Greater access is most pronounced among adolescents

Medicaid expansion under the Affordable Care Act (ACA) resulted in increased access to the most effective means of contraception — long-acting reversible contraception — researchers found.

In a study of more than 500,000 women, Medicaid expansion was associated with a 1.19% increase in use of long-acting reversible contraception, with the greatest gains seen among adolescents, Blair G. Darney, PhD, MPH, Department of Obstetrics & Gynecology, Oregon Health & Science University, and colleagues wrote in JAMA Network Open.

The Affordable Care Act increased the number of adults receiving health care coverage, particularly in Medicaid expansion states, and by extension increased access to preventive services, including contraception.

According to Darney and colleagues, research on publicly funded contraceptive services has focused on either Medicaid, single payers (such as state family-planning programs), or federal programs such as Title X, or has included only clinics that focus on reproductive clinic or those that provide publicly funded contraceptive services.

However, “objective clinical data that capture the association of Medicaid expansion under the ACA with changes to the provision of contraceptive care across the safety net, regardless of insurance status or payer type, is lacking,” wrote Darney and colleagues. “Even small increases in the use of the most effective methods of contraception translate into a large outcome on unintended pregnancy, birth, and abortion rates, as well as public cost savings.”

Here, Darney and colleagues examined the association of Medicaid expansion with changes in contraception use among women at community health centers, hypothesizing that expansion is associated with increases in the use long-acting reversible contraception (for example, IUDs and contraceptive implants).

The authors used EHR data from a clinical research network of more than 300 community health centers across 24 states to conduct a retrospective, cross-sectional study evaluated patients who received contraception before Medicaid expansion (2013) compared to the year immediately after expansion (2014) and over a longer period of time (2016).

The study population included 310,132 women from expansion states and 235,408 women from non-expansion states, ages 15 to 44 years, who were at risk for pregnancy, and had made an ambulatory care visit to one of the participating community health centers during the study period.

Darney and colleagues found that after Medicaid expansion, there was an increase in the annual use of long-acting reversible contraception in expansion states (from 4.4% in 2013 to 5.3% in 2014 and 6.1% in 2016), as well as non-expansion states (from 1.8% in 2015 to 2.2% in 2014 and 2.4% in 2016).

This represented a 0.58 (95% CI, 0.13-1.05) percentage point greater increase in the number of women in expansion states who received long-acting reversible contraception compared to women in non-expansion states in 2014. That rate more than doubled by 2016, with a 1.19 (95% CI, 0.41-1.96) percentage point larger increase among women in expansion states compared to women in non-expansion states.

The authors found that the increased use of long-acting reversible contraception was most pronounced among adolescents, increasing in expansion states from 4.0% in 2013 to 4.9% in 2014, and to 6.1% in 2016. On the other hand, there was no significant change in the use of long-acting reversible contraception among adolescents in non-expansion states.

“Although the absolute increase in contraceptive use attributable to Medicaid expansion is small, this difference is meaningful from a population health perspective,” Darney and colleagues observed. “Being without insurance is a known risk factor for unintended pregnancy; interventions that improve access to contraception for this population have profound population level outcomes.”

They also pointed out that their findings persisted when accounting for other safety net programs such as Title X, under which the Family Planning Program distributes federal grants to clinics providing comprehensive contraceptive services to lower-income individuals. Therefore, they added, “Medicaid expansion did not replace the benefits observed with Title X programs and can help improve access for women unable to visit a Title X clinic.”

In a commentary accompanying the study Michelle H. Moniz, MD, Department of Obstetrics and Gynecology, University of Michigan, and colleagues noted that Darney and colleagues found that that the proportion of total contraception users was higher in Title X clinics compared with non-Title X clinics before and after ACA implementation, and that the provision of long-acting reversible contraception was higher at Title X clinics than non-Title X clinics across the study period.

Thus, they wrote, these findings emphasize the importance of Title X, particularly in the face of new policy changes, such as a new rule that removes the requirement that Title X grantees offer a range of medically effective contraceptive options. They noted that this has led to some grantees, including Planned Parenthood, to leave the program.

“With a shift in Title X clinics from those focused on reproductive health to those focused more generally on primary care, women may lose access to evidence-based services, including the full range of available contraceptive methods,” Moniz and colleagues wrote, adding that “as the policy landscape governing contraceptive health care evolves, it will be crucial to continue evaluating the effects of these large-scale policy changes on the lives of women and their families.”

  1. Increased access to more effective contraception (in the form of long-acting reversible contraception) is associated with Medicare expansion.

  2. The biggest gains in access to long-acting reversible contraception was seen among adolescents.

Michael Bassett, Contributing Writer, BreakingMED™

Darney consults for Ipas, a global nonprofit focused on safe abortion, and served as an expert in the Oregon Department of Justice’s litigation on proposed rule changes to Title X.

Moniz reported receiving grant funding from the Agency for Healthcare Research and Quality (AHRQ).

Cat ID: 150

Topic ID: 88,150,191,138,192,150,462,925