By Melinda Young

EXECUTIVE SUMMARY

The Affordable Care Act’s contraceptive mandate led to an increase in injectable contraceptives, but did not help improve access to long-acting, reversible contraceptives (LARCs), research revealed.

  • On the clinic side, one of the chief barriers to LARC is the high cost to keep them in stock.
  • New research shows that state-run programs, such as the Delaware Contraceptive Access Now (DelCAN) program, can help improve LARC access.
  • DelCAN contributed to a 40% increase in LARC use.

The Delaware Contraceptive Access Now (DelCAN) program was created to increase access to contraceptives for women across the state, including long-acting, reversible contraceptives (LARC).

While the Affordable Care Act (ACA) contraceptive mandate led to an increase in injectable contraceptives, it did not increase the use of LARCs. This suggests a problem with clinics stocking LARCs, or a lack of training on insertion.1,2

DelCAN helped overcome these obstacles by using techniques that could be reproduced in other states. Researchers found a 40% increase in LARC use from the baseline.1

DelCAN’s goals are to reduce unintended pregnancies, reduce Medicaid costs for unintended pregnancies, and support policy development to increase contraceptive access to all women who desire it. (More information is available at: https://popcenter.umd.edu/delcaneval/evaluation.)

“We wanted to improve access to a full range of contraceptives, but LARCs were the ones with the most barriers to access because they required a technical skill that most providers didn’t have,” says Michel Boudreaux, PhD, assistant professor of health policy and management at the University of Maryland. “To get same-day service, clinics have to have LARC devices stocked. That’s something clinics weren’t doing and didn’t know how to do. They weren’t used to having that stock there and available.”

Cost Is Barrier to Access

Cost also was a barrier to access for LARCs. “The operating margins at these clinics is not super high, and they don’t like spending money on things they won’t get a return on,” Boudreaux explains.

It makes little financial sense for a clinic to store LARCs when they have no idea whether LARCs will be used, he says. But this practice limits access to a full range of contraceptives.

“To improve access to care, you want as many services as possible to be delivered on a same-day basis,” Boudreaux says.

Family planning centers and gynecologists want to avoid having patients ask for a particular contraceptive, only to be told they need to make another appointment to obtain it, he adds.

“That puts a lot of onus on the patient, who now will have to take time off, set up childcare, and get transportation for the second appointment,” he explains. “Making multiple appointments is a barrier to care, so you would want to have LARC at the clinic.”

DelCAN helped overcome this barrier by directing some state funding toward Title X programs for clinics to purchase a supply of LARCs, Boudreaux says. This is managed through the state pharmacy to help clinics get started.

“Then, they changed the way federally qualified health centers can bill, which means the clinics can bill Medicaid, the state, or whatever at a level that makes them whole,” Boudreaux explains. “In the private market, the ACA has regulations that say you have to be providing contraception at no cost to patients. In practice, it’s not working the way it’s intended.”

One of the reasons for this is legacy plans that started prior to the ACA. “The other thing — and I hesitate to say I know what’s going on with this — but there’s sometimes a mismatch between regulations and what the plans actually do,” Boudreaux says. “It’s not unusual if someone with a private plan is not getting the benefits they are entitled to, and that happens across the spectrum.”

The program’s success in increasing LARC use did not carry over to access to other contraceptives. “We looked at other contraceptive points, like other methods such as oral contraceptives, the patch, and the ring. Our study could not come to any conclusive finding on how use of those methods changed as a result of the intervention,” Boudreaux says. “That doesn’t mean that we found no effect; we just can’t confidently say we know what happens with other contraceptive types. The result for LARC is what we have the most confidence in.”

Other states, like Colorado, created programs similar to DelCAN. Some of these programs worked to reduce financial barriers to contraceptive care by making all methods free and ensuring clinics had the capacity to deliver services, he explains.

“Delaware was not the first of these programs, but was an early example of a comprehensive, statewide program,” Boudreaux says. “Other states are in the process of implementing programs or thinking about it.”

Patient-centered contraceptive access programs are worth a public investment, he notes. “We should make sure when people say they want to use a certain contraceptive, they can access it in the least-expensive way possible,” Boudreaux says.

Future research of these programs should study various populations outside of Title X programs, including the effects on unintended pregnancies and cost-benefit analysis, he adds.

“To choose the best program, we probably want to choose the one that costs the least amount of money, but has the most effect. We don’t have the financial data yet,” Boudreaux says. “So far, we find the program definitely seems to have increased long-acting contraceptive use among Title X clinics. I think a lot more research needs to be done to see how it impacts other populations and impacts unintended pregnancies.”

REFERENCES

  1. Boudreaux M, Xie L, Choi, YS, et al. Changes to contraceptive method use at Title X clinics following Delaware Contraceptive Access Now, 2008-2017. Am J Public Health 2020;110:1214-1220.
  2. Bullinger LR, Simon K. Prescription contraceptive sales following the Affordable Care Act. Matern Child Health J 2019;23:657-666.