The Effects on Outcomes and Cost Savings from the Provision of Free Long-Acting Reversible Contraceptives

More than half of pregnancies among women 15-24 in the US are unintended. Long-acting reversible contraceptives (LARC) are extremely effective contraceptive methods with failure rates of less than one percent. LARC use, however, has been hindered by their high cost and lack of acceptance. In early 2009, the Colorado Family Planning Initiative (CFPI) sought to address these access barriers by providing free LARCs and provider training at Title X–funded clinics, which serve a low-income population. The objective of our study was to estimate the causal impact of the CFPI on unintended pregnancies and its impact on Medicaid savings over five years.

We used a propensity score weighted difference-in-difference research design to account for unobserved contemporaneous trends in fertility rates using a group of non-Colorado counties as controls. The primary outcome was birth rate per 1000 for women ages 15-24. We obtained birth rates for all US counties from the Centers for Disease Control. We supplemented these data with information on county demographics, educational attainment, income, and unemployment rates from the Area Health Resource Files. The sample period included four years of pre-CFPI implementation and five years of post-CFPI implementation. We first selected controls counties by restricting comparison counties to those within thresholds based on key demographic characteristics, and the then estimated propensity scores with the remaining counties. Based on our model estimates and estimates of the number of women actually affected by the initiative, we calculated Medicaid cost savings. These estimates accounted for mother and child spending, also considering eligibility, attrition, and reimbursement rates over five years post-CFPI.

Our final sample consisted of 128 Colorado counties and 204 comparison counties. Baseline characteristics of Colorado and comparison counties were similar and the standardized differences were within the range of acceptable balance, with the exception of percent black females ages 15-19 and percent black female, which were slightly lower in Colorado counties. Our results show that fertility rates decline in both Colorado and comparison counties in the post-period, but Colorado experienced a larger and statistically significant decline of 8.15 births per thousand or about 2900 births averted. Thus, roughly half of the observed decline in fertility rates can be attributed to the CFPI. Our analysis also shows that Medicaid saved approximately $40 million over five years.

The CFPI significantly reduced unintended pregnancies in Colorado over and above observed declines in fertility rates across the country during the same time period. Removing LARC cost barriers for low-income women has the potential to reduce the large number of unintended pregnancies that still remain and are increasingly concentrated among poor and low income women. In addition, the initiative reduced state and federal spending on medical care, potentially outweighing the cost of the program.