Since January 2013, most private insurance plans have been required to cover contraceptive services without patient cost-sharing. While health insurance plans have covered some methods of contraception with low cost-sharing, not all plans or methods have been covered equally. This is particularly the case of long-acting reversible contraceptive (LARC) methods, intrauterine devices (IUDs) and implants, which are very effective but previously had high initial costs for patients. According to data from the 2011-2013 National Survey of Family Growth [PDF], 11.6% (4.4 million) of women using contraception use a LARC method.
The ACA directly affected cost-sharing for contraception.
Drs. Pace, Dusetzina, and Keating recently published an article in Medical Care that examines whether cost-sharing (such as co-payments) for LARC methods has decreased and whether LARC use has changed since ACA implementation. The authors used Truven Health MarketScan claims data to identify a cohort of women aged 18-45 with at least 12 months of continuous insurance coverage and claims for at least one contraceptive method. The time period studied was January 2010-December 2013, and the authors used a variety of methods, including interrupted time series adjusting for age, region, and plan type, to estimate trends in cost-sharing and utilization over time.
The ACA directly affected cost-sharing for contraception. Consistent with the intent of the legislation, Pace and colleagues found that the proportion of claims for which cost-sharing was $0 rose substantially over the study period. For IUDs, the proportion changed from 37% in 2010 to 88% in 2013. The change was even greater for implants, from 9% with $0 cost-sharing in 2010 to 81% in 2013.
Over time, there was a statistically significant trend in rising LARC utilization by month. However, the authors did not find any significant change in LARC uptake after ACA implementation (in fact, the authors found a slight decrease in the trend associated with the January 2013 implementation). However, in a sensitivity analysis that used April, 2013 as the start of ACA implementation (to account for delays in knowledge of the benefit), there was a statistically significant increase in the level of LARC use.
In at least some medical situations, LARC methods require separate insurance verification by the office and two visits (one for counseling and one for insertion/implantation). I’m not sure how many of you have tried scheduling appointments with OB/GYNs lately, but often wait times to get appointments are much longer than a month! At least at an anecdotal level, a delayed implementation effect makes perfect sense. The authors discuss additional barriers in the article as well. Preferences are also important, although relatively few prior studies have delved into contraceptive preferences. Perhaps now that cost has largely been removed as a barrier, future work will be able to assess other aspects of contraceptive choice.