Research Shows Benefits of Policies Increasing Access to Postpartum LARC
Medicaid expansion improved access
EXECUTIVE SUMMARY
Medicaid expansion and other policies can make postpartum long-acting reversible contraception (LARC) more affordable.
- With Medicaid expansion, more new mothers maintained health coverage.
- States also can create ways to make LARC affordable through programs in which hospitals can bill separately for intrauterine devices and their insertion.
- These changes may improve birth outcomes as well as postpartum contraception access.
Medicaid expansion and policies that increase access to immediate postpartum long-acting reversible contraception (LARC) may improve birth outcomes and improve postpartum contraception access, according to researchers.1,2
Insurance coverage plays a big role in contraceptive choices, says Carrie H. Wilson, MD, MPH, attending physician at Alameda Health System in Oakland, CA.
Wilson co-authored a recent study showing that half of emergency Medicaid patients who had recently given birth were unable to obtain their desired method of immediate postpartum contraception because of insurance ineligibility.3
Emergency Medicaid pays for the full cost of emergency department services and labor and delivery for immigrants, but it does not cover non-emergency healthcare.4
“I did this study when I was in Colorado as a resident because in clinical practice, I felt like I was seeing disparities,” Wilson explains. “I realized there was really no data about access to postpartum contraceptives for patients who had emergency Medicaid and who were mostly undocumented immigrants.”
With only emergency Medicaid, patients who had just given birth could not access LARC in the hospital. “Despite not having insurance coverage, the hospital provided tubal ligation service at a subsidized rate,” Wilson says. “Emergency Medicaid did not cover tubal ligation, so the hospital decided to provide this service because it was consistent with its mission as a safety net.”
Wilson and colleagues found that about three times more emergency Medicaid patients desired an intrauterine device (IUD) when they were admitted for delivery as actually received an IUD at delivery discharge.
“We need to make sure we have a system of helping patients get the contraception they want,” Wilson says. More research involving immigrants is needed to fully evaluate their contraceptive access and to learn how to help them achieve their reproductive healthcare goals, she adds.
Contraceptive access among pregnant and postpartum women needs improvement.1 “What we hope will happen is that people will have all the information they need to make an informed decision about whether they want to use a contraceptive method,” says Maria W. Steenland, SD, MPH, assistant professor at the Population Studies and Training Center at Brown University in Providence, RI. “All hospitals should make these methods available.”
Clinicians should do more to offer patient-centered care and offer patients an option of all safe and effective contraceptive methods. “There’s a lot of pushback against LARC in general, due to issues that have come out in research about patient-centeredness, and it’s due to the ways that providers are offering it,” Steenland notes. “It’s important we have a full range of methods.”
Patients need access to a variety of contraceptives, but they also need the power to freely choose their own method based on information they receive.
Access Linked to Cost
Access is closely tied to affordability. Before Medicaid expansion under the Affordable Care Act (ACA), most people with Medicaid during pregnancy would lose insurance soon after giving birth, says Erica L. Eliason, PhD, postdoctoral research fellow at Brown University School of Public Health.
“That pregnancy eligibility is only during pregnancy and 60 days afterward,” Eliason says. “People were experiencing a barrier to services.”
Overall, coverage increased after Medicaid expansion, including to people raising newborns. “We saw a decrease in that postpartum Medicaid insurance law,” Eliason says. “There are a lot of healthcare needs postpartum. There was demand for contraception in the postpartum period.”
Expanded Medicaid and other programs that provide healthcare coverage for new mothers help prevent early postpartum pregnancies. “Getting pregnant shortly after a pregnancy is mostly unintended because most want to wait at least six months before getting pregnant again,” Eliason says. Early postpartum pregnancies are associated with worse perinatal outcomes for mothers and babies, she adds.
Eliason and colleagues studied states that expanded Medicaid and those that did not.2 They looked at the types of postpartum contraception that were used, including over-the-counter methods, like condoms.
“We grouped them as long-lasting — [such as] LARCs — short-acting, and permanent,” Eliason explains.
LARCs included IUDs and implants. Short-acting were birth control pills, patches, rings, and injectables. Permanent was tubal ligation.
“We saw an increase in postpartum contraception use, driven by increases in long-acting contraception,” Eliason says. “We saw a shift in the type of LARC, and saw a decrease in short-acting contraception.”
The researchers also noted decreases in the use of nonprescription contraception, condoms, rhythm method, and withdrawal. “People were increasingly using IUDs and implants,” Eliason explains. “We saw differences by race and ethnicity.”
For example, Black individuals saw a decrease in early postpartum pregnancy. “This was good because they were one of the groups that had higher rates of unintended pregnancies prior,” Eliason says. “We saw lower rates of early postpartum pregnancy among Black women who were in Medicaid expansion states, both when comparing to non-expansion states and in their own states prior to expansion.”
Other Ways to Expand Access
States can address postpartum contraception coverage without expanding Medicaid. For example, Steenland and colleagues studied Medicaid policy change in South Carolina, which did not expand Medicaid under the ACA, but adopted a new reimbursement method for postpartum contraception.1 Before South Carolina’s reimbursement change, public and private companies almost always paid for childbirth using a global payment.
“Instead of a line item for each specific service, they have a set rate. That makes sense in a lot of ways because it’s easier, administratively, for insurance companies,” Steenland says. “But it also means that expensive procedures outside of what is absolutely medically necessary are unlikely to be provided because they can’t receive any extra money for them.” Few procedures fall in that category, but it can include placing IUDs and implants after childbirth when it is convenient for new mothers, she notes.
IUDs and implants are expensive. If they are placed weeks or months after a person gives birth, then it often is a two-visit process, which is inconvenient for new parents.
“Often, that’s when a lot of people lose insurance,” Steenland says. “What South Carolina did was tell hospitals that they could now bill for the amount necessary to pay for the device and insertion, along with the normal fee for the hospitalization.”
The South Carolina Birth Outcomes Initiative advocated for this change, which began in 2012. More states have implemented similar changes since then. “In this study, we compared hospitals that implemented the policy and those that didn’t,” Steenland says. “We basically found that those outcomes [of low birth weight and preterm birth] decreased in hospitals that implemented the policy compared to those that didn’t implement the policy.”
There are higher rates of postpartum uninsurance in states that did not expand Medicaid, Eliason says. That is a continuing problem for contraception access to many low-income people.
“There is one other policy that is under consideration in a number of states that specifically targets postpartum uninsurance,” Eliason says. “For Medicaid expansion, the goal wasn’t the postpartum period. Under the American Rescue Plan Act of 2020, states now have the option to adopt postpartum Medicaid expansion, pregnancy-related Medicaid, and expand postpartum Medicaid eligibility for up to one year.”
Postpartum Medicaid lasts 60 days, but the act expands it to a full 12 months. “That’s a more targeted policy that would have the same effect of increasing postpartum coverage and increasing access to postpartum services, such as contraception,” Eliason explains. “This went into effect in April 2022.”
Robert A. Hatcher, MD, MPH, chairman of the Contraceptive Technology Update editorial board, points out that “expansion of Medicaid and access to postpartum contraceptives and programs like the Contraceptive CHOICE Project — and others across the country — have been providing higher usage rates of our most effective contraceptives, the LARC methods. If the Title X funding cuts are not reversed quickly, the Contraceptive CHOICE Project — and public health programs in Utah, California, and elsewhere — may be reversed. This would be a tragic setback for reproductive-age women seeking to avoid unintended pregnancies.”
REFERENCES
- Steenland MW, Pace LE, Cohen JL. Association of Medicaid reimbursement for immediate postpartum long-acting reversible contraception with infant birth outcomes. JAMA Pediatr 2022;176:296-303.
- Eliason EL, Spishak-Thomas A, Steenland MW. Association of the Affordable Care Act Medicaid expansions with postpartum contraceptive use and early postpartum pregnancy. Contraception 2022;S0010-7824(22)00060-9.
- Wilson CH, Lazorwitz A, Hyer J, Guiahi M. Concordance of desired and administered postpartum contraceptives among emergency and full scope Medicaid patients. Womens Health Issues 2022;S1049-3867(22)00008-1.
- Health First Colorado. Emergency Medicaid.
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