The Impact of the Affordable Care Act Young Adult Provision on Childbearing: Evidence From Tax Data

Health insurance and fertility among low-income, childless, single women: evidence from the ACA Medicaid expansions

Expansions of Medicaid family planning services have been associated with decreases in pregnancy rates. Access to a broader range of medical, non-family planning services may influence pregnancy rates as well if the increased exposure to medical services spills over to other kinds of behaviour. Using a difference-in-difference approach, I examine the impact of the Affordable Care Act (ACA) Medicaid expansions on the propensity of low-income, single women to become single mothers. Previous expansions of Medicaid family planning services allow us to also investigate the influence of access to other medical services (i.e. non-family planning). I find that although access to contraceptives is associated with a reduction in the propensity of becoming a single mother among adult, low-income women, medical services beyond access to contraceptives can provide additional impacts.

Policy impacts on contraceptive access in the United States: a scoping review

Contraceptive access is influenced by policy decisions, which can expand and constrict the contraceptive options available. This study explored the impact of recent US federal policies on contraceptive access by identifying and reviewing empirical literature, which is then presented and discussed using Levesque et al.’s (2013) healthcare access framework. A scoping review was conducted to identify empirical studies (N = 96) examining the impact of recent federal policy (passed from 2009 to 2019) on contraceptive access. Most identified studies examined the role of the Affordable Care Act (n = 53) and Title X of the Public Health Service Act (n = 25), showing many benefits of both policies for contraceptive access, particularly through improved affordability, availability, and appropriateness of contraceptive care. Other identified studies examined the impact of policies funding abstinence-only sex education (n = 2) and the Teen Pregnancy Prevention Program (n = 3), military policies related to the availability of contraception (n = 1), guidelines for quality contraceptive care (n = 3), Title IX of the Education Amendments (n = 4), the Violence Against Women Act (n = 1), and the Veterans Access, Choice, and Accountability Act (n = 4). Through increased outreach efforts, normalising of care, availability of services, cost subsidies, and provider competencies, recent federal policy has, overall, enhanced contraceptive access across the dimensions of healthcare access. Numerous policy and practice gaps and needs are identified, and future directions for research, policy, and practice are suggested.

Policy impacts on contraceptive access in the United States: a scoping review

Contraceptive access is influenced by policy decisions, which can expand and constrict the contraceptive options available. This study explored the impact of recent US federal policies on contraceptive access by identifying and reviewing empirical literature, which is then presented and discussed using Levesque et al.’s (2013) healthcare access framework. A scoping review was conducted to identify empirical studies (N = 96) examining the impact of recent federal policy (passed from 2009 to 2019) on contraceptive access. Most identified studies examined the role of the Affordable Care Act (n = 53) and Title X of the Public Health Service Act (n = 25), showing many benefits of both policies for contraceptive access, particularly through improved affordability, availability, and appropriateness of contraceptive care. Other identified studies examined the impact of policies funding abstinence-only sex education (n = 2) and the Teen Pregnancy Prevention Program (n = 3), military policies related to the availability of contraception (n = 1), guidelines for quality contraceptive care (n = 3), Title IX of the Education Amendments (n = 4), the Violence Against Women Act (n = 1), and the Veterans Access, Choice, and Accountability Act (n = 4). Through increased outreach efforts, normalising of care, availability of services, cost subsidies, and provider competencies, recent federal policy has, overall, enhanced contraceptive access across the dimensions of healthcare access. Numerous policy and practice gaps and needs are identified, and future directions for research, policy, and practice are suggested.

Impacts of the Affordable Care Act's Medicaid Expansion on Live Births

BACKGROUND

We hypothesize that the Affordable Care Act's (ACA) Medicaid expansion, which extended health insurance coverage to preconception, between-conception, and postconception periods for women meeting income eligibility guidelines, impacted the number of live births in the United States by increasing access to contraception and financial well-being. These impacts may differ by maternal socioeconomic and demographic characteristics.

METHODS

Using data from birth certificates aggregated to the state-year level and a difference-in-differences design, we estimated the association between Medicaid expansion and count of live births. We also examined whether associations differed by socioeconomic and demographic characteristics.

RESULTS

Overall, Medicaid expansion was not meaningfully associated with the count of births (difference-in-differences ß = 0.002; 95% confidence interval [CI] = -0.010, 0.015). However, among certain groups, Medicaid expansion was associated with meaningful changes in the count of live births, though all confidence intervals included the null value. The estimate of the relation between Medicaid expansion and the count of live births was -0.025 (95% CI = -0.052, 0.001) for those ages 18-24 years; -0.078 (95% CI = -0.231, 0.075) for those who were married, and -0.035 (95% CI = -0.104, 0.034) for those who were unmarried.

CONCLUSIONS

Despite its potential to impact live births, our results indicate that the ACA's Medicaid expansion was not, in general, associated with live births of US residents of reproductive age. However, for younger, married, and unmarried women, the magnitude of estimates supports the hypothesis of a potentially meaningful effect of Medicaid expansions on live births.

Association of Affordable Care Act Medicaid Expansions with Births Among Low-Income Women of Reproductive Age

Background: This study examined the association between Medicaid expansions under the Affordable Care Act (ACA) and births among low-income women of reproductive age in the United States. Methods: We used data from the 2008 to 2019 American Community Survey to estimate the association between state adoption of Medicaid expansion under the ACA and the percent of low-income women of reproductive age with a birth in the past year using a difference-in-difference research design. Subgroup analysis was explored by race and ethnicity, age group, educational attainment, marital status, and number of children. Results: We found that Medicaid expansion was associated with a small reduction in births among low-income women of reproductive age by 0.45 percentage points (95% confidence interval: -0.84 to -0.05). In subgroup analyses, we found reductions in births among Hispanic women, American Indian or Alaska Native women, women 25-29 years of age, women 35-39 years of age, unmarried women, and women with more than three children. Conclusions: Reductions in births associated with Medicaid expansion could suggest that expanding Medicaid addressed previously unmet reproductive health care needs among low-income women of reproductive age. The reductions in births among low-income women that we observe were occurring among some groups with higher unintended pregnancy rates, including Hispanic women, American Indian or Alaska Native women, young women, and unmarried women. These findings underscore the importance of reproductive health care access through insurance coverage on empowering women to have control over their reproductive decision-making and timing.

The effects of the dependent coverage provision on young women's utilization of sexual and reproductive health services

The Affordable Care Act dependent coverage provision expanded insurance for young adults by allowing maintained coverage through a parent's plan until the age of 26. This study examines whether this provision was associated with changes in sexual and reproductive health service utilization among young adult women, and if effects differed by race/ethnicity. The National Survey of Family Growth data were used to examine utilization among women before (2006-2009) and after (2011-2013) enactment of the provision. A difference-in-differences model was used to evaluate the effects on four measures of sexual and reproductive health services and one measure of health insurance coverage, treating women 19-25 years old as the exposure group and women 27-34 years old as the control group. This study finds that the dependent coverage provision was associated with a significant decrease in the probability of lacking health insurance, but finds no effects on sexual and reproductive health service utilization overall. In stratified models, increases in receipt of birth control prescriptions and methods as well as birth control check-ups or tests were present only for Hispanic women. There were no significant effects on birth control counseling or information or STD service utilization for any groups. Lacking health insurance coverage decreased only among non-Hispanic White women and Hispanic women, but was not significant for non-Hispanic Black women. These results suggest that women's utilization of sexual and reproductive health services overall may not increase with parental insurance gains, but Hispanic women do increase utilization of some birth control services with this improved coverage.

Health insurance and opioid deaths: Evidence from the Affordable Care Act young adult provision

The concurrence of health insurance expansion under the Affordable Care Act (ACA) and increasing opioid-related mortality has led to debate whether insurance increases or decreases opioid deaths. I use the introduction of the ACA young adult (YA) provision as a quasi-experiment and utilize the resulting policy-induced variation across states over time in YA access to insurance to study the effect of coverage on opioid-related mortality. I rely on the share of state populations which stood to gain insurance before the ACA to perform a dose-response analysis, and find that the YA provision reduced opioid-related mortality. The analysis suggests that 1 percentage point more coverage reduced opioid mortality among YA by 2.5/100,000 or 19.8%.