Decreasing Unintended Pregnancy

The Affordable Care Act (ACA) increased access without cost to highly effective contraceptive methods, despite a legal challenge that was adjudicated by the Supreme Court, and it may help reduce unintended and teenage pregnancies.¹ Unintended and teenage pregnancies are associated with delayed prenatal care, fetal exposures to tobacco and alcohol, and poorer health out-comes for newborns, as well as negative economic and social consequences for mothers and their children.^2,3 Approximately 2.8 million unintended pregnancies occur in the United States each year, and, although teenage pregnancy rates have been declining for the last 2 decades, more than 430 000 pregnancies occurred among adolescents aged 15 to 19 years in the United States in 2011, including nearly 124 000 among adolescents aged 15 to 17 years.⁴ US teenage pregnancy rates are nearly 7 times higher than rates in some developed countries, and use of highly effective long-acting reversible contraception (LARC) remains low (<5%).³

LARC, in particular, are effective methods of birth control; however, compared with other reversible methods, cost of LARC can be a barrier if not covered by insurance due to initial costs (including both the purchase of the contraceptive and administration by a provider), which can exceed $1000.⁵ When women are educated about LARC and provided with timely access, counseling, and follow-up without cost, they often choose and use these highly effective methods, which can be effective for 3 to 10 years, are associated with lower pregnancy rates, and may save insurers money over time.⁵ For example, in the CHOICE study, conducted from 2007 through 2011, 72% of 1404 adolescent girls and women aged 15 to 19 years chose a LARC method when provided with education and contraception at no cost compared with LARC usage rates lower than 5% among US teens.³

It is important for health care professionals and public health workers to educate women about the availability without cost of these highly effective methods. Clinicians should offer the full range of contraceptive services to patients who wish to delay or prevent pregnancy and work with them to select an effective and appropriate method.² Reducing unintended pregnancy has taken on an increased urgency as the Zika virus has been linked to birth defects and is anticipated to spread to the continental United States.

Affordable Care Act Coverage Requirements

Women of all ages are more likely to choose and continue using highly effective contraceptive methods when the contraceptive methods and accompanying services (including patient education and counseling) are provided without cost.^2,3 The ACA may help to further reduce unintended pregnancies by removing cost as a barrier to contraception, including for the most effective methods. The ACA requires most private plans and Medicaid expansion plans to cover a wide range of preventive services without cost sharing.⁶ In 2011, the federal government endorsed the Institute of Medicine’s recommendations for women’s preventive services. The guide-lines state that plans must cover without cost sharing “all Food and Drug Administration (FDA)-approved contraceptive methods, sterilization procedures, and patient education and counseling for all women with reproductive capacity, as prescribed by a health care provider.”⁶ The FDA has currently identified 18 distinct methods of contraception in its birth control guide.⁶ However, since the contraception coverage requirement came into effect, studies of health plan benefits found that many plans subject to the ACA preventive service coverage requirements were not covering some of the 18 required methods, including some LARC methods.⁷

On May 11, 2015, the federal government issued subregulatory guidance to clarify the contraception coverage requirement.⁶ The guidance states explicitly that insurers must provide coverage without cost sharing for contraceptives in all of the 18 methods currently identified by the FDA. The coverage must be comprehensive, including the clinical services, patient education, and counseling needed for provision of a particular contraceptive method. The regulations allow plans to use some reasonable medical management techniques, such as covering only a generic version instead of an equivalent brand name item. However, plans must defer to the determination of a woman’s attending health care professional, and cover without cost sharing, any contraceptive item or service that the clinician determines to be of medical necessity. Medical necessity may include considerations such as severity of adverse effects, differences in permanence and reversibility of contraceptives, and ability to adhere to the appropriate use of the item or service, as determined by the physician. This coverage must be obtainable in a way that is not unduly burdensome to the woman or her physician.

Benefits

LARC methods such as intrauterine devices and contraceptive implants might be a suitable option for many women because they require no effort after insertion, avoiding the unintended pregnancies that can occur with inconsistent or improper use of other contraceptive methods.⁸ Prevention of unintended pregnancies through improved access to contraception could have a substantial benefit on women’s health. For women with preexisting medical conditions, access to the most appropriate contraceptive method will help to reduce medical complications associated with unplanned pregnancies and facilitate improving health prior to desired pregnancies.² Access to effective contraception also is associated with improved perinatal outcomes by reducing the risk of preterm births associated with short interpregnancy intervals.⁸ Access to effective contraception could help to significantly reduce teenage pregnancies and births, including repeat teenage births, which represent 1 in 5 US teenage births.⁸ LARC methods are safe and effective for most women.²

Remaining Challenges

Even though the ACA has removed cost as a barrier to access effective contraceptive methods for many women, other barriers such as limited availability, problematic policies involving reimbursement for clinicians and health care centers, and lack of awareness of these methods may still remain.² Although most plans must follow the ACA provisions, traditional Medicaid plans, grandfathered private plans (ie, those existing and not significantly changed since before enactment of the ACA), and the US Department of Defense and Veterans Administration benefits packages are not required to provide the comprehensive coverages called for by the ACA. It is also important for reimbursement policies to facilitate efficient and effective provision of contraception. Because most state Medicaid programs pay for labor and delivery services using a single bundled payment, clinicians are unable to be separately reimbursed for the high up-front cost of LARC devices with immediate postpartum insertion. Flexible payment arrangements that allow stocking and separate reimbursement for these devices without burdening health care professionals and health care centers could potentially increase utilization of these highly effective contraceptive methods. However, many women do not receive the LARC service if insertion is not provided immediately postpartum, or if the device is not immediately available during an office visit.

Physician Role

Women must be aware of the availability of these highly effective contraceptive methods to use them. Physicians can play a key role in counseling women about the most effective contraceptive methods and the availability of these methods without cost through most health plans.² Counseling opportunities include well woman and family planning visits, and when providing care during and immediately following pregnancy. The ACA’s coverage requirements in combination with the reduction of other barriers could help significantly decrease the number of unintended pregnancies in the United States.