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Trends in Birth Rates After Elimination of Cost Sharing for Contraception by the Patient Protection and Affordable Care Act

IMPORTANCE: Reducing out-of-pocket costs is associated with improved patterns of contraception use. It is unknown whether reducing out-of-pocket costs is associated with fewer births. OBJECTIVE: To evaluate changes in birth rates by income level among commercially insured women before (2008-2013) an...

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Autores principales: Dalton, Vanessa K., Moniz, Michelle H., Bailey, Martha J., Admon, Lindsay K., Kolenic, Giselle E., Tilea, Anca, Fendrick, A. Mark
Formato: Online Artículo Texto
Lenguaje:English
Publicado: American Medical Association 2020
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7648257/
https://www.ncbi.nlm.nih.gov/pubmed/33156347
http://dx.doi.org/10.1001/jamanetworkopen.2020.24398
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author Dalton, Vanessa K.
Moniz, Michelle H.
Bailey, Martha J.
Admon, Lindsay K.
Kolenic, Giselle E.
Tilea, Anca
Fendrick, A. Mark
author_facet Dalton, Vanessa K.
Moniz, Michelle H.
Bailey, Martha J.
Admon, Lindsay K.
Kolenic, Giselle E.
Tilea, Anca
Fendrick, A. Mark
author_sort Dalton, Vanessa K.
collection PubMed
description IMPORTANCE: Reducing out-of-pocket costs is associated with improved patterns of contraception use. It is unknown whether reducing out-of-pocket costs is associated with fewer births. OBJECTIVE: To evaluate changes in birth rates by income level among commercially insured women before (2008-2013) and after (2014-2018) the elimination of cost sharing for contraception under the Patient Protection and Affordable Care Act (ACA). DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study used data from Clinformatics Data Mart database from January 1, 2008, to December 31, 2018, for women aged 15 to 45 years who were enrolled in an employer-based health plan and had pregnancy benefits for at least 1 year. Women without household income information and women with evidence of having undergone a hysterectomy were excluded. EXPOSURE: Section 2713 of the ACA. MAIN OUTCOMES AND MEASURES: The primary outcome was the proportion of reproductive-aged women with a live birth by year (measured yearly from 2008 to 2018 [11 time points]) within 3 income categories. The secondary outcome was the distribution of contraceptive method fills in 3 categories by year: (1) most effective methods (long-acting reversible contraception or sterilization), (2) moderately effective methods (pill, patch, ring, and injectable), and (3) no prescription or surgical method. RESULTS: The analytic sample included 4 590 989 women (mean [SD] age; 30.8 [9.1] years in 2013; 3 069 053 White [66.9%]) enrolled in 47 721 health plans. A total of 500 898 participants (40.8%) resided in households with incomes less than 400% of the federal poverty level in 2013. In all 3 years (2008, 2013, and 2018), women in the lowest income category were younger than women in the other income groups (median range, 21-22 years vs 30-34 years) and in households with a higher median number of dependents (9-10 vs 2-4). There was an associated decrease in births in all income groups in the period after the elimination of out-of-pocket costs. The estimated probability of birth decreased most precipitously among women in the lowest income group from 8.0% (95% CI, 7.4%-8.5%) in 2014 to 6.2% (95% CI, 5.7%-6.7%) in 2018, representing a 22.2% decrease (P < .001). The estimated probability decreased in the middle income group by 9.4%, from 6.4% (95% CI, 6.3%-6.4%) to 5.8% (95% CI, 5.7%-5.8%) (P < .001), and in the highest income group by 1.8%, from 5.6% (95% CI, 5.6%-5.7%) to 5.5% (95% CI, 5.4%-5.5%) (P < .001) in the period after the elimination of cost sharing. CONCLUSIONS AND RELEVANCE: In this cross-sectional study, the elimination of cost sharing for contraception under the ACA was associated with improvements in contraceptive method prescription fills and a decrease in births among commercially insured women. Women with low income had more precipitous decreases than women with higher income, suggesting that enhanced access to contraception may address well-documented income-related disparities in unintended birth rates.
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spelling pubmed-76482572020-11-17 Trends in Birth Rates After Elimination of Cost Sharing for Contraception by the Patient Protection and Affordable Care Act Dalton, Vanessa K. Moniz, Michelle H. Bailey, Martha J. Admon, Lindsay K. Kolenic, Giselle E. Tilea, Anca Fendrick, A. Mark JAMA Netw Open Original Investigation IMPORTANCE: Reducing out-of-pocket costs is associated with improved patterns of contraception use. It is unknown whether reducing out-of-pocket costs is associated with fewer births. OBJECTIVE: To evaluate changes in birth rates by income level among commercially insured women before (2008-2013) and after (2014-2018) the elimination of cost sharing for contraception under the Patient Protection and Affordable Care Act (ACA). DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study used data from Clinformatics Data Mart database from January 1, 2008, to December 31, 2018, for women aged 15 to 45 years who were enrolled in an employer-based health plan and had pregnancy benefits for at least 1 year. Women without household income information and women with evidence of having undergone a hysterectomy were excluded. EXPOSURE: Section 2713 of the ACA. MAIN OUTCOMES AND MEASURES: The primary outcome was the proportion of reproductive-aged women with a live birth by year (measured yearly from 2008 to 2018 [11 time points]) within 3 income categories. The secondary outcome was the distribution of contraceptive method fills in 3 categories by year: (1) most effective methods (long-acting reversible contraception or sterilization), (2) moderately effective methods (pill, patch, ring, and injectable), and (3) no prescription or surgical method. RESULTS: The analytic sample included 4 590 989 women (mean [SD] age; 30.8 [9.1] years in 2013; 3 069 053 White [66.9%]) enrolled in 47 721 health plans. A total of 500 898 participants (40.8%) resided in households with incomes less than 400% of the federal poverty level in 2013. In all 3 years (2008, 2013, and 2018), women in the lowest income category were younger than women in the other income groups (median range, 21-22 years vs 30-34 years) and in households with a higher median number of dependents (9-10 vs 2-4). There was an associated decrease in births in all income groups in the period after the elimination of out-of-pocket costs. The estimated probability of birth decreased most precipitously among women in the lowest income group from 8.0% (95% CI, 7.4%-8.5%) in 2014 to 6.2% (95% CI, 5.7%-6.7%) in 2018, representing a 22.2% decrease (P < .001). The estimated probability decreased in the middle income group by 9.4%, from 6.4% (95% CI, 6.3%-6.4%) to 5.8% (95% CI, 5.7%-5.8%) (P < .001), and in the highest income group by 1.8%, from 5.6% (95% CI, 5.6%-5.7%) to 5.5% (95% CI, 5.4%-5.5%) (P < .001) in the period after the elimination of cost sharing. CONCLUSIONS AND RELEVANCE: In this cross-sectional study, the elimination of cost sharing for contraception under the ACA was associated with improvements in contraceptive method prescription fills and a decrease in births among commercially insured women. Women with low income had more precipitous decreases than women with higher income, suggesting that enhanced access to contraception may address well-documented income-related disparities in unintended birth rates. American Medical Association 2020-11-06 /pmc/articles/PMC7648257/ /pubmed/33156347 http://dx.doi.org/10.1001/jamanetworkopen.2020.24398 Text en Copyright 2020 Dalton VK et al. JAMA Network Open. http://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the CC-BY License.
spellingShingle Original Investigation
Dalton, Vanessa K.
Moniz, Michelle H.
Bailey, Martha J.
Admon, Lindsay K.
Kolenic, Giselle E.
Tilea, Anca
Fendrick, A. Mark
Trends in Birth Rates After Elimination of Cost Sharing for Contraception by the Patient Protection and Affordable Care Act
title Trends in Birth Rates After Elimination of Cost Sharing for Contraception by the Patient Protection and Affordable Care Act
title_full Trends in Birth Rates After Elimination of Cost Sharing for Contraception by the Patient Protection and Affordable Care Act
title_fullStr Trends in Birth Rates After Elimination of Cost Sharing for Contraception by the Patient Protection and Affordable Care Act
title_full_unstemmed Trends in Birth Rates After Elimination of Cost Sharing for Contraception by the Patient Protection and Affordable Care Act
title_short Trends in Birth Rates After Elimination of Cost Sharing for Contraception by the Patient Protection and Affordable Care Act
title_sort trends in birth rates after elimination of cost sharing for contraception by the patient protection and affordable care act
topic Original Investigation
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7648257/
https://www.ncbi.nlm.nih.gov/pubmed/33156347
http://dx.doi.org/10.1001/jamanetworkopen.2020.24398
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