Dataset Information

Medicaid Expansion at Title X Clinics: Client Volume, Payer Mix, and Contraceptive Method Type.

ABSTRACT: BACKGROUND:Title X supports access to family planning and preventive care services. Given its focus on low-income clients, Title X clinics may have been particularly affected by the Affordable Care Act's Medicaid expansion. OBJECTIVES:To examine the impact of the Affordable Care Act's Medicaid expansion on Title X client volumes, health insurance coverage, and contraceptive method mix. RESEARCH DESIGN:A difference-in-differences design compared changes in the outcomes of interest before and after expansion, for expansion versus nonexpansion states. SUBJECTS:Administrative data from Family Planning Annual Reports that describe Title X clients who sought services. MEASURES:Female client volume was measured using a participation ratio defined as the number of female clients per 100 women aged 15-44 with incomes <250% of the federal poverty line. We also examined the share of clients by insurance type and contraceptive method type. RESULTS:We did not find evidence that expansion was related to changes in client volume. We did find a significant 9.9 percentage point increase in the share of clients with Medicaid and a significant 10.0 percentage point decrease in the share of clients without coverage. We found suggestive evidence that expansion was associated with increased use of long-acting reversible contraceptives, but those results were somewhat sensitive to model specification. CONCLUSIONS:Expansion was associated with meaningful increases in Medicaid coverage at Title X clinics and declines in uninsurance. Our results have important implications for the financial stability of Title X clinics in light of historical declines in Title X grant revenues.

SUBMITTER: Boudreaux M

PROVIDER: S-EPMC6522286 | biostudies-literature | 2019 Jun

REPOSITORIES: biostudies-literature

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Medicaid Expansion at Title X Clinics: Client Volume, Payer Mix, and Contraceptive Method Type.

Boudreaux Michel M Choi Yoon Sun YS Xie Liyang L Marthey Daniel D

Medical care 20190601 6

<h4>Background</h4>Title X supports access to family planning and preventive care services. Given its focus on low-income clients, Title X clinics may have been particularly affected by the Affordable Care Act's Medicaid expansion.<h4>Objectives</h4>To examine the impact of the Affordable Care Act's Medicaid expansion on Title X client volumes, health insurance coverage, and contraceptive method mix.<h4>Research design</h4>A difference-in-differences design compared changes in the outcomes of in ...[more]

PMID: 30973473

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Project description:ContextThe Affordable Care Act resulted in unprecedented reductions in the uninsured population through subsidized private insurance and an expansion of Medicaid. Early estimates from the beginning of 2014 showed that the Medicaid expansion decreased uninsured discharges and increased Medicaid discharges with no change in total discharges.ObjectiveTo provide new estimates of the effect of the ACA on discharges for specific conditions.Design, setting, and participantsWe compared outcomes between states that did and did not expand Medicaid using state-level all-capture discharge data from 2009-2014 for 42 states from the Healthcare Costs and Utilization Project's FastStats database; for a subset of states we used data through 2015. We stratified the analysis by baseline uninsured rates and used difference-in-differences and synthetic control methods to select comparison states with similar baseline characteristics that did not expand Medicaid.Main outcomeOur main outcomes were total and condition-specific hospital discharges per 1,000 population and the share of total discharges by payer. Conditions reported separately in FastStats included maternal, surgical, mental health, injury, and diabetes.ResultsThe share of uninsured discharges fell in Medicaid expansion states with below (-4.39 percentage points (p.p.), -6.04 --2.73) or above (-7.66 p.p., -9.07 --6.24) median baseline uninsured rates. The share of Medicaid discharges increased in both small (6.42 p.p. 4.22-6.62) and large (10.5 p.p., 8.48-12.5) expansion states. Total and most condition-specific discharges per 1,000 residents did not change in Medicaid expansion states with high or low baseline uninsured rates relative to non-expansion states (0.418, p = 0.225), with one exception: diabetes. Discharges for that condition per 1,000 fell in states with high baseline uninsured rates relative to non-expansion states (-0.038 95% p = 0.027).ConclusionsEarly changes in payer mix identified in the first two quarters of 2014 continued through the Medicaid expansion's first year and are distributed across all condition types studied. We found no change in total discharges between Medicaid expansion and non-expansion states, however residents of states that should have been most affected by the Medicaid expansion were less likely to be hospitalized for diabetes.

Project description:ContextImproving contraceptive method choice is a goal of international family planning. Method mix-the percentage distribution of total contraceptive use across various methods-reflects both supply (availability of affordable methods) and demand (client preferences). We analyze changes in method mix, regional contrasts, and the relationship of the mix to contraceptive prevalence.MethodsWe use 789 national surveys from the 1960s through 2019, from 113 developing countries with at least 1 million people and with data on use of 8 contraceptive methods. Two measures assess the "evenness" of the mix: method skew (more than 50% use is by 1 method), and the average deviation (AD) of the 8 methods' shares from their mean value. Population weighted and unweighted results are compared because they can differ substantially.ResultsUse of traditional methods has declined but still represents 11% of all use (population weighted) or 17% (unweighted country average). Vasectomy's share was historically low with the exception of a few countries but is now even lower. The previous trend toward greater overall evenness in the mix has slowed recently. Sub-Saharan Africa shows a hormonal method progression from oral contraceptives to injectables to implants in a substantial number of countries. In some countries with high HIV prevalence, the condom share has increased. The leading method's share differs by region: female sterilization in Asia (39%) and in Latin America (31%), the pill in the Middle East/North Africa (32%), and the injectable in sub-Saharan Africa (36%). Method skew persists in 30% of countries. "Evenness" of mix is not related to contraceptive prevalence.ConclusionThe marked diversity in predominant methods underscores the conclusion that no single method mix is ideal or appropriate everywhere. But that diversity across countries, coupled with the persisting high degree of extreme skewness in many of them, argues for continued concerted efforts for programs to increase method choice.

Project description:BackgroundYouth ages 15 to 24, who comprise a large portion of sub-Saharan Africa, face a higher burden of unmet contraceptive need than adults. Despite increased international and national commitments to improving young people's access to contraception, significant barriers impede their access to a full range of methods. To further explore these barriers among youth in Kenya, Nigeria, and Uganda, we conducted a qualitative study to capture the challenges that affect contraceptive method decisionmaking and complicate youth access to the full method mix.MethodsTo understand factors that impact young people's contraceptive decisionmaking process across all three countries, we conducted a total of 35 focus group discussions with 171 youth ages 15 to 24 and 130 in-depth interviews with key stakeholders working in youth family planning. Questionnaires aligned with the High Impact Practices in Family Planning's elements of adolescent-friendly contraceptive services. Data were coded with MAXQDA and analyzed using a framework for contraceptive decisionmaking to identify relevant patterns and themes.ResultsIn all three countries, youth reported that condoms are the most commonly sought contraceptive method because they are easiest to access and because youth have limited knowledge of other methods. Youth from diverse settings shared uncertainty and concern about the safety and side effects of many methods other than condoms, complicating their ability to take full advantage of other available methods. While most youth in Kenya, Nigeria, and Uganda reported at least moderate confidence in obtaining the information needed to help choose a method, and only a few youth reported that they are completely unable to access contraceptives, other barriers still present a major deterrent for youth, including cost, inconvenient facility hours and long wait times, and stigma from family, community members, and providers.ConclusionsYoung people's ability to fully exercise their method choice remains limited despite availability of services, leading them to take the path of least resistance. Program implementers and policymakers should consider the diverse and often interconnected barriers that youth face in attempting to enjoy the benefits of a full spectrum of contraceptive methods and design multi-level interventions to mitigate such barriers.

Project description:IntroductionAccess to effective contraception prevents unintended pregnancies among sexually active female youth. Potentially impacted by the Affordable Care Act's Medicaid-related policies, contraception use increased among sexually active high-school students from 2013 to 2019.MethodsAnalyses conducted in 2021 assessed state-level Youth Risk Behavior Survey data among female students in grades 9-12 who reported being sexually active. States that expanded Medicaid were compared with other states in 2013 (baseline) and 2019 (after expansion). Measured outcomes included self-reported use of moderately effective or highly effective, long-acting reversible contraception at last sex. Long-acting reversible contraception included intrauterine devices and implants. Moderately effective contraception included birth control pills, injectables, patches, or rings. Results were weighted and adjusted for age and race/ethnicity.ResultsStudents in Medicaid expansion states (n=27,564) did not differ significantly from those in nonexpansion states (n=6,048) at baseline or after expansion with respect to age, age at first sex, or the number of sexual partners in the past 3 months; however, race/ethnicity population characteristics changed over time. Postexpansion increased use of intrauterine devices/implants was greater in Medicaid expansion states than in nonexpansion states (238.1% increase vs 120.0% increase, adjusted p=0.047). For those aged 16-17 years, Medicaid expansion states had a 283.3% increase in intrauterine device/implant use compared with an increase of 69.7% in nonexpansion states (adjusted p=0.004).ConclusionsMedicaid expansion was associated with a greater population-level increase in intrauterine device/implant use among sexually active female high-school students aged 16-17 years. These findings point to the possibility that the Affordable Care Act's Medicaid-related policies played a role in young women's use of intrauterine devices/implants.

Project description:BACKGROUND:Increased contraceptive use has been associated with a decrease in high parity births, births that occur close together in time, and births to very young or to older women. These types of births are also associated with high risk of under-five mortality. Previous studies have looked at the change in the level of contraception use and the average change in these types of high-risk births. We aim to predict the distribution of births in a specific country when there is a change in the level and method of modern contraception. METHODS:We used data from full birth histories and modern contraceptive use from 207 nationally representative Demographic and Health Surveys covering 71 countries to describe the distribution of births in each survey based on birth order, preceding birth space, and mother's age at birth. We estimated the ecologic associations between the prevalence and method-mix of modern contraceptives and the proportion of births in each category. Hierarchical modelling was applied to these aggregated cross sectional proportions, so that random effects were estimated for countries with multiple surveys. We use these results to predict the change in type of births associated with scaling up modern contraception in three different scenarios. RESULTS:We observed marked differences between regions, in the absolute rates of contraception, the types of contraceptives in use, and in the distribution of type of birth. Contraceptive method-mix was a significant determinant of proportion of high-risk births, especially for birth spacing, but also for mother's age and parity. Increased use of modern contraceptives is especially predictive of reduced parity and more births with longer preceding space. However, increased contraception alone is not associated with fewer births to women younger than 18 years or a decrease in short-spaced births. CONCLUSIONS:Both the level and the type of contraception are important factors in determining the effects of family planning on changes in distribution of high-risk births. The best predictions for how birth risk changes with increased modern contraception and for different contraception methods allow for more nuanced predictions specific to each country and can aid better planning for the scaling up of modern contraception.

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Medicaid Expansion at Title X Clinics: Client Volume, Payer Mix, and Contraceptive Method Type.

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Medicaid Expansion at Title X Clinics: Client Volume, Payer Mix, and Contraceptive Method Type.

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