ACA Mandate Reduced Out-of-Pocket Cost for IUDs, Upped Use

Diana Mahoney

April 18, 2018

In the United States, as out-of-pocket costs for intrauterine devices (IUDs) drop, more women are choosing this long-acting contraceptive option, a new study has shown.

The Affordable Care Act's (ACA's) mandate that private health plans provide coverage for contraceptive services for women has lessened the financial burden associated with birth control. However, the data on whether these cost reductions have led to an increase in long-acting reversible contraceptive use are inconsistent, Erica Heisel, MD, from the University of Michigan in Ann Arbor, and colleagues write in an article published online in Obstetrics & Gynecology.

Their results show that uptake of IUD placement increased by a small but significant amount among the women they surveyed, going from 12.5% using this form of contraception in 2009 to 13.8% in 2013/14 (P < .001).

In an ACOG "Editor's Picks" podcast accompanying publication of this paper, the editor-in-chief of Obstetrics & Gynecology, Nancy Cheshire, MD, said: "If we try to take some of these hurdles from women in terms of safe and reliable contraception, they are going to avail themselves of this opportunity. The reality is that contraception costs money, and by removing that cost...you can increase access. This paper does a nice job [of showing this]."

Plans Going From High Out-of-Pocket Costs to None Saw Biggest Increase in Use

In their paper, Heisel and coauthors say prior contemporary studies on this topic have not considered baseline cost and have examined women enrolled in employer-based health plans, which often had generous contraceptive coverage even before mandated coverage.

"Our objective was to evaluate whether women enrolled in health plans with high out-of-pocket cost before the ACA's contraceptive mandate responded differently to the elimination of out-of-pocket costs than those in plans with lower baseline cost," they explain.

They conducted a cross-sectional pre–post analysis, using a national sample of women, comparing new IUD insertions and out-of-pocket costs among women enrolled in employer-sponsored health plans in 2009 and 2014.

They used data on 543,499 women between the ages of 15 and 45 years with at least 12 months of continuous enrollment in 1930 employer-based health plans that were used for IUD services in both years.

They grouped the plans into three categories for each year on the basis of the mean patient out-of-pocket cost: no cost, low cost, and high cost.

High out-of-pocket costs were defined as those above the 75th percentile among the full sample of patients in 2009 ($368), and low out-of-pocket cost was defined as greater than $0 but less than the 75th percentile.

The study's primary outcome was changes in IUD insertions before and after mandated coverage. A secondary outcome was patient out-of-pocket cost.

As well demonstrating the small but significant increase in IUD insertions across the whole population, they also showed that there were bigger increases in IUD uptake among those who saw the biggest fall in out-of-pocket costs for contraception.

Almost half of plans went from low out-of-pocket cost to no out-of-pocket cost, 15.3% of plans went from high out-of-pocket cost to no out-of-pocket costs, 14.5% of plans had no out-of-pocket cost in both years, and 0.8% of plans had high out-of-pocket cost in both years.

The plans that went from high out-of-pocket cost in 2009 to no out-of-pocket cost in 2014 saw a higher average increase in the rate of plan IUD insertions over time (2.4%) compared with plans with no out-of-pocket cost in both 2009 and 2014 (−1.0%; P = .02).

Reducing Costs Increases Uptake of IUD Placement, but There Are Other Barriers

The results show that the contraception mandate increased the proportion of patients with no out-of-pocket costs for IUDs.

Further, "our findings suggest that baseline levels of out-of-pocket cost may help identify groups with unmet demand for IUD placement before mandated first-dollar coverage," the authors write. "Those with the highest out-of-pocket cost at baseline (who are often in high-deductible health plans) saw the largest decreases in out-of-pocket costs and also demonstrated the steepest increases in IUD insertions after elimination of costs," they stress.

"This suggests that baseline cost should be considered in evaluations of this policy and others that eliminate patient out-of-pocket cost," they assert.

However, they note that out-of-pocket cost is not the only barrier to IUD insertion.

"Despite mandated coverage of contraception, IUD utilization remains low for patients seeking contraception," they write. "Beyond reducing out-of-pocket cost, it is important to consider other factors that may represent barriers to IUD insertion such as availability of same-day IUD insertion at outpatient clinics and a sufficient supply of trained health care providers."

One study coauthor disclosed a relationship with Bayer. The other authors have disclosed no relevant financial relationships.

Obstet Gynecol. 2018;131:843-849. Abstract

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