Free Birth Control, Fewer Births

Unintended pregnancies decline when copays and patient fees are eliminated

Birth rates among women with employer-based health insurance dropped significantly after the Affordable Care Act eliminated copays and other patient fees for birth control, according to a large study recently published in JAMA Network.

While the birth rates declined in all insured income groups, the rate of decrease was highest among women in households with earnings below the official poverty line.

With insurance fees for all types of contraceptives removed by 2014, fewer insured women went without birth control pills or other prescription contraception, according to the findings. Procedures for IUDs and hormone implants, which are the most reliable and expensive forms of reversible birth control, rose significantly in all income groups.

Free and Reliable Birth Control Reduced Unintended Pregnancies

Prior to the ACA rules, women with health insurance through employers or other commercial providers often paid all or most of the price for contraceptives. An IUD could easily cost a patient more than $1,000, UCLA Anderson’s Martha Bailey explains in a subsequent opinion article published in Nature. The JAMA Network study is authored by University of Michigan’s Vanessa K. Dalton, Michelle H. Moniz, UCLA’s Bailey, and Michigan’s Lindsay K. Admon, Giselle E. Kolenic, Anca Tilea and A. Mark Fendrick.

The study results suggest that free, reliable birth control reduced unintended pregnancies, the authors note. About half of all pregnancies in the population at large are unintended, and birth rates from unintended pregnancies are much higher among low-income women than other income groups.

The free birth control may be a factor in declining U.S. birth rates generally in recent years, a phenomenon that researchers have struggled to explain. Birth rates are down about 19% since 2007, although there was relatively little change between 2011 and 2015. But the desire to use contraception is affected by many other factors, such as lifestyle goals and financial concerns, Bailey notes in an email. “Unfortunately, (our) results can’t tell us how much of these broader changes are due to increasing access to contraception.”

Several previous studies have similarly associated reduced or erased out-of-pocket insurance costs with more consistent contraceptive use, as well as higher uptakes of the most effective methods. The JAMA Network study set out to determine whether these changes led to fewer births, as well as whether the access to free contraception particularly benefited low-income women.

Pregnancy Rates Fell for Low-Income Women

The researchers looked at anonymized records of some 7.76 million women, aged 15 to 45 years old, enrolled in 47,721 employer-based health plans (obtained as an employee or as a dependent of one) between 2008 and 2018. The subjects were categorized into three household incomes; under 100% of the federal poverty rate; between 100% and 399%; and 400% and over. Eliminating subjects that had undergone hysterectomies and those with unknown household incomes brought the sample down to about 4.59 million.

Among the lowest income group, the probability of pregnancy dropped more than 22%, from 8% in 2014 to 6.2% in 2018. Birth probability declined from 6.4% to 5.8% in the middle income group, and from 5.6% to 5.5% in the highest income group.

Women in low earning households generally have higher birth rates than those with more money. But in the study, differences in birth rates between the lowest and highest income groups narrowed by more than 62% between 2008 and 2018. By 2018, about 3.2% of all subjects were using long acting methods of birth control, up from about 2.2% in 2013.

Although Medicaid now covers all contraception costs, millions of ineligible women who get birth control from subsidized clinics continue to pay fees determined by an income-based sliding scale, Bailey writes in Nature. Broadening free contraception beyond the commercially insured population, she notes, could reduce abortion rates and the economic cost to both families and taxpayers that often comes from unintended pregnancies.