Medicaid Expansion Impacts Contraception Access, Women’s Health

Medicaid expansion has an impact on women’s health by opening up access to longer-acting, effective contraceptives that can prevent unwanted pregnancies in adults and adolescents, a study published in JAMA Open Network found.

The researchers studied over 310,000 women from expansion states and more than 235,000 women in nonexpansion states. More of the women in the expansion state were non-Hispanic white. They largely lived in rural areas, tended to have lower incomes, and were more likely to have Medicaid coverage.

“Our findings suggest that Medicaid expansion under the ACA improved access to the most effective contraception, [long-acting reversible contraception] LARC, among a population at high risk of unintended pregnancy,” the researchers found. “Furthermore, the observed increase in LARC in our sample of patients in safety net settings supports previous evidence that when cost barriers are removed, women choose LARC methods.”

Women in nonexpansion states had a much steeper increase in receiving contraceptives after ACA expansion. Within the year following ACA expansion in 2014, the percentage of moderately effective or most effective contraceptive reception went from 17.9 percent to 19.6 percent. By 2016, it had jumped up almost another percentage point to hit 20.4 percent.

In Medicaid expansion states, the increase in women accessing moderately effective or most effective contraceptives was not as dramatic, but they continued to access these contraceptives at a higher rate than women in nonexpansion states.

Prior to expansion, 23.7 percent of women in these states accessed such contraceptives. Women in expansion states were 24.4 percent more likely to receive a moderately effective or most effective contraception in the year after expansion and utilization continued at this rate through 2016.

Use of the most effective contraception—long-acting reversible contraceptives, which include intrauterine devices (IUDs) and etonogestrel single-rod contraceptive implants—increased across both categories of women as well, but saw a steeper rise for women in Medicaid expansion states.

Almost 4.5 percent of women in Medicaid expansion states (4.4 percent ) used long-acting reversible contraception in 2013. In 2014 after Medicaid expansion went into effect, that percentage rose to 5.3 percent, and, by 2016, 6.1 percent of women in Medicaid expansion states were using long-acting reversible contraception.

In contrast, in nonexpansion states, use of long-acting reversible contraception rose from 1.8 percent to 2.2 percent post-expansion, to 2.4 percent two years after expansion. Thus, by 2016, 3.7 percent fewer women in nonexpansion states were using long-acting reversible contraception than in Medicaid expansion states.

Among adolescents, contraception usage rose for those in Medicaid expansion states, but not for those in nonexpansion states. Expansion states saw a one percent increase in the most effective contraceptive methods in the first year after expansion. Then it rose another two percentage points to 6.1 percent in 2016.

In nonexpansion states, adolescent contraceptive reception hovered around 2 percent.

Finally, women who went to an expansion state Title X clinic were more likely to receive both moderately effective contraceptives or a combination of moderately effective and most effective contraceptives.

“Although the absolute increase in contraceptive use attributable to Medicaid expansion is small, this difference is meaningful from a population health perspective,” the researchers argued. “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.”

Medicaid expansion has proven influential on women’s health in a variety of ways.

In a separate study, researchers found that Medicaid expansion improved postpartum coverage. The extended coverage led to more outpatient utilization, particularly for mothers with severe morbidity.

Also, presumptive eligibility under Medicaid expansion helped pregnant women as well as children receive care during the coronavirus pandemic.

Medicaid expansion can help protect women from the high out-of-pocket spending that they might otherwise face on alternative forms of insurance, specifically high-deductible health plans. Such plans have left women with bills of $4,569 after they gave birth—not because of rising cost, but because of rising cost-sharing, with women shouldering a higher amount of the price.

The researchers for the study published in JAMA Open Network highlighted the need to explore whether the effects of Medicaid expansion on contraception reception continued after 2016.