obamacare birth control costs

At the Intersection of Health, Health Care and Policy

doi: 10.1377/hlthaff.2015.0127

, 34, no.7 (2015):1204-1211Health AffairsACA Mandate Removed Cost Sharing

Women Saw Large Decrease In Out-Of-Pocket Spending For Contraceptives AfterNora V. Becker and Daniel Polsky

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By Nora V. Becker and Daniel Polsky

Women Saw Large Decrease InOut-Of-Pocket Spending ForContraceptives After ACAMandate Removed Cost Sharing

ABSTRACT The Affordable Care Act mandates that private health insuranceplans cover prescription contraceptives with no consumer cost sharing.The positive financial impact of this new provision on consumers whopurchase contraceptives could be substantial, but it has not yet beenestimated. Using a large administrative claims data set from a nationalinsurer, we estimated out-of-pocket spending before and after themandate. We found that mean and median per prescription out-of-pocketexpenses have decreased for almost all reversible contraceptive methodson the market. The average percentages of out-of-pocket spending fororal contraceptive pill prescriptions and intrauterine device insertions bywomen using those methods both dropped by 20 percentage points afterimplementation of the ACA mandate. We estimated average out-of-pocketsavings per contraceptive user to be $248 for the intrauterine device and$255 annually for the oral contraceptive pill. Our results suggest that themandate has led to large reductions in total out-of-pocket spending oncontraceptives and that these price changes are likely to be salient forwomen with private health insurance.

Contraceptives are among the mostwidely used medical services in theUnited States, and 99 percent ofsexually active women have usedat least one type of contraceptive

in their lifetime.1 Contraceptives are much lesscostly than maternal deliveries for insurers andpatients, and their use has been shown to resultin net savings to insurers.2

Contraceptive use also has important effectson families and the economy. Studies of the ef-fects of legalization of the contraceptive pill inthe 1960s and 1970s found that increased accessto contraception was associated with lower ratesof subsequent entry into poverty, higher rates oflabor-force participation and entry into profes-sional school, and higher wages for women.36

These economic gains also affect subsequentgenerations: The children of women with in-creased access to contraception have higher

rates of college completion and higher incomes,compared to children whose mothers did nothave access to family planning.7

A variety of contraceptive products are cur-rently available to women in the United States.Somelike the oral contraceptive pillare rela-tively inexpensivebutmust bepurchasedmonth-ly. Others can be very expensive but require onlya one-time purchase for months or years of con-traceptive coverage. These methods of long-act-ing reversible contraceptives (sometimes calledLARCs) are the intrauterine device (IUD) and thesubdermal implant. Both are much more effec-tive than oral contraceptives, but before the ACAthey could require a one-time out-of-pocket pay-ment of several hundred dollars.This high up-front cost may have deterred

some women from using long-acting reversiblecontraceptionmethods.A recent studyofwomenenrolled in private health insurance who ex-

doi: 10.1377/hlthaff.2015.0127HEALTH AFFAIRS 34,NO. 7 (2015): 120412112015 Project HOPEThe People-to-People HealthFoundation, Inc.

Nora V. Becker ([email protected]) is an MD/PhD candidate in theDepartment of Health CareManagement and Economicsin the Wharton School,University of Pennsylvania, inPhiladelphia.

Daniel Polsky is executivedirector of the Leonard DavisInstitute of Health Economics,a professor of medicine in thePerelman School of Medicine,and the Robert D. EilersProfessor of Health CareManagement in the WhartonSchool, all at the University ofPennsylvania.

1204 Health Affairs July 2015 34:7

Womens Health


pressed interest in an IUD found that womenwith a lower out-of-pocket spending require-ment for the device and insertion procedurewere significantly more likely to receive an IUDthan women who faced higher out-of-pocketexpenses.8

The Affordable CareAct (ACA) includes aman-date that preventive servicesa category ofservices that includes both prescription contra-ceptives and their related medical servicesbecovered with no consumer cost sharing. Thismandate went into effect August 1, 2012. It re-quired that insurance plans come into compli-ance at the beginning of the subsequent planyear, which for many women was January 1,2013. The mandate includes all contraceptivemethods approved by the Food andDrug Admin-istration (FDA), including female sterilizationand prescription emergency contraception, butit excludes over-the-counter emergency contra-ception and abortifacients.9 The mandate doesnot require that insurance companies coverevery brand of prescription contraceptive on themarket.The ACAmandate applies nationally to all pri-

vate health insurance plans, including those of-fered in the health insurance Marketplaces andby employers. The only exceptions are grand-fathered plans and those offered by employersthat receive an exemption for religious reasons.Grandfathered plans are health plans that havenot substantially changed their cost-sharing re-quirements since March 2010, the month whenthe ACA became law. These plans are graduallybeing phased out of the employer-sponsoredhealth insurance marketplace but still covered36 percent of insured workers as of 2013.10 Thismeans that a significant subset ofwomenare stillenrolled in plans that are not yet subject to theACAs mandate of zero cost sharing for contra-ception.The inclusion of prescription contraceptive

coverage in the ACAsmandate has drawn a largeamountofpolitical attention.Muchof thedebatesurrounding the mandate has focused on eitherthe effect of themandate on employers religiousfreedom or the potential impact of the mandateon womens health.11,12 Its financial impacts onwomen as consumers have attracted far less at-tention. However, one recent survey of severalhundred privately insured women found thatthe average out-of-pocket price for the pill haddropped from$14.35 permonth in 2012 to $6.48in 2014.13

Our aim was to systematically quantify de-clines in out-of-pocket spending between 2012and 2013 for all available reversible prescriptioncontraceptivemethods. This will allow an under-standing of relative changes in price acrossmethods, particularly between the pill andlong-acting reversible contraception methods.We also put these spending changes into theirfinancial context for women as consumers byexamining how these price declines affect boththeir total out-of-pocket spending on health careand the proportion of that spending that is spenton prescription contraceptives.

Study Data And MethodsWe used a 10 percent sample of the Clinfor-maticsDataMart fromOptum Insight, a claimsdatabase from a large national insurer, to calcu-late monthly out-of-pocket spending betweenJanuary 2008 and June 2013 for the eight cate-gories of prescription contraceptives listed inExhibit 1. Our sample consisted of 17.6 millionmonth-level observations for 790,895 womenages 1345 who were enrolled in private healthinsurance for at least one month during thisperiod. The mean and median lengths of insur-ance enrollment were 22.3 and 17.0 months, re-spectively. The data set included women in allfifty states and the District of Columbia.

Exhibit 1

Characteristics Of Prescription Contraceptives And Consumers Out-Of-Pocket Expenses

Category Delivery method Delivery locationConsumers out-of-pocket expenseis cost of:

Oral contraceptive pill Oral Pharmacy MedicationEmergency contraception Oral Pharmacy Medication

Patch Cutaneous Pharmacy Device(s)Ring Intravaginal Pharmacy Device(s)

Diaphragm or cervical cap Barrier Pharmacy Device(s)Intrauterine device Intrauterine Physician office Device and insertion procedure

Implant Subdermal Physician office Device and insertion procedureInjection Intramuscular Physician office Medication and injection procedure

SOURCE Authors analysis.

July 2015 34 :7 Health Affairs 1205


Estimating Average Out-Of-Pocket Spend-ing Per claim out-of-pocket spending was calcu-lated using pharmacy claims for contraceptivemethods delivered in a pharmacy, such as oralcontraceptives, the contraceptive patch andring, and diaphragms and cervical caps. Con-traceptive methods delivered in a physician of-fice (IUDs, implants, and injections) were iden-tified in the medical claims data using CurrentProcedural Terminology, Fourth Edition (CPT-4);level 2 Healthcare Common Procedure CodingSystem (HCPCS); and International Classificationof Diseases, Ninth Revision (ICD-9), proceduraland diagnostic codes.We estimated out-of-pock-et spending for these threemethods by aggregat-ing all patient cost sharing for the encounterduring which the method or device was deliv-ered, because procedural costs associated withthesemethods are billed separately from the costof the device itself.For all contraceptive methods, we report the

six-month mean or median per claim out-of-pocket expense. For short-term products suchas the pill, the patch, and the ring, this calcula-tion is not equivalent to the per month out-of-pocket expense because many women receivetwo to three months of contraceptive supplieswhen they fill their prescriptions. Our cost esti-mates are therefore not comparable withmonth-ly estimates reported previously in the surveyliterature.Before the ACA mandate, contraceptives were

subject to yearly deductibles and out-of-pocketlimits. The average costs per method thereforedeclined predictably over the course of a givenyear as somewomenused up their deductibles orhit their out-of-pocket spending limits and in-curred lower out-of-pocket expenses for theirmethod of contraception. To remove the influ-ence of deductibles and out-of-pocket limitsfrom our estimates, in some of our analyses weregressed pre-August 2012 out-of-pocket ex-penses on a set of monthly dummies and thenplotted the residual variation in out-of-pocketspending.14

Estimating Changes In Total Out-Of-Pock-et Spending To estimate the share of out-of-pocket spending forprescription contraceptives,we focused on users of the pill and women whohad new IUD insertions, since the pill and theIUD are the two most commonly used reversibleprescription contraceptive methods in theUnited States.15 To minimize selection bias, welimited our spending analysis to women whowere continuously enrolled in insurance fromJanuary 2012 to June 2013. We then comparedspending patterns among pill users and womenwho received IUD insertions in the pre period(JanuaryJune 2012) to patterns in the post

period (JanuaryJune 2013).Wedefined pill users aswomenwhohad at least

one claim for an oral contraceptive pill in boththe pre and post periods.We included spendingin both periods for pill users. We defined IUDusers as women who had an IUD inserted ineither the pre or the post period. We includedspending for IUD users only in the period inwhich they received their IUD.For each woman, we summed her out-of-pock-

et spending on either pills or IUD insertion anddivided that value by her total out-of-pocketspending during that period. Using these per-centages and the mean and median total out-of-pocket spending values for these users, wethen estimated the mean and median impliedsavings on pills and IUD insertions per womanattributable to the ACA mandate.Implied savingswerecalculatedbymultiplying

the mean (or median) total spending by themean (or median) percentage of spending spenton that method for each period and then sub-tracting the 2013 estimate from the 2012 esti-mate. This calculation took into account the pos-sibility that total average out-of-pocket spendingmight have changed during this time period. Forpill users, this value was then multiplied by twoto estimate total yearly spending.All costs are presented in inflation-adjusted

2013 dollars. Analyses were performed usingStata/MP, version 13.Limitations There were a number of impor-

tant limitations to our study. Claims for emer-gency contraception and diaphragms or cervicalcaps were infrequent in our data, so we recom-mend caution when interpreting estimates forthese methods. Additionally, we did not includecost sharing for physician appointments or costsof IUD or implant removals in our estimates,which resulted in a conservative estimate of out-of-pocket spending.

The inclusion ofprescriptioncontraceptivecoverage in the ACAsmandate has drawn alarge amount ofpolitical attention.

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For contraceptive methods obtained in a phy-sician office and reported in medical claims (theIUD, implant, and injection), we calculated ex-penses per encounter. If a woman received an-other expensive service at the same encounterfor instance, if an IUD or implant was insertedimmediately after maternal deliveryit is possi-ble that we erroneously included the costs ofthose procedures in some of our totals.We there-fore report both means and medians in our re-sults.We also conducted a sensitivity analysis inwhich we excluded the top 1 percent of expensesfor each of these methods. This lowered the esti-matedmean expenses slightly but had almost noeffect on the estimated median expenses.Finally, our implied savings estimates as-

sumed that in the absence of the mandate, out-of-pocket expenses for consumers would havestayed the same as they were in the period Janu-aryJune 2012. This could be an unrealistic as-sumption in particular for IUDs, which demon-strated adynamic averagemonthly out-of-pocketprice prior to the mandates implementation.Because of this limitation, the savings estimatesshould be interpreted as short-term changes inout-of-pocket spending only and should not beused for long-term estimates of out-of-pocketspending reductions.

Study ResultsAdjustedmean per claim out-of-pocket spendingdeclined for both the pill and the IUD after im-

plementation of the ACA mandate (Exhibit 2).The average adjusted out-of-pocket expense for apill prescription fell from $33.58 in June 2012 to$19.84 in June 2013, and the out-of-pocket ex-pense for an IUD insertion fell from $293.28to $145.24.To better examine the change in costs for all

contraceptive methods, we report the unadjust-ed six-month mean and median per claim out-of-pocket spending for each prescription con-traceptive method in the pre and post periods(Exhibit 3). At baseline in 2012, themethod thatwas most expensive up front was the implant,with a mean expense of $320.31, followed by theIUD, at $262.38. The methods with the lowestper claim expense were the pill ($32.74), emer-gency contraceptives ($26.16), and diaphragmsor cervical caps ($34.48).However, out-of-pocket spending for short-

term methods compared to that of long-termmethods must be considered in the context ofthe length of time the methods are used. Short-termmethods such as the pill must be purchasedrepeatedly over time, while the out-of-pocket ex-pense for long-term methods such as IUDs is aone-time expense. In the long run, long-actingreversible contraception methods such as theIUDor implant have been shown to be less costlythan repeatedly purchasing a short-termmethodsuch as the pill for an equivalent length of time.16

We observed large decreases in the mean out-of-pocket expenses of most methods followingimplementation of the mandate (Exhibit 3).

Exhibit 2

Trend In Mean Adjusted Per Claim Out-Of-Pocket Expenses For Oral Contraceptive Pill Prescription Fills And IntrauterineDevice (IUD) Insertions, 200813

SOURCE Authors analysis of data for 200813 from the Clinformatics Data Mart from Optum Insight. NOTES Out-of-pocket expensesare per claim averages by month, adjusted for preAugust 2012 monthly variation. Out-of-pocket expenses for the pill (orange line)represent monthly averages per prescription fill and relate to the left-hand y axis. For the IUD (blue line) they represent monthlyaverages per insertion encounter and relate to the right-hand y axis. All expenses are presented in inflation-adjusted 2013 dollars.

$255Per yearThe average user of thepill saved $254.91 peryear after the ACAmandate took effect.

July 2015 34:7 Health Affairs 1207


From June 2012 to June 2013 the mean out-of-pocket expense for the pill declined by 38 per-cent, and the mean out-of-pocket expense for anIUD declined by 68 percent. We also found de-creases in spending for emergency contracep-tion (93 percent), diaphragms or cervical caps(84 percent), the implant (72 percent), and theinjection (68 percent). In contrast, spending forthe ring and the patch declined only 2 percentand 3 percent, respectively, over this period.Median out-of-pocket per prescription spend-

ing fell to zero for almost all prescription con-traceptive methods following implementationof the ACA mandate. This suggests that whilesome women were still paying large amountsout of pocket for their contraception, the major-ity of women were paying nothing by June 2013.The ring and the patch were the exceptions:Their mean and median out-of-pocket expensesremained similar during this time period.To assess the relative magnitude of these out-

of-pocket spending changes for contraceptiveusers, we examined total mean and medianout-of-pocket spending and the percentage ofthat spending spent on contraceptives for pillusers and women who received IUD insertions(Exhibit 4). Because the mandate was imple-mented mid-2012, we compared spending per-centages in the first six months of 2012 withthose in the first six months of 2013. For womenwho were enrolled in insurance continuouslyand had at least one claim for oral contraceptivepills in both periods, the mean and median per-centages of out-of-pocket spending spent on thepill dropped from 44.0 percent and 36.0 percentto 22.4 percent and0.0 percent, respectively. For

women who received an IUD during the sameperiods, the mean and median out-of-pocketspendingpercentages in the period they receivedtheir IUD dropped from 30.3 percent and13.2 percent to 11.3 percent and 0.0 percent, re-spectively.We used these values to estimate the per wom-

an savings on yearly oral contraceptive pill costsfor pill users and on IUD insertions for womenreceiving IUDs. We estimated that the averagepill user saved $254.91 per year, and the medianpill user saved $204.65 per year (Exhibit 4). Themean and median savings on IUD insertionswere estimated to be $248.30 and $107.95, re-spectively, per woman.

DiscussionOut-of-pocket expenses used in this study for theperiod before the implementation of the ACAmandate were roughly equivalent to those inother available data.16,17 However, we found sub-stantial drops in both the mean and the medianout-of-pocket spending for most contraceptivemethods after the mandates implementation.Median spending for almost all contraceptivemethods fell to zero within tenmonths of imple-mentation, and mean spending dropped bylarge percentages (3893 percent, dependingon the method). Mean out-of-pocket spendingremained above zero for two reasons: Not allbrands are required to be covered with zero costsharing, and a subset of women in the data wereenrolled in grandfatheredplans thatwerenot yetsubject to the mandate.Before the mandates implementation, out-of-

pocket expenses for contraceptives for womenusing them represented a significant portion(3044 percent) of these womens total out-of-pocket health care spending. This is a findingthat, to our knowledge, has not been previouslyreported. It is likely that contraceptives are asignificant proportion of total health spendingbecause contraceptive users tend to be youngwomen with few serious health issues. For thesewomen, obtaining contraceptives is likely theirprimary reason for visiting ahealth careproviderand paying out-of-pocket amounts. Because con-traceptives represented a large portion of theirhealth care spending before the mandate, theprice reductions caused by the ACA are likelyto be salient for these women.A recent industry report estimated that the

ACA mandate saved women $483 million inout-of-pocket spending on the pill in 2013.18

Our findings suggest that reductions in out-of-pocket expenditures on contraceptives in 2013were in factmuch higher, as demonstrated usinga quick back-of-the-envelope calculation. The

Exhibit 3

Mean And Median Per Prescription Out-Of-Pocket Expenses For Prescription ContraceptiveMethods Before And After Implementation Of The Affordable Care Act Mandate, 2012 And2013

Out-of-pocket expense ($)

JanuaryJune 2012 JanuaryJune 2013

Category Mean Median Mean MedianOral contraceptive pill 32.74 20.29 20.37 0.00Emergency contraceptive 26.16 20.29 1.75 0.00

Ring 52.63 35.51 51.53 35.00Patch 74.36 60.88 71.91 60.00

Diaphragm or cervical cap 34.48 35.51 5.53 0.00Injection 51.35 45.66 16.63 0.00

Intrauterine device 262.38 40.59 84.30 0.00Implant 320.31 53.21 91.01 0.00

SOURCE Authors analysis of data for 200813 from the Clinformatics Data Mart from Optum Insight.NOTES All out-of-pocket expenses are per claim unadjusted six-month means and medians, calculatedbefore (JanuaryJune 2012) or after (JanuaryJune 2013) implementation of the mandate. Allexpenses are presented in inflation-adjusted 2013 dollars.

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most recent estimates suggest that there are6.88 million privately insured pill users in theUnited States.15 Multiplying this by our conser-vativemedian estimateof $204.65per year yieldsan estimate of $1.4 billion per year in out-of-pocket savings on the pill alone.

Policy ImplicationsOur findings suggest that the ACA mandate willlikely significantly reduce the out-of-pocket ex-penditures of contraceptive users, in some casesto nothing. But it is still too early to predict thefinal impact of the mandate on health care useand spending, or the mandates impact on otherhealth and socioeconomic outcomes for women.Economic theory and empirical evidence sug-

gest that decreasing out-of-pocket contraceptionexpenses to consumers will result in increaseduse.19,20 An increase in the use of contraceptivescould have long-ranging impacts upon womenshealth and the economy, potentially loweringfertility rates and increasing economic opportu-nities for women and their families.46,21

The ACA mandate also changes the relativeprices of different contraceptive methods. Be-cause long-acting reversible contraceptivemeth-ods are more costly up front, it is possible thatremoving financial barriers to allmethodsmightinduce women to choose long-acting reversiblecontraceptive methods at higher rates.The CHOICE Project, a recent prospective co-

hort study of 9,256 women ages 1445, offeredparticipants their choice of contraceptive at nocost after they received counseling and educa-tion about all available methods.22,23 With thebarriers of cost, knowledge, and access removed,75 percent of participants chose a long-actingreversible contraception method. Participantswho chose such methods had higher rates ofcontinuing to use their device and of satisfactionat twelve and twenty-four months of follow-up.In addition, their rates of pregnancies, births,and abortions in the twenty-four-month follow-up period were much lower than national ratesduring the same period.Some policy makers and media outlets have

raised concerns that no-cost contraceptives, orincreased use of more effective contraceptives,might increase risky sexual behavior. However,the CHOICE Project found no evidence of in-creased sexual risk taking among the studycohort.TheCHOICEProject enrolledonlywomenwho

were interested in starting a new contraceptivemethod and specifically counseled participantsabout the relative effectiveness of long-actingreversible contraception methods compared tomore short-term methods. In contrast, the ACAmandate lowered the out-of-pocket expense forcontraceptives for all women in private healthplans, many of whom might be uninterested inchanging their current contraceptive method.Furthermore, the ACA mandate does not di-

Exhibit 4

Out-Of-Pocket Spending On Prescription Birth Control By Oral Contraceptive Pill Users And Women Receiving IntrauterineDevices (IUDs), 2012 And 2013

JanuaryJune 2012 JanuaryJune 2013

Mean Median Mean MedianPill users

Total out-of-pocket spending $557.08 $284.10 $524.12 $244.19Out-of-pocket spending spent on the pill 44.0% 36.0% 22.4% 0.0%Implied spending on the pill per six-month period $244.93 $102.32 $117.47 $0.00Implied savings per user per year (spending in 2012 lessspending in 2013) a a $254.91 $204.65

Intrauterine device users

Total out-of-pocket spending $1,181.52 $817.31 $975.34 $418.86Out-of-pocket spending spent on IUD insertion 30.3% 13.2% 11.3% 0.0%Implied spending per insertion $358.34 $107.95 $110.04 $0.00Implied savings per user per year (spending in 2012 lessspending in 2013) a a $248.30 $107.95

SOURCE Authors analysis of data for 200813 from the Clinformatics Data Mart from Optum Insight. NOTES Spending was calculatedfor a subset of women who were continuously enrolled in private insurance from January 2012 through June 2013. Oral contraceptivepill users are women who had at least one claim for the pill in each of the two periods. Their spending is included in both periods.Intrauterine device users are women who had an IUD inserted in either period. Their spending is included only in the period duringwhich the IUD was inserted. Implied savings were calculated by multiplying the mean or median total spending by the mean or medianper person percentage of spending spent on that method for each period, and then subtracting the 2013 estimate from the 2012estimate. For pill users, this value was then multiplied by two to estimate total yearly savings. All costs are presented in inflation-adjusted 2013 dollars. aNot applicable.

July 2015 34:7 Health Affairs 1209


rectly change providers behavior or affectconsumers knowledge about contraceptives, al-though some providers may take it upon them-selves to educate their patients about the man-date. In some cases, women may not even beaware that their coverage has changed. A recentstudy of young adults experiences in shoppingfor health insurance on HealthCare.gov foundthat many were unaware that well-women visitsand contraception were included as preventiveservices with no cost sharing.24

The impact of the ACAmandate on contracep-tive utilization will therefore depend on howsensitive consumers are to out-of-pocket ex-penses for contraceptives and howmany womenwere dissuaded from using contraceptive prod-ucts by that expense before themandates imple-mentation.25 Very few studies have estimated theresponsiveness of consumers to the out-of-pock-et expenseof contraceptives in theUnitedStates,and no study has estimated it for the populationof privately insured women affected by the ACAmandate. Future work will need to measurewhether these spending changes result in in-creased use of contraceptives or changes in thechoice of contraceptive methods.Lastly, insurance companies are required to

cover all contraceptivemethodswithno consum-er cost sharing in plans that are not grandfath-ered, but they are not required to cover allbrands. The large national insurer that providedour data appeared to be interpreting this broad-ly, as out-of-pocket spending for the patch andthe vaginal ring did not follow the same patternas spending for other methods. Mean and medi-an out-of-pocket expenses for the patch andvaginal ring remained very similar to preman-date levels.These findings areconsistentwith results from

several recent studies suggesting that not all in-surers are fully complying with the mandate.26,27

In response to these reports, the Departmentsof Labor, Health and Human Services, and theTreasury jointly issued new guidelines May 11,2015, clarifying the requirements of the man-date. These guidelines specify that insurersmustcover with no cost sharing at least one of theeighteen FDA-approved contraceptive methods,including methods such as the patch and the

ring.28 Insurers can use cost sharing to directconsumers to lower-cost methods within a cate-gory, as long as at least one method within eachcategory is covered with zero cost sharing.With this new clarification from the adminis-

tration of President Barack Obama, we expectthat the pattern of out-of-pocket expenses forthe patch and the ring among the populationwe studied will soon resemble that of othermethods.

ConclusionWe found theACA-mandated removal of consum-er cost sharing for prescription contraceptives innongrandfathered insurance plans resulted inlarge reductions in out-of-pocket spending oncontraceptives. A woman who uses oral con-traceptive pills or the IUD, the two most com-monly used reversible prescription contracep-tive methods, has the potential to save severalhundreds of dollars each year. This represents asignificant portion of the average total out-of-pocket medical spending in this population.The impact of these reductions in out-of-pocketexpenditures on the use of contraceptives, fertil-ity, and womens health will depend on the pricesensitivity of privately insured women for pre-scription contraceptives.

The authors thank Karin Rhodes forinsightful comments on an earlier draftof this article, and Robert Nathenson

and the staff at the Leonard DavisInstitute of Health Economics,University of Pennsylvania, for technical

and logistical support with data accessand management.

It is still too early topredict the finalimpact of the mandateon health care use andspending, or on otherhealth andsocioeconomicoutcomes for women.

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NOTES

1 Daniels K, Mosher WD, Jones J.Contraceptive methods women haveever used: United States, 19822010.Natl Health Stat Report. 2013;(62):115.

2 Foster DG, Rostovtseva DP, BrindisCD, Biggs MA, Hulett D, Darney PD.Cost savings from the provision ofspecific methods of contraception ina publicly funded program. Am JPublic Health. 2009;99(3):44651.

3 Bailey MJ, Hershbein B, Miller AR.The opt-in revolution? Contracep-tion and the gender gap in wages[Internet]. Cambridge (MA): Na-tional Bureau of Economic Research;2012 Mar [cited 2015 May 15].(NBER Working Paper No. 17922).Available from: http://www.nber.org/papers/w17922.pdf

4 Goldin C, Katz LF. The power of thepill: oral contraceptives and wom-ens career and marriage decisions. JPolit Econ. 2002;110(4):73070.

5 Browne SP, LaLumia S. The effects ofcontraception on female poverty. JPolicy Anal Manage. 2014;33(3):60222.

6 Ananat EO, Hungerman DM. Thepower of the pill for the next gen-eration [Internet]. Cambridge (MA):National Bureau of Economic Re-search; 2007 Sep [cited 2015May 15]. (NBER Working PaperNo. 13402). Available from: http://www.nber.org/papers/w13402.pdf

7 Bailey MJ. Fifty years of familyplanning: new evidence on the long-run effects of increasing access tocontraception [Internet]. Cambridge(MA): National Bureau of EconomicResearch; 2013 Oct [cited 2015May 15]. (NBER Working PaperNo. 19493). Available from: http://www.nber.org/papers/w19493.pdf

8 Gariepy AM, Simon EJ, Patel DA,Creinin MD, Schwarz EB. The im-pact of out-of-pocket expense on IUDutilization among women with pri-vate insurance. Contraception. 2011;84(6):e3942.

9 Kraemer J. The ACAs contraceptioncoverage mandate: Constitutionallimits on exempting employers.Health Affairs Blog [blog on the In-ternet]. 2014 Mar 20 [cited 2015May 15]. Available from: http://healthaffairs.org/blog/2014/03/20/the-acas-contraception-coverage-mandate-constitutional-limits-on-exempting-employers/

10 Henry J. Kaiser Family Foundation,

Health Research and EducationalTrust. Employer health benefits:2013 annual survey [Internet].Menlo Park (CA): KFF; 2013 Sep[cited 2015 Jun 8]. Available from:http://kff.org/private-insurance/report/2013-employer-health-benefits/

11 Annas GJ, Ruger TW, Ruger JP.Money, sex, and religion: the Su-preme Courts ACA sequel. N Engl JMed. 2014;371(9):8626.

12 Gossett DR, Kiley JW, Hammond C.Contraception is a fundamentalprimary care service. JAMA. 2013;309(19):19978.

13 Sonfield A, Tapales A, Jones RK,Finer LB. Impact of the federal con-traceptive coverage guarantee onout-of-pocket payments for contra-ceptives: 2014 update. Contracep-tion. 2014;91(1):448.

14 Lovell MC. Seasonal adjustment ofeconomic time series and multipleregression analysis. J Am Stat Assoc.1963;58(304):9931010.

15 Jones J, Mosher W, Daniels K. Cur-rent contraceptive use in the UnitedStates, 20062010, and changes inpatterns of use since 1995. NatlHealth Stat Report. 2012;(60):125.

16 Trussell J, Lalla AM, Doan QV, ReyesE, Pinto L, Gricar J. Cost effective-ness of contraceptives in the UnitedStates. Contraception. 2009;79(1):514.

17 Center for American Progress. Thehigh costs of birth control: its not asaffordable as you think [Internet].Washington (DC): The Center; 2012Feb 15 [cited 2015 May 18]. (FactSheet). Available from: https://www.americanprogress.org/issues/women/news/2012/02/15/11054/the-high-costs-of-birth-control/

18 IMS Institute for Healthcare Infor-matics. Medicine use and shiftingcosts of healthcare: a review of theuse of medicines in the United Statesin 2013 [Internet]. Parsippany (NJ):IMS; 2014 Apr [cited 2015 May 18].Available from: http://www.imshealth.com/cds/imshealth/Global/Content/Corporate/IMS%20Health%20Institute/Reports/Secure/IIHI_US_Use_of_Meds_for_2013.pdf

19 Pauly MV. The economics of moralhazard: comment. Am Econ Rev.1968;58(3):5317.

20 Manning WG, Newhouse JP, DuanN, Keeler EB, Leibowitz A, Marquis

MS. Health insurance and the de-mand for medical care: evidencefrom a randomized experiment. AmEcon Rev. 1987;77(3):25177.

21 Bailey MJ. Mommas got the pill:how Anthony Comstock andGriswoldv. Connecticut shaped US childbear-ing. Am Econ Rev. 2010;100(1):98129.

22 Secura GM, Madden T, McNicholasC, Mullersman J, Buckel CM, ZhaoQ, et al. Provision of no-cost, long-acting contraception and teenagepregnancy. N Engl J Med. 2014;371(14):131623.

23 McNicholas C, Madden T, Secura G,Peipert JF. The ContraceptiveCHOICE Project round up: what wedid and what we learned. Clin ObstetGynecol. 2014;57(4):63543.

24 Wong CA, Asch DA, Vinoya CM, FordCA, Baker T, Town R, et al. The ex-perience of young adults onHealthCare.gov: suggestions for im-provement. Ann Intern Med. 2014;161(3):2312.

25 Pauly MV, Held PJ. Benign moralhazard and the cost-effectivenessanalysis of insurance coverage. JHealth Econ. 1990;9(4):44761.

26 Sobel L, Salganicoff A, Kurani N.Coverage of contraceptive services: areview of health insurance plans infive states [Internet]. Menlo Park(CA): Henry J. Kaiser Family Foun-dation; 2015 Apr 16 [cited 2015May 26]. Available from: http://kff.org/private-insurance/report/coverage-of-contraceptive-services-a-review-of-health-insurance-plans-in-five-states/

27 National Womens Law Center. Stateof birth control coverage: healthplan violations of the AffordableCare Act [Internet]. Washington(DC): NWLC; 2015 Apr [cited 2015Jun 18]. Available from: http://www.nwlc.org/resource/state-birth-control-coverage-health-plan-violations-affordable-care-act

28 Departments of Labor, Health andHuman Services, and the Treasury.FAQs about Affordable Care Act im-plementation (part XXVI) [Inter-net]. Washington (DC): HHS; 2015May 11 [cited 2015 May 26]. Avail-able from: http://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/aca_implementation_faqs26.pdf

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