Evaluation of Medicaid Expansion Under the Affordable Care Act and Contraceptive Care in US Community Health Centers.

Key PointsQuestionWas Medicaid expansion under the Affordable Care Act associated with improvements in contraceptive use quality metrics in the US health care safety net? FindingsIn this cross-sectional study including more than 500 000 women, Medicare expansion was associated with an increase in use of the most effective contraceptive methods (long-acting reversible contraception) by 1.2 percentage points among women at risk of pregnancy in states that expanded Medicaid compared with nonexpansion states, controlling for other payers for contraceptive care (such as Title X and 1115 waiver programs). MeaningAffordable Care Act-sponsored Medicaid expansion was independently associated with a small but meaningful increase in access to the most effective methods of contraception. This cross-sectional study evaluates the association of Medicaid expansion under the Affordable Care Act with changes in use of contraception among patients at risk of pregnancy receiving care at US community health centers. ImportanceUse of effective contraception decreases unintended pregnancy. It is not known whether Medicaid expansion under the Affordable Care Act increased use of contraception for women who are underserved in the US health care safety net. ObjectiveTo evaluate the association of Medicaid expansion under the Affordable Care Act with changes in use of contraception among patients at risk of pregnancy at US community health centers, with the hypothesis that Medicaid expansion would be associated with increases in use of the most effective contraceptive methods (long-acting reversible contraception). Design, Setting, and ParticipantsThis was a participant-level retrospective cross-sectional study comparing receipt of contraception before (2013) vs immediately after (2014) and a longer time after (2016) Medicaid expansion. Electronic health record data from a clinical research network of community health centers across 24 states were included. The sample included all female patients ages 15 to 44 years at risk for pregnancy, with an ambulatory care visit at a participating community health center during the study period (315 clinics in expansion states and 165 clinics in nonexpansion states). ExposuresMedicaid expansion status (by state). Main Outcomes and MeasuresTwo National Quality Forum-endorsed contraception quality metrics, calculated annually: the proportion of women at risk of pregnancy who received (1) either a moderately effective or most effective method (hormonal and long-acting reversible contraception) methods and (2) the most effective method (long-acting reversible contraception). ResultsThe sample included 310132 women from expansion states and 235408 women from nonexpansion states. The absolute adjusted increase in use of long-acting reversible contraceptive methods was 0.58 (95% CI, 0.13-1.05) percentage points greater among women in expansion states compared with nonexpansion states in 2014 and 1.19 (95% CI, 0.41-1.96) percentage points larger in 2016. Among adolescents, the association was larger, particularly in the longer term (2014 vs 2013: absolute difference-in-difference, 0.80 [95% CI, 0.30-1.30] percentage points; 2016 vs 2013: absolute difference, 1.79 [95% CI, 0.88-2.70] percentage points). Women from expansion states who received care at a Title X clinic had the highest percentage of women receiving most effective contraceptive methods compared with non-Title X clinics and nonexpansion states. Conclusions and RelevanceIn this study, Medicaid expansion was associated with an increase in use of long-acting reversible contraceptive methods among women at risk of pregnancy seeking care in the US safety net system, and gains were greatest among adolescents.