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

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          Key Points

          Question

          Was Medicaid expansion under the Affordable Care Act associated with improvements in contraceptive use quality metrics in the US health care safety net?

          Findings

          In 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).

          Meaning

          Affordable Care Act–sponsored Medicaid expansion was independently associated with a small but meaningful increase in access to the most effective methods of contraception.

          Abstract

          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.

          Abstract

          Importance

          Use 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.

          Objective

          To 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 Participants

          This 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).

          Exposures

          Medicaid expansion status (by state).

          Main Outcomes and Measures

          Two 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).

          Results

          The sample included 310 132 women from expansion states and 235 408 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 Relevance

          In 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.

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          Most cited references39

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          Inference with Difference-in-Differences and Other Panel Data

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            Disparities in Rates of Unintended Pregnancy In the United States, 1994 and 2001

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              • Article: not found

              Regression analysis for correlated data.

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                Author and article information

                Journal
                JAMA Netw Open
                JAMA Netw Open
                JAMA Netw Open
                JAMA Network Open
                American Medical Association
                2574-3805
                4 June 2020
                June 2020
                4 June 2020
                : 3
                : 6
                : e206874
                Affiliations
                [1 ]Oregon Health & Science University, Portland, Oregon
                [2 ]OHSU-PSU School of Public Health, Portland, Oregon
                [3 ]National Institute of Public Health, Center for Population Health, Cuernavaca, Morelos, Mexico
                [4 ]OCHIN Inc, Portland, Oregon
                Author notes
                Article Information
                Accepted for Publication: March 23, 2020.
                Published: June 4, 2020. doi:10.1001/jamanetworkopen.2020.6874
                Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Darney BG et al. JAMA Network Open.
                Corresponding Author: Blair G. Darney, PhD, MPH, Department of Obstetrics & Gynecology, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Mail Code UHN-50, Portland, OR 97239 ( darneyb@ 123456ohsu.edu ).
                Author Contributions: Dr Darney and Ms Hoopes had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
                Concept and design: Darney, Hoopes, Rodriguez, Hatch, Templeton, Oakley, Cottrell.
                Acquisition, analysis, or interpretation of data: Darney, Jacob, Hoopes, Hatch, Marino, Templeton.
                Drafting of the manuscript: Darney, Jacob, Hoopes, Rodriguez, Hatch, Oakley.
                Critical revision of the manuscript for important intellectual content: Darney, Hoopes, Rodriguez, Hatch, Marino, Templeton, Oakley, Cottrell.
                Statistical analysis: Darney, Jacob, Hoopes, Marino.
                Obtained funding: Hatch, Marino, Cottrell.
                Administrative, technical, or material support: Jacob, Rodriguez, Hatch, Templeton, Oakley, Cottrell.
                Supervision: Darney, Hatch, Cottrell.
                Conflict of Interest Disclosures: Dr Darney consults for Ipas, a global nonprofit focused on safe abortion, and served as an expert in the Oregon Department of Justice’s litigation on proposed rule changes to Title X. Dr Rodriguez has served as a contraceptive trainer for Merck and the American Congress of Obstetricians and Gynecologists; served on an advisory board for Bayer; served as a consultant for the World Health Organization; and received research funding via her institution from the Laura and John Arnold Foundation/Arnold Ventures, the National Institutes of Health, Merck and the Robert Wood Johnson Foundation on projects for which she is the primary investigator. Ms Hoopes and Dr Cottrell reported grants from Agency for Health Care Research & Quality during the conduct of the study. No other disclosures were reported.
                Funding/Support: The EVERYWOMAN study is funded by the Agency for Healthcare Research and Quality (award 1R01HS025155-01) and conducted with the Accelerating Data Value across a National Community Health Center Network (ADVANCE) Clinical Research Network, a member of the People-Centered Research Foundation Consortium, an initiative of the Patient-Centered Outcomes Research Institute. The ADVANCE network is led by OCHIN Inc in partnership with the Health Choice Network, Fenway Health, Oregon Health and Science University, and the Robert Graham Center/HealthLandscape and funded through the People-Centered Research Foundation (contract number 1237).
                Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
                Meeting Presentations: Portions of these findings were presented at the Population Association of America annual meeting; April 27, 2017; Chicago, Illinois.
                Additional Contributions: The authors thank Frances M. Biel, MPH, MS, OCHIN Inc, for her assistance with the revision of this manuscript and Carrie Tillotson, MPH, OCHIN Inc, for her assistance with figure creation. These individuals were compensated for their contributions.
                Article
                zoi200307
                10.1001/jamanetworkopen.2020.6874
                7273194
                32496568
                d538367e-d992-45d8-a895-c45757bd933a
                Copyright 2020 Darney BG et al. JAMA Network Open.

                This is an open access article distributed under the terms of the CC-BY License.

                History
                : 2 December 2019
                : 23 March 2020
                Categories
                Research
                Original Investigation
                Online Only
                Health Policy

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