1
|
Kraus EM, Chavan NR, Whelan V, Goldkamp J, DuBois JM. Reproductive decision making in women with medical comorbidities: a qualitative study. BMC Pregnancy Childbirth 2023; 23:848. [PMID: 38082419 PMCID: PMC10712035 DOI: 10.1186/s12884-023-06093-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 10/30/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND A growing number of reproductive-age women in the U.S. have chronic medical conditions, increasing their risk of perinatal morbidity and mortality. Still, they experience unintended pregnancies at similar rates to low-risk mothers. We have limited understanding of how these individuals consider decisions about pregnancy and contraceptive use. The purpose of this study was to understand factors that influence reproductive decision-making among pregnant women with chronic medical conditions. METHODS We conducted 28 semi-structured interviews with pregnant women with pre-existing medical conditions admitted to a tertiary maternal hospital to examine factors influencing reproductive decision making. Maternal demographic characteristics, medical history, and pregnancy outcome data were obtained through participant surveys and abstraction from electronic health records. Interview transcripts were coded and analyzed using Dedoose® with both deductive and inductive content analysis. RESULTS Out of 33 eligible participants, 30 consented to participate and 28 completed interviews. The majority of participants identified as black, Christian, made less than $23,000 yearly, and had a variety of preexisting medical conditions. Overarching themes included: 1) Perceived risks-benefits of pregnancy, 2) Perceived risks-benefits of birth control, 3) Determinants of contraceptive utilization, and 4) Perceived reproductive self-agency. Contraception was viewed as acceptable, but with concerning physical and psychological side effects. Although some considered pregnancy as a health threat, more experienced pregnancy as positive and empowering. Few planned their pregnancies. CONCLUSIONS Preexisting health conditions did not significantly influence reproductive decision-making. Barriers to birth control use were generally based in patient value-systems instead of external factors. Interventions to improve uptake and use of birth control in this cohort should focus on improving care for chronic health conditions and influencing patient knowledge and attitudes toward contraception.
Collapse
Affiliation(s)
- Elena M Kraus
- Department of Obstetrics, Gynecology and Women's Health, Maternal Fetal Medicine, Saint Louis University School of Medicine, St. Louis, MO, 63117, USA.
- Department of Obstetrics & Gynecology, Creighton University School of Medicine, Omaha, NE, 68178, USA.
| | - Niraj R Chavan
- Department of Obstetrics, Gynecology and Women's Health, Maternal Fetal Medicine, Saint Louis University School of Medicine, St. Louis, MO, 63117, USA
| | - Victoria Whelan
- Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Jennifer Goldkamp
- Mercy Clinic Maternal and Fetal Medicine, Saint Louis, MO, 63141, USA
| | - James M DuBois
- Division of General Medical Sciences, Washington University School of Medicine, St. Louis, MO, 63110, USA
| |
Collapse
|
2
|
Shaw JG, Goldthwaite LM, Marić I, Shaw KA, Stevenson DK, Shaw GM. Postpartum long-acting reversible contraception among privately insured: U.S. National analysis 2007-2016, by term and preterm birth. Contraception 2023; 125:110065. [PMID: 37210023 DOI: 10.1016/j.contraception.2023.110065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 05/06/2023] [Accepted: 05/08/2023] [Indexed: 05/22/2023]
Abstract
OBJECTIVES To investigate postpartum long-acting reversible contraception (LARC) use among privately insured women, with specific consideration of use after preterm delivery. STUDY DESIGN We used the national IBM MarketScan Commercial Database to identify singleton deliveries from 2007 to 2016, spontaneous preterm birth, and follow-up ≤12 weeks postpartum. We assessed ≤12-week postpartum LARC placement overall and after spontaneous preterm deliveries, across study years. We examined timing of placement, rates of postpartum follow-up, and state-level variation in postpartum LARC. RESULTS Among 3,132,107 singleton deliveries, 6.6% were spontaneous preterm. Over the time period, total postpartum LARC use increased 4.8% to 11.7% for intrauterine devices (IUDs), 0.2% to 2.4% for implants. In 2016, those who experienced a spontaneous preterm birth were less likely to initiate postpartum IUDs compared to their peers (10.2% vs 11.8%, p < 0.001), minimally more likely to initiate implants (2.7% vs 2.4%, p = 0.04) and more likely to present for postpartum care (61.7% vs 55.9%, p < 0.001). LARC placement prior to hospital discharge was rare (preterm: 8 per 10,000 deliveries vs all others: 6.3 per 10,000 deliveries, p = 0.002). State-level analysis showed wide variation in postpartum LARC (range 6%-32%). CONCLUSIONS While postpartum LARC use increased among the privately insured 2007-2016, few received LARC prior to hospital discharge. Those experiencing preterm birth were no more likely to receive inpatient LARC. Postpartum follow-up remained low and regional variation of LARC was high, highlighting the need for efforts to remove barriers to inpatient postpartum LARC for all who desire it-public and privately insured alike. IMPLICATIONS Among the half of U.S. births that are privately insured, postpartum LARC is increasing after both term and preterm births, yet exceedingly few (<0.1%) received LARC prior to hospital discharge.
Collapse
Affiliation(s)
- Jonathan G Shaw
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA.
| | | | - Ivana Marić
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Kate A Shaw
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California, USA
| | - David K Stevenson
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Gary M Shaw
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| |
Collapse
|
3
|
Policy impacts on contraceptive access in the United States: a scoping review. JOURNAL OF POPULATION RESEARCH 2023. [DOI: 10.1007/s12546-023-09298-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
AbstractContraceptive 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.
Collapse
|
4
|
Swan LET. Policy impacts on contraceptive access in the United States: a scoping review. JOURNAL OF POPULATION RESEARCH 2023; 40:5. [DOI: https:/doi.org/10.1007/s12546-023-09298-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2022] [Indexed: 06/22/2023]
Abstract
AbstractContraceptive 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.
Collapse
|
5
|
Fusco N, Sils B, Graff JS, Kistler K, Ruiz K. Cost-sharing and adherence, clinical outcomes, health care utilization, and costs: A systematic literature review. J Manag Care Spec Pharm 2023; 29:4-16. [PMID: 35389285 PMCID: PMC10394195 DOI: 10.18553/jmcp.2022.21270] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND: US health plans are adopting benefit designs that shift greater financial burden to patients through higher deductibles, additional copay tiers, and coinsurance. Prior systematic reviews found that higher cost was associated with reductions in both appropriate and inappropriate medications. However, these reviews were conducted prior to contemporary benefit design and medication utilization. OBJECTIVE: To assess the relationship and factors associated with cost-sharing and (1) medication adherence, (2) clinical outcomes, (3) health care resource utilization (HRU), and (4) costs. METHODS: A systematic review of literature published between January 2010 and August 2020 was conducted to identify the relationship between cost-sharing and medication adherence, clinical outcomes, HRU, and health care costs. Data were extracted using a standardized template and were synthesized by key questions of interest. RESULTS: From 1,995 records screened, 79 articles were included. Most studies, 71 of 79 (90%), reported the relationship between cost-sharing and treatment adherence, persistence and/or discontinuation; 16 (20%) reported data on cost-sharing and HRU or medication initiation, 11 (14%) on costsharing and health care costs, and 6 (8%) on cost-sharing and clinical outcomes. The majority of publications found that, regardless of disease area, increased cost-sharing was associated with worse adherence, persistence, or discontinuation. The aggregate data suggested the greater the magnitude of cost-sharing, the worse the adherence. Among studies examining clinical outcomes, cost-sharing was associated with worse outcomes in 1 study and the remaining 3 found no significant differences. Regarding HRU, higher-cost-sharing trended toward decreased outpatient and increased inpatient utilization. The available evidence suggested higher cost-sharing has an overall neutral to negative impact on total costs. Studies evaluating elimination of copays found either decreased or no impact in total costs. CONCLUSIONS: The published literature shows consistent impacts of higher cost sharing on initiation and continuation of medications, and the greater the cost-sharing, the worse the medication adherence. The evidence is limited regarding the impact of cost-sharing on clinical outcomes, HRU, and costs. Limited evidence suggests increased cost-sharing is associated with more inpatient care and less outpatient care; however, a neutral to no difference was suggested for other outcomes. Although increased costsharing is intended to decrease total costs, studies evaluating reducing or eliminating cost-sharing found that total costs did not rise. Today's growing cost-containment environment should carefully consider the broader impact cost-sharing has on treatment adherence, clinical outcomes, resource use, and total costs. It may be that cost-sharing is a blunt, rather than precise, tool to curb health care costs, affecting both necessary and unnecessary health care use. DISCLOSURES: This study and the development of this article were funded by the National Pharmaceutical Council. Mr Sils is an employee of the National Pharmaceutical Council. Dr Graff is a former employee of the National Pharmaceutical Council. Drs Fusco and Kistler and Ms Ruiz are employees of Xcenda. Xcenda received funding to conduct the literature review.
Collapse
Affiliation(s)
| | - Brian Sils
- National Pharmaceutical Council, Washington, DC
| | | | | | | |
Collapse
|
6
|
De Silva DA, Gleason JL. Affordable Care Act (ACA) Implementation and Adolescent Births by Insurance Type: An Interrupted Time Series Analysis of Births between 2009 and 2017 in the United States. J Pediatr Adolesc Gynecol 2022; 35:685-691. [PMID: 35820607 DOI: 10.1016/j.jpag.2022.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 06/22/2022] [Accepted: 07/05/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND In 2010, the Affordable Care Act (ACA) was enacted, with full provisions in effect by 2014, including expanded Medicaid coverage, changes to the marketplace, and contraceptive coverage, but its impact on birth trends, particularly adolescent births, is currently unknown. OBJECTIVES We sought to determine whether ACA implementation was associated with changes in adolescent births and whether this differed by insurance type (Medicaid or private insurance). METHODS We used revised 2009-2017 birth certificate data, restricted to resident women with a Medicaid or privately paid singleton birth (N = 27,748,028). Segmented regression analysis was used to examine births to adolescent mothers (12-19 years old) before and after the ACA. RESULTS There were 27,748,028 singleton births (n = 2,013,521 adolescent births) among U.S. residents between 2009 and 2017 in this analytic sample. Adjusted models revealed that the ACA was associated with a 23% significant decrease in odds of an adolescent birth (OR = 0.78; 95% CI, 0.77-0.79) for Medicaid-funded births and a 19% decrease (OR = 0.81; 95% CI, 0.79-0.83) for privately insured births, with a further declining trend. Overall declines in adolescent births among the Medicaid population appear to be driven by states that chose to expand Medicaid. CONCLUSION Beyond the declining secular trend already observed in adolescent pregnancy over the last 10 years, the ACA appears to have had a substantial impact on adolescent births, likely due to Medicaid expansion and increased access to affordable contraception. From a population health perspective, efforts to undo the ACA could have important consequences for maternal, infant, and family health in the United States.
Collapse
Affiliation(s)
- Dane A De Silva
- Department of Family Science, School of Public Health, University of Maryland, College Park, MD, United States.
| | - Jessica L Gleason
- Department of Family Science, School of Public Health, University of Maryland, College Park, MD, United States
| |
Collapse
|
7
|
Downey MMB, Patteson Poehling C, O'Connell S. Measurement and Operationalization of the Social Determinants of Health and Long-Acting Reversible Contraception Use in the U.S.: A Systematic Scoping Review. AJPM FOCUS 2022; 1:100032. [PMID: 37791245 PMCID: PMC10546546 DOI: 10.1016/j.focus.2022.100032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
Introduction The objective of this review was to conduct a systematic evaluation of the measurement and operationalization of the social determinants of health in research on long-acting reversible contraception use in the U.S. To contribute to the ongoing refinement of the quality of social determinants of health and long-acting reversible contraception use research, this systematic scoping review examines how social determinants of health are measured and operationalized in studies that examine long-acting reversible contraception initiation and usage at the patient level. Methods A detailed search of 5 electronic databases (PubMed, Embase, Web of Science, CINAHL, and PsycINFO) was conducted between December 2020 and January 2021 according to PRISMA guidelines. Determinants were assessed using the Dahlgren and Whitehead model. The protocol and data extraction template were developed a priori. Results A total of 27 articles representing 26 studies were included in our study. A total of 12 studies were retrospective and cross-sectional in design; the remaining studies were a combination of designs. Healthcare services and health insurance were identified as the most frequently researched categories of determinants. There was wide variation in reported operationalization of race and ethnicity, limited engagement with sexuality, and uneven geographic representation across studies. Discussion This systematic scoping review is the first, to the best of our knowledge, to focus on the measurement and operationalization of social determinants of health and on current long-acting reversible contraception use research. Future research on the impact of social determinants of health on long-acting reversible contraception use must explore the full range of factors shaping contraceptive decision making and use and focus on equity-informed data collection methods and reporting.
Collapse
Affiliation(s)
| | - Catherine Patteson Poehling
- School of Social Work, College of Education and Human Sciences, the University of Southern Mississippi, Hattiesburg, Mississippi
| | - Samantha O'Connell
- Tulane University Office of Academic Affairs & Provost, New Orleans, Louisiana
| |
Collapse
|
8
|
Pace LE, Saran I, Hawkins SS. Impact of Medicaid Eligibility Changes on Long-acting Reversible Contraception Use in Massachusetts and Maine. Med Care 2022; 60:119-124. [PMID: 34908011 DOI: 10.1097/mlr.0000000000001666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Availability of long-acting reversible contraception (LARC) is an important indicator of high-quality women's health care. There are limited data on the impact of state-level Medicaid eligibility changes on LARC use. STUDY DESIGN We used All-Payers Claims Databases to examine LARC insertions among women enrolled in Medicaid in Massachusetts, which expanded Medicaid in 2014, and Maine, which restricted Medicaid eligibility in 2013. We used interrupted time series (ITS) analyses to determine the impact of Medicaid eligibility changes on level and trends in LARC insertions in these states. RESULTS In Massachusetts, graphical evidence demonstrates that after Medicaid expansion, there was an immediate increase in mean monthly LARC insertions and insertions per 1000 enrollees. In ITS regression adjusting for age, LARC insertions per enrollee increased immediately after Medicaid expansion by 32% (P<0.001). After expansion, as the number of enrollees continued to rise, mean monthly LARC insertions rose, but there was a slightly decreasing trend in insertions per enrollee by 1% per month (P<0.001). In Maine, graphical evidence shows that initial reductions in Medicaid eligibility were associated with an immediate drop in LARC insertion numbers and rates per 1000, with ITS regression demonstrating an immediate 17% drop in insertions per enrollee (P<0.001). As Maine's Medicaid enrollment declined from 2013 to 2015, the number of LARC insertions remained flat, leading to an increasing trend in insertions per enrollee, similar to pre-2013 trends (P=0.17). CONCLUSIONS Medicaid eligibility changes were associated with immediate changes in LARC uptake. Medicaid expansion may help ensure access to this effective contraceptive method.
Collapse
Affiliation(s)
| | - Indrani Saran
- Boston College, School of Social Work, Chestnut Hill, MA
| | | |
Collapse
|
9
|
Ahrens KA, Skjeldestad FE. Trends in initiation of hormonal contraceptive methods among teenagers born between 1989 and 1997 in Norway and the United States. Contraception 2021; 104:635-641. [PMID: 34329611 DOI: 10.1016/j.contraception.2021.07.105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 07/16/2021] [Accepted: 07/17/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To assess initiation of hormonal contraception among women aged 15-19 in the US and Norway by birth cohort. STUDY DESIGN We used population-based survey (US) and administrative (Norway) data to estimate the cumulative probability of age at first use of hormonal contraception for female residents born between 1989 and 1997 in 3-year birth cohorts. Differences between countries were assessed using confidence intervals, and differences between birth cohorts were assessed using survival analysis. RESULTS At age 15, first use of any hormonal method was higher among US respondents (16%-17% US vs 10%-13% Norway), whereas for ages 16 to 19 use was higher among Norwegian women (by age 19, 60%-64% US vs 76%-78% Norway). Similar patterns were observed for pill use; however, depot medroxyprogesterone acetate (DMPA), implant, and intrauterine device (IUD) use tended to be higher among US women. In both countries, cumulative first use of the pill, patch, ring, and DMPA declined across birth cohorts while first use of implants and IUDs increased. CONCLUSION Age at initiation and type of first hormonal method use differed between US and Norwegian teenagers. These differences may contribute to the lower teen birth rate in Norway.
Collapse
Affiliation(s)
- Katherine A Ahrens
- Muskie School of Public Service, University of Southern Maine, Portland, ME United States.
| | - Finn Egil Skjeldestad
- Department of Community Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| |
Collapse
|
10
|
Norris HC, Richardson HM, Benoit MAC, Shrosbree B, Smith JE, Fendrick AM. Utilization Impact of Cost-Sharing Elimination for Preventive Care Services: A Rapid Review. Med Care Res Rev 2021; 79:175-197. [PMID: 34157906 DOI: 10.1177/10775587211027372] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Consumer cost-sharing has been shown to diminish utilization of preventive services. Recent efforts, including provisions within the Affordable Care Act, have sought to increase use of preventive care through elimination of cost-sharing for clinically indicated services. We conducted a rapid review of the literature to determine the impact of cost-share elimination on utilization of preventive services. Searches were conducted in PubMed, Scopus, and CINAHL Complete databases as well as in grey literature. A total of 35 articles were included in qualitative synthesis and findings were summarized for three clinical service categories: cancer screenings, contraceptives, and additional services. Impacts of cost-sharing elimination varied depending on clinical service, with a majority of findings showing increases in use. Studies that included socioeconomic status reported that those who were financially vulnerable incurred substantial increases in utilization. Future investigations on additional clinical services are warranted as is research to better elucidate populations who most benefit from cost-sharing elimination.
Collapse
Affiliation(s)
- Hope C Norris
- The University of Michigan, Ann Arbor, MI, USA.,New York University, New York, NY, USA
| | | | - Marie-Anais C Benoit
- The University of Michigan, Ann Arbor, MI, USA.,The George Washington University, Washington, DC, USA
| | | | | | | |
Collapse
|
11
|
Becker NV, Keating NL, Pace LE. ACA Mandate Led To Substantial Increase In Contraceptive Use Among Women Enrolled In High-Deductible Health Plans. Health Aff (Millwood) 2021; 40:579-586. [PMID: 33819082 DOI: 10.1377/hlthaff.2020.01710] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The Affordable Care Act (ACA) mandated that private health plans cover contraceptives without out-of-pocket expenses for patients. Previously, long-acting reversible contraceptives (LARCs) were subject to deductibles, making them a higher-cost service for women with high-deductible health plans (HDHPs); however, the ACA mandate applied to HDHPs as well as traditional health plans. Using a national commercial claims database, we examined LARC use among continuously enrolled reproductive-age women between 2010 and 2017, comparing 9,014 women enrolled in HDHPs with 443,363 women enrolled in non-HDHPs. Using a quasi-experimental difference-in-differences analysis, we found that pre-ACA HDHP enrollees had lower LARC initiation rates than women in non-HDHPs and that rates of LARC initiation increased by 35 percent more postmandate for women in HDHPs than for women in traditional plans. These findings suggest that the ACA had a particularly important impact for women in HDHPs, who faced higher pre-ACA out-of-pocket expenses for these contraceptive methods.
Collapse
Affiliation(s)
- Nora V Becker
- Nora V. Becker is an assistant professor in the Division of General Medicine at the University of Michigan, in Ann Arbor, Michigan
| | - Nancy L Keating
- Nancy L. Keating is a professor of health care policy and medicine in the Department of Health Care Policy, Harvard Medical School, and the Division of General Internal Medicine, Brigham and Women's Hospital, both in Boston, Massachusetts
| | - Lydia E Pace
- Lydia E. Pace is an assistant professor in the Division of Women's Health, Brigham and Women's Hospital, and an assistant professor of medicine at Harvard Medical School
| |
Collapse
|
12
|
Lee LK, Chien A, Stewart A, Truschel L, Hoffmann J, Portillo E, Pace LE, Clapp M, Galbraith AA. Women's Coverage, Utilization, Affordability, And Health After The ACA: A Review Of The Literature. Health Aff (Millwood) 2021; 39:387-394. [PMID: 32119612 DOI: 10.1377/hlthaff.2019.01361] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Women of working age (ages 19-64) faced specific challenges in obtaining health insurance coverage and health care before the Affordable Care Act. Multiple factors contributed to women's experiencing uninsurance, underinsurance, and increased financial burdens related to obtaining health care. This literature review summarizes evidence on the law's effects on women's health care and health and finds improvements in overall coverage, access to health care, affordability, preventive care use, mental health care, use of contraceptives, and perinatal outcomes. Despite major progress after the Affordable Care Act's implementation, barriers to coverage, access, and affordability remain, and serious threats to women's health still exist. Highlighting the law's effects on women's health is critical for informing future policies directed toward the continuing improvement of women's health care and health.
Collapse
Affiliation(s)
- Lois K Lee
- Lois K. Lee ( lois. lee@childrens. harvard. edu ) is a faculty physician in the Division of Emergency Medicine, Boston Children's Hospital, and an associate professor of pediatrics and emergency medicine at Harvard Medical School, both in Boston, Massachusetts
| | - Alyna Chien
- Alyna Chien is a faculty physician in the Division of General Pediatrics, Boston Children's Hospital, and an assistant professor of pediatrics at Harvard Medical School
| | - Amanda Stewart
- Amanda Stewart is a faculty physician in the Division of Emergency Medicine, Boston Children's Hospital, and an instructor of pediatrics at Harvard Medical School
| | - Larissa Truschel
- Larissa Truschel is a fellow in the Division of Emergency Medicine, Boston Children's Hospital, and an instructor of pediatrics at Harvard Medical School
| | - Jennifer Hoffmann
- Jennifer Hoffmann is a faculty physician in the Division of Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, and an assistant professor of pediatrics at the Northwestern University Feinberg School of Medicine, both in Chicago, Illinois
| | - Elyse Portillo
- Elyse Portillo is a fellow physician in the Division of Emergency Medicine, Boston Children's Hospital, and an instructor of pediatrics at Harvard Medical School
| | - Lydia E Pace
- Lydia E. Pace is an associate physician in the Division of Women's Health, Brigham and Women's Hospital, and an assistant professor in medicine at Harvard Medical School
| | - Mark Clapp
- Mark Clapp is a faculty physician in the Department of Obstetrics and Gynecology, Massachusetts General Hospital, and an instructor in obstetrics, gynecology and reproductive medicine at Harvard Medical School
| | - Alison A Galbraith
- Alison A. Galbraith is an associate professor of population medicine at the Harvard Pilgrim Health Care Institute and Harvard Medical School, both in Boston
| |
Collapse
|
13
|
Cost sharing, postpartum contraceptive use, and short interpregnancy interval rates among commercially insured women. Am J Obstet Gynecol 2021; 224:282.e1-282.e17. [PMID: 32898503 DOI: 10.1016/j.ajog.2020.08.109] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 08/07/2020] [Accepted: 08/28/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Increasing access to effective birth control after childbirth may meet many women's preferences and reduce short interpregnancy interval rates. Eliminating out-of-pocket costs for contraception has been reported to increase the use of the most effective methods among women with employer-based insurance, but the prevalence and effects of patient cost sharing for contraception have not been studied during the postpartum period. OBJECTIVE This study aimed to examine the association between cost sharing for long-acting reversible contraception and postpartum contraception use patterns and pregnancies in the 12 months after delivery. STUDY DESIGN We conducted a retrospective cohort analysis of commercially insured women undergoing childbirth from 2014 to 2018 using Optum's (Eden Prairie, MN) de-identified Clinformatics Data Mart database. This large national database includes nonretired employees and their dependents who are enrolled in health insurance plans sponsored by large- or medium-sized US-based employers. Women with 12 months of continuous enrollment postpartum were included. Childbirth, pregnancy, and contraceptive method (female sterilization, long-acting reversible contraceptives, other hormonal methods, and no prescription method observed) were identified using claims data. Contraceptive use patterns were observed at 3, 6, and 12 months postpartum and adjusted for individual and plan characteristics. Median out-of-pocket costs were $0 for sterilization and other hormonal methods but nonzero for long-acting reversible contraception. We therefore used simple and multivariable logistic regressions to examine the association between plan-level cost sharing (no cost sharing, $0; low cost sharing, >$0-<$200; and high cost sharing, ≥$200 out-of-pocket cost) for any long-acting reversible contraceptive insertion and contraceptive use patterns and short interpregnancy interval rates, controlling for age, household income, race and ethnicity, region, and insurance plan type. RESULTS Among 25,298 plans with cost sharing data, we identified 172,941 women with continuous enrollment for 12 months postpartum, including 82,500 (47.7%) in no cost sharing, 22,595 (13.1%) in low cost sharing, and 67,846 (39.2%) in high cost sharing plans. The percentage of postpartum women in the study sample using any prescription contraceptive method was 39.5% by 3 months, 43.8% by 6 months, and 46.0% by 12 months. At all time points, postpartum women in no cost sharing plans had a higher predicted probability of long-acting reversible contraceptive use (eg, at 12 months: no cost sharing, 22.0%; low cost-sharing, 17.5%; high cost sharing, 18.3%; P<.001) and a lower predicted probability of no prescription method use (eg, at 12 months: no cost sharing, 51.8%; low cost sharing, 55.0%; high cost sharing, 54.9%; P<.001) than those in low or high cost sharing plans. Predicted probabilities of female sterilization and other hormonal method use did not differ substantively by plan cost sharing for long-acting reversible contraception at any time point. The proportion of women experiencing a short interpregnancy interval was low (1.9% by 3 months, 1.9% by 6 months, 2.0% by 12 months) and did not differ by plan cost sharing for long-acting reversible contraception at any time point. CONCLUSION Out-of-pocket costs for long-acting reversible contraception influence the method of contraception used by postpartum women with employer-based insurance. Eliminating financial barriers to long-acting reversible contraception access after childbirth may help women initiate their preferred method and increase the use of long-acting reversible contraceptives among interested women who otherwise might utilize less effective methods.
Collapse
|
14
|
Time Trends in Massachusetts Adolescents' Postabortion Contraceptive Uptake. J Adolesc Health 2021; 68:364-369. [PMID: 32747051 DOI: 10.1016/j.jadohealth.2020.05.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 04/30/2020] [Accepted: 05/22/2020] [Indexed: 11/21/2022]
Abstract
PURPOSE The purpose of the study was to assess uptake of postabortion contraception across changes in insurance regulations and insurance type used on the day of abortion, accounting for demographic characteristics and consent type (parental vs. judicial) for abortion among Massachusetts adolescents. METHODS We conducted a retrospective record review of 1,375 minors (≤17 years) presenting for their first lifetime surgical abortion at a statewide network of abortion clinics between 2010 and 2016. Postabortion contraceptive method was defined as long-acting reversible contraception (LARC) placed onsite, short-acting reversible contraception (SARC) provided onsite, or no method received. RESULTS The proportion of minors leaving with no method dropped from 38% in 2010 to 21% in 2016, while LARC placement increased from 19% to 45%. No difference was observed by consent type. Both LARC and SARC were more prevalent among minors with Medicaid or private insurance compared to those not using insurance on the day of abortion. In a multinomial regression model accounting for consent type and demographic characteristics, minors who received care during the final epoch of the study (relative risk ratio [RRR] = 3.30; 95% confidence interval [CI]: 2.23-4.88) or used private insurance (RRR = 3.91; 95% CI: 2.24-6.84) or Medicaid (RRR = 5.54; 95% CI: 3.37-9.11) on the day of service had significantly higher relative risk of receiving LARC versus no method (p < .001), with similar results for LARC versus SARC. CONCLUSIONS Postabortion contraceptive uptake changed over time. Disparately low LARC uptake among minors not using insurance to pay for their abortions highlights a need to ensure equitable access to all methods, regardless of ability to pay.
Collapse
|
15
|
Lin CJ, Maier J, Nwankwo C, Burley C, deBorja L, Aaraj YA, Lewis E, Rhem M, Nowalk MP, South-Paul J. Awareness and Use of Contraceptive Methods and Perceptions of Long-Acting Reversible Contraception Among White and Non-White Women. J Womens Health (Larchmt) 2020; 30:1313-1320. [PMID: 33297819 DOI: 10.1089/jwh.2020.8642] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Background: Unintended pregnancies continue to account for half of all pregnancies in the United States, primarily due to incorrect or inconsistent use of contraception methods. Long-acting reversible contraception (LARC) methods are safe and highly effective, yet underutilized. Low uptake of LARC may be due to inadequate education, misconceptions, and cultural factors such as race, ethnicity, or religion. This study examined racial differences in contraceptive awareness and use among women seeking care at family health centers. Materials and Methods: Focus groups were used to identify recurrent themes in contraceptive choice of participants and develop a survey, completed by nonpregnant female patients 18-45 years of age from seven family health centers. Results: Among a total of 465 participants, 210 (46.2%) of whom were non-white, awareness of most types of birth control was generally high. Awareness of all types of contraceptives was significantly higher among white than non-white women (p < 0.001). Across most types of contraceptives, use was significantly higher among white women than non-white women with the exception of injectable hormones which were used significantly more often by non-white women (46.0% vs. 28.5%; p < 0.001). Reasons for using LARC did not vary by type nor by race but reasons for not using LARC varied by race and by specific method. Conclusions: Differing patterns of awareness, use, and perceptions of contraceptive methods between white and non-white women were revealed. By understanding factors that influence contraceptive awareness, use, and perceptions, clinicians can better address the contraceptive needs and concerns of their female patients. Clinical Trial # NCT03486743.
Collapse
Affiliation(s)
- Chyongchiou J Lin
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - John Maier
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Chidinma Nwankwo
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Cassie Burley
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Leyan deBorja
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Yassmin Al Aaraj
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Elizabeth Lewis
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Marla Rhem
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Mary Patricia Nowalk
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jeannette South-Paul
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
16
|
Ellison JE, Hanchate AD, Kazis LE, Cole MB. Association of the National Dependent Coverage Expansion With Insurance Use for Sexual and Reproductive Health Services by Female Young Adults. JAMA Netw Open 2020; 3:e2030214. [PMID: 33337495 PMCID: PMC7749438 DOI: 10.1001/jamanetworkopen.2020.30214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Sexual and reproductive health services are a primary reason for care seeking by female young adults, but the association of the 2010 Patient Protection and Affordable Care Act Dependent Coverage Expansion (ACA-DCE) with insurance use for these services has not been studied to our knowledge. Insurer billing practices may compromise dependent confidentiality, potentially discouraging dependents from using insurance or obtaining care. OBJECTIVE To evaluate the association between implementation of ACA-DCE and insurance use for confidential sexual and reproductive health services by female young adults newly eligible for parental coverage. DESIGN, SETTING, AND PARTICIPANTS For this cross-sectional study, a difference-in-differences analysis of a US national sample of commercial claims from January 1, 2007, to December 31, 2009, and January 1, 2011, to December 31, 2016, captured insurance use before and after policy implementation among female young adults aged 23 to 25 years (treatment group) who were eligible for dependent coverage compared with those aged 27 to 29 years (comparison group) who were ineligible for dependent coverage. Data were analyzed from January 2019 to February 2020. EXPOSURES Eligibility for parental coverage under the ACA-DCE as of 2010. MAIN OUTCOMES AND MEASURES Probability of insurance use for contraception and Papanicolaou testing. Emergency department and well visits were included as control outcomes not sensitive to confidentiality concerns. Linear probability models adjusted for age, plan type, annual deductible, comorbidities, and state and year fixed effects, with SEs clustered at the state level. RESULTS The study sample included 4 690 699 individuals (7 268 372 person-years), with 2 898 275 in the treatment group (mean [SD] age, 23.7 [0.8] years) and 1 792 424 in the comparison group (mean [SD] age; 27.9 [0.8] years). Enrollees in the treatment group were less likely to have a comorbidity (77.3% vs 72.9%) and more likely to have a high deductible plan (14.6% vs 10.1%) than enrollees in the comparison group. Implementation of the ACA-DCE was associated with a -2.9 (95% CI, -3.4 to -2.4) percentage point relative reduction in insurance use for contraception and a -3.4 (95% CI, -3.9 to -3.0) percentage point relative reduction in Papanicolaou testing in the treatment vs comparison groups. Emergency department and well visits increased 0.4 (95% CI, 0.2-0.7) and 1.7 (95% CI, 1.3-2.1) percentage points, respectively. CONCLUSIONS AND RELEVANCE The findings suggest that implementation of the ACA-DCE was associated with a reduction in insurance use for sexual and reproductive health services and an increase in emergency department and well health visits by female young adults newly eligible for parental coverage. Some young people who gained coverage under the expansion may not be using essential, confidential services.
Collapse
Affiliation(s)
- Jacqueline E. Ellison
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Amresh D. Hanchate
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Lewis E. Kazis
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts
| | - Megan B. Cole
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts
| |
Collapse
|
17
|
Sridhar A, Friedman SR, Sim MSK, Troung W, Elias S. Impact of perceived contraceptive policy changes on long acting reversible contraception dispensing trends. EUR J CONTRACEP REPR 2020; 26:58-61. [PMID: 33198521 DOI: 10.1080/13625187.2020.1837767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE We observed the long-term trend of Long Acting Reversible Contraception (LARC) usage before and after the 2016 presidential election. METHODS We observed the rate of LARC dispensed at a university student health centre in the 18 months preceding and 27 months following the 2016 U.S. presidential election which posed threat to contraception access. We applied a segmented regression model using two linear regression line segments to evaluate whether there is a time point where the trend of LARC dispensing changed. We fit the regression models with a breakpoint at month 0 (election month) and 3 months with a Locally Estimated Scatterplot Smoothing (LOESS) estimate with parameters obtained by estimating simple linear regression models separately below and above the breakpoint '0'. RESULTS There were a total of 2067 LARC methods dispensed from May 2015 to February 2019. The average number of LARC methods dispensed before November 2016 was 38/month and increased to 51/month post-presidential election. The LARC dispense rate significantly increased each month (0.38, 1.74; 95% confidence level, p < 0.05) until a breakpoint at 6 months (standard error 4.11) post-election followed by slower decrease (-0.59/month, 95% confidence level: -1.37, 0.20; p=not significant). CONCLUSION Our study is the first to report long-term trends (27 months post-election) in LARC uptake amidst the public discourse that suggested the end of a policy that provided LARC insurance coverage. Although this observational study cannot suggest causality, the findings could reflect actions taken to prevent unintended pregnancy in response to the event of uncertain national policy.
Collapse
Affiliation(s)
- Aparna Sridhar
- Department of Obstetrics and Gynecology, University of California Los Angeles, Los Angeles, CA, USA.,University of California Los Angeles Arthur Ashe Student Health & Wellness Center, Los Angeles, CA, USA
| | - Sarah R Friedman
- Department of Urology, University of California Los Angeles, Los Angeles, CA, USA
| | - Myung-Shin K Sim
- University of California Los Angeles General Internal Medicine & Health Services Research, Los Angeles, CA, USA
| | - William Troung
- University of California Los Angeles Arthur Ashe Student Health & Wellness Center, Los Angeles, CA, USA
| | - Sam Elias
- University of California Los Angeles Arthur Ashe Student Health & Wellness Center, Los Angeles, CA, USA
| |
Collapse
|
18
|
Dalton VK, Moniz MH, Bailey MJ, Admon LK, Kolenic GE, Tilea A, Fendrick AM. Trends in Birth Rates After Elimination of Cost Sharing for Contraception by the Patient Protection and Affordable Care Act. JAMA Netw Open 2020; 3:e2024398. [PMID: 33156347 PMCID: PMC7648257 DOI: 10.1001/jamanetworkopen.2020.24398] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
IMPORTANCE Reducing out-of-pocket costs is associated with improved patterns of contraception use. It is unknown whether reducing out-of-pocket costs is associated with fewer births. OBJECTIVE To evaluate changes in birth rates by income level among commercially insured women before (2008-2013) and after (2014-2018) the elimination of cost sharing for contraception under the Patient Protection and Affordable Care Act (ACA). DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study used data from Clinformatics Data Mart database from January 1, 2008, to December 31, 2018, for women aged 15 to 45 years who were enrolled in an employer-based health plan and had pregnancy benefits for at least 1 year. Women without household income information and women with evidence of having undergone a hysterectomy were excluded. EXPOSURE Section 2713 of the ACA. MAIN OUTCOMES AND MEASURES The primary outcome was the proportion of reproductive-aged women with a live birth by year (measured yearly from 2008 to 2018 [11 time points]) within 3 income categories. The secondary outcome was the distribution of contraceptive method fills in 3 categories by year: (1) most effective methods (long-acting reversible contraception or sterilization), (2) moderately effective methods (pill, patch, ring, and injectable), and (3) no prescription or surgical method. RESULTS The analytic sample included 4 590 989 women (mean [SD] age; 30.8 [9.1] years in 2013; 3 069 053 White [66.9%]) enrolled in 47 721 health plans. A total of 500 898 participants (40.8%) resided in households with incomes less than 400% of the federal poverty level in 2013. In all 3 years (2008, 2013, and 2018), women in the lowest income category were younger than women in the other income groups (median range, 21-22 years vs 30-34 years) and in households with a higher median number of dependents (9-10 vs 2-4). There was an associated decrease in births in all income groups in the period after the elimination of out-of-pocket costs. The estimated probability of birth decreased most precipitously among women in the lowest income group from 8.0% (95% CI, 7.4%-8.5%) in 2014 to 6.2% (95% CI, 5.7%-6.7%) in 2018, representing a 22.2% decrease (P < .001). The estimated probability decreased in the middle income group by 9.4%, from 6.4% (95% CI, 6.3%-6.4%) to 5.8% (95% CI, 5.7%-5.8%) (P < .001), and in the highest income group by 1.8%, from 5.6% (95% CI, 5.6%-5.7%) to 5.5% (95% CI, 5.4%-5.5%) (P < .001) in the period after the elimination of cost sharing. CONCLUSIONS AND RELEVANCE In this cross-sectional study, the elimination of cost sharing for contraception under the ACA was associated with improvements in contraceptive method prescription fills and a decrease in births among commercially insured women. Women with low income had more precipitous decreases than women with higher income, suggesting that enhanced access to contraception may address well-documented income-related disparities in unintended birth rates.
Collapse
Affiliation(s)
- Vanessa K. Dalton
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Program on Women’s Healthcare Effectiveness Research, University of Michigan, Ann Arbor
| | - Michelle H. Moniz
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Program on Women’s Healthcare Effectiveness Research, University of Michigan, Ann Arbor
| | - Martha J. Bailey
- Institute for Social Research Population Studies Center, University of Michigan, Ann Arbor
| | - Lindsay K. Admon
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Program on Women’s Healthcare Effectiveness Research, University of Michigan, Ann Arbor
| | - Giselle E. Kolenic
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor
| | - Anca Tilea
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor
| | - A. Mark Fendrick
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Internal Medicine, University of Michigan, Ann Arbor
- Center for Value-Based Insurance Design, University of Michigan, Ann Arbor
| |
Collapse
|
19
|
Management of bothersome bleeding associated with progestin-based long-acting reversible contraception: a review. Curr Opin Obstet Gynecol 2020; 32:408-415. [PMID: 32889971 DOI: 10.1097/gco.0000000000000664] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To describe common bleeding patterns and treatment strategies to minimize bothersome bleeding in users of progestin-based long-acting reversible contraception (LARC). RECENT FINDINGS Most levonorgestrel intrauterine device users will establish a favorable bleeding pattern within a year; NSAIDs are the most effective bridge to help with bothersome bleeding during that time period. Early follicular phase insertion and fundal placement are associated with more favorable early bleeding profiles. Recent studies exploring tranexamic acid, mifepristone, and tamoxifen's adjunct role show modest or no benefit. The progestin implant is associated with more persistent unpredictable bleeding disproportionately affecting women with higher etonogestrel serum levels; recent studies indicate that oral contraceptives, ulipristal acetate, and tamoxifen may all provide temporary relief. SUMMARY Women's healthcare providers can offer patients adjunct medical therapies to minimize bothersome bleeding associated with progestin LARC use, which may result in increased satisfaction and continuation rates of these effective forms of contraception.
Collapse
|
20
|
Nelson AL. Pulling back the curtain on trends in contraceptive use in recent years: what can we predict for the future? F S Rep 2020; 1:63-64. [PMID: 32845943 PMCID: PMC7382345 DOI: 10.1016/j.xfre.2020.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Anita L Nelson
- Department of Obstetrics and Gynecology, Western University of Health Sciences, Pomona, California
- Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, California
- Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California
| |
Collapse
|
21
|
Darney BG, Jacob RL, Hoopes M, Rodriguez MI, Hatch B, Marino M, Templeton A, Oakley J, Cottrell EK. Evaluation of Medicaid Expansion Under the Affordable Care Act and Contraceptive Care in US Community Health Centers. JAMA Netw Open 2020; 3:e206874. [PMID: 32496568 PMCID: PMC7273194 DOI: 10.1001/jamanetworkopen.2020.6874] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 03/23/2020] [Indexed: 11/14/2022] Open
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.
Collapse
Affiliation(s)
- Blair G. Darney
- Oregon Health & Science University, Portland, Oregon
- OHSU-PSU School of Public Health, Portland, Oregon
- National Institute of Public Health, Center for Population Health, Cuernavaca, Morelos, Mexico
| | | | | | | | - Brigit Hatch
- Oregon Health & Science University, Portland, Oregon
- OCHIN Inc, Portland, Oregon
| | - Miguel Marino
- Oregon Health & Science University, Portland, Oregon
- OHSU-PSU School of Public Health, Portland, Oregon
| | | | | | - Erika K. Cottrell
- Oregon Health & Science University, Portland, Oregon
- OCHIN Inc, Portland, Oregon
| |
Collapse
|
22
|
What Women Want: Factors Impacting Contraceptive Satisfaction in Privately Insured Women. Womens Health Issues 2020; 30:93-97. [DOI: 10.1016/j.whi.2019.11.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 11/10/2019] [Accepted: 11/21/2019] [Indexed: 11/23/2022]
|
23
|
Johnston EM, McMorrow S. The Relationship Between Insurance Coverage and Use of Prescription Contraception by Race and Ethnicity: Lessons From the Affordable Care Act. Womens Health Issues 2020; 30:73-82. [PMID: 31889615 DOI: 10.1016/j.whi.2019.11.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 11/12/2019] [Accepted: 11/25/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND We describe contraception use by race and ethnicity before and after the Affordable Care Act (ACA) and assess the relationship between insurance coverage and prescription contraception use in both periods. STUDY DESIGN Using data for women ages 15 to 45 at risk of unintended pregnancy from the 2006-2010 and 2015-2017 National Surveys of Family Growth, we examined changes in patterns of contraception use over time by race and ethnicity. We also examined changes in insurance coverage over the same period and considered how the relationship between insurance coverage and prescription contraception use has changed over time within each racial and ethnic group using both descriptive and multivariate regression methods. RESULTS Before the ACA, Black and Hispanic women were less likely than White women to use prescription contraception by 13.2 and 9.9 percentage points, respectively. After the ACA Medicaid and Marketplace coverage expansions, all groups experienced a decrease in uninsurance, but only Black women experienced a significant increase in prescription contraception use. As a result, the post-ACA Black-White difference in prescription contraception use narrowed to 3.9 percentage points, and the Hispanic-White gap remained unchanged. CONCLUSIONS Our results suggest that, despite significant declines in uninsurance under the ACA, there was no increase in use of prescription contraception for White or Hispanic women. Moreover, the decrease in uninsurance among Black women did not fully explain the large increase in use of prescription contraception for this population.
Collapse
Affiliation(s)
- Emily M Johnston
- Health Policy Center, Urban Institute, Washington, District of Columbia.
| | - Stacey McMorrow
- Health Policy Center, Urban Institute, Washington, District of Columbia
| |
Collapse
|
24
|
Magoon K, Beamish C, Dowshen N, Akers A. Insurance Plan Adherence to Mandate for Long-Acting Reversible Contraceptives in a Large Pediatric Hospital Network. J Pediatr Adolesc Gynecol 2019; 32:612-614. [PMID: 31401256 PMCID: PMC7422932 DOI: 10.1016/j.jpag.2019.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 07/18/2019] [Accepted: 08/05/2019] [Indexed: 12/01/2022]
Abstract
STUDY OBJECTIVE Long-acting reversible contraceptives (LARCs) are the most effective form of pregnancy prevention for sexually active adolescents, yet usage rates are low. The Affordable Care Act (ACA) mandated insurers cover LARCs without cost-sharing. Compliance with this policy is not well documented. This study assessed LARC coverage by insurers in a large pediatric health system. DESIGN, SETTING, PARTICIPANTS, AND INTERVENTIONS Between June and August 2016, LARC coverage was assessed through content reviews of insurance Web sites, formularies, and summaries of benefits for all Pennsylvania Medicaid plans and the top 20 commercial insurers for a large pediatric health system. MAIN OUTCOME MEASURES The primary outcome was adherence to the ACA mandate for LARC coverage without cost-sharing. RESULTS Among the 37 plans (17 public, 20 private), 21 (56.8%) were adherent and 16 (43.2%) were nonadherent. Among nonadherent plans, 3 plans covered LARC services but required cost-sharing, whereas 13 did not cover LARC services at all. There was not a statistically significant difference in LARC coverage between public and private plans. CONCLUSION Despite the landmark ACA mandate, insurance coverage of LARCs in pediatric hospitals is low for young women among private and public insurers. Insurer failure to adhere to the ACA among pediatric patients represents a barrier to LARC access for those at high risk of unintended pregnancy.
Collapse
Affiliation(s)
- Katie Magoon
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.
| | - Claire Beamish
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Nadia Dowshen
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Aletha Akers
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| |
Collapse
|
25
|
MacCallum-Bridges CL, Margerison CE. The Affordable Care Act contraception mandate & unintended pregnancy in women of reproductive age: An analysis of the National Survey of Family Growth, 2008-2010 v. 2013-2015. Contraception 2019; 101:34-39. [PMID: 31655071 DOI: 10.1016/j.contraception.2019.09.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 09/06/2019] [Accepted: 09/08/2019] [Indexed: 11/15/2022]
Abstract
OBJECTIVE(S) The Affordable Care Act contraception mandate could reduce unintended pregnancies by increasing access and affordability of contraceptive resources, e.g., long-acting reversible contraceptives (LARCs). We assessed: (1) whether unintended pregnancies decreased post-mandate, and (2) whether this decrease differed by demographic characteristics. STUDY DESIGN We used data from the National Survey of Family Growth (unweighted n = 7409) in logistic regression analyses to compare odds of unintended pregnancy pre-mandate (2008-2010) vs post-mandate (2013-2015), overall and stratified by demographic characteristics. RESULTS Paralleling an increase in long-acting reversible contraceptive use (p < 0.01), post-mandate, the odds of experiencing unintended pregnancy in the prior year decreased 15% overall (OR: 0.85, 95% CI: 0.62, 1.17), with the greatest reduction observed among women with government-sponsored insurance (OR: 0.63, 95% CI: 0.41, 0.97). CONCLUSIONS Unintended pregnancy decreased following the contraception mandate, although possibly due to chance. The short study period relative to the mandate could under-estimate the mandate's effect.
Collapse
Affiliation(s)
- Colleen L MacCallum-Bridges
- Department of Epidemiology and Biostatistics, Michigan State University, 939 Fee Road, East Lansing, MI 48825, United States.
| | - Claire E Margerison
- Department of Epidemiology and Biostatistics, Michigan State University, 939 Fee Road, East Lansing, MI 48825, United States
| |
Collapse
|
26
|
Cost Sharing and Utilization of Postpartum Intrauterine Devices and Contraceptive Implants Among Commercially Insured Women. Womens Health Issues 2019; 29:465-470. [PMID: 31495642 DOI: 10.1016/j.whi.2019.07.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 07/09/2019] [Accepted: 07/26/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Cost sharing may impede postpartum contraceptive use. We evaluated the association between out-of-pocket costs and long-acting reversible contraceptive (LARC) insertion among commercially insured postpartum women. METHODS Using the Clinformatics Data Mart, we examined out-of-pocket costs for LARC insertions at 0 to 3 and 4-60 days postpartum among women in employer-sponsored health plans from 2013 to 2016. Patient costs were estimated by summing copayment, coinsurance, and deductible payments for LARC services (device + placement). Multivariable logistic regression evaluated the association between plan cost sharing for LARC services (at least one beneficiary with >$200 cost share) and LARC insertion by 60 days postpartum (yes/no). RESULTS We identified 396,073 deliveries among women in 51,797 employer-based plans. Overall, LARC placement by 60 days postpartum was observed after 5.2% (n = 20,604) of deliveries. Inpatient LARC insertion (n = 233; 0.06% of deliveries) was less common than outpatient LARC insertion (n = 20,375; 5.14% of deliveries). Cost sharing was observed in 23.4% of LARC insertions (inpatient IUD: median, $50.00; range, $0.93-5,055.91; inpatient implant: median, $11.91; range, $2.49-650.14; outpatient IUD: median, $25.00; range, $0.01-3,354.80; outpatient implant: median, $27.20; range, $0.18-2,444.01). Among 5,895 plans with at least one LARC insertion and after adjusting for patient age, poverty status, race/ethnicity, region, and plan type, women in plans with cost sharing of more than $200 demonstrated lower odds of LARC use by 60 days postpartum (odds ratio, 0.74; 95% confidence interval, 0.71-0.77). CONCLUSIONS Cost sharing for postpartum LARC is associated with use, suggesting that out-of-pocket costs may impede LARC access for some commercially insured postpartum women. Reducing out-of-pocket costs for the most effective forms of contraception may increase use.
Collapse
|
27
|
Factors Associated with New Uptake of Long-Acting Reversible Contraceptives Since the Affordable Care Act Among Privately Insured Women in Pennsylvania. Womens Health Issues 2019; 29:370-375. [DOI: 10.1016/j.whi.2019.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 06/13/2019] [Accepted: 06/17/2019] [Indexed: 01/01/2023]
|
28
|
Weisman CS, Chuang CH, Snyder AH, Liu G, Leslie DL. ACA’s Contraceptive Coverage Requirement: Measuring Use And Out-Of-Pocket Spending. Health Aff (Millwood) 2019; 38:1537-1541. [DOI: 10.1377/hlthaff.2018.05484] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Carol S. Weisman
- Carol S. Weisman is a distinguished professor of public health sciences and obstetrics and gynecology, Penn State College of Medicine, in Hershey, Pennsylvania
| | - Cynthia H. Chuang
- Cynthia H. Chuang is a professor of medicine, public health sciences, and obstetrics and gynecology and chief of the Division of General Internal Medicine, Penn State College of Medicine
| | - Ashley H. Snyder
- Ashley H. Snyder is an assistant professor of medicine, Penn State College of Medicine
| | - Guodong Liu
- Guodong Liu is an associate professor of public health sciences, Penn State College of Medicine
| | - Douglas L. Leslie
- Douglas L. Leslie is a professor of public health sciences and psychiatry and director of the Center for Applied Studies in Health Economics, Penn State College of Medicine
| |
Collapse
|
29
|
Intrauterine Device Insertion Before and After Mandated Health Care Coverage: The Importance of Baseline Costs. Obstet Gynecol 2019; 131:843-849. [PMID: 29630013 DOI: 10.1097/aog.0000000000002567] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate changes in out-of-pocket cost for intrauterine device (IUD) placement before and after mandated coverage of contraceptive services and to examine how changes in out-of-pocket cost influence IUD insertion as a function of baseline cost. METHODS We conducted a cross-sectional pre-post analysis at the plan level using a large deidentified medical claims database to analyze our primary outcome, new IUD insertions among women enrolled in employer-sponsored health plans in 2009 and 2014, and our secondary outcome, out-of-pocket cost. Patient costs and utilization were aggregated by plan and year to conduct a plan-specific analysis. Plans were classified by mean out-of-pocket cost level: no out-of-pocket cost, low out-of-pocket cost (less than the 75th percentile), and high out-of-pocket cost (75th percentile or greater). A generalized estimating equation was used to evaluate average plan utilization of IUD services in 2009 and 2014 as a function of plan cost category and year. RESULTS Overall, average plan utilization of IUD services demonstrated a significant increase between 2009 (12.5%, 95% CI 11.6-13.4%) and 2014 (13.8%, 95% CI 13.0-14.7%; P<.001). When plans were grouped by out-of-pocket cost level, significant differences in plan utilization over time were observed. Plans that went from high out-of-pocket cost in 2009 to no out-of-pocket cost in 2014 saw a higher average increase in the rate of plan IUD insertions over time (2.4%, 95% CI 0.04-4.5%) compared with plans with no out-of-pocket cost in both 2009 and 2014 (-1.0%, 95% CI -3.3 to 1.4%, P=.02). Among all women in all plans, the 75th percentile of out-of-pocket cost in 2009 was $368; this number dropped to $0 in 2014. CONCLUSION Women in plans with the greatest reduction in out-of-pocket cost after mandated coverage of contraception had the greatest gains in IUD insertion. This suggests that baseline cost should be considered in evaluations of this policy and others that eliminate patient out-of-pocket cost.
Collapse
|
30
|
Goldin Evans M, Broyles S, Frederiksen B, Gee RE, Phillippi S, Sothern M, Theall KP, Wightkin J. Long-acting reversible contraceptive utilization after policy change increasing device reimbursement to wholesale acquisition cost in Louisiana. Am J Obstet Gynecol 2019; 221:128.e1-128.e10. [PMID: 31042498 DOI: 10.1016/j.ajog.2019.04.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 03/20/2019] [Accepted: 04/19/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Unintended pregnancies, occurring in nearly 1 out of every 2 (45%) pregnancies in the United States, are associated with adverse health and social outcomes for the infant and the mother. The risk of unintended pregnancies is significantly reduced when women use long-acting reversible contraceptives, namely intrauterine devices and implants. Inadequate reimbursement for long-acting reversible contraceptive devices may be an access barrier to long-acting reversible contraceptive uptake. In 2014, the Louisiana Department of Health Bureau of Health Services Financing implemented a policy change that increased the Medicaid reimbursement rates for acquiring long-acting reversible contraceptive devices to the wholesale acquisition cost. OBJECTIVE To examine the association of a Medicaid policy change that increased the long-acting reversible contraceptive device reimbursement rate to the wholesale acquisition cost (ie, price set by the manufacturers) on long-acting reversible contraceptive uptake among women at risk for unintended pregnancy. MATERIALS AND METHODS This retrospective, repeated cross-sectional study used 2013-2015 Louisiana Medicaid claims data and contraceptive provision measures to assess associations between patient (age, race, urban/rural residence, postpartum status) and provider (urban/rural location, specialty) characteristics and long-acting reversible contraceptive uptake among contraceptive users (N = 193,623) using bivariate and logistic regression analyses. RESULTS After long-acting reversible contraceptive reimbursement increased, there was a 2-fold likelihood increase in use in 2015 vs 2013 (odds ratio, 2.08; 95% confidence interval, 1.69-2.55). Long-acting reversible contraceptive uptake was more likely across all patient and provider subgroups in 2015 vs 2013 but notably among patients receiving contraceptive care from family planning clinics (odds ratio, 3.93; 95% confidence interval, 2.34-6.62). CONCLUSION Removal of a provider-level financial barrier to long-acting reversible contraceptive provision was associated with increased long-acting reversible contraceptive uptake among women at risk for unintended pregnancy. Efforts to improve long-acting reversible contraceptive access should focus on equitable healthcare reimbursement for healthcare providers of reproductive-aged women.
Collapse
|
31
|
Satterwhite CL, French V, Allison M, Honderick T, Ramaswamy M. Access to contraception in local health departments, four Midwest states, 2017-2018. Contraception 2019; 99:363-367. [PMID: 30871935 DOI: 10.1016/j.contraception.2019.02.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Revised: 02/19/2019] [Accepted: 02/20/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Describe contraception availability at local health departments (LHDs) serving largely rural populations. STUDY DESIGN We invited administrators at LHDs located in four Midwest states to participate in an online survey conducted from September 2017-April 2018. We collected data on clinic staffing, patient population, receipt of Title X funds, and services provided to assess the proportion of LHDs providing any prescription method of contraception; secondary outcomes included healthcare staff training level and other reproductive health services provided. RESULTS Of 344 LHDs invited, 237 administrators completed the survey (68.9%). Three-quarters served rural populations. One-third (34.6%) provided short-acting hormonal contraception; however, availability varied by state (Kansas: 58.0%, 40/69; Missouri: 37.5%, 33/88; Nebraska: 16.7%, 3/18; Iowa: 9.7%, 6/62; p<.01). Only 8.4% of LHDs provided IUDs; 7.6% provided implants, and 5.9% provided both methods. LHDs in Nebraska and Kansas provided any long-acting method more frequently (Kansas: 17.4%, Nebraska: 16.7%, Iowa: 8.1%, Missouri: 4.6%; p=.04). LHDs receiving Title X funds (27.0%) were much more likely to provide any prescription contraception (85.1% vs. 14.2%, p<.01). Most LHDs relied on registered nurses (RNs) to provide medical care; 81.0% reported that RNs provided care≥20 days per month. Pregnancy testing was widely available in Missouri and Kansas (>87%) and less commonly available in Iowa and Nebraska (<18%) (p<.01). CONCLUSION LHDs in these states are currently ill-equipped to offer comprehensive contraceptive services. Women seeking care at LHDs have limited, if any, contraceptive options. IMPLICATIONS Local health departments in the Midwest, serving a largely rural population, rarely offer prescription contraception, especially long-acting reversible methods. Women residing in settings without broad access to publicly-funded healthcare providers may have limited access to comprehensive contraceptive services. Efforts to ensure rural access are needed.
Collapse
Affiliation(s)
- Catherine Lindsey Satterwhite
- University of Kansas School of Medicine, Department of Preventive Medicine and Public Health, 3901 Rainbow Blvd, MS: 1008, Kansas City, KS 66160; University of Kansas School of Medicine, Department of Obstetrics and Gynecology, 3901 Rainbow Blvd, MS: 2028, Kansas City, KS 66160.
| | - Valerie French
- University of Kansas School of Medicine, Department of Obstetrics and Gynecology, 3901 Rainbow Blvd, MS: 2028, Kansas City, KS 66160.
| | - Molly Allison
- University of Kansas School of Medicine, Department of Preventive Medicine and Public Health, 3901 Rainbow Blvd, MS: 1008, Kansas City, KS 66160.
| | - Tanya Honderick
- University of Kansas School of Medicine, Department of Preventive Medicine and Public Health, 3901 Rainbow Blvd, MS: 1008, Kansas City, KS 66160.
| | - Megha Ramaswamy
- University of Kansas School of Medicine, Department of Preventive Medicine and Public Health, 3901 Rainbow Blvd, MS: 1008, Kansas City, KS 66160.
| |
Collapse
|
32
|
Bullinger LR, Simon K. Prescription Contraceptive Sales Following the Affordable Care Act. Matern Child Health J 2019; 23:657-666. [DOI: 10.1007/s10995-018-2680-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
33
|
Moniz MH, Kirch MA, Solway E, Goold SD, Ayanian JZ, Kieffer EC, Clark SJ, Tipirneni R, Kullgren JT, Chang T. Association of Access to Family Planning Services With Medicaid Expansion Among Female Enrollees in Michigan. JAMA Netw Open 2018; 1:e181627. [PMID: 30646135 PMCID: PMC6324283 DOI: 10.1001/jamanetworkopen.2018.1627] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE To date, 32 states and the District of Columbia have expanded Medicaid programs under the Patient Protection and Affordable Care Act. It is vital to understand whether expanded health insurance coverage of low-income individuals improves access to family planning services as a first step toward improving reproductive health outcomes. OBJECTIVE To evaluate the association of Medicaid expansion coverage with access to birth control and family planning services among women of reproductive age enrolled in the Michigan expansion plan. DESIGN, SETTING, AND PARTICIPANTS In a survey study, from January 13 through December 15, 2016, telephone surveys of a stratified sample of enrollees in Michigan's Section 1115 Medicaid Expansion waiver program, the Healthy Michigan Plan (HMP), were conducted. Interviewers completed surveys for 4090 sampled enrollees, of whom 1166 were women aged 19 to 44 years. Surveys were conducted with a computer-assisted telephone interviewing system in English, Arabic, and Spanish. The sample was weighted to 113 565 women. Dates of data analysis were from January 27 through September 18, 2017. MAIN OUTCOMES AND MEASURES Self-reported change in access to birth control and family planning services through HMP (better, worse, about the same, or don't know/doesn't apply), compared with before enrollment. RESULTS Among the 1166 survey respondents aged 19 to 44 years (mean [SD] age, 31.0 [0.3] years) and the weighted sample of 113 565, 74.7% (95% CI, 72.2%-76.9%) lived in very-low-income households (<100% federal poverty level), 64.0% (95% CI, 60.5%-67.3%) reported at least 1 chronic medical condition, 23.5% (95% CI, 20.6%-26.6%) reported fair or poor health, and 17.7% (95% CI, 15.7%-19.9%) lived in rural settings. Overall, 35.5% (95% CI, 32.2%-39.0%) reported increased access to family planning services. After adjusting, those most likely to report increased access were women without health insurance coverage in the year preceding HMP enrollment (adjusted odds ratio [aOR], 2.02; 95% CI, 1.41-2.89) compared with women with health insurance for the full 12 months preceding enrollment; younger women (aOR for 19-24 years, 2.80 [95% CI, 1.75-4.50]; aOR for 25-34 years, 2.35 [95% CI, 1.60-3.45]) compared with women aged 35 to 44 years; and women with a recent visit to a primary care clinician (aOR 1.69; 95% CI, 1.03-2.76) compared with women without a primary care visit in the preceding 12 months. CONCLUSIONS AND RELEVANCE One in 3 women of reproductive age reported better ability to access birth control and family planning services through HMP compared with before enrollment. This finding suggests that Medicaid expansion is associated with improved access to family planning services, which may enable low-income women to maintain optimal reproductive health.
Collapse
Affiliation(s)
- Michelle H. Moniz
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Matthias A. Kirch
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Erica Solway
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Susan D. Goold
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- School of Public Health, University of Michigan, Ann Arbor
- Department of Internal Medicine, University of Michigan, Ann Arbor
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor
| | - John Z. Ayanian
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- School of Public Health, University of Michigan, Ann Arbor
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Edith C. Kieffer
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- School of Social Work, University of Michigan, Ann Arbor
| | - Sarah J. Clark
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Pediatrics, University of Michigan, Ann Arbor
| | - Renuka Tipirneni
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Jeffrey T. Kullgren
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Internal Medicine, University of Michigan, Ann Arbor
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor
- Veterans Affairs Ann Arbor Center for Clinical Management Research, University of Michigan, Ann Arbor
| | - Tammy Chang
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Family Medicine, University of Michigan, Ann Arbor
| |
Collapse
|
34
|
Dalton VK, Carlos RC, Kolenic GE, Moniz MH, Tilea A, Kobernik EK, Fendrick AM. The impact of cost sharing on women's use of annual examinations and effective contraception. Am J Obstet Gynecol 2018; 219:93.e1-93.e13. [PMID: 29752935 DOI: 10.1016/j.ajog.2018.04.051] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 04/24/2018] [Accepted: 04/30/2018] [Indexed: 10/16/2022]
Abstract
BACKGROUND We sought to describe the relationship between the elimination of out-of-pocket costs and women's use of preventive care office visits and long-acting reversible contraception after accounting for baseline levels of cost sharing. OBJECTIVES The objective of this analysis was to describe the relationship between the elimination of out-of-pocket costs and utilization of preventive care visits and long-acting reversible contraception insertion while taking baseline cost sharing levels under consideration. STUDY DESIGN In 2017, we used administrative health plan data to examine changes in out-of-pocket costs and service utilization among 2,172,065 women enrolled in 15,118 employer-based health plans between 2008 and 2015. We used generalized estimating equations to examine utilization patterns. RESULTS Women in this sample generally had low costs at baseline ($24 and $29 for preventive care visits and long-acting reversible contraception insertion, respectively). The elimination of baseline out-of-pocket costs were related to changes in the utilization of both services but more consistently for contraceptive device placement. Women whose low/moderate out-of-pocket costs were eliminated were more likely to use a preventive care office visit than women with persistent low/moderate costs (odds ratio, 1.05; 95% confidence interval, 1.04-1.05), but women with high out-of-pocket costs had lower utilization rates, even after their costs were eliminated. In contrast, the odds of having a contraceptive device placed was higher among all groups of women when out-of-pocket costs were zero, as compared with women with low/moderate costs. For instance, when compared with women with low/moderate costs, women were less likely to have a contraceptive device inserted (odds ratio, 0.92; 95% confidence interval, 0.86-0.97) when they had high costs but more likely after their costs were eliminated (odds ratio, 1.15; 95% confidence interval, 1.09-1.20). CONCLUSION Out-of-pocket costs were low prior to the Affordable Care Act. Eliminating costs was associated with increases in preventive service use among those with high levels of cost, but effect sizes were low, suggesting that cost is only 1 barrier. Failing to recognize that cost sharing was already low could cause us to falsely conclude that the elimination of cost sharing was ineffective.
Collapse
|
35
|
Bell KN, Meyn LA, Chen BA. Long-Acting Reversible Contraceptive Uptake before and after the Affordable Care Act Contraceptive Mandate in Women Undergoing First Trimester Surgical Abortion. Womens Health Issues 2018; 28:301-305. [PMID: 29853173 DOI: 10.1016/j.whi.2018.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 03/27/2018] [Accepted: 04/20/2018] [Indexed: 10/14/2022]
Abstract
OBJECTIVE To compare long-acting reversible contraceptive (LARC) uptake before and after the Affordable Care Act (ACA) contraceptive mandate among women undergoing a first trimester surgical abortion. STUDY DESIGN We conducted a retrospective chart review of 867 women undergoing a first trimester surgical abortion at an academic gynecology practice between December 2010 and December 2014 (excluding August to December 2012) to evaluate intrauterine device and contraceptive implant uptake before and after the ACA contraceptive mandate. RESULTS Before the ACA contraceptive mandate, 79% of privately insured women (213 of 271) had full LARC coverage (no out-of-pocket costs) compared with 92% (298 of 324) after the mandate (p < .001). We found no difference in postabortal LARC uptake before and after the ACA in women with private insurance, Medicaid, or overall. Among all women, 46% chose a postabortal LARC method before the mandate as compared with 48% after the mandate (p = .63). Among privately insured women, 45% used a postabortal LARC method before the mandate as compared with 50% after the mandate (p = .25). One-half of privately insured women (268 of 534) with full or partial LARC coverage used a postabortal LARC method compared with 32% of privately insured women (18 of 56) with no LARC coverage after implementation of the ACA contraceptive mandate (p = .01). CONCLUSIONS Despite the significant increase in full coverage of LARC among privately insured women, there was no change in postabortal LARC use after the ACA. However, privately insured women with full or partial LARC coverage were more likely to use a postabortal LARC method compared with privately insured women with no LARC coverage after the implementation of the ACA contraceptive mandate.
Collapse
Affiliation(s)
- Kimberly N Bell
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Leslie A Meyn
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Beatrice A Chen
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Magee-Womens Research Institute, Pittsburgh, Pennsylvania.
| |
Collapse
|
36
|
Snyder AH, Weisman CS, Liu G, Leslie D, Chuang CH. The Impact of the Affordable Care Act on Contraceptive Use and Costs among Privately Insured Women. Womens Health Issues 2018; 28:219-223. [DOI: 10.1016/j.whi.2018.01.005] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 01/19/2018] [Accepted: 01/22/2018] [Indexed: 11/26/2022]
|
37
|
Trussell J. Effect of Providing Contraception Free of Charge. Am J Public Health 2018. [PMID: 29513583 DOI: 10.2105/ajph.2018.304316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- James Trussell
- James Trussell is with the Office of Population Research, Princeton University, Princeton, NJ, and University of Edinburgh, Edinburgh, Scotland
| |
Collapse
|
38
|
Advancing Sex- and Gender-Informed Approaches to Health in an Academic Medical Center. Womens Health Issues 2018; 28:117-121. [DOI: 10.1016/j.whi.2017.11.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 11/03/2017] [Accepted: 11/09/2017] [Indexed: 02/03/2023]
|
39
|
Gyllenberg F, Juselius M, Gissler M, Heikinheimo O. Long-Acting Reversible Contraception Free of Charge, Method Initiation, and Abortion Rates in Finland. Am J Public Health 2018; 108:538-543. [PMID: 29470111 DOI: 10.2105/ajph.2017.304280] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVES To evaluate whether a public program providing long-acting reversible contraceptive (LARC) methods free of charge increases the LARC initiation rate and reduces the unintended pregnancy rate in the general population. METHODS Since 2013, all women in Vantaa, Finland, have been entitled to 1 LARC method free of charge. With time-series analysis between 2000 and 2015, we assessed whether this public program was associated with changes in steady-state mean rates of LARC initiation and abortions. RESULTS The initiation rate of LARCs (1/1000 women) increased 2.2-fold from 1.9 to 4.2 after the intervention (P < .001). Concomitantly, the abortion rate (1/1000 women) declined by 16% from 1.1 to 0.9 in the total sample (P < .001), by 36% from 1.3 to 0.8 among those aged 15 to 19 years (P < .001), and by 14% from 2.0 to 1.7 among those aged 20 to 24 years (P = .01). CONCLUSIONS The LARC program was associated with increased uptake of LARC methods and fewer abortions in the population. Public Health Implications. Entitling the population to LARC methods free of charge is an effective means to reduce the unmet need of contraception and the need for abortion, especially among women younger than 25 years.
Collapse
Affiliation(s)
- Frida Gyllenberg
- Frida Gyllenberg and Oskari Heikinheimo are with the Department of Obstetrics and Gynecology, University of Helsinki, Helsinki, Finland. Frida Gyllenberg is also with the City of Vantaa, Vantaa, Finland. Mikael Juselius is with the Bank of Finland, Helsinki. Mika Gissler is with the Information Services Department, National Institute for Health and Welfare, Helsinki, and with Karolinska Institute, Department of Neurobiology, Care Sciences and Society, Division of Family Medicine, Stockholm, Sweden
| | - Mikael Juselius
- Frida Gyllenberg and Oskari Heikinheimo are with the Department of Obstetrics and Gynecology, University of Helsinki, Helsinki, Finland. Frida Gyllenberg is also with the City of Vantaa, Vantaa, Finland. Mikael Juselius is with the Bank of Finland, Helsinki. Mika Gissler is with the Information Services Department, National Institute for Health and Welfare, Helsinki, and with Karolinska Institute, Department of Neurobiology, Care Sciences and Society, Division of Family Medicine, Stockholm, Sweden
| | - Mika Gissler
- Frida Gyllenberg and Oskari Heikinheimo are with the Department of Obstetrics and Gynecology, University of Helsinki, Helsinki, Finland. Frida Gyllenberg is also with the City of Vantaa, Vantaa, Finland. Mikael Juselius is with the Bank of Finland, Helsinki. Mika Gissler is with the Information Services Department, National Institute for Health and Welfare, Helsinki, and with Karolinska Institute, Department of Neurobiology, Care Sciences and Society, Division of Family Medicine, Stockholm, Sweden
| | - Oskari Heikinheimo
- Frida Gyllenberg and Oskari Heikinheimo are with the Department of Obstetrics and Gynecology, University of Helsinki, Helsinki, Finland. Frida Gyllenberg is also with the City of Vantaa, Vantaa, Finland. Mikael Juselius is with the Bank of Finland, Helsinki. Mika Gissler is with the Information Services Department, National Institute for Health and Welfare, Helsinki, and with Karolinska Institute, Department of Neurobiology, Care Sciences and Society, Division of Family Medicine, Stockholm, Sweden
| |
Collapse
|
40
|
Abstract
The Affordable Care Act (ACA) of 2010 placed a substantial emphasis on public health and prevention. Subsequent research on its effects reveals some notable successes and some missteps and offers important lessons for future legislators. The ACA's Prevention and Public Health Fund, intended to give public health budgetary flexibility, provided crucial funding for public health services during the Great Recession but proved highly vulnerable to subsequent budget cuts. Several programs that aimed to increase strategic thinking and planning around public health at the state level have proven to be more enduring, suggesting that the convening authority of the federal government can be a powerful tool for progress, especially when buttressed by some funding. Most important, by expanding insurance and mandating a minimum level of coverage, the ACA both increased access to clinical preventive services and freed up local public health budgets to engage in population health activities.
Collapse
Affiliation(s)
- Nadia Chait
- Robert F. Wagner Graduate School of Public Service, New York University, New York, NY 10012, USA; ,
| | - Sherry Glied
- Robert F. Wagner Graduate School of Public Service, New York University, New York, NY 10012, USA; ,
| |
Collapse
|
41
|
Williams JAR, Ortiz SE. Examining public knowledge and preferences for adult preventive services coverage. PLoS One 2017; 12:e0189661. [PMID: 29261757 PMCID: PMC5738055 DOI: 10.1371/journal.pone.0189661] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 11/29/2017] [Indexed: 11/21/2022] Open
Abstract
Introduction To examine (1) what individuals know about the existing adult preventive service coverage provisions of the Affordable Care Act (ACA), and (2) which preventive services individuals think should be covered without cost sharing. Methods An online panel from Survey Monkey was used to obtain a sample of 2,990 adults age 18 and older in March 2015, analyzed 2015–2017. A 17-item survey instrument was designed and used to evaluate respondents’ knowledge of the adult preventive services provision of the ACA. Additionally, we asked whether various preventive services should be covered. The data include age, sex, race/ethnicity, and educational attainment as well as measures of political ideology, previous insurance status, the number of chronic conditions, and usual source of care. Results Respondents correctly answered 38.6% of the questions about existing coverage under the ACA, while on average respondents thought 12.1 of 15 preventive services should be covered (SD 3.5). Respondents were more knowledgeable about coverage for routine screenings, such as blood pressure (63.4% correct) than potentially stigmatizing screenings, such as for alcohol misuse (28.8% correct). Blood pressure screening received the highest support of coverage (89.8%) while coverage of gym memberships received the lowest support (59.4%). Individuals with conservative ideologies thought fewer services on average should be covered, but the difference was small—around one service less than those with liberal ideologies. Conclusions Overwhelmingly, individuals think that most preventive services should be covered without cost sharing. Despite several years of coverage for preventive services, there is still confusion and lack of knowledge about which services are covered.
Collapse
Affiliation(s)
- Jessica A R Williams
- Department of Health Management and Policy, University of Kansas School of Medicine, Kansas City, Kansas, United States of America
| | - Selena E Ortiz
- Department of Health Policy and Administration, College of Health and Human Development, The Pennsylvania State University, University Park, Pennsylvania, United States of America
| |
Collapse
|
42
|
|
43
|
Gomez AM, Freihart B. Motivations for Interest, Disinterest and Uncertainty in Intrauterine Device Use Among Young Women. Matern Child Health J 2017. [DOI: 10.1007/s10995-017-2297-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|