Evaluation of Medicaid Expansion Under the Affordable Care Act and Contraceptive Care in US Community Health Centers

Blair G Darney 1 2 3, R Lorie Jacob 4, Megan Hoopes 4, Maria I Rodriguez 1, Brigit Hatch 1 4, Miguel Marino 1 2, Anna Templeton 4, Jee Oakley 4, Erika K Cottrell 1 4

Affiliations

PMID: 32496568
PMCID: PMC7273194
DOI: 10.1001/jamanetworkopen.2020.6874

Free PMC article

Abstract

Importance: Use of effective contraception decreases unintended pregnancy. It is not known whether Medicaid expansion under the Affordable Care Act increased use of contraception for women who are underserved in the US health care safety net.

Objective: To evaluate the association of Medicaid expansion under the Affordable Care Act with changes in use of contraception among patients at risk of pregnancy at US community health centers, with the hypothesis that Medicaid expansion would be associated with increases in use of the most effective contraceptive methods (long-acting reversible contraception).

Design, setting, and participants: This was a participant-level retrospective cross-sectional study comparing receipt of contraception before (2013) vs immediately after (2014) and a longer time after (2016) Medicaid expansion. Electronic health record data from a clinical research network of community health centers across 24 states were included. The sample included all female patients ages 15 to 44 years at risk for pregnancy, with an ambulatory care visit at a participating community health center during the study period (315 clinics in expansion states and 165 clinics in nonexpansion states).

Exposures: Medicaid expansion status (by state).

Main outcomes and measures: Two National Quality Forum-endorsed contraception quality metrics, calculated annually: the proportion of women at risk of pregnancy who received (1) either a moderately effective or most effective method (hormonal and long-acting reversible contraception) methods and (2) the most effective method (long-acting reversible contraception).

Results: The sample included 310 132 women from expansion states and 235 408 women from nonexpansion states. The absolute adjusted increase in use of long-acting reversible contraceptive methods was 0.58 (95% CI, 0.13-1.05) percentage points greater among women in expansion states compared with nonexpansion states in 2014 and 1.19 (95% CI, 0.41-1.96) percentage points larger in 2016. Among adolescents, the association was larger, particularly in the longer term (2014 vs 2013: absolute difference-in-difference, 0.80 [95% CI, 0.30-1.30] percentage points; 2016 vs 2013: absolute difference, 1.79 [95% CI, 0.88-2.70] percentage points). Women from expansion states who received care at a Title X clinic had the highest percentage of women receiving most effective contraceptive methods compared with non-Title X clinics and nonexpansion states.

Conclusions and relevance: In this study, Medicaid expansion was associated with an increase in use of long-acting reversible contraceptive methods among women at risk of pregnancy seeking care in the US safety net system, and gains were greatest among adolescents.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Darney consults for Ipas, a global nonprofit focused on safe abortion, and served as an expert in the Oregon Department of Justice’s litigation on proposed rule changes to Title X. Dr Rodriguez has served as a contraceptive trainer for Merck and the American Congress of Obstetricians and Gynecologists; served on an advisory board for Bayer; served as a consultant for the World Health Organization; and received research funding via her institution from the Laura and John Arnold Foundation/Arnold Ventures, the National Institutes of Health, Merck and the Robert Wood Johnson Foundation on projects for which she is the primary investigator. Ms Hoopes and Dr Cottrell reported grants from Agency for Health Care Research & Quality during the conduct of the study. No other disclosures were reported.