Study Documents First Data on Eliminating Out-of-Pocket Contraceptive Costs Under the ACA

Study Documents First Data on Eliminating Out-of-Pocket Contraceptive Costs Under the ACA

January 30,2014 — Summary of: "Changes in Out-of-Pocket Payments for Contraception by Privately Insured Women During Implementation of the Federal Contraceptive Coverage Requirement," Finer et al., Contraception, Dec. 13, 2013.

Under federal rules being implemented as part of the Affordable Care Act (PL 111-148), most private health plans must "include coverage of contraceptive methods, services and counseling for women" and "do so without requiring copayments, deductibles or other forms of out-of-pocket costs" for women, Lawrence Finer, director of domestic research at the Guttmacher Institute, and colleagues wrote in the study.

Finer and colleagues noted that many privately insured women had access to contraceptives with no or very little out-of-pocket costs even before the contraceptive coverage requirements took effect.

However, by flatly prohibiting consumer cost-sharing, the requirements eliminated cost as a potential barrier to choosing a contraceptive method, "a change that could be particularly important for women considering an intrauterine device (IUD) or implant," which are highly effective but have significant upfront costs, according to the researchers.

In this study, Finer and colleagues aimed to document "the initial reach and impact of the contraceptive coverage requirement."


Finer and colleagues used data from Waves 1 and 2 of the Guttmacher Institute's Continuity and Change in Contraceptive Use Study, which was launched in the fall of 2012 to monitor contraceptive use over 18 months among a national sample of women ages 18 to 39. The researchers partnered with the research firm GfK to identify a baseline survey population of women at risk of pregnancy from a nationally representative sample.

Wave 1 included 4,643 eligible respondents who answered a 60-question survey over three weeks in November and December 2012. For Wave 2, 3,207 respondents answered the same survey over three weeks in May and June 2013.

The researchers focused on women who had out-of-pocket costs for contraceptives and who used hormonal methods or an IUD in the last 30 days. The women were not actively seeking to become pregnant.

The survey questions asked how much each woman paid out of pocket for her method and whether she had private insurance, Medicaid or another government-sponsored health insurance, some other type of health insurance, or no health insurance. The researchers noted that because only 1% of respondents indicated they had some other type of health insurance, they excluded this group from their analysis.

The researchers asked pill, patch, vaginal ring and injectable users the survey questions at both waves, while IUD users were only asked about cost the first time they reported use because it was assumed they would only pay for it when they first obtained it. Patch and implant users were excluded from the analyses because the sample size was too small, the researchers noted.


The proportion of women who reported having private health insurance, using the pill during both waves and not paying anything out of pocket increased from 15% to 40%, the study found.

Similarly, the proportion of privately insured women who did not pay anything for the vaginal ring increased from 23% to 52%.

Although there was no significant difference between waves for injectable or IUD users, the researchers found a "significant decline in the proportion of IUD users who paid $91 or more, from 30% to 5%."

As anticipated, the proportion of publicly insured and uninsured pill users who paid nothing out of pocket did not significantly change.

Discussion and Conclusion

"The findings of this study indicate that the federal contraceptive coverage requirement is already having a substantial impact in eliminating out-of-pocket costs among privately insured women for at least some methods of contraception -- including oral contraceptives, the most popular reversible method in the United States," Finer and colleagues wrote.

The rapid pace of the change -- "in just the first several months that the requirement has been in wide effect -- is particularly noteworthy," they added. Although more "progress can be expected as more private health plans become subject to the requirement," it appears that "private health plans may not be treating every method of contraception identically," the researchers noted. This is evidenced by "the lack of apparent improvement in cost sharing for the injectable and the IUD," they wrote, adding that additional research could "inform policymakers' decision making about oversight and enforcement of the provision."

Further, the researchers noted that the significant number of Medicaid beneficiaries who are paying for contraception -- even though a four-decade-old law should exempt them from such costs -- "suggests a need ... to reexamine how the cost-sharing protections for contraception under Medicaid are being applied by state agencies and Medicaid managed care plans."