The effect of health insurance on sexual health: Evidence from the Affordable Care Act's dependent coverage mandate

Effects of marriage equality legislation on sexual health of the US population

Even though prior research has investigated the relationship between same-sex partnership recognition policies and health outcomes, the impact of same-sex marriage laws on sexually transmitted infections has not received much attention. Using state-level panel data from 2000 to 2019, I show that marriage equality legislation decreases the spread of (shorter-term) syphilis infections and of (longer-term) human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) infections among the general population. Event study analyses correcting for non-staggered treatment implementation confirm these negative effects, but also suggest that standard difference-in-differences models understate the impact of the legislation by up to 8% points. Further analysis supports that these legislation effects operate through three mechanisms: increasing social tolerance, strengthening relationship commitment, and expanding health care access and coverage for HIV/AIDS prevention and treatment. Disaggregating the results by sexual behavior reveals that legal access to same-sex marriage leads to sizable decreases in AIDS rates among men who have sex with men (MSM) (the most at-risk population for an infection). Even though there is economically significant evidence that the legislation improves sexual health of the heterosexual population due to increased utilization of preventive sexual health care, the legislation does not have a direct impact on infection rates for the non-MSM population.

Unintended consequences of health insurance: Affordable Care Act's free contraception mandate and risky sex

Health insurance is a primary driver of rising medical expenditures. Economic theory suggests that insurance induces an increase in risky behaviors, but previous empirical evidence is mixed. I use a mandate in the Affordable Care Act in which contraceptives were covered at zero cost to consumers to test for unintended effects of insurance on risky sex. Leveraging mandated zero cost-sharing for contraception and pre-policy insured rates as a measure of treatment intensity, I provide evidence that this 2012 policy reduced fertility but caused unintended consequences: a decline in condom use and a subsequent increase in sexually transmitted infections (STIs). I discuss shortcomings of controlling for nonparallel pre-trends using state-trends, and I suggest an alternative to control for pre-trends directly in the context of dose-response difference-in-differences. Finally, estimates based on the 2010 dependent coverage mandate indicate health insurance provides an overall net positive effect on insurance and STI prevention.

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.

Trends and Disparities in Sexual and Reproductive Health Behaviors and Service Use Among Young Adult Women (Aged 18-25 Years) in the United States, 2002-2015

OBJECTIVES

To describe trends in sexual and reproductive health behaviors and service utilization among young women in the United States.

METHODS

We analyzed data from 8835 female respondents aged 18 to 25 years from 4 cycles of the National Survey of Family Growth, a nationally representative cross-sectional survey, from 2002 to 2015. We used bivariate and multivariable logistic regression to compare rates of self-reported sexual activity, sexually transmitted infection-related care, and contraception use over time and by race/ethnicity.

RESULTS

Sexually transmitted infection-related care and human papilloma virus vaccination increased from 2002 to 2013-2015, whereas sexual activity and contraception use remained stable. Compared with White women, racial/ethnic minority women were less likely to report effective contraception use, and Black women were less likely to report human papilloma virus vaccination; these differences did not change over time.

CONCLUSIONS

Sexual and reproductive health service utilization increased from 2002 to 2015 among young women, whereas sexual activity remained stable. Overall, rates of recommended care were low, and racial and ethnic disparities persisted. Public Health Implications. Young women could benefit from clinical interventions and health policies to increase recommended care and reduce disparities.