recent years, about 50% of all pregnancies are mistimed or unwanted at conception. Although controversy exists regarding the best strategies to ensure all pregnancies are both wanted and planned, considerable evidence supports the importance of access to family planning services. In this study, MacCallum-Bridges and Margerison compared data from before and after implementation of the contraception coverage mandate of the Affordable Care Act (ACA), arguably the most significant step to improve access in U.S. history. The ACA mandate required that insurance plans provide Food and Drug Administration (FDA)-approved female contraception and contraceptive services without co-pays, starting Aug. 1, 2012.

The authors used cross-sectional data from the 2006-2010 and 2013-2015 cycles of the National Survey of Family Growth (NSFG), a nationally representative survey of noninstitutionalized men and women in the United States ages 15-44 years. They included interview responses from sexually active women of reproductive age (18-44 years) at risk for pregnancy. The sample intervals allowed them to compare pre- and post-mandate periods, and to control for seasonality in unintended pregnancies (24 months in both the pre-mandate [July 2008-June 2010] and post-mandate [September 2013-August 2015] periods). They calculated odds ratios for unintended pregnancy, and adjusted these for potential confounders (insurance type, race/ethnicity, age group, income level, educational level, and relationship status) in a variety of models. They also evaluated the effect of contraceptive use, and specifically long-acting reversible contraception (LARC) use, in other models.

The basic demographic characteristics of the survey respondents did not change between the pre-mandate and post-mandate periods. However, insurance coverage increased, highest and lowest income levels increased, education level increased, and current LARC use increased (from 8.9% to 13.4%, P < 0.01). The proportion of women reporting an unintended pregnancy in the prior year decreased from 5.5% in the pre-mandate period to 4.9% in the post-mandate period (P = 0.45). The percentage of pregnancies that were unintended decreased from 44.7% in the pre-mandate period to 37.9% in the post-mandate period (P = 0.21).

Although the odds ratios comparing unintended pregnancy in the pre- and post-mandate periods did not differ significantly for most comparisons, the point estimates favored the post-mandate period. The odds of experiencing an unintended pregnancy in the prior year decreased 15% overall (odds ratio [OR], 0.85; 95% confidence interval [CI], 0.62). Notably, the authors observed the greatest reduction in the group of women with government-sponsored insurance (OR, 0.63; 95% CI, 0.41-0.97).

COMMENTARY

Another election is right around the corner, and healthcare remains a primary focus of the policy debate (at least for those who still care about policy). The only outcome that appears certain is that the ACA will change.

Republicans seem to have lost steam for repeal-and-replace legislation for the ACA, but we can expect more attempts if they remain in power after 2020. But more people, even in red states, seem to have recognized the benefits of the ACA, as evidenced in victories by Democrats in the gubernatorial elections in Kentucky and Louisiana. Expanded eligibility for Medicaid to individuals with incomes up to 138% of the federal poverty level has been of particular benefit to single women. Individuals with incomes between 100% and 400% of the federal poverty level receive refundable tax credits to lower the cost of their monthly premiums.1 Between 2013 and 2015, the proportion of women 15-44 years of age who were uninsured fell by 36%. The ACA mandated that marketplace plans cover core sexual and reproductive health services, including contraception care, at no cost.

I still hold the old-fashioned belief that data should inform policy. The analysis by MacCallum-Bridges and Margerison provides new information supporting how the ACA affected unintended pregnancy rates. Although the intervention’s influence is modest (the ORs all show weak effects and CIs overlap 1.0), the overall trends toward a reduction following the programs implementation are consistent with what we would expect with expanded access. Future analyses should strengthen these associations, as these data reflect the earliest results of the program. I also note that the largest reduction (47% decrease, CI did not overlap 1.0) in unintended pregnancy occurred in women using government insurance. This likely demonstrates the effect of expanded Medicaid on the most vulnerable population of women.

The increase in LARC use likely drove the decrease in unintended pregnancy. The CHOICE study showed the effect of removing cost barriers from contraception decision-making. Peipert and coauthors compared repeat abortion rates in the St. Louis region, the site of CHOICE, to Kansas City, MO, a community of similar size and ethnic profile and subject to the same state laws.2 They observed a 20% decline in the number of abortions in the St. Louis area between 2008-2010 compared to no decline in Kansas City or the rest of Missouri, and a significant decrease in the number of repeat abortions.

The Colorado Family Planning Initiative took the concept of the CHOICE project and enacted the changes in real clinics. The state of Colorado received support from a private foundation to increase the availability of LARC methods at Title X–funded clinics through provider training, counseling materials, and no-cost provision of LARC methods in 2009. The program proved wildly successful. LARC use among women 15-24 years old grew from 5% to 19% in this high-risk population. Pregnancy rates decreased by 29% among low-income 15- to 19-year-olds, and 14% for 20- to 24-year-olds, and abortion rates fell 34% and 18%, respectively. The state of Colorado noted a 23% reduction in infant Special Supplemental Nutrition Program for Women, Infants, and Children program enrollment between 2010 and 2013.3

As community leaders, clinicians have an obligation to advocate for sound public health policy. The requirement for mandatory contraception coverage provides a lightning rod for some groups to oppose the ACA. As clinicians, we understand how these comprehensive requirements support the reproductive life cycle needs of our patients. Elimination of cost sharing for LARC methods with implementation of the ACA has resulted in an increase in LARC uptake, according to studies using insurance claims databases.4 We now see early evidence that this is reducing the rate of unintended pregnancy throughout the United States.

REFERENCES

  1. Hasstedt K. How dismantling the ACA’s marketplace coverage would impact sexual and reproductive health. Guttmacher Policy Review 2017;20:48-52.
  2. Peipert JF, Madden T, Allsworth JE, Secura GM. Preventing unintended pregnancies by providing no-cost contraception. Obstet Gynecol 2012;120:1291-1297.
  3. Ricketts S, Klingler G, Schwalberg R. Game change in Colorado: Widespread use of long-acting reversible contraceptives and rapid decline in births among young, low-income women. Perspect Sex Reprod Health 2014;46:125-132.
  4. Carlin CS, Fertig AR, Dowd BE. Affordable Care Act's mandate eliminating contraceptive cost sharing influenced choices of women with employer coverage. Health Aff 2016;35:1608-1615.