Oral Contraceptive Use After the ACA's Contraceptive Mandate

Implementation of the Affordable Care Act (ACA)’s contraceptive mandate in 2012 was associated with more consistent use of generic oral contraceptives (OCs), according to a new study in Health Affairs by Lydia Pace, MD, MPH, of Brigham and Women’s Hospital in Boston and colleagues.

The study analyzed insurance claims for 635,075 women with employer-sponsored health insurance who were initiating use of OCs with either generic or brand-name pills, to examine rates of discontinuation and nonadherence, their relationships with cost sharing, and trends before and during the first year after implementation of the ACA’s contraceptive mandate.

The researchers used data from the Truven Health Market-Scan Commercial Claims and Encounters data for January 1, 2010, through December 31, 2013. The study found that cost sharing decreased markedly after implementation of the ACA contraceptive mandate, more significantly for generic than for brand-name OCs. Higher copays were associated with greater discontinuation of and nonadherence to generic pills than was found with zero copayments. Discontinuation of the use of generic or brand-name pills decreased slightly but significantly after implementation of the ACA contraceptive mandate, as did nonadherence to brand-name pills.

A total of 77.7% of claims required no out-of-pocket costs (no deductible or copay) in 2013 for generic pills compared with 54.9% of claims for brand-name pills. For brand-name pills, the ACA mandate was associated with lower levels of discontinuation. However, among those who continued to use their pills, no significant change was noted in consistency of use, the researchers wrote.

The study found that the relationship was more complex for women starting use of name-brand OCs, for whom small copays ($1 to $5) were associated with better adherence, and copays of up to $20 were associated with better continuation. Only copays over $30 significantly increased the likelihood of less consistent use of brand-name pills.

The researchers wrote that their findings have important policy implications. First, the ACA has benefited women with employer-sponsored insurance through reduced cost sharing for OCs, with approximately three-fourths of users of generic pills and half the users of brand-name pills having no cost sharing in 2013. Second, the study results suggest that reductions in cost sharing for OCs encourage consistent use of OCs, particularly generic ones. Third, the study shows that discontinuation of the use of and nonadherence to OCs are common among women with employer-sponsored insurance who initiate use of OCs, and that they remained prevalent during the first year following implementation of the ACA contraceptive mandate.

“Our study finds that cost sharing does impact women’s ability to use pills as prescribed, and that reducing cost sharing, as achieved by the ACA, may help women use pills consistently,” Pace said in a statement. “Since the Pill remains the most common contraceptive method, nonadherence among women seeking to avoid pregnancy is a critical public health concern and strategies to promote adherence could help reduce unintended pregnancies.”

The investigators recommend continued investigation of factors that affect contraceptive adherence and discontinuation among publicly insured and uninsured women.