Health insurance coverage among women of reproductive age before and after implementation of the affordable care act.

OBJECTIVES: The Affordable Care Act's expansions to Medicaid and private coverage are of particular importance for women of childbearing age, who have numerous preventive care and reproductive health care needs. STUDY DESIGN: We conducted two national surveys, one in 2012 and one in 2015, collecting information about health insurance coverage and access to care from 8000 women aged 18-39. We examine type of insurance and continuity of coverage between time periods, including poverty status and whether or not women live in a state that expanded Medicaid coverage. RESULTS: The proportion of women who were uninsured declined by almost 40% (from 19% to 12%), though several groups, including US-born and foreign-born Latinas, experienced no significant declines. Among low-income women in states that expanded Medicaid, the proportion uninsured declined from 38% to 15%, largely due to an increase in Medicaid coverage (from 40% to 62%). Declines in uninsurance in nonexpansion states were only marginally significant. CONCLUSIONS: Despite substantial improvements in health insurance coverage, significant gaps remain, particularly in states that have not expanded Medicaid and for Latinas. IMPLICATIONS: This analysis examines changes in insurance coverage that occurred after the Affordable Care Act was implemented. While coverage has improved for many populations, sizeable gaps in coverage remain for Latinas and women in states that did not expand Medicaid.

Impact of the federal contraceptive coverage guarantee on out-of-pocket payments for contraceptives: 2014 update.

BACKGROUND: The Affordable Care Act requires most private health plans to cover contraceptive methods, services and counseling, without any out-of-pocket costs to patients; that requirement took effect for millions of Americans in January 2013. STUDY DESIGN: Data for this study come from a subset of the 1842 women aged 18-39 years who responded to all four waves of a national longitudinal survey. This analysis focuses on the 892 women who had private health insurance and who used a prescription contraceptive method during any of the four study periods. Women were asked about the amount they paid out of pocket in an average month for their method of choice. RESULTS: Between fall 2012 and spring 2014, the proportion of privately insured women paying zero dollars out of pocket for oral contraceptives increased substantially, from 15% to 67%. Similar changes occurred among privately insured women using injectable contraception, the vaginal ring and the intrauterine device. CONCLUSIONS: The implementation of the federal contraceptive coverage requirement appears to have had a notable impact on the out-of-pocket costs paid by privately insured women, and that impact has increased over time. IMPLICATIONS: This study measures the out-of-pocket costs for women with private insurance prior to the federal contraceptive coverage requirement and after it took effect; in doing so, it highlights areas of progress in eliminating these costs.

Return on investment: a fuller assessment of the benefits and cost savings of the US publicly funded family planning program.

UNLABELLED: Policy Points: The US publicly supported family planning effort serves millions of women and men each year, and this analysis provides new estimates of its positive impact on a wide range of health outcomes and its net savings to the government. The public investment in family planning programs and providers not only helps women and couples avoid unintended pregnancy and abortion, but also helps many thousands avoid cervical cancer, HIV and other sexually transmitted infections, infertility, and preterm and low birth weight births. This investment resulted in net government savings of $13.6 billion in 2010, or $7.09 for every public dollar spent. CONTEXT: Each year the United States' publicly supported family planning program serves millions of low-income women. Although the health impact and public-sector savings associated with this program's services extend well beyond preventing unintended pregnancy, they never have been fully quantified. METHODS: Drawing on an array of survey data and published parameters, we estimated the direct national-level and state-level health benefits that accrued from providing contraceptives, tests for the human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs), Pap tests and tests for human papillomavirus (HPV), and HPV vaccinations at publicly supported family planning settings in 2010. We estimated the public cost savings attributable to these services and compared those with the cost of publicly funded family planning services in 2010 to find the net public-sector savings. We adjusted our estimates of the cost savings for unplanned births to exclude some mistimed births that would remain publicly funded if they had occurred later and to include the medical costs for births through age 5 of the child. FINDINGS: In 2010, care provided during publicly supported family planning visits averted an estimated 2.2 million unintended pregnancies, including 287,500 closely spaced and 164,190 preterm or low birth weight (LBW) births, 99,100 cases of chlamydia, 16,240 cases of gonorrhea, 410 cases of HIV, and 13,170 cases of pelvic inflammatory disease that would have led to 1,130 ectopic pregnancies and 2,210 cases of infertility. Pap and HPV tests and HPV vaccinations prevented an estimated 3,680 cases of cervical cancer and 2,110 cervical cancer deaths; HPV vaccination also prevented 9,000 cases of abnormal sequelae and precancerous lesions. Services provided at health centers supported by the Title X national family planning program accounted for more than half of these benefits. The gross public savings attributed to these services totaled approximately $15.8 billion-$15.7 billion from preventing unplanned births, $123 million from STI/HIV testing, and $23 million from Pap and HPV testing and vaccines. Subtracting $2.2 billion in program costs from gross savings resulted in net public-sector savings of $13.6 billion. CONCLUSIONS: Public expenditures for the US family planning program not only prevented unintended pregnancies but also reduced the incidence and impact of preterm and LBW births, STIs, infertility, and cervical cancer. This investment saved the government billions of public dollars, equivalent to an estimated taxpayer savings of $7.09 for every public dollar spent.

Changes in out-of-pocket payments for contraception by privately insured women during implementation of the federal contraceptive coverage requirement.

BACKGROUND: As part of the Affordable Care Act, a federal requirement for private health plans to cover contraceptive methods, services and counseling, without any out-of-pocket costs to patients, took effect for millions of Americans in January 2013. STUDY DESIGN: Data for this study come from a subset of the 3207 women aged 18-39 years who responded to two waves of a national longitudinal survey. This analysis focused on the 889 women who were using hormonal contraceptive methods in both the fall 2012 and spring 2013 waves and the 343 women who used the intrauterine device at either wave. Women were asked about the amount they paid out of pocket in an average month for their method of choice. RESULTS: Between Wave 1 and Wave 2, the proportion of privately insured women paying zero dollars out of pocket for oral contraceptives increased substantially, from 15% to 40%; by contrast, there was no significant change among publicly insured or uninsured women (whose coverage was not affected by the new federal requirement). Similar changes were seen among privately insured women using the vaginal ring. CONCLUSIONS: The initial implementation of the federal contraceptive coverage requirement appears to have had a notable impact on the out-of-pocket costs paid by privately insured women. Additional progress is likely as the requirement phases in to apply to more private plans, but with evidence that not all methods are being treated equally, policymakers should consider stepped-up oversight and enforcement of the provision. IMPLICATIONS: This study measures the out-of-pocket costs for women with private, public and no insurance prior to the federal contraceptive coverage requirement and after it took effect; in doing so, it highlights areas of progress in eliminating these costs and areas that need further progress.

The Affordable Care Act and reproductive health: potential gains and serious challenges.

After nearly a century of failed or incomplete legislative efforts, the Patient Protection and Affordable Care Act (PPACA), enacted by Congress in March 2010, establishes the principle that every American is entitled to affordable and effective health insurance coverage regardless of income or health status. Although many aspects of the act have received broad attention, its impact on reproductive health has received considerably less scrutiny, except when debated through the specific lens of particularly polarized ideological concerns. If fully implemented as planned, the PPACA has the potential to improve reproductive health in the United States in at least three ways: increasing the number of women and men with insurance coverage; increasing the value of insurance coverage for addressing reproductive health needs; and improving access to reproductive health services and information more generally. Several PPACA provisions stand out as having particular importance for reproductive health, including Medicaid family planning expansions, standards for an essential health benefits package, expanded coverage for contraception and other clinical preventive services, and teen pregnancy prevention programs. All these potential gains, however, are threatened by political, economic, and logistical challenges to the PPACA and by flaws in the legislation itself.

The public costs of births resulting from unintended pregnancies: national and state-level estimates.

CONTEXT: Births resulting from unintended pregnancies are associated with substantial maternity and infant care costs to the federal and state governments; these costs have never been estimated at the national and state levels. METHODS: The proportions of births paid for by public insurance programs in 2006 were estimated, by pregnancy intention status, using data from the Pregnancy Risk Assessment Monitoring System and similar state surveys, or were predicted by multivariate linear regression. Public costs were calculated using state-level estimates of the number of births, by intention status, and of the cost of a publicly funded birth. RESULTS: In 2006, 64% of births resulting from unintended pregnancies were publicly funded, compared with 48% of all births and 35% of births resulting from intended pregnancies. The proportion of births resulting from unintended pregnancies that were publicly funded varied by state, from 42% to 81%. Of the 2.0 million publicly funded births, 51% resulted from unintended pregnancies, accounting for $11.1 billion in costs-half of the total public expenditures on births. In seven states, the costs for births from unintended pregnancies exceeded a half billion dollars. CONCLUSIONS: Public insurance programs are central in assisting American families in affording pregnancy and childbirth; however, they pay for a disproportionately high number of births resulting from unintended pregnancy. The resulting budgetary impact warrants increased public efforts to reduce unintended pregnancy.

Reassessing adolescent male sexual and reproductive health in the United States: research and recommendations.

Adolescent males are practicing safer sexual behaviors and experiencing healthier outcomes than their predecessors. In recent years, adolescent males have tended to start having sex later in life, have fewer sexual partners, use condoms and other contraceptive methods more often, and father fewer children. Yet sexual activity during adolescence remains the norm, and thus adolescent sexual and reproductive health (SRH) remains an important concern. Moreover, large disparities remain in risk and outcomes according to race/ethnicity, sexual orientation, social connectivity, and where men live. Policy and program advances have been limited. Adolescent males are less likely than they were a decade ago to be receiving broad-based SRH information in school, and their access to clinical services has increased only marginally. Most new funding has been provided for ineffective abstinence-only education programs. Prerequisites for continued progress include research to fill in gaps in our knowledge, arriving at societal consensus around key controversies, and new tactics and allies in the political arena.

U.S. insurance coverage of contraceptives and the impact of contraceptive coverage mandates, 2002.

CONTEXT: In 1993, coverage of reversible contraception by U.S. health insurance plans was extremely low. Little is known about how coverage has changed since then, particularly in response to state mandates. METHODS: In 2001-2002, a nationally representative sample of 205 health care insurers responded to a survey about coverage of reproductive health care services in "typical" employment-based managed care plans (excluding self-insured plans). Data were analyzed to compare coverage in states with and without contraceptive coverage mandates, and to show trends in coverage between 1993 and 2002. RESULTS: In 2002, almost every reversible contraceptive service and supply studied was covered by at least 89% of typical plans; 86% of plans covered the five leading prescription methods (the diaphragm, one- and three-month injectables, the IUD and oral contraceptives). Coverage of each contraceptive service and supply studied was higher in 2002 than in 1993 (78-97% vs. 32-59%). Plans in states with mandates were significantly more likely to cover the five leading prescription methods (87-92%, depending on type of plan) than were those designed locally in states without mandates (47-61%). Between 1993 and 2002, state mandates were estimated to account for 30% and 40% of the increase in coverage of oral contraceptives and the three-month injectable, respectively. CONCLUSIONS: Coverage of reversible contraception--and by extension, choice within a range of covered methods--has increased substantially since 1993, in part because of state mandates. This state-by-state approach, however, has inherent limitations that can best be dealt with at the federal level.