Data comparing changes in birth rates before and after the Affordable Care Act (ACA) was passed suggest that reducing out-of-pocket costs is associated with increased contraceptive use.1

Investigators evaluated changes in birth rates by income level among women with commercial insurance before the ACA was fully implemented, from 2008 to 2013, to after its implementation, from 2014 to 2018.

“We were looking at the one part of the Affordable Care Act that eliminated women’s out-of-pocket spending at the time of getting a contraceptive method,” says Vanessa K. Dalton, MD, MPH, director of the program on women’s healthcare effectiveness research at the University of Michigan Medical School.

Researchers studied a sample of 5 million women over 10 years, but the data were not analyzed on a state-by-state basis. “We adjusted for regions, where you are in the country, but I’m not sure what it would mean to look at individual states because the sample is not selected in a way that the message [with state data] could be meaningful,” Dalton says.

The ACA enabled women to choose more expensive methods of birth control because most women can obtain their contraceptives at no out-of-pocket costs because of the ACA’s mandates. More expensive methods often are more effective methods, Dalton says. The cost of contraceptives is important to both low-income women and to women with commercial insurance.

“We demonstrated that not only do women who are commercially insured increase their use of more effective methods or any method, but it ultimately leads to a faster decline in birth rates,” Dalton explains.

Birth Rates Declining

Although birth rates are falling among many subpopulations of women, there are complicated differences in their birth rates — particularly among low-income women and other vulnerable populations. “Some of this is due to higher rates of unintended pregnancy,” Dalton adds. “Cost barrier is one of the reasons why unintended pregnancy rates are higher in some populations than others.”

After the ACA was passed, a greater decline in birth rate occurred among some low-income women. As a result, the birth rate gap has been shrinking between low-income and affluent women since the ACA was enacted.

“One of the questions that we get asked about our work in general is why we are looking at commercially insured women,” Dalton says. Investigators are interested in uninsured women and women on Medicaid, but most women insured in the United States are insured by their employer. Also, many people with relatively low income do not qualify for Medicaid, even in states that accepted Medicaid expansion. For these women, choosing a $1,000 device is not feasible, Dalton says.

While not all commercially insured women have access to contraceptives with no out-of-pocket costs, most do. This population can be studied more easily for patterns in their contraceptive use and how the ACA affected these patterns.

“The message is that the Affordable Care Act was effective at removing the cost of contraception, and was followed by an increase in prescription contraception use that was followed by a further decline in the birth rate,” Dalton says. “The effect is not huge, but you don’t have to change birth rates much to have a long-term impact.”

While not all unintended pregnancies are unwanted, there is a societal cost for mistimed births, she notes. “We’re concluding that, to some degree, understanding how to prevent unintended pregnancies is not going to be solved with one approach; it’s a complicated problem,” Dalton says. “But the ACA appeared to be successful in what it was meant to do: decreased cost, increased access, and this is followed by a decline in birth.”

More Action Needed to Address Inequities

The ACA addressed some inequities in healthcare coverage, but it is a basic minimum of what is needed to improve healthcare access, Dalton says. “Just because someone is insured doesn’t mean they are not experiencing financial stress because of the cost of medical care,” she explains. “The ACA was basic — the minimum of what you have to do to remove systemic inequities, at least in the employer-based health insurance world.”

The ACA was one step toward leveling the playing field in terms of healthcare access. “Also, we don’t need the ACA to make these decisions,” Dalton says. “States can decide to implement regulations that would require health plans in their states to come in line with this.”

Providing contraception to women with no out-of-pocket expense also is a fiscally sound policy. “Employers and payers have an investment here,” Dalton says. “Health insurance companies’ biggest expense for this age group is pregnancy and delivery.”

From the health insurance payer’s standpoint, covering contraception is cost-effective. “Does [saving] $100 or $1,000 change behavior?” Dalton asks. “I would say it looks like it does.”

Stakeholders and legislators might get on board with offering women no-cost contraception options if it appears this is worthwhile from a business standpoint, she adds.

“For me, the really important message is the equity piece,” Dalton says. “The fact that this sample includes low-income workers and high-income workers, and we know their health plans worked very differently in the beginning.”

If the ACA were reversed by legislative or court actions, then the most vulnerable families would be at risk for having some financial consequences related to their contraceptive coverage, as well as healthcare coverage in general, Dalton adds.


  1. Dalton VK, Moniz MH, Bailey MJ, et al. Trends in birth rates after elimination of cost sharing for contraception by the Patient Protection and Affordable Care Act. JAMA Netw Open 2020;3:e2024398.