Association for Public Policy Analysis & Management

This paper analyzes how access to publicly subsidized health insurance plans affects the birth rate in the United States. Uninsured women of childbearing age face higher risks of unintended pregnancy because they lack access to the most effective contraception methods which are prescription based. Lack of insurance coverage and unintended pregnancies are particularly critical issues for low-income women. In 2010, women below 100% of the federal poverty level (FPL) were three times more likely to be uninsured and five times more likely to have an unintended pregnancy than women at or above 200% of the FPL (author’s calculation using American Community Survey, 2010; Finer & Zolna, 2011). Prior to the Affordable Care Act (ACA), Medicaid eligibility was based on both financial and categorical eligibility requirements. While low income childless women were not eligible, low income pregnant women were. This meant women who lacked access to publicly subsidized prescription-based contraception would have the full cost of their pregnancy covered if they became pregnant. The ACA removed categorical eligibility requirements by allowing states to extend Medicaid coverage to all adults up to 138% of the FPL. Additionally, adults between 100 (138) and 400% of the FPL were eligible for subsidies to purchase non-group health insurance in non-expansion (expansion) states. These changes led to an increase in access to prescription contraception for low-income women. Better control over fertility choices could reduce the number of births by reducing the number of unintended pregnancies.

In order to test this hypothesis, I use data on all U.S. births between 2010 and 2015 from the Vitality Statistics database. Following the imputed eligibility approach introduced in Currie and Gruber (1996), I divide women into various demographic bins and then measure share of women in each bin eligible for Medicaid or subsidized Marketplace coverage in each month and in each state according to that state’s laws. This measure of access to publically subsidized coverage is created using the American Community Survey and lagged 48 weeks to account for gestational age. I also address pre-ACA subsidized health insurance programs and family planning waivers. My preliminary results suggest that access to subsidized health insurance had a negative effect on the birth rate, and that reduction is greater for younger women.