Association of the affordable care act Medicaid expansions with postpartum contraceptive use and early postpartum pregnancy

Objectives: Before the Affordable Care Act (ACA), 55% of individuals giving birth with Medicaid lost in-surance postpartum, potentially affecting their access to postpartum contraception. We evaluate the as-sociation of the ACA Medicaid expansions with postpartum contraceptive use and pregnancy at the time of the survey. Methods: We used 2012-2019 Pregnancy Risk Assessment Monitoring System data to estimate difference -in-difference models for the association of Medicaid expansions with the use of postpartum contraception (mean: 4 months postpartum): any contraception, long-acting reversible contraception, or LARC (contra-ceptive implant and intrauterine device), short-acting (contraceptive pill, patch, and ring), permanent, or non-prescription methods (condoms, rhythm method, and withdrawal), and pregnancy at the time of the survey. We examine low-income respondents overall and stratified by race and ethnicity. Results: We find that Medicaid expansion was associated with a 7.0 percentage point (95% CI: 3.0, 11.0) increase in postpartum LARC, a 3.1 percentage point (95% CI:-6.0,-0.2) decrease in short-acting contra-ception, and a 3.9 percentage point (95% CI:-6.2,-1.5) decrease in non-prescription contraceptive use overall. In stratified analyses, we find that increases in LARC use were concentrated among non-Hispanic White and Black respondents, with shifts in other postpartum contraceptives towards LARCs. Medicaid expansion was associated with a decrease in early postpartum pregnancy only among non-Hispanic Black respondents. Conclusions: Medicaid expansions led to shifts from methods with a lower upfront out-of-pocket cost for people without insurance towards methods with the higher upfront out-of-pocket cost for people without insurance. These changes suggest that Medicaid expansion improved postpartum contraceptive access. Implications: These findings indicate that postpartum uninsurance was a barrier to postpartum contra-ceptive access prior to Medicaid expansions under the Affordable Care Act. Medicaid expansions increased access to the full range of contraceptive methods.

Automated summary

The implementation of the Affordable Care Act has led to an increase in postpartum contraceptive use, particularly for long-acting reversible contraception.