Threats to ACA associated with temporary increase in Long-Acting Reversible Contraception

ABSTRACT

Long-Acting Reversible Contraception methods (LARCs) have a lower uptake rate than oral contraception, despite being more reliable and potentially cheaper in the long run. Historically, high insertion costs have stunted their uptake. The Affordable Care Act eradicated these costs by classifying contraception as preventative care that insurers must offer at no charge as of late 2012. Additionally, the ACA required that all employer-provided insurance plans have contraceptive coverage. After four years of coverage, the 2016 national election represented a credible threat to the ACA and contraceptive coverage and access. Utilizing the National Survey of Family Growth, I estimate how LARC uptake changed during and after 2016 using data from 2011 to 2019. I find that use of LARCs spiked in 2016 and 2017 for Medicaid users and 2017 and 2019 for women with private insurance.

KEYWORDS:

• Contraception
• LARC
• insurance
• uncertainty
• baby bust

JEL CLASSIFICATION:

• I1 – Health
• J1 - Demographic Economics
• H3 - Fiscal Policies and Behavior of Economic Agents

Disclosure statement

No potential conflict of interest was reported by the author(s).

Notes

¹ https://www.hrsa.gov/womens-guidelines/index.html

² The ACA contraception mandate did not apply to male contraception measures, such as vasectomies or condoms, which are not required to be covered by insurance at the federal level (Nguyen, Shih, and Turok 2014).

³ The only successful challenge of the contraception policies in the ACA came from the 2014 Burwell V. Hobby Lobby case which held that privately owned companies could refuse to offer contraceptive coverage due to religious objection. ACA policies were crafted to provide no cost ‘contraceptive policies’ for women who lost coverage under this pretence (Gonzales and Schwartz 2019).

⁴ https://webarchive.loc.gov/all/20,160,601,001,035/https://www.donaldjtrump.com/positions/healthcare-reform

⁵ The subdermal arm implant, Nexplanon, can last for three years; hormonal IUDs, such as Mirena, last for five, and copper IUDs can last up to 12 years (Planned Parenthood, nd).

⁶ Rates in Daniels and Abma (2018) are lower than those in Table 1 as theirs include non-reversible and non-prescription methods.

⁷ In May 2017, Executive Order 13,798 instructed, ‘all executive departments and agencies shall …. respect and protect the freedom of persons and organizations to engage in religious and political speech.’ In October 2017 HHS issues amendments: https://www.dol.gov/newsroom/releases/dol/dol20200515 and https://www.govinfo.gov/content/pkg/FR-2017-10-13/pdf/2017-21852.pdf.These expanded the Brussel V. Hobby Lobby amendment by now including publicly held companies and allowing for reasons of moral in addition to religious objection.

⁸ Title X funding was always limited to non-abortion services, but in 2018, the policies were amended to restrict funding from facilities that perform abortions or refer patients to other facilities for abortion services. https://opa.hhs.gov/grant-programs/title-x-service-grants/title-x-statutes-regulations-and-legislative-mandates These ‘Compliance Integrity Requirements’ went into effect in 2019. https://www.federalregister.gov/documents/2019/03/04/2019-03461/compliance-with-statutory-program-integrity-requirements

⁹ Dawson (2020) estimates that after Planned Parenthood and other clinics left the Title X network, its capacity to provide contraception was diminished by approximately 46%, or a reduction of 1.6 million potential patients.

¹⁰ https://www.federalregister.gov/documents/2019/05/21/2019-09667/protecting-statutory-conscience-rights-in-health-care-delegations-of-authority

¹¹ Data on women for the age 45 to 49 began being collected in 2015, but is not available prior.

¹² In the sample, approximately 50% of women aged 15–49 at risk of unintended pregnancy report using prescription contraception during their interview year.

¹³ https://www.cdc.gov/nchs/data/nsfg/NSFG_2015-2017_UG_App2_CombiningFileReleases_Aug2020_final.pdf

¹⁴ Medicaid covered LARCs at a federal level, but states have a lot of leeway in how they allocate Medicaid services and the realistic availability of Medicaid covered LARCs varied by state (Walls et al. 2016).

¹⁵ The largest post 2013 increase in LARC usage, by those with private insurance, is observed in 2015. This corresponds with the prior year’s roll out of the insurance marketplace (Palmer 2020) and rise in private insurance rates observed in 2014 and 2015, which had the highest rates of coverage in the overall NSFG sample.

¹⁶ The longer pre-period is used in robustness check, but the higher magnitude coefficients are questionable since they are estimated against years where LARCs had minimal usage, likely due to insurance constraints.

¹⁷ Any insurance includes those with no insurance, private insurance, Medicaid, and NSFG classified ‘other government insurance,’ which includes those on military or veteran plans, Indian, CHIPS, or state-sponsored health care.

¹⁸ Vasectomy rates, as reported by surveyed women within the NSFG sample, stayed steady during the sample period of 2013 through 2019 with an average of 11% and standard deviation of (1.1%) of women reporting surgically sterile partners.