EXECUTIVE SUMMARY
The Affordable Care Act mandates employers and payers to provide free contraception, including long-acting reversible contraception (LARC). But the authors of a new study found that the proportion of people paying $0 for most contraceptive methods declined between 2014 and 2020.
- More people are paying out-of-pocket costs for every contraceptive method except oral contraceptives.
- The proportion of people paying zero costs for intrauterine devices never reached 90%, and it has declined steadily in the past decade.
- Religious exemptions and incorrect coding are two possible reasons for the decline.
Anecdotal reports of women not having access to free long-acting reversible contraception (LARC) as mandated by the Affordable Care Act (ACA) are now backed by evidence. Free LARC access has dropped since the first couple of years under the contraceptive coverage requirement, and there is no easy explanation for why this is happening.1
Researchers also found that the proportion of people paying $0 for all contraceptive methods — except oral contraceptives — declined from 2014 to 2020.1
“Anecdotally, you hear of people having out-of-pocket costs for these expensive methods, but we wanted to see if we could document that,” says Cynthia Chuang, MD, MSc, lead study author and a professor of medicine and chief of the Division of General Internal Medicine at Penn State.
Chuang and colleagues used Healthcare Common Procedure Coding System (HCPCS), International Classification of Diseases (ICD-9 and ICD-10), National Drug Codes, and Current Procedural Terminology (CPT)-4 codes to identify contraceptive claims between 2006 and 2020. The period pertaining to the ACA contraceptive mandate’s effect on cost started in 2013 because it was the first full-benefit year after the mandate went into effect.
“When the ACA’s contraceptive requirement goes into place, the proportion of people paying $0 for IUDs [intrauterine devices] jumps up sharply,” Chuang explains. “But it doesn’t get above 90%.”
It peaked in 2014 and declined to 70%, where it has been stable in recent years. “Everyone is supposed to pay zero,” Chuang says.
The U.S. Supreme Court’s decision in the Burwell v. Hobby Lobby Stores, Inc. case in 2014 gave closely held corporations with sincere religious objections the right to not pay for contraceptive methods that went against their religious beliefs. This has had some impact on blocking free access to certain contraceptives, such as IUDs and emergency contraception. But the number of companies that stopped covering LARC for that reason is probably not enough to cause the increase in people paying out-of-pocket costs, Chuang notes.
“We kind of assume that with those exceptions, it would still be higher than it is,” Chuang says. “What causes that drop-off in the 2015-2016 range is unclear.”
Theories on Contributing Factors
Investigators have several theories about contributing factors to the decline in free coverage of LARC. One is that new IUDs were coming to the market around 2016, and some insurance payers may have provided coverage for only one type of IUD and not all IUDs.
“We suspect that might be the case, but that doesn’t explain why the implant also dropped off in the 2016 time range because there is only one implant on the market — Nexplanon,” Chuang adds.
Another possibility is that some health insurers and employers are not following the rules. There is no one to police their practices to ensure they provide contraception at no out-of-pocket cost.
“Is there a degradation of following the contraceptive mandate over time? We don’t know. But we’re concerned about this drop-off because that’s not supposed to happen,” Chuang says.
Another possibility involves the different ways providers code contraception. “One of the things we’ve been speculating about is it is possible that when providers are doing the IUD or Nexplanon, they use a diagnosis code that causes insurers to not pay the full cost,” Chuang says. “The ACA contraceptive mandate says it needs to be covered. But what if a person wants to get an IUD because of menstrual irregularities, and the provider codes it for heavy menstrual bleeding rather than for a contraceptive reason? But this is all speculation — we don’t know.”
As worrisome as the findings are, it is possible they will show an even worse picture in 2020 to 2023. “We’re really concerned about data after 2020,” Chuang says. “The Trump administration in 2017 released a new set of rules that basically expanded the Hobby Lobby exception to any employer.”
The decision was supposed to be for closely held for-profit companies, but the Trump administrations rules said that almost any employer who had a moral or religious objection to covering contraception could stop, Chuang says. “That was held up for several years because a federal judge put an injunction on it and kept it from going into effect,” she adds. “Then, there was a Supreme Court case in 2020, the Little Sisters of the Poor vs. Pennsylvania, and the court’s decision upheld the Trump rules and let them go into effect.”2
The result is that any employer, beginning in 2020, could say contraceptive coverage violates their religious beliefs, and their company will not provide coverage for contraception. “Employers don’t have to file for that. They can just stop,” Chuang says. “We have to wait a couple of years later to see what effect that has had.”
Chuang and colleagues also found that oral contraceptive pills are the only type of contraception that did not change in the percentage of women who received it without out-of-pocket expenses.
“The patch and ring had a small decline from 2019 to 2020, and we don’t understand that, either,” Chuang says. “It may make sense [for a dip in usage] in 2020 because it was the first year of the pandemic, but it doesn’t make sense why they were more likely to have out-of-pocket costs for their method.”
It is possible insurers used coding mistakes as a way to deny coverage of some contraception. Plus, even oral contraceptive pills had a sizeable number of women who were unable to access them at zero charge. There are no current data to explain why any woman has to pay for their pills when the law says they should be provided at no charge.
There are ways that providers and policy advocates could help improve no-charge access to contraception, Chuang says. On the federal level, there should be an enforcement initiative to target payers who are collecting copays for something that should not be charged to patients.
“It would be advantageous if the federal government was able to monitor whether or not employers and health insurance companies were complying with the contraceptive mandate and hold them accountable to make sure people who are insured are getting the benefits they’re entitled to by federal law,” Chuang says.
States also can play a big role. “There are states that because they feared during the Trump administration that the whole Affordable Care Act would go down have passed state laws that were parallel to the contraceptive mandate,” Chuang explains. “The state mandates say, ‘In our state, we require that you provide no-cost coverage for contraceptive methods.’” More states could enact laws like that, she adds.
Providers and clinicians also could ensure their patients receive free contraception by monitoring their own coding. For example, if a patient asks for LARC because of menstrual irregularities, then the physician could tell the patient that although their use of LARC is to alleviate menstrual discomfort, it also provides a contraceptive benefit. If the patient approves, the physician can ensure the insurance company understands that this device should be covered by the ACA mandate of providing contraception at no cost.
“It’s good for consumers to know that the ACA requires contraception to be covered,” Chuang adds.
REFERENCES
- Chuang CH, Weisman CS, Liu G, et al. Impact of the Affordable Care Act on prescription contraceptive use and costs among privately-insured women, 2006-2020. Womens Health Issues 2023;S1049-3867(23)00154-8.
- Supreme Court of the United States. Little Sisters of the Poor Saints Peter and Paul Home v. Pennsylvania. Decided July 8, 2020.
The Affordable Care Act mandates employers and payers to provide free contraception, including long-acting reversible contraception. But the authors of a new study found that the proportion of people paying $0 for most contraceptive methods declined between 2014 and 2020.
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