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Trends in Birth Rates After Elimination of Cost Sharing for Contraception by the Patient Protection and Affordable Care Act.

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?

SUBMITTER: Dalton VK

PROVIDER: S-EPMC7648257 | biostudies-literature | 2020 Nov

REPOSITORIES: biostudies-literature

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Trends in Birth Rates After Elimination of Cost Sharing for Contraception by the Patient Protection and Affordable Care Act.

Dalton Vanessa K VK Moniz Michelle H MH Bailey Martha J MJ Admon Lindsay K LK Kolenic Giselle E GE Tilea Anca A Fendrick A Mark AM

JAMA network open 20201102 11

<h4>Importance</h4>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.<h4>Objective</h4>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).<h4>Design, setting, and participants</h4>This cross-secti ...[more]

PMID: 33156347

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Project description:ImportanceThe Patient Protection and Affordable Care Act (ACA) expanded Medicaid eligibility at the discretion of states to US individuals earning up to 138% of the federal poverty level (FPL) and made private insurance subsidies available to most individuals earning up to 400% of the FPL. Its national impact remains debated.ObjectiveTo determine the association of the ACA with ambulatory quality, patient experience, utilization, and cost.Design, setting, and participantsThis cross-sectional study used difference-in-differences (DiD) analyses comparing outcomes before (2011-2013) and after (2014-2016) ACA implementation for US adults aged 18 to 64 years with income below and greater than or equal to 400% of the FPL. Participants were respondents to the Medical Expenditure Panel Survey, a nationally representative annual survey. Data analysis was performed from January 2021 to March 2022.ExposuresACA implementation.Main outcomes and measuresFor quality and experience, this study examined previously published composites based on individual measures, including high-value care composites (eg, preventive testing) and low-value care composites (eg, inappropriate imaging), an overall patient experience rating, a physician communication composite, and an access-to-care composite. For utilization, outpatient, emergency, and inpatient encounters and prescribed medicines were examined. Overall and out-of-pocket expenditures were analyzed for cost.ResultsThe total sample included 123 171 individuals (mean [SD] age, 39.9 [13.4] years; 65 034 women [52.8%]). After ACA implementation, adults with income less than 400% of the FPL received increased high-value care (diagnostic and preventive testing) compared with adults with income 400% or higher of the FPL (change from 70% to 72% vs change from 84% to 84%; adjusted DiD, 1.20%; 95% CI, 0.18% to 2.21%; P = .02) with no difference in any other quality composites. Individuals with income less than 400% of the FPL had larger improvements in experience, communication, and access composites compared with those with income greater than or equal to 400% of the FPL (global rating of health, change from 69% to 73% vs change from 79% to 81%; adjusted DiD, 2.12%; 95% CI, 0.18% to 4.05%; P = .03). There were no differences in utilization or cost, except that receipt of primary care increased for those with lower income vs those with higher income (change from 65% to 66% vs change from 80% to 77%; adjusted DiD, 2.97%; 95% CI, 1.18% to 4.77%; P = .001) and total out-of-pocket expenditures decreased for those with lower income vs those with higher income (change from $504 to $439 vs from $757 to $769; adjusted DiD, -$105.50; 95% CI, -$167.80 to -$43.20; P = .001).Conclusions and relevanceIn this cross-sectional national study, the ACA was associated with improved patient experience, communication, and access and decreased out-of-pocket expenditures, but little or no change in quality, utilization, and total cost.

Project description:BackgroundDespite public perception, most of the nearly 20 million US veterans have health coverage outside the Veterans Health Administration (VHA), and VHA eligibility and utilization vary across veterans. Out-of-pocket healthcare spending thus remains a potential source of financial hardship for veterans. The Affordable Care Act (ACA) aimed to expand health insurance access, but its effect on veterans' financial risk protection has not been explored.ObjectiveTo evaluate whether ACA implementation was associated with changes in veterans' risk of catastrophic health expenditures, and to characterize drivers of catastrophic health spending among veterans post-ACA.DesignUsing multivariable linear probability regression, we examined changes in likelihood of catastrophic health spending after ACA implementation, stratifying by age (18-64 vs 65+), household income tercile, and payer (VHA vs non-VHA). Among veterans with catastrophic spending post-ACA, we evaluated sources of out-of-pocket spending.ParticipantsNationally representative sample of 13,030 veterans aged 18+ from the 2010 to 2017 Medical Expenditure Panel Survey.InterventionACA implementation, January 1, 2014.Main measuresLikelihood of catastrophic health expenditures, defined as household out-of-pocket spending exceeding 10% of household income.Key resultsAmong veterans aged 18-64, ACA implementation was associated with a 26% decrease in likelihood of catastrophic health expenditures (absolute change, -1.4 percentage points [pp]; 95% CI, -2.6 to -0.2; p=0.03), which fell from 5.4% pre-ACA to 3.9% post-ACA. This was driven by a 38% decrease in catastrophic spending among veterans with non-VHA coverage (absolute change, -1.8pp; 95% CI, -3.0 to -0.6; p=0.003). In contrast, catastrophic expenditure rates among veterans aged 65+ remained high, at 13.0% pre- and 12.5% post-ACA. Major drivers of veterans' spending post-ACA include dental care, prescription drugs, and home care.ConclusionsACA implementation was associated with reduced household catastrophic health expenditures for younger but not older veterans. These findings highlight gaps in veterans' financial protection and areas amenable to policy intervention.

Project description:ImportanceFluoride varnish reduces children's tooth decay, yet few clinicians provide it. Most state Medicaid programs have covered this service during medical visits for children aged 1 to 5 years, but private insurers began covering it only in 2015 due to the Patient Protection and Affordable Care Act (ACA) mandate that they cover a set of recommended preventive services without cost-sharing. Evidence on clinicians' behavior change postmandate is limited.ObjectiveTo examine monthly changes in fluoride varnish applications among pediatric clinicians following the ACA mandate.Design, setting, and participantsUsing all-payer claims data from Massachusetts, this cohort study applied an interrupted time-series approach with linear regression models comparing changes in monthly clinician-level outcomes before and after the mandate. Participants included clinicians who billed at least 5 well-child visits for patients aged 1 to 5 years and were observed at least once premandate. Adjusted for clinician fixed effects, models were assessed overall and separately for clinicians categorized by their monthly share of well-child visits paid by private insurers before the mandate: mostly private (>66% of visits paid by private insurers), mostly public (<33% of visits paid by private insurers), or mixed (33%-66% of visits paid by private insurers) insurance types. Analysis was performed from June 1, 2022, to July 31, 2023.ExposurePreenactment and postenactment of the ACA mandate for private insurers to cover fluoride varnish applications without cost-sharing.Main outcomes and measuresClinician-month measures of whether fluoride varnish was provided during at least 1 well-child visit and the share of such visits, analyzed separately for clinicians who did and did not apply fluoride varnish premandate.ResultsThe sample included 2405 clinicians, with 107 841 clinician-months. Premandate, 10.48% of the visits included fluoride varnish applications. Two years postmandate, the likelihood of ever applying fluoride varnish was 13.64 (95% CI, 10.97-16.32) percentage points higher. For clinicians providing fluoride varnish premandate, the share of visits with fluoride varnish increased by 9.22 (95% CI, 5.41-13.02) percentage points. This increase was observed in clinicians who treated children with insurance that was mostly mixed and mostly private; no substantial change was observed among those treating children with mostly public insurance.Conclusions and relevanceIn this cohort study of pediatric primary care clinicians, an association between the ACA mandate and an increase in fluoride varnish application was observed, especially among clinicians primarily treating privately insured patients and those applying it premandate. However, application remains infrequent, suggesting persistent barriers.

Project description:ImportanceThere is limited evidence on whether the Affordable Care Act Medicaid expansion beginning in 2014 improved access to elective procedures. Uninsured individuals are at higher risk of obesity and may have experienced improved uptake of bariatric surgery following Medicaid expansion.ObjectiveTo examine the association between Medicaid expansion and the receipt of inpatient elective bariatric surgery among Medicaid-covered and uninsured individuals aged 26 to 64 years.Design setting and participantsThis cohort study used difference-in-differences analysis of all-payer data (2010-2017) of 637 557 elective bariatric surgeries for patients aged 26 to 74 years from 11 Medicaid expansion states and 6 nonexpansion states. Nonexpansion states and individuals aged 65 to 74 years were control cohorts. Data analysis was performed from July 6, 2020, to July 23, 2021.ExposureLiving in a Medicaid expansion state.Main outcomes and measuresThe main outcomes were the (1) number of elective bariatric surgeries, (2) population count, and (3) rate of bariatric surgery (number of surgeries per 10 000 population) among Medicaid-covered and uninsured individuals.ResultsOf the 600 798 elective bariatric surgeries in adults aged 26 to 64 years between 2010 and 2017 from the 17 study states, Medicaid-covered and uninsured individuals accounted for 18.3% of the total surgery volume in expansion states and 14.5% in nonexpansion states. A total of 296 798 patients (78.9%) in expansion states were women vs 177 386 (78.9%) in nonexpansion states. Among individuals aged 26 to 64 years, the median age was 44 (IQR, 37-52) years. Racial and ethnic distribution was non-Hispanic White, 60.2%; non-Hispanic Black, 17.7%; Hispanic, 16.6%; and other, 5.5%. Between 2013 and 2017, the volume of bariatric surgeries for Medicaid-covered and uninsured patients increased annually by 30.3% in expansion states and 16.5% in nonexpansion states. Medicaid expansion was associated with a 36.6% annual increase (95% CI, 8.2% to 72.5%) in surgery volume, a 9.0% annual increase (95% CI, 3.8% to 14.5%) in the population, and a 25.5% change (95% CI, -1.3% to 59.4%) in the rate of bariatric surgery. By race and ethnicity, Medicaid expansion was associated with an increase in the rate of bariatric surgery among non-Hispanic White individuals (31.6%; 95% CI, 6.1% to 63.0%) but no significant change among non-Hispanic Black (5.9%; 95% CI, -19.8% to 39.9%) and Hispanic (28.9%; 95% CI, -24.4% to 119.8%) individuals.Conclusions and relevanceThis cohort study found that Medicaid expansion was associated with increased rates of bariatric surgery among lower-income non-Hispanic White individuals, but not among Hispanic and non-Hispanic Black individuals.

Project description:The effect of the Affordable Care Act (ACA) dependent coverage provision on pregnancy-related health care and health outcomes is unknown.To determine whether the dependent coverage provision was associated with changes in payment for birth, prenatal care, and birth outcomes.Retrospective cohort study, using a differences-in-differences analysis of individual-level birth certificate data comparing live births among US women aged 24 to 25 years (exposure group) and women aged 27 to 28 years (control group) before (2009) and after (2011-2013) enactment of the dependent coverage provision. Results were stratified by marital status.The dependent coverage provision of the ACA, which allowed young adults to stay on their parent's health insurance until age 26 years.Primary outcomes were payment source for birth, early prenatal care (first visit in first trimester), and adequate prenatal care (a first trimester visit and 80% of expected visits). Secondary outcomes were cesarean delivery, premature birth, low birth weight, and infant neonatal intensive care unit (NICU) admission.The study population included 1?379?005 births among women aged 24-25 years (exposure group; 299?024 in 2009; 1?079?981 in 2011-2013), and 1?551?192 births among women aged 27-28 years (control group; 325?564 in 2009; 1?225?628 in 2011-2013). From 2011-2013, compared with 2009, private insurance payment for births increased in the exposure group (36.9% to 35.9% [difference, -1.0%]) compared with the control group (52.4% to 51.1% [difference, -1.3%]), adjusted difference-in-differences, 1.9 percentage points (95% CI, 1.6 to 2.1). Medicaid payment decreased in the exposure group (51.6% to 53.6% [difference, 2.0%]) compared with the control group (37.4% to 39.4% [difference, 1.9%]), adjusted difference-in-differences, -1.4 percentage points (95% CI, -1.7 to -1.2). Self-payment for births decreased in the exposure group (5.2% to 4.3% [difference, -0.9%]) compared with the control group (4.9% to 4.3% [difference, -0.5%]), adjusted difference-in-differences, -0.3 percentage points (95% CI, -0.4 to -0.1). Early prenatal care increased from 70% to 71.6% (difference, 1.6%) in the exposure group and from 75.7% to 76.8% (difference, 0.6%) in the control group (adjusted difference-in-differences, 0.6 percentage points [95% CI, 0.3 to 0.8]). Adequate prenatal care increased from 73.5% to 74.8% (difference, 1.3%) in the exposure group and from 77.5% to 78.8% (difference, 1.3%) in the control group (adjusted difference-in-differences, 0.4 percentage points [95% CI, 0.2 to 0.6]). Preterm birth decreased from 9.4% to 9.1% in the exposure group (difference, -0.3%) and from 9.1% to 8.9% in the control group (difference, -0.2%) (adjusted difference-in-differences, -0.2 percentage points (95% CI, -0.3 to -0.03). Overall, there were no significant changes in low birth weight, NICU admission, or cesarean delivery. In stratified analyses, changes in payment for birth, prenatal care, and preterm birth were concentrated among unmarried women.In this study of nearly 3 million births among women aged 24 to 25 years vs those aged 27 to 28 years, the Affordable Care Act dependent coverage provision was associated with increased private insurance payment for birth, increased use of prenatal care, and modest reduction in preterm births, but was not associated with changes in cesarean delivery rates, low birth weight, or NICU admission.

Dataset Information

Trends in Birth Rates After Elimination of Cost Sharing for Contraception by the Patient Protection and Affordable Care Act.

Publications

Trends in Birth Rates After Elimination of Cost Sharing for Contraception by the Patient Protection and Affordable Care Act.

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