Payment for contraceptive services at safety net clinics


After Medicaid expansion under the Affordable Care Act (ACA), use of insurance for visits to safety net clinics specifically for contraception increased in all states, according to a recent study.

Birth control

After Medicaid expansion under the Affordable Care Act (ACA), use of insurance for visits to safety net clinics specifically for contraception increased in all states, according to a study in the journal Medical Care. In the states where the coverage was expanded, however, levels of insurance for visits of all types remained higher. 

“Besides Medicaid expansion, there are other federal and state programs that cover contraception for low income and uninsured women, namely Title X and state Section 1115 waivers,” said principal investigator Blair Darney, PhD, MPH, an assistant professor of ob/gyn at Oregon Health & Science University in Portland.

What is unknown, though, is whether or how using insurance to pay for contraceptive visits has changed at safety net clinics following Medicaid expansion. 

“Our dataset is unique in that it lets us include the uninsured, who are often missing from health services research, as well as federal and state programs across safety net clinics in the United States,” Dr. Darney told Contemporary OB/GYN.

The study sample comprised 162,666 contraceptive visits among women, aged 10 to 49 years, at 237 safety net clinics in 11 states with a common electronic health record. Seven of the states expanded Medicaid in 2014 (California, Minnesota, Nevada, Ohio, Oregon, Wisconsin and Washington), while the remaining four had not expanded coverage (Alaska, Indiana, Montana and North Carolina). Visits occurred from 12 months pre-expansion (January to December 2013) to 12 months post-expansion (January to December 2014) for both groups of states. 

The proportion of uninsured contraceptive visits at safety net clinics significantly decreased following Medicaid expansion under the ACA, from 24.8% to 16.7% in expansion states and from 27.4% to 20.6% in non-expansion states. “But the gap between the two groups of states widened after ACA implementation: a 2.7%-point difference in 2013 compared to a 4.1%-point difference in 2014,” Dr. Darney said. 

She and her colleagues were surprised by the strong evidence of a “spill-over” effect of the ACA. “Even in non-expansion states, public insurance coverage for contraceptive visits grew,” Dr. Darney said. “Also, private coverage through ACA provisions such as state insurance exchanges or marketplaces grew.”

Providers who serve low-income women need to understand the landscape of payment for contraceptive services, according to Dr. Darney.  “There are ongoing policy debates about how best to use public funds to provide family planning services for low-income women; for instance, recent changes to the Title X program,” she said. “Providers can advocate for evidence-based policies and programs.”

Meanwhile, study results show that Medicaid expansion, as well as other provisions of the ACA and Title X, “are important policies to provide essential preventive care for women,” Dr. Darney said. 

Many providers, however, have left the Title X program following recent changes to the program “that hamper provision of evidence-based care, including restrictions on referrals for abortion, limits to privacy protections for adolescents and emphasis on less effective or non-evidence-based contraceptive methods,” Dr. Darney said.


Nonetheless, “safety net clinics will continue to fill gaps in coverage for low-income women,” she said. “Continued focus on Title X and state programs, plus training and education for providers about the most effective methods of contraception, can help to expand access to the full range of effective contraceptive methods in this population.”


Dr. Darney reports no relevant financial disclosures.

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