Summary of "Are women benefiting from the Affordable Care Act? A real-world evaluation of the impact of the Affordable Care Act on out-of-pocket costs for contraceptives," Law et al., Contraception, January 2016.
Beginning on August 1, 2012," the Affordable Care Act (ACA) (PL 111-148) "mandated that health plans must cover most Food and Drug Administration (FDA) approved contraceptive methods and sterilization procedures ... and patient education and counseling for all women with reproductive capacity without cost sharing," according to Amy Law of Bayer HealthCare Pharmaceuticals Inc. and colleagues. According to the researchers, the contraceptive coverage rule "did not affect health plans widely until January 2013 when most [plans] initiated their new plan year."
While other research has "evaluated the impact of the ACA contraceptive [coverage] provision on out-of-pocket costs for contraceptives among women in the U.S.," Law and colleagues wrote that their study "sought to provide a more comprehensive analysis of the cost savings for most FDA approved contraceptives among women insured by multiple commercial health plan types by identifying women with contraceptive usage in years 2011, 2012, and 2013 from a large commercial claims database."
Methods
For the study, the researchers looked at claims data on women ages 15 to 44 with any contraceptive usage who had pharmacy and medical coverage for 2011, 2012 and 2013. Data came from the Truven Health MarketScan Commercial database, which includes information on more than 60 million individuals. The researchers sorted women "into 3 separate cross-sectional study populations for ... 2011, 2012, and 2013," although they noted that the cohorts might have had some overlap.
The researchers looked at the database's medical and pharmacy drug claims to calculate "the number and proportions of women with one or more claims for any contraceptive ... in years 2011, 2012, and 2013." According to the researchers, a woman with multiple prescriptions for the same contraceptive "was counted only once in the category of 'any contraceptive usage'" to avoid double-counting, while a woman who "received multiple types of contraceptives ... in the same year ... was counted once for each contraceptive type."
The researchers also assessed contraceptive cost "for any contraceptives and by each contraceptive type, including total payment (both health plan and patient payment), patient co-pay, and out-of-pocket payment (sum of copay, coinsurance, and deductible)" for 2011 to 2013 "on two different levels: cost per contraceptive healthcare claim and total annual cost per woman with contraceptives." They also looked at demographic information, such as age, residence and plan type.
Findings
The researchers found that there were:
- 2,447,316 contraceptive users among 9,320,237 women ages 15 to 44 with database claims in 2011;
- 2,515,296 contraceptive users among 9,599,891 women ages 15 to 44 with database claims in 2012; and
- 2,243,253 contraceptive users among 8,348,989 women ages 15 to 44 with database claims in 2013.
The mean age of women in the database for all years was roughly 27. Among all women with database claims, 26.3 percent were contraceptive users in 2011, 26.2 percent were contraceptive users in 2012 and 26.9 percent were contraceptive users in 2013. According to the researchers, women ages 20 to 24 "were of the greatest proportions" of "women with any contraceptive use" in 2011, 2012 and 2013, "followed by women aged 25-29 years."
About 22 percent of women used oral contraceptives for all three years, making oral contraceptives "the predominant contraceptive type used." Meanwhile, the proportion of women in the database who used implants, injectable and intrauterine devices (IUDs) "increased from years 2011 to 2013." According to the researchers, "[t]he proportions of women in the claims database who used permanent contraceptive methods were low in comparison to other contraceptive types (0.5% in all study years)."
The researchers found that between 2011 and 2013, the "mean co-pays per contraceptive claim decreased from $15 to $4 (73.3%) for any contraceptives, from $8 to $3 (62.5%) for permanent contraceptives, [and] from $15 to $4 (73.3%) for non-permanent contraceptives." When divided by type of contraceptive method, the mean copay per claim over the same time period fell by:
- 83.3 percent, from $12 to $2, for implants;
- 71.4 percent, from $7 to $2, for IUDs;
- 71.4 percent, from $14 to $4, for oral contraceptives;
- 65.4 percent, from $26 to $9, for rings;
- 62.5 percent, from $8 to $3, for injectables; and
- 62.1 percent, from $29 to $11, for patches.
Meanwhile, between 2011 and 2013, the "mean total annual co-pays per woman decreased from $67 to $19 (71.6%) for any contraceptives, from $12 to $5 (58.3%) for permanent contraceptives, [and] from $68 to $20 (70.6%) for non-permanent contraceptives." When categorized by method, the mean total annual copay declined by:
- 81 percent, from $21 to $4, for implants;
- 75 percent, from $8 to $2, for IUDs;
- 71.2 percent, from $66 to $19, for oral contraceptives;
- 65.9 percent, from $123 to $42, for rings;
- 65 percent, from $20 to $7, for injectables; and
- 63.2 percent, from $136 to $50, for patches.
Overall, between 2011 and 2013, the "mean out-of-pocket expenses per contraceptive claim decreased 66.7% for any contraceptives, 73.4% for permanent contraceptives, [and] 70.0% for non-permanent contraceptives." When considered by method, the mean out-of-pocket cost declined by:
- 76.3 percent for IUDs;
- 68 percent for implants;
- 66.7 percent for oral contraceptives;
- 61.8 percent for rings;
- 64.7 percent for injectables; and
- 56.8 percent for patches.
According to the researchers, the "mean total annual out-of-pocket expenses decreased in a similar manner" over the same period. Meanwhile, "[t]he proportions of commercially-insured women with $0 out-of-pocket expenses for any contraceptives increased from 10.1% in 2011 to 69.6% in 2013," the researchers wrote.
Discussion
Among women tracked in the study, the researchers found "a substantial decrease in out-of-pocket costs for FDA approved contraceptives one year pre- and post-implementation of the ACA contraceptive and family planning" rules.
For example, the researchers noted that "mean total annual out-of-pocket expenses decreased" about 72 percent, from $298 to $82, for permanent contraceptives and by about 68 percent, from $94 to $30, for non-permanent contraceptives. Meanwhile, "the proportions of women using contraceptives who did not incur any out-of-pocket expenses for IUDs increased from 54.8% in 2011 to 91.6% in 2013," a finding that compliments other studies on the subject.
The researchers noted that the study found 22 percent of participating women used oral contraception, up from the 17 percent of reproductive-age women identified by the National Survey of Family Growth (NSFG) as using oral contraception "during years 2006-2008." Relatedly, the researchers said their findings show that LARC use "may have increased from 2011 to 2013 among the commercially-insured study populations," although more research is needed. Specifically, the researchers noted that the proportions of women "receiving injectables (1.3% to 1.6%), implants (0.2% to 0.4%), and IUDs (1.2% to 1.6%) increased during years 2011 to 2013." However, noting that NSFG data found that "LARC use increased from 3.7% in 2007 to 8.5% in 2009" among reproductive-age women, the researchers wrote that their study "suggests there is not a large upward trend in LARC use in the U.S., at least among those in younger age groups."
Further, the researchers noted that their study found only 0.5 percent of women in all study years opted for sterilization, compared with NSFG's 2006-2008 data that found "that 27% of all women 15-44 years of age used sterilization." According to the researchers, "The greater proportions of women using female sterilization found in the NSFG may ... be related to inclusion of women in the study population with other insurance types (i.e. Medicaid)" and the comparatively young age range of women in the Law et al. study.
The researchers noted that about "half of the pregnancies in the U.S. are unintended, with direct costs alone estimated at $4.5 billion annually." According to the researchers, "The contraceptive [coverage] provisions of the ACA have the potential to reduce this cost burden and additionally eliminate some of the disparities in reproductive healthcare by allowing women to choose more effective contraceptive methods without incurring out-of-pocket costs." They noted that, as of 2013, roughly 30 percent of "commercially-insured women ... still [had] cost-sharing for contraceptives."
The researchers wrote, "The shift towards preventative healthcare is a federally recognized mechanism to improve the access, quality, and outcomes of healthcare in this nation and implementation of the ACA, in regard to women's reproductive healthcare, has greatly impacted the costs of FDA approved contraceptives." Citing their findings on how "out-of-pocket costs of FDA approved contraceptives have decreased nearly 70% since the implementation of the ACA," the researchers concluded, "This improvement in women's reproductive healthcare may lead to better family planning and lower the risk for unintended pregnancy in the U.S."
