Panel Paper: State Prescription Contraceptive Insurance Mandates: Effects on Unintended Births

Friday, November 3, 2017
Hong Kong (Hyatt Regency Chicago)

*Names in bold indicate Presenter

Emily M. Johnston, Urban Institute and E. Kathleen Adams, Emory University

Research Objective: The Affordable Care Act (ACA) requires health insurance plans to cover women’s preventive health services, including FDA-approved contraceptives, without cost sharing. Increased access to no-cost contraceptives has the potential to increase women’s use of effective contraception and decrease rates of unintended pregnancy by removing financial barriers to access. Prior to the ACA, 28 states implemented their own contraception coverage mandates by requiring insurers that covered prescription drugs to also cover the full range of FDA-approved contraceptive drugs and devices. While less comprehensive than the ACA requirement, which both mandates coverage and eliminates cost sharing, these state mandates were designed to increase access to prescription contraceptives for privately insured women. Previous studies have found that state mandates increased the coverage of prescription contraceptives for privately insured women, increased women’s use of prescription contraceptives, and decreased abortion rates. We build on this body of literature by analyzing the effect of state contraception coverage mandates on unintended and mistimed births.
Study Design: We use pooled Pregnancy Risk Assessment Monitoring Survey (PRAMS) data (1996-2012) and variation in the year of implementation of state mandates (2000-2008) to test the effects of these mandates on the likelihood of unintended and mistimed birth. We use difference-in-differences analysis to compare outcomes among privately insured women in state-years with mandates to privately insured women in state-years without mandates. All models include state and year fixed effects, robust standard errors clustered at the state level, and PRAMS survey-weights. We supplement individual-level analysis with state-level models to estimate the effect of mandates on the number of unintended births by state.
Population Studied: The study sample includes 116,772 privately insured women residing in 11 treatment states that implemented contraceptive coverage mandates and 13 control states that did not implement mandates. The state-level study sample includes 159 state-years and measures the counts of unintended birth and total births among privately insured women.
Principal Findings: The presence of a contraception coverage mandate decreased the likelihood of unintended birth by 1.99 percentage points and mistimed birth by 2.18 percentage points. These declines reduce the rate of unintended birth among privately insured women from 32.4% to 30.4%, and reduce the rate of a mistimed birth from 26.7% to 24.5%. At the state level, mandates decreased the number of unintended births among privately insured women, on average, by 646 births, a 5% reduction, while the number of mistimed births decreased by 766 births, an 8% reduction.
Conclusion: State contraceptive coverage mandates reduced the likelihood of an unintended birth or mistimed birth among privately insured women and decreased the number of unintended births among privately insured women within states.
Implications for Public Policy: Reducing financial barriers to contraception is a successful policy tool for reducing the likelihood and number of unplanned births. As the contraception coverage requirement under the ACA is more comprehensive than the mandates studied here, the ACA is likely to have a larger effect on decreasing unintended births than the findings reported here.