Contraceptive Choice after the Affordable Care Act

Research Objective:  To determine whether contraceptive choices were affected by elimination of patient copayments for contraceptives as mandated by the Affordable Care Act (ACA).  

 Study Design:  Using medical and prescription claims data from one regional health insurer between 2009 and 2014, we will compare individual-level contraception use and type before and after the date that employers comply with the mandate, using women enrolled in grandfathered or exempt plans as controls. The ACA mandates full coverage of preventive care services, including contraception for women, so women’s out-of-pocket cost for contraception falls to zero for those covered by employment-based contracts subject to the ACA mandate.  Employer compliance with the contraception coverage mandate occurs upon contract renewal following the effective legislation date of August 2012, unless the employer made no changes to plan design or was deemed exempt from the mandate (“grandfathered”).    Timing differences in compliance dates, in addition to grandfathered employer plans, will be used to identify the treatment effect of the coverage/price change.  We will categorize contraceptives into short-term methods (e.g. daily hormonal, emergency hormonal, injectable, and topical methods) and long-term methods (e.g. implantable devices and tubal ligation). 

Population Studied:  The study sample includes women ages 18-45 enrolled in middle market and large employer group health plans from one regional health insurer.  Our sample includes over 150,000 women-year observations on nearly 30,000 unique women enrolled in 500 middle market and large employer group health plans. 

Principal Findings:  Compliance occurred between August 2012 and January 2014 for 486 employer groups in the sample; 13 employers had grandfathered or exempt plans.  Prior to compliance, we find that short-term methods had average out-of-pocket patient costs ranging from $29 every 3 months to $57 per month, where long-term methods (providing protection for 3+ years) averaged between $230 to $327 in patient out-of-pocket costs.  We hypothesize that contraception use will increase after compliance and will shift toward long-term methods that had higher patient cost-sharing prior to the mandate.  Increased use of long-term methods could reduce rates of unintended pregnancy because of their greater efficacy. Using a variety of econometric specifications, we find that that reducing the patient cost of contraception increases the use of contraception, especially long-term methods, as expected, although the effect sizes are small.

Conclusions:  The ACA mandate provides a natural experiment to study the effect of coverage and price on the contraceptive choices of women.  This study will contribute important evidence on the price sensitivity of contraceptive choices as these data allow us to follow women’s choices before and after a price change. 

Implications for Policy or Practice:  These findings will inform employers, insurers, and policy makers about the impact of contraception coverage on women’s choices and the associated health care costs.  Increased access to contraception could reduce the rate of unintended pregnancy and the resulting societal costs.