Examining Trends in Contraception, Birth Rates Under ACA

Previously published data shows that reducing out-of-pocket costs is associated with improved contraception use, but researchers sought to better understand how the elimination of cost sharing under the Affordable Care Act (ACA) affected birth rate trends.

“Results from our study of this large sample of commercially insured women suggest that the elimination of cost sharing was associated with an increase in the birth rate reduction within all income groups but most notably in the 2 lower income groups,” explained Vanessa K Dalton, MD, department of obstetrics and gynecology, University of Michigan, Ann Arbor, and colleagues, in the study published in JAMA Network Open.

Dr Dalton and colleagues 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. The final sample included 4,590,989 women.

“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),” said researchers.

Across all income groups, the researchers examined decreased birth rates 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.

“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,” concluded the researchers. “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.” —Edan Stanley