Contraceptive Services After Medicaid Expansion in a State with a Medicaid Family Planning Waiver Program

Abstract

Background:

Medicaid family planning programs provide coverage for contraceptive services to low-income women who otherwise do not meet eligibility criteria for Medicaid. In some states that expanded Medicaid eligibility following the Affordable Care Act (ACA), women who were previously eligible only for family planning services became eligible for full-scope Medicaid. The objective of this study was to provide context for the impact of the ACA Medicaid expansion on contraceptive service provision to women in Oregon who were newly enrolled in Medicaid following the expansion.

Materials and Methods:

We used Medicaid eligibility data to identify women ages 15–44 years who were newly enrolled in Oregon's Medicaid program following the ACA expansion (n = 305,042). Using Medicaid claims data, we described contraceptive services and other preventive reproductive care received in 2014–2017.

Results:

Overall, 20% of women newly enrolled in Medicaid received contraceptive counseling and 31% received at least one method. The most frequently received methods were the pill (38% of women who received any method), intrauterine device (28%), implant (15%), and injectable (12%). Community health centers played a significant role in contraceptive service provision, particularly for the implant and injectable. Nine of 10 women (89%) who received contraceptive services also received other preventive reproductive services.

Conclusions:

This study provides insight regarding receipt of contraceptive services and preventive reproductive care following Medicaid expansion in a state with a Medicaid family planning program. These findings underscore the importance of Medicaid expansion for reproductive health even in states with preexisting Medicaid family planning.

Introduction

Almost half of all pregnancies (45%) in the United States are unintended.¹ Low-income women of reproductive age experience a disproportionate share of unintended pregnancies. Low-income women are more likely to report an unintended pregnancy than higher income women¹ and are less likely to receive contraceptive services.²

Beginning in the mid-1990s, many states expanded eligibility for Medicaid coverage of family planning services for low-income individuals by securing a “waiver” of federal policy from the Centers for Medicare and Medicaid Services. Most of these states provided family planning coverage solely on the basis of income to individuals not otherwise eligible for Medicaid.³ Medicaid family planning programs have been shown to be cost-effective and cost-saving⁴ and may have increased access to a broader range of contraceptive methods.⁵ Oregon is one of 25 states with federal approval to expand their family planning program.³ The Oregon ContraceptiveCare Program (CCare) began in 1999. CCare serves Oregonians who are able to get pregnant or able to get someone else pregnant who have incomes ≤250% of the federal poverty level (FPL) and are not eligible for full-scope Medicaid. In the quarter before Medicaid expansion, CCare reported 69,467 clients with active enrollment.⁶ CCare services are limited to those that prevent unintended pregnancy and include annual examinations; contraceptive methods; follow-up visits to evaluate or manage problems associated with contraceptive methods; and medical procedures, laboratory tests, and counseling services associated with contraceptive management.

In addition to receiving contraceptive services from CCare and other Medicaid family planning programs, the number of low-income women eligible for Medicaid coverage increased as a result of the Patient Protection and Affordable Care Act (ACA). The ACA provided federal funds to allow states to expand Medicaid eligibility to low-income adults not previously eligible. As of November 2019, 36 states and the District of Columbia have expanded Medicaid eligibility following passage of the ACA.⁷ In 2014 Oregon expanded Medicaid eligibility to all individuals <138% FPL, effectively eliminating the need for many low-income women to become pregnant to obtain Medicaid eligibility (the income eligibility threshold for pregnant women in the state is 185% FPL). Before the ACA expansion, adults with incomes <100% FPL were eligible for Medicaid in Oregon. Several recent studies provide evidence that the ACA Medicaid expansion was associated with increased access to affordable insurance coverage and health care services for low-income women.^8
–10 The ACA Medicaid expansion is estimated to have extended coverage to approximately 499,000 additional individuals in Oregon and >17 million nationally¹¹; approximately 30% of these new enrollees were expected to be women of reproductive age.¹²

Because of expanded Medicaid eligibility, more women now have access to primary, gynecologic, and contraceptive care. Compared with the contraceptive services covered by Medicaid family planning programs, full-scope Medicaid coverage not only provides comprehensive family planning services but also includes preconception care and other preventive services. The provision of comprehensive family planning services aligns with recommendations jointly issued by the Centers for Disease Control and Prevention and the Office of Population Affairs (OPA) that address how family planning providers can deliver high-quality family planning services. According to the 2014 report, comprehensive family planning services should include preconception health services to improve infant and maternal health, a full range of contraceptive methods, and sexually transmitted infection screening and treatment services to prevent infertility and improve health.¹³

Evidence regarding the impact of the ACA Medicaid expansion on access to contraceptive services is limited. The ACA Medicaid expansion was expected to increase insurance coverage for contraceptive services nationally but predominately in states without Medicaid family planning waiver programs.¹⁴ In a study of female Medicaid enrollees of reproductive age in Michigan, a state without a Medicaid family planning eligibility expansion, women reported increased access to contraceptive services after the ACA expansion.¹⁵ Similarly, an analysis of prescription drug data found a significant increase in dispensed contraception associated with Medicaid expansion.¹⁶ However, findings from a study conducted in California, which has a Medicaid family planning waiver program, indicated no increases in use of family planning services for low-income women after the ACA Medicaid expansion.¹⁷ Several studies have more broadly examined the overall effect of the ACA on use of contraceptive services. Several analyses of national survey data have not found evidence of a population-level change in utilization of contraceptive services following the ACA.^18
–20 Of importance, these studies also capture possible effects of other ACA provisions beyond Medicaid expansion, such as the individual mandate, the health insurance marketplace, and the contraceptive mandate.

A 2017 report issued by the Kaiser Family Foundation on Medicaid family planning programs in the context of the ACA Medicaid expansion raised concerns about new barriers for accessing care for women shifting from Medicaid family planning programs to full-scope Medicaid coverage. Specifically, the report called for data on “service utilization by type, wait times, geographic proximity of providers to enrollees, appropriateness of care, and ability to see the provider of an individual's choosing.”²¹

The objective of this study was to address this call and provide context for the impact of the Medicaid expansion on contraceptive service provision to women in Oregon who were newly enrolled in Medicaid. Specifically, we: (1) described the types of contraceptive methods and contraceptive counseling received by women newly enrolled in Medicaid following Medicaid expansion; (2) compared the scope of other preventive reproductive services for newly enrolled women who did and did not receive contraceptive services; and (3) examined the sequencing of preventive services received as a result of contraceptive service visits for newly enrolled women.

Materials and Methods

Study population and data source

The study population included women ages 15–44 years who were newly enrolled in Oregon's Medicaid program following the ACA Medicaid expansion in the years 2014–2017. Medicaid enrollment files were used to identify the study population. The newly enrolled expansion population was defined as women who were never enrolled in Medicaid in 2013 except because of pregnancy. The Medicaid enrollment data also provided information on demographic characteristics of women in the study. Additional linked data sources used for this analysis included Medicaid claims and provider data, and birth certificate data. The study received ethical approval from review boards at the Oregon Health Authority and Oregon State University.

Measures

We constructed several measures for receipt of contraceptive methods and counseling using Medicaid claims data. Receipt of contraceptive methods was identified using codes from the OPA measure for Most or Moderately Effective Contraceptive Methods, which includes sterilization, the intrauterine device (IUD), implant, injectable, oral pill, patch, ring, and diaphragm.²² Although we used the numerator specifications from the OPA measure, our measure differs in several ways, including the measurement time interval and inclusion of women with evidence of pregnancy and infecundity in the denominator. Receipt of contraceptive counseling was identified based on the presence of International Classification of Diseases (ICD)-9 code V25.0x and ICD-10 code Z30.0x.

For each contraceptive service identified in nonpharmacy claims, we identified the type of provider and place of service. The type of provider was identified by linking the performing provider in each claim to the Oregon Medicaid provider file, which contains information about provider type and specialty. Provider types and specialties were collapsed into meaningful categories including physicians (primary care, obstetricians and gynecologists [OB/GYNs], and other specialists), advance practice clinicians (advance practice nurses and physician assistants), and all others. Place of service was drawn directly from claims and was collapsed into meaningful categories including medical office, outpatient hospital, inpatient hospital, community health centers (federally qualified health centers [FQHCs], local health departments, rural health centers, and school-based health centers [SBHCs]), and all others.

We assessed receipt of other preventive reproductive services including well-woman visits, sexually transmitted infection (STI)/HIV screening, and cervical cancer screening. Well-woman visits were identified using codes for gynecological and nongynecological routine visits, including ICD codes V72.31, V70.0, Z01.419, Z01.411, Z00.00, and Z00.01. Receipt of STI/HIV screening was identified based on the presence of ICD codes V74.5, Z11.3, and Z11.4. We used a measure of cervical cancer that included codes for cervical cytology drawn from the Oregon Health Authority's State Performance Measure for Coordinated Care Organizations.²³

Demographic characteristics were retrieved from the Medicaid enrollment files and included age, rurality, and race/ethnicity. To address missing race/ethnicity data in the Medicaid enrollment files, we used all available enrollment records and linked birth certificates for women who had given birth. Women with any records indicating Hispanic ethnicity were categorized as Hispanic. For non-Hispanic women with multiple racial groups indicated across records, we categorized race according to the least represented group in Oregon per the following order: Native Hawaiian/Pacific Islander (NH/PI), American Indian/Alaska Native (AI/AN), black, Asian, and white.²⁴ We classified rurality using residential zip codes from enrollment data based on Rural Urban Commuting Area Codes Categorization B (urban, large rural city/town, and small and isolated small rural town).²⁵ Missing race/ethnicity and rurality data were classified as separate categories. We constructed a measure of infecundity and any pregnancy during the study period using diagnosis and procedure codes from the OPA Most or Moderately Effective Contraceptive Methods measure specification.²²

Analytic strategy

First, we described demographic characteristics of women newly enrolled in Medicaid following the Medicaid expansion by receipt of any contraceptive service during the study period. We then separately described the proportion of women who ever received contraceptive counseling and a contraceptive method during the study period. Among those who received counseling, we assessed whether they received counseling and a method, or counseling only. For women who received a method, we described the method mix. If women received more than one method during the study period we described the most effective method received.²⁶ For all nonpharmacy contraceptive visits we summarized the provider types and places of service. We also examined provider types and places of service specifically for the IUD, implant, injectable, and pill.

To assess receipt of additional preventive reproductive services, we identified well-woman visits, STI/HIV screening, and cervical cancer screening received during the study period. For these analyses we identified a subpopulation of women who received any nonpharmacy contraceptive service. Some women may have been enrolled in Medicaid for only a short duration and may have had limited opportunities to access preventive services. Because >90% of women who received contraceptive services were enrolled for at least 1 year, we did not limit the analytic sample based on enrollment duration. First, we described receipt of each service for women who did and did not receive nonpharmacy contraceptive services. We then estimated unadjusted and adjusted logistic regression models to compare service receipt for those with and without contraceptive visits. Adjusted models included variables for age, race/ethnicity, rurality, any pregnancy during the study period, infecundity, and duration of enrollment. As a sensitivity analysis, we also ran these models excluding women with any evidence of infecundity during the study period (n = 7,425). Because results of these sensitivity analyses were virtually identical to the main model results, we present only the main model results.

We assessed the scope and sequencing of services received within 1 year of each woman's first nonpharmacy contraceptive visit during the study. We described preventive services received at the time of, in the 12 months before, and in the 12 months after the first contraceptive visit. For these last two categories, we described the mean duration between contraceptive and preventive service receipt. All analyses were conducted using Stata 15.

Results

The study population included 305,042 women ages 15–44 years who were newly enrolled in Oregon's Medicaid program after expansion during years 2014–2017 (Table 1). A total of 102,804 (34%) women in the study population received any contraceptive service over the course of the study, whereas 202,238 women did not receive contraceptive services. The demographic characteristics of women who received contraceptive services differed in several key ways from women who did not receive services. The mean age of women who received contraceptive services was 25 years (SD = 7.6) compared with a mean age of 29 years (SD = 8.8) among those who did not receive services (p < 0.001). Women who received contraceptive services were more likely to be white (62%), less likely to be Hispanic (17%), and less likely to have missing data on race/ethnicity (13%) compared with women who did not receive contraceptive services (p < 0.001). Two of five women who received contraceptive services (41%) were ever pregnant during the study period compared with 32% of women who did not receive contraceptive services (p < 0.001). Approximately 2% of women had any evidence of infecundity. Women who received contraceptive services were less likely to be enrolled in Medicaid for less than 1 year compared with women who did not receive contraceptive services (8% vs. 28%, p < 0.001).

Table 1.

Characteristics of All Newly Enrolled Women Ages 15–44 Years and Those Receiving Contraceptive Services in Oregon 2014–2017

Characteristic	Women who did not receive contraceptive services (N = 202,238)		Women who received contraceptive services (N = 102,804)		p-value
Characteristic	% or mean	n or SD	% or mean	n or SD	p-value
Age	28.6	8.8	25.0	7.6	<0.001
Race/ethnicity					<0.001
White	49.4	99,811	62.4	64,164
Black	2.4	4,879	2.8	2,836
Asian	3.5	6,297	2.3	2,408
American Indian/Alaska Native	1.9	3,788	2.3	2,373
Native Hawaiian/Pacific Islander	0.8	1,567	0.5	510
Hispanic	20.8	41,972	16.8	17,287
Missing	21.7	43,924	12.9	13,226
Rurality					<0.001
Urban	83.8	167,397	83.2	85,486
Large rural city/town	12.2	24,724	13.1	13,468
Small/isolated rural town	3.7	7,419	3.5	3,563
Missing	0.4	698	0.3	287
Pregnancy during study period	32.4	65,415	40.6	41,766	<0.001
Evidence of infecundity during study period	2.5	5,095	2.3	2,320	<0.001
Duration of enrollment					<0.001
<1 year	27.7	55,962	7.9	8,132
1–2 years	34.5	69,675	24.7	25,385
2–3 years	22.0	44,561	29.5	30,311
3–4 years	11.1	22,400	24.7	25,413
>4 years	4.8	9,640	13.2	13,563

Contraceptive services (counseling and/or methods) were received by 34% of women (n = 102,804); 20% of women received contraceptive counseling and 31% received at least one method (Table 2). For those who received a contraceptive method, the most frequently received method was the pill (38% of women), followed by the IUD (28%), implant (15%), and injectable (12%). Less frequently received methods included sterilization (5%), the ring (2%), patch (1%), and diaphragm (<1%). Most women (89%) who received contraceptive counseling also received a method, whereas only 11% of those who received counseling did not receive a method.

Table 2.

Types of Contraceptive Services and Most Effective Method Received by Newly Enrolled Women Ages 15–44 Years in Oregon 2014–2017

Service received	All women (N = 305,042)
Service received	%	n
Contraceptive counseling	19.9	60,799
Counseling and method	88.7	53,923
Counseling only	11.3	6,876
Contraceptive method	31.4	95,928
Sterilization	4.9	4,735
IUD	27.7	26,569
Implant	14.6	14,026
Injectable	11.8	11,337
Pill	37.8	36,256
Patch	0.8	813
Ring	2.2	2,099
Diaphragm	0.1	93

IUD, intrauterine device.

Women received contraceptive services from a range of providers and places (Table 3). For nonpharmacy visits, types of providers included advance practice nurses (33%), OB/GYNs (16%), other specialist physicians (15%), and primary care physicians (7%). The most frequent place of service was a medical office (74%). About 13% of contraceptive visits occurred at community health centers, including FQHCs, local health departments, rural health clinics, and SBHCs.

Table 3.

Types of Provider and Places of Service for Contraceptive Service Visits for Newly Enrolled Women Ages 15–44 Years in Oregon 2014–2017

Measure	Visits for all methods		Visits for the IUD		Visits for the implant		Visits for the injectable		Visits for the pill		p-value
Measure	%	n	%	N	%	N	%	n	%	n	p-value
Type of claim											<0.001
Pharmacy	51.3	205,151	< 0.1	23	0.4	93	8.3	4,471	73.5	174,243
Nonpharmacy	48.7	194,656	100.0	49,115	99.6	22,659	91.7	49,590	26.5	62,669
Type of provider^*											<0.001
Physician
Primary care	7.2	14,084	4.1	2,033	5.4	1,233	11.7	5,792	7.6	4,793
OB/GYN	16.5	32,046	30.0	14,715	19.2	4,340	11.5	5,717	4.8	3,010
Other specialist	14.8	28,793	12.6	6,190	13.8	3,127	19.8	9,797	9.7	6,106
Advance practice clinician
Advance practice nurse	33.0	64,279	32.5	15,978	40.8	9,239	30.2	14,966	39.5	24,764
Physician assistant	2.8	5,378	2.1	1,013	3.8	860	4.8	2,382	1.7	1,082
Other or unknown	25.7	50,076	18.7	9,186	17.0	3,860	22.1	10,940	36.6	22,921
Place of service^*											<0.001
Medical office	74.0	144,075	75.0	36,860	75.1	17,010	75.2	37,268	85.1	53,346
Community health center
FQHC	6.8	13,326	4.5	2,220	9.0	2,045	10.9	5,416	5.6	3,515
Local health department	5.4	10,435	2.9	1,405	5.2	1,172	7.8	3,880	6.2	3,899
Rural health clinic	1.0	1,915	0.7	335	1.2	265	2.0	1,004	0.5	285
SBHC	0.2	445	0.1	56	0.2	34	0.3	173	0.3	176
Outpatient hospital	8.2	16,028	14.3	7,016	7.2	1,621	3.2	1,579	1.5	936
Inpatient hospital	3.2	6,318	0.5	245	1.5	329	< 0.1	3	< 0.1	2
Other	1.1	2,114	2.0	978	0.8	183	0.5	267	0.8	510

Excluding pharmacy claims.

FQHC, federally qualified health center; OB/GYN, obstetrician and gynecologist; SBHC, school-based health center.

Patterns of service provision varied across types of method. Receipt of the IUD, implant, and injectable was identified primarily from nonpharmacy claims, whereas 74% of pill claims were pharmacy claims (p < 0.001). Service provision by type of provider differed for each method (p < 0.001). Advance practice nurses played a substantial role in service provision for all methods that we examined, particularly the implant (41% of implant visits). OB/GYNs also played a substantial role, particularly for the IUD (30%) and implant (19%). We identified significant variation in place of service across methods (p < 0.001). IUD visits occurred most frequently in a medical office (75%) or outpatient hospital setting (14%). Similarly, 75% of implant visits occurred in medical offices and 7% in outpatient hospital settings. Of note, 16% of implant visits occurred at community health centers with 9% of visits occurring in FQHCs and 5% in local health departments. For the injectable, 75% of visits occurred in a medical office and 21% were in a community health center, including 11% in FQHCs and 8% at local health departments. Most visits for the pill occurred in a medical office (85%).

During the study period, 88% of women with contraceptive visits also received at least one of the three other preventive reproductive services that we examined (Table 4). Half of these women (50%) received a well-woman visit, 43% received STI/HIV screening, and 44% received cervical cancer screening. Women without contraceptive visits were less likely to receive each of these services (all p-values <0.001). Unadjusted and adjusted logistic regression models also indicated significantly greater receipt of each preventive reproductive service among women who had a contraceptive visit compared with women without a contraceptive visit.

Table 4.

Additional Preventive Reproductive Services by Women With and Without Contraceptive Visits for Newly Enrolled Women Ages 15–44 years in Oregon 2014–2017

Preventive service	Women with contraceptive visits ^a (N = 88,121)		Women without contraceptive visits ^a (N = 159,173)		p-value	Unadjusted models, with vs. without contraceptive visits (N = 247,301)	Adjusted models, with vs. without contraceptive visits (N = 207,172)
Preventive service	%	n	%	n	p-value	OR (95% CI)	aOR (95% CI)
Well-woman visit	50.4	44,385	31.9	50,741	<0.001	2.2 (2.1–2.2)	2.2 (2.2–2.3)
STI/HIV screening	43.4	38,192	13.2	20,986	<0.001	5.0 (4.9–5.1)	4.2 (4.1–4.3)
Cervical cancer screening	44.5	39,241	26.8	42,685	<0.001	2.2 (2.2–2.2)	2.6 (2.5–2.6)
Any of these services	88.7	78,207	42.5	67,648	<0.001	4.0 (3.9–4.0)	4.1 (4.0–4.2)

Excluding pharmacy claims.

Adjusted for age, race/ethnicity, rurality, pregnancy, infecundity, and duration of enrollment.

CI, confidence interval; OR, odds ratio; STI, sexually transmitted infection.

Almost two thirds of women (62%) who received contraceptive services also received other preventive reproductive care within 1 year of their first contraceptive visit during the study period (n = 55,063 women) (Table 5). One in four women received preventive care during the same visit at which they received contraceptive services. All three types of preventive services that we examined were frequently received at these contraceptive visits including well-woman visits (50% of visits), STI/HIV screening (54%) and cervical cancer screening (37%). One in four women (24%) received a preventive service during the 12 months before their first contraceptive visit during the study. Compared with services received at the same visit, they were more likely to receive cervical cancer screening (54% of visits) and less likely to receive STI/HIV screening (40%). The mean time between the preventive visit and the contraceptive visit was 4.4 months (SD = 3.4). Almost one third of women received a preventive service during the 12 months after their first contraceptive visit. More than half of these visits included a well-woman examination and a substantial percentage included STI/HIV screening (50%) and cervical cancer screening (42%). The mean time between the contraceptive visit and the preventive service visit was 4.6 months (SD = 3.6).

Table 5.

Additional Preventive Reproductive Services Received Before, During, and After First Contraceptive Visit for Newly Enrolled Women Ages 15–44 Years in Oregon 2014–2017

Measure	All women with contraceptive visits^* (N = 88,121)
Measure	% or mean	N or SD
Received at first contraceptive visit	25.3	22,260
Well-woman visit	49.5	11,008
STI/HIV screening	54.2	12,056
Cervical cancer screening	36.8	8,197
Received preventive service in year before first contraceptive visit	24.4	21,505
Well-woman visit	54.0	11,610
STI/HIV screening	40.1	8,622
Cervical cancer screening	55.8	12,008
Months between preventive service and contraceptive visit	4.4	3.4
Received preventive service in year after first contraceptive visit	30.1	27,240
Well-woman visit	58.7	15,976
STI/HIV screening	49.7	13,531
Cervical cancer screening	42.1	11,479
Months between preventive service and contraceptive visit	4.6	3.6

Excluding pharmacy claims.

Discussion

Our study results indicate that a significant number of women enrolled in Oregon's Medicaid program after implementation of the ACA received contraceptive services. One in three women in our study received a contraceptive method in the 4 years after Medicaid expansion. This claims-based measure likely underestimates the actual number of women who received and used contraceptive methods during this time period, given that claims data do not capture several methods, including condoms and male sterilization, which account for 9% and 6% of national contraceptive method use, respectively.²⁷ We also expect that claims data underestimate current use of longer acting methods, including the IUD, implant, and female sterilization, given that some users would have received these methods before the study time period. In addition, women who are pregnant, postpartum, or seeking pregnancy are also likely to be overrepresented in our study population because these women are more likely to be eligible for Medicaid; these reasons for not using a contraceptive method account for only 7.5% of women in national estimates.²⁷ We found that 20% of women received contraceptive counseling in the 4 years after Medicaid expansion. This estimate is low compared with national self-reported survey data indicating that 18% of women at age 15–49 years received contraceptive counseling in the past 12 months.²⁸ Counseling services in clinic settings, however, may not be consistently billed for and identifiable in claims data.

Advance practice clinicians played a substantial role in contraceptive service provision across methods, whereas primary care physicians played a relatively minor role. The important role of advance practice clinicians in the delivery of contraceptive care has increased in recent years, yet little research has examined the contraceptive capacities and practices of this segment of the workforce.^29,30 Of particular importance to contraceptive care, advance practice clinicians are more likely to provide counseling during primary care visits,³¹ potentially contributing to the relatively high receipt of contraceptive counseling in our study. Our study also highlights the limitations of claims data for addressing questions related to provider characteristics, as a substantial percentage of claims in our dataset were missing provider information. This challenge may explain some of the lack of prior research on health care provider characteristics as related to contraceptive care.

We found that women newly enrolled after Medicaid expansion received contraceptive services at a variety of places. Although most services occurred in a medical office setting, several other key service providers emerged. Community health centers, which include FQHCs, local health departments, and rural health centers, played a significant role in service provision across methods, particularly for the implant and injectable, methods that are typically less frequently used. Publicly funded clinics are an important source of contraceptive care for young women,³² who are more likely to use these methods. A national survey of FQHCs reported that 81% of clinics prescribed and dispensed the injectable.³³ Method availability is an important factor in women's choice of contraceptive service provider³⁴ and may contribute to the role played by community health centers in provision of these specific methods. The lesser role of other places of service, particularly medical offices, in provision of these methods could indicate reduced availability of some methods in the medical office setting or may simply reflect differences in method preferences of those who seek services at community health centers relative to other locations. Efforts should be made to ensure that Medicaid-enrolled women who receive care outside of community health centers have access to the full range of contraceptive methods wherever they receive primary and gynecological care.

Medicaid expansion provides important benefits with respect to comprehensive preventive reproductive care, even in states with preexisting Medicaid family planning programs. The majority of women in our study who accessed contraceptive services also received other types of preventive reproductive care that would not have been covered by CCare, Oregon's Medicaid family planning program. Specifically, CCare only covers visits focused on contraceptive management and not broader preventive reproductive services. Some women in our study received preventive reproductive services subsequent to receiving contraceptive care, suggesting that a need for and familiarity with contraceptive services may have served as an entry point into receiving more comprehensive care. Others received contraceptive services only after receiving other preventive reproductive services, suggesting that comprehensive insurance coverage could serve as an entry point into receiving contraceptive services, perhaps for those not previously using a contraceptive method. Others may have already been using a method before enrolling in Medicaid. No other studies, to our knowledge, have examined the sequencing of receipt of contraceptive services and other preventive reproductive care. Additional research is needed to more fully understand these patterns of service utilization, including data from the patient perspective that capture health care utilization outside of a single payor and contraceptive methods, such as condoms, that are accessed outside of the health care system.

Several limitations of the administrative data available for this study should be considered when interpreting these study findings. Our data source is limited to Medicaid claims data. We therefore lack information about women's receipt of contraceptive services and other preventive reproductive care before enrolling in Medicaid. Some women likely received services supported by CCare or from clinics that receive federal Title X funding. Others may have paid for care out of pocket or not accessed services at all. Throughout the country, the number of women receiving contraceptive services at clinics supported by Title X funds decreased substantially after the ACA; in Oregon specifically, the number decreased by 33% from 68,160 patients in 2010 to 45,560 in 2016.³⁵ We also lack information about services received but not billed to Medicaid for women currently enrolled in Medicaid. In addition, we are unable to determine whether women received the contraceptive method that they wanted and if they were satisfied with the care that they received after enrollment in Medicaid. The information available regarding Medicaid eligibility and enrollment has certain limitations. We defined the Medicaid expansion study population as those newly enrolled in Medicaid after implementation of the ACA. Some women who were newly enrolled in Medicaid may have been previously eligible but not enrolled for a variety of reasons. Finally, our findings may not be directly generalizable to other settings, as many factors such as local health system characteristics and population demographics may vary across states.

Conclusions

This study provides much needed insight regarding the receipt of contraceptive services and preventive reproductive care after Medicaid expansion in a state with a Medicaid family planning program.²¹ Our results indicate that following a transition from narrow-scope coverage for contraceptive services to eligibility for full-scope Medicaid, the majority of women seeking contraceptive services also received other important preventive reproductive services. These findings underscore the importance of Medicaid expansion for reproductive health, even in states with preexisting Medicaid family planning programs, and can be used to advocate for policy change.

Footnotes

Disclosure Statement

No competing financial interests exist.

Funding Information

This work was supported by the National Center for Chronic Disease Prevention and Health Promotion (NCCDPP) of the Centers for Disease Control and Prevention (CDC) under Award Number 1U01DP004783-01 to S.M.H. (PI) and J.L. (PI). The content is solely the responsibility of the authors and does not necessarily represent the official views of the Centers for Disease Control.

References

Finer

, Zolna

. Declines in unintended pregnancy in the United States, 2008–2011. N Engl J Med, 2016; 374:843–852.

Pazol

, Robbins

, Black

, et al. Receipt of Selected Preventive Health Services for Women and Men of Reproductive Age—United States, 2011–2013. MMWR Morb Mortal Wkly Rep, 2017; 66:1–31.

Guttmacher Institute. Medicaid Family Planning Eligibility Expansions. State Laws and Policies Web site. Available at: www.guttmacher.org/state-policy/explore/medicaid-family-planning-eligibility-expansions. Published 2019. Updated August 1, 2019 Accessed August, 2019.

Foster

, Rostovtseva

, Brindis

, Biggs

, Hulett

, Darney

. Cost savings from the provision of specific methods of contraception in a publicly funded program. Am J Public Health, 2009; 99:446–451.

Thompson

, Rocca

, Kohn

, et al. Public Funding for Contraception, Provider Training, and Use of Highly Effective Contraceptives: A Cluster Randomized Trial. Am J Public Health, 2016; 106:541–546.

State of Oregon Oregon ContraceptiveCare Medicaid Section 1115 Waiver Project # 11-W-00142/0 Narrative and Data Report for Quarter 4, 2013 (October through December 2013). Baltimore, MD: Centers for Medicare & Medicaid Services, 2014.

Kaiser Family Foundation. Status of State Action on the Medicaid Expansion Decision. Available at: www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act. Published 2019. Accessed April, 2019.

Johnston

, Strahan

, Joski

, Dunlop

, Adams

. Impacts of the Affordable Care Act's Medicaid Expansion on Women of Reproductive Age: Differences by Parental Status and State Policies. Womens Health Issues, 2018; 28:122–129.

Lee

, Monuteaux

, Galbraith

. Women's affordability, access, and preventive care after the Affordable Care Act. Am J Prev Med, 2019; 56:631–638.

10.

Margerison

, MacCallum

, Chen

, Zamani-Hank

, Kaestner

. Impacts of Medicaid expansion on health among women of reproductive age. Am J Prev Med, 2020; 58:1–11.

11.

Kaiser Family Foundation. Medicaid Expansion Enrollment, Timeframe: FY 2017. Available at: www.kff.org/health-reform/state-indicator/medicaid-expansion-enrollment/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D. Published 2019. Accessed October, 2019.

12.

Kenney

, Zuckerman

, Dubay

, et al. Opting in to the Medicaid Expansion under the ACA: Who Are the Uninsured Adults Who Could Gain Health Insurance Coverage?. Washington, DC: Robert Wood Johnson Foundation & the Urban Institute; 2012.

13.

Gavin

, Moskosky

, Carter

, et al. Providing quality family planning services: Recommendations of CDC and the U.S. Office of Population Affairs. MMWR Recomm Rep, 2014; 63(Rr-04):1–54.

14.

August

, Steinmetz

, Gavin

, et al. Projecting the unmet need and costs for contraception services after the Affordable Care Act. Am J Public Health, 2016; 106:334–341.

15.

Moniz

, Kirch

, Solway

, et al. Association of access to family planning services with Medicaid expansion among female enrollees in Michigan. JAMA Network Open, 2018; 1:e181627–e181627.

16.

Ghosh

, Simon

, Sommers

. The effect of health insurance on prescription drug use among low-income adults: Evidence from recent Medicaid expansions. J Health Econ, 2019; 63:64–80.

17.

Early

, Dove

, Thiel de Bocanegra

, Schwarz

. Publicly funded family planning: Lessons From California, before and after the ACA's Medicaid expansion. Health Aff (Millwood), 2018; 37:1475–1483.

18.

Arora

, Desai

. Impact of Affordable Care Act coverage expansion on women's reproductive preventive services in the United States. Prev Med, 2016; 89:224–229.

19.

Bearak

, Jones

. Did contraceptive use patterns change after the Affordable Care Act? A descriptive analysis. Womens Health Issues, 2017; 27:316–321.

20.

Johnston

, McMorrow

. The relationship between insurance coverage and use of prescription contraception by race and ethnicity: Lessons from the Affordable Care Act. Womens Health Issues, 2020; 30:73–82.

21.

Guyer

, Osius

, Woda

, et al.: Medicaid Family Planning Programs: Case Studies of Six States after ACA Implementation. San Francisco, CA: Kaiser Family Foundation; 2017.

22.

Office of Population Affairs. Most or Moderately Effective Contraceptive Methods. U.S. Department of Health & Human Services. Available at: www.hhs.gov/opa/performance-measures/most-or-moderately-effective-contraceptive-methods/index.html. Published 2019. Accessed September 2019 .

23.

Oregon Health Authority (OHA). CCO State Quality Measure Specification Sheet for 2018 Measurement Year 2018.

24.

Oakley

, Harvey

, Yoon

, Larson

, Luck

Reconciling race and ethnicity data across multiple time points and datasets. Americal Public Health Association Annual Meeting; 5 November 2017, 2017; Atlanta, GA.

25.

University of Washington. Rural-Urban Community Area Codes (RUCAs). Available at: http://depts.washington.edu/uwruca/. Published n.d. Accessed August 2018 .

26.

Trussell

Contraceptive failure in the United States. Contraception, 2011; 83:397–404.

27.

Daniels

, Abma

. Current Contraceptive Status Among Women Aged 15–49: United States, 2015–2017. NCHS Data Brief, No. 327. Hyattsville, MD: National Center for Health Statistics, 2018.

28.

National Center for Health Statistics. Key Statistics from the National Survey of Family Growth - F Listing. Centers for Disease Control and Prevention. Available at: www.cdc.gov/nchs/nsfg/key_statistics/f_2015–2017.htm. Published 2019. Accessed December 2019 .

29.

Harper

, Stratton

, Raine

, et al. Counseling and provision of long-acting reversible contraception in the US: National survey of nurse practitioners. Prev Med, 2013; 57:883–888.

30.

Harvey

, Beckman

, Murray

. Health care provider and contraceptive care setting: The relationship to contraceptive behavior. Contraception, 1989; 40:715–729.

31.

Deshefy-Longhi

, Swartz

, Grey

. Characterizing nurse practitioner practice by sampling patient encounters: An APRNet study. J Am Acad Nurse Pract, 2008; 20:281–287.

32.

Frost

, Lindberg

. Trends in Receipt of Contraceptive Services: Young Women in the U.S., 2002–2015. Am J Prev Med, 2019; 56:343–351.

33.

Wood

, Beeson

, Bruen

, et al. Scope of family planning services available in Federally Qualified Health Centers. Contraception, 2014; 89:85–90.

34.

Frost

, Gold

, Bucek

. Specialized Family Planning Clinics in the United States: Why women choose them and their role in meeting women's health care needs. Womens Health Issues, 2012; 22:e519–e525.

35.

Frost

, Zolna

, Frohwirth

, et al. Publicly Supported Family Planning Services in the United. States: Likely Need, Availability and Impact, 2016. New York: Guttmacher Institute, 2019.