The effect of contraceptive access reform on privately insured patients: Evidence from Delaware Contraceptive Access Now

Abstract

Background Many states are implementing comprehensive programs aimed at reducing persistent barriers to contraceptive care. Evidence on the effectiveness of these programs is essential for practice improvement and policy development. Objective To evaluate changes in the probability of initiating a contraceptive method by women with employer sponsored insurance after implementation of Delaware Contraceptive Access Now (DelCAN), a statewide initiative that aimed to increase access to long-acting reversible contraceptives (LARCs). Design, setting, and participants We used a difference-in-differences design to examine contraceptive initiation rates. Data came from IBM Marketscan and covered women age 15–44 enrolled in employer sponsored insurance. The primary outcome was insertion of a LARC, both in the overall study population and in the immediate postpartum (IPP) setting. Secondary analysis examined changes to other contraceptive method types. Results The cohort of 4,550,459 enrollees generated a sample of 11,888,837 person-years and 615,670 childbirth hospitalizations. Difference-in-differences estimates suggested that DelCAN was associated with a 0.3 percentage point (95% CI [0.2, 0.5], p<0.001) increase in the LARC insertion rate in the overall study population and a 0.4 percentage point increase (95% CI [0.2, 0.6], p<0.001) in the percent of births adopting IPP LARC. Associations between DelCAN and LARC insertion appeared stronger for adolescents compared to older women. Results for other method types were less consistent. Conclusions A comprehensive statewide program was associated with increased LARC insertion rates among enrollees with employer sponsored insurance. Understanding the effect of these programs is critical for on-going policy development for states engaged in contraceptive access reform.

Contraceptive access reform and abortion: Evidence from Delaware

“…For example, despite potential confounding from pre‐existing disparate trends, evaluations from Colorado provide suggestive evidence of abortion effects in patients under the age of 20 13 . Other studies on DelCAN also found larger effects on LARC uptake among teenagers 24,25 . However, as we show in Appendix Figure A4, the trend in abortion rates within Delaware was generally similar for younger and older patients, which is not suggestive of heterogeneous effects by age.…”

“…There are several possible explanations for why we did not observe strong evidence of an effect on abortion from DelCAN, despite previous evidence that the program increased LARC use. First, we expected that effects on abortion would be contemporaneous with changes in contraceptive use observed in other studies 23–25 . However, program effects in Delaware may grow over time as providers continue to adapt to new practice styles and patients become more aware of available services, especially considering that the program components were gradually introduced over 2015–2020.…”

“…Second, the uptake of more effective contraceptives from DelCAN 23–26,54 could have been by people who would have, in the absence of the program, not chosen abortion, by people who substituted more effective methods for less effective methods, or by people who would have taken other precautionary actions (such as reducing sexual activity) had they not had access to the contraceptive services facilitated by DelCAN. Boudreaux et al (2020) found suggestive evidence that increased LARC use among Title X patients was partly due to substitution for sterilization; however, existing work has struggled to find clear and consistent evidence about changes to other method types 23 …”

“…A separate study suggested that LARC use increased among Title X patients by 3.2 percentage points (a 40% increase from baseline) 23 . Increased LARC initiation has also been observed in Medicaid claims data 24 and in claims from large employers 25 . Analysis of the Pregnancy Risk Assessment Monitoring System (PRAMS) suggests that LARC use increased among postpartum patients 26 .…”

“…In Medicaid, moderate method use increased for 15 to 18 year olds, but decreased for older patients 24 . Among large employers, estimates of changes to other method types were inconclusive 25 …”