National Partnership for Women & Families

Monthly Women's Health Research Review

Study: Boosting Awareness of ACA's Expanded Contraceptive Coverage Is 'Essential' To Improve 'Use of Effective Contraception'

Summary of "Women's Awareness of Their Contraceptive Benefits Under the Patient Protection and Affordable Care Act," Chuang et al., American Journal of Public Health, November 2015.

"[W]hen contraception is provided at no cost, women choose more effective and more expensive methods ... and have fewer unintended pregnancies," according to Cynthia Chuang of Penn State College of Medicine's Division of General Internal Medicine and colleagues.

The researchers noted that under the Affordable Care Act (PL 111-148) most private insurance policies must cover FDA-approved contraceptive methods without cost-sharing. However, they wrote, "Although this contraceptive coverage requirement went into effect in August 2012, whether privately insured women are aware of their newly expanded contraceptive benefits is unknown."

Methods

For the study, researchers looked at data on 987 women from the MyNewOptions study, "an ongoing randomized controlled trial of an intervention to assist women with contraceptive decision making." The researchers recruited "the sample in 2014 from Highmark Health members in Pennsylvania who were aged 18 to 40 years."

To qualify for the study, participants had to be sexually active, have no intention to become pregnant within the next year, not be surgically sterile, and not have a partner who had a vasectomy.

To assess awareness of insurance coverage, researchers asked the participants, "'To the best of your knowledge, does your health insurance policy currently cover these birth control methods at no cost to you (no copay or deductible payment)? -- tubal sterilization ('tubes tied'), birth control pills, IUD." Researchers also asked participants whether they would use a different method "if they did not have to worry about cost."

Results

The researchers found that greater than one-third of participants "were not intending a pregnancy for at least 5 years or ever," about 40% "were intending pregnancy between 1 and 5 years, and nearly one quarter were unsure."

However, "[d]espite the large proportion of women who were not intending a pregnancy soon," fewer than 9.0% were currently using a long-acting reversible contraceptive method: 7.5% of women were using an intrauterine device and 0.9% of women were using the contraceptive implant.

In terms of contraceptive coverage awareness, the researchers found that 57.8% of women "were aware that they had full coverage for birth control pills, the most prevalent contraceptive method currently used in [their] study." By contrast, "fewer than 5.0% and 12.0% of women were aware that they had first-dollar coverage for tubal sterilization and the IUD, respectively." The researchers added, "Awareness of sterilization and IUD coverage did not differ by age, but younger women were more likely to be aware of birth control pill coverage than were older women."

Meanwhile, about 20% of women said they would switch to a different contraceptive method "if they did not have to worry about cost." Among women who would select another method, 30% would opt for an IUD, while 9% would use a contraceptive implant.

Discussion

"Privately insured women are largely unware of their contraceptive benefits under the ACA, and a substantial proportion would switch methods if there were no cost barrier," the researchers wrote. However, they noted that "[i]t is unclear whether the high proportion of women reporting 'I don't know' about [contraceptive] coverage reflects a lack of method awareness or a lack of knowledge about coverage."

The researchers cited Kaiser Foundation Health Plan's 2002 quarterly notifications to beneficiaries in California about "their policy change to include 100% coverage of injectables and LARCs, resulting in a significant increase in the use of these methods," as well as the CHOICE project in St. Louis, Mo., which provided local women with "dedicated counseling promoting LARCs" and "no-cost contraception, resulting in an high uptake of LARCs and a reduction in unintended pregnancy." According to the researchers, "These demonstrations suggest that the ACA mandate may not lead to more effective contraceptive method use without efforts to inform both women and health care providers of the coverage mandate and to provide accurate information about method options." Further, they noted that "it is not clear whether insurers are complying with the mandate or if there is an adequate workforce to provide LARCs."

The researchers concluded, "For the ACA contraceptive coverage mandate to affect the use of effective contraception, raising women's awareness of the expanded benefit is an essential first step."