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After Health Care Act, Sharp Drop in Spending on Birth Control

New York TimesJuly 7, 2015Articles

Out-of-pocket spending on most major birth control methods fell sharply in the months after the Affordable Care Act began requiring insurance plans to cover contraception at no cost to women, a new study has found. Spending on the pill, the most popular form of prescription birth control, dropped by about half in the first six months of 2013, compared with the same period in 2012, before the mandate took effect.

The study, by health economists from the University of Pennsylvania, analyzed health insurance claims from a large private insurer with business in all 50 states and the District of Columbia. It evaluated the effect of the Affordable Care Act, the biggest piece of social legislation in decades, on women’s pocketbooks. It estimated that savings from the pill alone were about $1.4 billion in 2013.

Cost has long been a major obstacle to women getting birth control, and declines in what they pay for contraceptives have the potential to increase access and reduce unplanned pregnancies. About half of the 6.6 million pregnancies a year in the United States are unintended, far higher than in most developed countries.

The study, published online in Health Affairs on Tuesday, was not able to definitively establish whether the law drove women’s falling expenditures on birth control, but experts said the magnitude and timing of the decline suggested that it was.

Researchers who led the study took a random sample from a private database of millions of patients — about 790,000 women from 13 to 45 — and analyzed their contraceptive use from 2008 to 2013. The data was leased by the University of Pennsylvania on the condition that the insurer not be identified.

Experts cautioned that the sample, while large, represented claims from just one insurer and was not designed to be nationally representative. However, they said the trends it showed were convincing. Smaller studiesalso have found sharp declines in out-of-pocket spending, though experts said Tuesday’s study was the largest to date.

“I find this study persuasive and consistent with what other studies are finding,” said Alina Salganicoff, the director of women’s health policy at the Kaiser Family Foundation, a health policy research group, who did not take part in the study. “I think we’re seeing a clear pattern in the research.”

The study did not address whether free or cheaper birth control led to fewer unintended pregnancies. Findings from pilot studies in St. Louis andColorado suggested that when cost was not an issue, birth control use increased and women tended to choose the most effective methods, such as long-acting intrauterine devices and implants. That helped drive down rates of abortion and unintended pregnancy in both states.

“We have no doubt that the cost makes a difference,” said Diana Zuckerman, the president of the National Center for Health Research in Washington. “When you have free contraception, it’s going to affect pregnancy and abortion as well because money matters.”

Contraception coverage has improved drastically since the early 1990s, with most insurance companies now covering the full range of birth control methods. But women still had to bear some cost, a requirement that experts say discouraged some lower-income women from getting it and that the Affordable Care Act largely eliminated.

“Co-payments were part of the movement to dissuade people from getting unnecessary care, but they ended up dissuading people from getting necessary care too,” said Adam Sonfield, a senior policy analyst at the Guttmacher Institute, which tracks reproductive health measures and policies.

The study comes amid growing calls for birth control to be available to women over the counter, a change that some women’s groups and professional medical societies support. Such a step would require approval from the Food and Drug Administration, and a Republican bill in the Senate would encourage companies to apply for over-the-counter status for their products.

Opponents have criticized the Republican legislation, saying it could reduce access for women if it meant that birth control was no longer covered in full. (Plans are required to cover most prescription medication, but not over-the-counter medication.) Senator Patty Murray, a Democrat from Washington who helped write the Affordable Care Act, called birth control “an extremely important part of women’s health care and their costs.”

Some Democrats in Congress note that many of the Republican sponsors of the bill on over-the-counter sales have voted to repeal the Affordable Care Act, which mandated the provision of free prescription contraceptives. Republicans say their bill does not take away women’s right to get birth control with a prescription, it simply increases women’s options.

The Affordable Care Act requires insurance plans to cover the full cost of preventive services, including prescription contraception. The mandate for contraception began in August 2012, and insurers were supposed to comply by the beginning of new plan periods, which for many women was Jan. 1, 2013.

Researchers used data from 2008 as a baseline for spending on prescription contraception, but their analysis compared spending in the first six months of 2012 with that in the first six months of 2013, when the mandate was in effect.

Average spending on the pill dropped by about half to $117 for the first six months of 2013, compared with $244 in the first six months of 2012. Spending per prescription — which can be up to three months of the pill — fell to $20.37 from $32.74. Spending on intrauterine devices declined by about 70 percent to about $110. (That includes the cost of insertion but not of removal.)

Average spending on implants, small devices inserted under the skin that prevent pregnancy for several years, declined by about 72 percent to about $91 per device. The steepest decline was for emergency contraception, which fell by more than 90 percent to an average of $1.75 per prescription.

Birth control represented about 44 percent of out-of-pocket spending on medical care in the first six months of 2012 among women in the study. That share had declined to about 22 percent in the first half of 2013. The age groups represented in the study tend to have relatively few health problems.

There were many reasons spending did not fall to zero, said Nora Becker, one of the study’s authors. Health plans phased in the requirement, so the change did not happen immediately for everyone, and not all brands were required to be covered. Some older plans were grandfathered — about a third of all plans in 2013, according to the study — and others received an exemption for religious reasons. Some plans continued to leave some costs uncovered, a pattern that the Obama administration has warned against.

Spending on two methods in the data remained largely unchanged — the ring and the patch — a pattern some experts attributed to that sporadic coverage.

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