Expert Commentary

Women’s sexual health and the Affordable Care Act: Research roundup

This compilation of the latest research on women’s sexual health will help journalists understand changes to the Affordable Care Act’s contraceptive mandate. Studies highlight how contraceptive use and cost has changed in recent years, changes in insurance coverage and outcomes related to contraceptive use.

Birth control pills

A provision in the Affordable Care Act of 2010 made it compulsory for all new health insurance plans to fully cover the cost of contraceptives for their subscribers. This was part of Obamacare’s mandate that cost-sharing (the requirement for recipients of care to contribute a co-payment) be removed from some forms of preventative care.

There are, however, a few exceptions to this requirement. Plans that did not cover birth control before and were not substantially changed after the enactment of the ACA were grandfathered in — in other words, they remained the same. Further, the Supreme Court’s 2014 decision in Burwell v. Hobby Lobby Stores Inc. allowed for-profit employers an exemption from this provision on religious grounds.

A 2017 mandate widened this exemption, allowing any employer not to offer this benefit. Citing America’s “long history of providing conscience protections,” the rule, written by the Health and Human Services Department and two other agencies, now “encompasses non-governmental plan sponsors that object based on sincerely held religious beliefs, and institutions of higher education in their arrangement of student health plans.” It also expanded the grounds for objection to include “(non-religious) moral convictions.”

We assembled the latest research on women’s sexual health for journalists to consult amid these changes. The following studies highlight how contraceptive use has changed in recent years, trends in contraceptive costs, changes in insurance coverage nationwide and outcomes related to contraceptive use.


Contraceptive use

Did Contraceptive Use Patterns Change After the Affordable Care Act? A Descriptive Analysis
Bearak, Jonathan M.; Jones, Rachel K. Women’s Health Issues, May 2017, Vol. 27. DOI: 10.1016/j.whi.2017.01.006.
Findings: “We observed no changes in contraceptive use patterns among sexually active women. However, use of the pill nearly doubled, from 21 percent to 40 percent, among young women aged 18 to 24 who had not had sex in the last month. Many of these women cited benefits of the pill in addition to pregnancy prevention.”

Current Contraceptive Use and Variation by Selected Characteristics Among Women Aged 15-44: United States, 2011-2013
Daniels, Kimberly; et al. National Health Statistics Reports, November 2015.
Abstract: “Among women currently using contraception, the most commonly used methods were the pill (25.9 percent, or 9.7 million women), female sterilization (25.1 percent, or 9.4 million women), the male condom (15.3 percent, or 5.8 million women), and long-acting reversible contraception (LARC) — intrauterine devices or contraceptive implants (11.6 percent, or 4.4 million women). Differences in method use were seen across social and demographic characteristics. Comparisons between time points reveal some differences, such as higher use of LARC in 2011–2013 compared with earlier time points.”

Changes in Use of Long-Acting Reversible Contraceptive Methods Among U.S. Women, 2009–2012
Kavanaugh, Megan L.; Jerman, Jenna; Finer, Lawrence B. Obstetrics & Gynecology, November 2015, Vol. 126. DOI: 10.1097/AOG.0000000000001094.
Findings: “The prevalence of LARC use among contracepting U.S. females increased from 8.5 percent in 2009 to 11.6 percent in 2012 (P<.01). The most significant increases occurred among Hispanic females (from 8.5 percent to 15.1 percent), those with private insurance (7.1-11.1 percent), those with fewer than two sexual partners in the previous year (9.2-12.4 percent), and those who were nulliparous (2.1-5.9 percent) (all P<.01). In multivariable analyses adjusting for key demographic characteristics, the strongest associations with LARC use in 2012 were parity (adjusted odds ratios [ORs] 4.3-5.5) and having a history of stopping non-LARC hormonal use (adjusted OR 1.9). Women aged 35-44 years (adjusted OR 0.3) were less likely to be LARC users than their counterparts (all P<.001). Poverty status was not associated with LARC use. There were no differences in discontinuation of LARC methods resulting from dissatisfaction between minority women and non-Hispanic white women.”

Trends in Long-Acting Reversible Contraception Use in Adolescents and Young Adults: New Estimates Accounting for Sexual Experience
Pazol, Karen; et al. The Journal of Adolescent Health, October 2016, Vol. 59. DOI: 10.1016/j.jadohealth.2016.05.018.
Findings: “Among adolescents and young adults, 56 percent and 14 percent, respectively, have never had vaginal intercourse, versus 1 percent-4 percent for women aged 25-44 years. Given the high percentage of adolescents and young adults who never had vaginal intercourse, LARC estimates were higher for these age groups (p < .05), but not for women aged 25-44 years, when limited to those at risk for unintended pregnancy. Among adolescents at risk, the increase in LARC use from 2006-2008 (1.1 percent) to 2008-2010 (3.6 percent) was not significant (p = .07), and no further increase occurred from 2008-2010 to 2011-2013 (3.2 percent); by contrast, among young adults at risk, LARC use increased from 2006-2008 (3.2 percent) to 2008-2010 (6.9 percent) and from 2008-2010 to 2011-2013 (11.1 percent).”

Trends in Long-Acting Reversible Contraception Use Among U.S. Women Aged 15-44
Branum, Amy M.; Jones, Jo. NCHS Data Brief, February 2015, No. 188.
Findings: “Use of long-acting reversible contraceptives (LARCs) declined between 1982 and 1988, remained stable through 2002, and then increased nearly five-fold in the last decade among women aged 15-44, from 1.5 percent in 2002 to 7.2 percent in 2011–2013.”


Contraceptive Costs

Women Saw Large Decrease In Out-Of-Pocket Spending For Contraceptives After ACA Mandate Removed Cost Sharing
Becker, Nora V.; Polsky; Daniel. Health Affairs, July 2015, Vol. 34. DOI: 10.1377/hlthaff.2015.0127.
Findings: The out-of-pocket costs for most contraceptive methods were significantly reduced after the introduction of the Affordable Care Act’s mandate that birth control be fully covered by private insurers. This included an average decrease for a six-month birth control pill prescription from $33.58 in June 2012 to $19.84 one year later. On average, women on the pill saved $254.91 per year. IUD and emergency contraception costs also fell. Out-of-pocket spending on the contraceptive ring and patch saw only minimal decreases.

Impact of the Federal Contraceptive Coverage Guarantee on Out-of-Pocket Payments for Contraceptives: 2014 Update
Sonfield, Adam; et al. Contraception, January 2015, Vol. 91. DOI: 10.1016/j.contraception.2014.09.006.
Findings: “The findings of this study suggest that the federal contraceptive coverage guarantee has had a substantial impact in eliminating out-of-pocket costs among privately insured women using some methods of contraception — including oral contraceptives, the most popular reversible method in the United States. Between fall 2012 and spring 2014, the proportion of pill users paying zero dollars out of pocket increased from 15 percent to 67 percent, with similar trends for injectable, ring and IUD users.”


Unintended Pregnancy and Teen Birth Rate Trends

Investigating Recent Trends in the U.S. Teen Birth Rate
Kearney, Melissa S.; Levine, Phillip B. Journal of Health Economics, May 2015, Vol. 41. DOI: 10.1016/j.jhealeco.2015.01.003.
Abstract: “We investigate trends in the U.S. rate of teen childbearing between 1981 and 2010, focusing specifically on the sizable decline since 1991. We focus on establishing the role of state-level demographic changes, economic conditions, and targeted policies in driving recent aggregate trends. We offer three main observations. First, the recent decline cannot be explained by the changing racial and ethnic composition of teens. Second, the only targeted policies that have had a statistically discernible impact on aggregate teen birth rates are declining welfare benefits and expanded access to family planning services through Medicaid, but these policies can account for only 12.6 percent of the observed decline since 1991. Third, higher unemployment rates lead to lower teen birth rates and can account for 16 percent of the decline in teen birth rates since the Great Recession began.”

Declines in Unintended Pregnancy in the United States, 2008–2011
Finer, Lawrence B.; Zolna, Mia R. New England Journal of Medicine, March 2016, Vol. 374. DOI: 10.1056/NEJMsa1506575.
Findings: “After a long period of minimal change, the rate of unintended pregnancy in the United States declined substantially between 2008 and 2011. The rate of 45 unintended pregnancies per 1,000 in 2011 was the lowest level seen in at least three decades. The decline occurred in nearly all demographic groups, including those defined by age, income, education, race and ethnicity, and religious affiliation. … A likely explanation for the decline in the rate of unintended pregnancy is a change in the frequency and type of contraceptive use over time. Evidence shows that the overall use of any method of contraception among women and girls at risk for unintended pregnancy increased slightly between 2008 and 2012. More important, the use of highly effective long-acting methods, particularly intrauterine devices, among U.S. females who used contraception increased from 4 percent to 12 percent between 2007 and 2012, and this increase occurred in almost all demographic groups. In a 2012 study, women and girls at high risk of unintended pregnancy who had free access to and used highly effective methods of contraception had much lower rates of unintended pregnancy than did those who used other methods, including commonly used methods such as the oral contraceptive pill.”

Programs to Reduce Teen Pregnancy, Sexually Transmitted Infections, and Associated Sexual Risk Behaviors: A Systematic Review
Goesling, Brian; et al. The Journal of Adolescent Health: Official Publication of the Society for Adolescent Medicine May 2014, Vol. 54. DOI: 10.1016/j.jadohealth.2013.12.004.
Findings: “This systematic review provides a comprehensive, updated assessment of programs with evidence of effectiveness in reducing teen pregnancy, STIs, or associated sexual risk behaviors. To conduct this assessment, we identified and assessed some 200 program impact studies released from 1989 through January 2011. Of the studies assessed, 88 met the review criteria for study design and execution. Analysis of the study impact findings identified 31 programs with evidence of effectiveness. To provide context for these findings and identify the relative strengths and weaknesses of the evidence, we also examined the study design quality and other characteristics of all 88 studies included in the analysis.”

Game Change in Colorado: Widespread Use of Long-Acting Reversible Contraceptives and Rapid Decline in Births Among Young, Low-Income Women
Ricketts, Sue; Klingler, Greta; Schwalberg, Renee. Perspectives on Sexual and Reproductive Health, September 2014, Vol. 46. DOI: 10.1363/46e1714.
Findings: “The Colorado Family Planning Initiative increased access to LARC methods among young, low-income women, and this improved access was immediately followed by a substantial reduction in the birthrate among this population. Unlike other studies, this one was an ecological analysis of a population-based intervention. Therefore, while it has the limitations of an ecological analysis, we were able to measure changes in population health. Program data confirm the increase in LARC use among clients receiving Title X-funded services, and the effectiveness of these methods appears to be borne out in the decline in fertility rates, abortion rates, births to high-risk women and WIC [Women, Infants and Children] enrollment in the period after program rollout.”

Provision of No-Cost, Long-Acting Contraception and Teenage Pregnancy
Secura, Gina M.; et al. The New England Journal of Medicine, October 2014, Vol. 371. DOI: 10.1056/NEJMoa1400506.
Findings: “We found that pregnancy, birth, and abortion rates were low among teenage girls and women enrolled in a project that removed financial and access barriers to contraception and informed them about the particular efficacy of LARC [long-acting reversible contraception] methods. The observed rates of pregnancy, birth, and abortion were substantially lower than national rates among all U.S. teens, particularly when compared with sexually experienced U.S. teens. Stratification according to factors known to be associated with sexual behavior and pregnancy risk (age and race) showed that this was true among both older teens (18 to 19 years of age) and younger teens, as well as among both white and black teens.”



HPV Uptake Pre- and Post-Affordable Care Act: Variation by Insurance Status, Race, and Education
Corriero, Rosemary; et al. Journal of Pediatric and Adolescent Gynecology, July 2017. DOI: 10.1016/j.jpag.2017.07.002.
Findings: “Vaccination uptake increased when comparing pre- and post-ACA waves of data. This increase in vaccination coverage could be related to the increased preventative service coverage, which includes vaccines, required by the ACA. Future studies may focus on the role insurance has on vaccination uptake, and meeting Healthy People 2020 objectives for vaccination coverage.”


Insurance Coverage

Health Insurance Coverage among Women of Reproductive Age before and after Implementation of the Affordable Care Act
Jones, Rachel K.; Sonfield, Adam. Contraception, May 2016, Vol. 93. DOI: 10.1016/j.contraception.2016.01.003.
Findings: “The proportion of women who were uninsured declined by almost 40 percent (from 19 percent to 12 percent), though several groups, including U.S.-born and foreign-born Latinas, experienced no significant declines. Among low-income women in states that expanded Medicaid, the proportion uninsured declined from 38 percent to 15 percent, largely due to an increase in Medicaid coverage (from 40 percent to 62 percent). Declines in uninsurance in nonexpansion states were only marginally significant.”

Changes in Self-Reported Insurance Coverage, Access to Care, and Health Under the Affordable Care Act
Sommers, Benjamin D.; et al. JAMA, July 2015, Vol. 314. DOI: 10.1001/jama.2015.8421.
Findings: “This analysis of a large national survey of U.S. adults demonstrated significant improvements in trends for self-reported coverage, access to a personal physician and medications, and health after the ACA’s first and second open enrollment periods. Consistent with other research, we found that national trends in coverage and access prior to the ACA were worsening. Those trends improved after October 2013, when the ACA’s open enrollment began. Subgroup analyses demonstrated that the largest improvements in coverage and access to medicine occurred among racial/ethnic minorities. The results suggest that the ACA may be associated with reductions in long-standing disparities in access to care, one of the goals of the ACA.”

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