Advertisement

Affordable Care Act (ACA) Implementation and Adolescent Births by Insurance Type: An Interrupted Time Series Analysis of Births between 2009 and 2017 in the United States

  • Author Footnotes
    1 Present address: Division of Population Health Data, Office of Family Health Services, 109 Governor St, Richmond, VA 23219.
    Dane A. De Silva
    Correspondence
    Corresponding author.
    Footnotes
    1 Present address: Division of Population Health Data, Office of Family Health Services, 109 Governor St, Richmond, VA 23219.
    Affiliations
    Department of Family Science, School of Public Health, University of Maryland, College Park, MD, United States
    Search for articles by this author
  • Jessica L. Gleason
    Affiliations
    Department of Family Science, School of Public Health, University of Maryland, College Park, MD, United States
    Search for articles by this author
  • Author Footnotes
    1 Present address: Division of Population Health Data, Office of Family Health Services, 109 Governor St, Richmond, VA 23219.

      Abstract

      Background

      In 2010, the Affordable Care Act (ACA) was enacted, with full provisions in effect by 2014, including expanded Medicaid coverage, changes to the marketplace, and contraceptive coverage, but its impact on birth trends, particularly adolescent births, is currently unknown.

      Objectives

      We sought to determine whether ACA implementation was associated with changes in adolescent births and whether this differed by insurance type (Medicaid or private insurance).

      Methods

      We used revised 2009-2017 birth certificate data, restricted to resident women with a Medicaid or privately paid singleton birth (N = 27,748,028). Segmented regression analysis was used to examine births to adolescent mothers (12-19 years old) before and after the ACA.

      Results

      There were 27,748,028 singleton births (n = 2,013,521 adolescent births) among U.S. residents between 2009 and 2017 in this analytic sample. Adjusted models revealed that the ACA was associated with a 23% significant decrease in odds of an adolescent birth (OR = 0.78; 95% CI, 0.77-0.79) for Medicaid-funded births and a 19% decrease (OR = 0.81; 95% CI, 0.79-0.83) for privately insured births, with a further declining trend. Overall declines in adolescent births among the Medicaid population appear to be driven by states that chose to expand Medicaid.

      Conclusion

      Beyond the declining secular trend already observed in adolescent pregnancy over the last 10 years, the ACA appears to have had a substantial impact on adolescent births, likely due to Medicaid expansion and increased access to affordable contraception. From a population health perspective, efforts to undo the ACA could have important consequences for maternal, infant, and family health in the United States.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Pediatric and Adolescent Gynecology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Obama B
        United States health care reform: progress to date and next steps.
        JAMA. 2016; 316: 525-532https://doi.org/10.1001/jama.2016.9797
        • Mazurenko O
        • Balio CP
        • Agarwal R
        • et al.
        The effects of Medicaid expansion under the ACA: a systematic review.
        Health Aff. 2018; 37: 944-950https://doi.org/10.1377/hlthaff.2017.1491
        • French MT
        • Homer J
        • Gumus G
        • Hickling L
        Key provisions of the Patient Protection and Affordable Care Act (ACA): a systematic review and presentation of early research findings.
        Health Serv Res. 2016; 51: 1735-1771https://doi.org/10.1111/1475-6773.12511
        • Leftwich HK
        • Alves MVO
        Adolescent pregnancy.
        Pediatr Clin N Am. 2017; 64: 381-388https://doi.org/10.1016/j.pcl.2016.11.007
        • Centers for Disease Control and Prevention (CDC)
        Vital signs: health insurance coverage and health care utilization — United States, 2006–2009 and January-March 2010.
        MMWR Morb Mortal Wkly Rep. 2010; 59: 1448-1454
        • Adams EK
        • Dunlop AL
        • Strahan AE
        • et al.
        Prepregnancy insurance and timely prenatal care for Medicaid births: before and after the Affordable Care Act in Ohio.
        J Womens Health (Larchmt). 2018; (Published online August 29)https://doi.org/10.1089/jwh.2017.6871
        • Bullinger LR
        • Simon K
        Prescription contraceptive sales following the Affordable Care Act.
        Matern Child Health J. 2019; 23: 657-666https://doi.org/10.1007/s10995-018-2680-1
        • Bearak JM
        • Jones RK
        Did contraceptive use patterns change after the Affordable Care Act? A descriptive analysis.
        Women's Health Issues. 2017; 27: 316-321https://doi.org/10.1016/j.whi.2017.01.006
        • Thoma ME
        • De Silva DA
        • MacDorman MF
        Examining interpregnancy intervals and maternal and perinatal health outcomes using U.S. vital records: important considerations for analysis and interpretation.
        Paediatr Perinat Epidemiol. 2019; 33: O60-O72https://doi.org/10.1111/ppe.12520
        • Martin JA
        • Hamilton BE
        • Osterman MJK
        • et al.
        Births: final data for 2017.
        Natl Vital Stat Rep. 2018; 67: 1-50
        • Daw JR
        • Sommers BD
        Association of the Affordable Care Act dependent coverage provision with prenatal care use and birth outcomes.
        JAMA. 2018; 319: 579-587https://doi.org/10.1001/jama.2018.0030
        • Shah MK
        • Gee RE
        • Theall KP
        Partner support and impact on birth outcomes among teen pregnancies in the United States.
        J Pediatr Adolesc Gynecol. 2014; 27: 14-19https://doi.org/10.1016/j.jpag.2013.08.002
        • Chen XK
        • Wen SW
        • Fleming N
        • et al.
        Teenage pregnancy and adverse birth outcomes: a large population based retrospective cohort study.
        Int J Epidemiol. 2007; 36: 368-373https://doi.org/10.1093/ije/dyl284
        • Penfold RB
        • Zhang F
        Use of interrupted time series analysis in evaluating health care quality improvements.
        Acad Pediatr. 2013; 13: S38-S44https://doi.org/10.1016/j.acap.2013.08.002
        • Lopez Bernal J
        • Cummins S
        • Gasparrini A
        The use of controls in interrupted time series studies of public health interventions.
        Int J Epidemiol. 2018; 47: 2082-2093https://doi.org/10.1093/ije/dyy135
        • Fretheim A
        • Tomic O
        Statistical process control and interrupted time series: a golden opportunity for impact evaluation in quality improvement.
        BMJ Qual Saf. 2015; 24: 748-752https://doi.org/10.1136/bmjqs-2014-003756
        • Lopez Bernal J
        • Soumerai S
        • Gasparrini A
        A methodological framework for model selection in interrupted time series studies.
        J Clin Epidemiol. 2018; 103: 82-91https://doi.org/10.1016/j.jclinepi.2018.05.026
      1. Cohen PN: Marriage promotion and the myth of teen pregnancy. Family inequality. Published April 27, 2015. Accessed April 23, 2019. https://familyinequality.wordpress.com/2015/04/27/marriage-promotion-and-the-myth-of-teen-pregnancy/

        • Martinez GM
        • Abma JC
        Sexual activity, contraceptive use, and childbearing of teenagers aged 15-19 in the United States.
        NCHS Data Brief. 2015; : 1-8
        • Romero L
        • Pazol K
        • Gavin L
        • et al.
        Vital signs: trends in use of long-acting reversible contraception among teens aged 15–19 years seeking contraceptive services — United States, 2005–2013.
        MMWR Morb Mortal Wkly Rep. 2015; 64: 363-369
      2. Kaiser Family Foundation: Key facts about the uninsured population. The Henry J. Kaiser Family Foundation. Published December 7, 2018. Accessed August 12, 2019. https://www.kff.org/uninsured/fact-sheet/key-facts-about-the-uninsured-population/

      3. Wachino V, Artiga S, Rudowitz R: How is the ACA impacting Medicaid enrollment? The Henry J. Kaiser Family Foundation. Published 2014. Accessed August 28, 2019. https://www.kff.org/medicaid/issue-brief/how-is-the-aca-impacting-medicaid-enrollment/

        • Armstrong MA
        • Postlethwaite DA
        • Darbinian JA
        • et al.
        Are health plan design and prior use of long-acting reversible contraception associated with pregnancy intention?.
        J Womens Health (Larchmt). 2017; 26: 450-460https://doi.org/10.1089/jwh.2014.5146
        • Abramowitz J
        Planning parenthood: the Affordable Care Act young adult provision and pathways to fertility.
        J Popul Econ. 2018; 31: 1097-1123https://doi.org/10.1007/s00148-017-0676-6
        • Arora P
        • Desai K
        Impact of Affordable Care Act coverage expansion on women's reproductive preventive services in the United States.
        Prev Med. 2016; 89: 224-229https://doi.org/10.1016/j.ypmed.2016.05.026
        • Riddell L
        • Taylor R
        • Alford O
        Impact of the Affordable Care Act on use of covered contraceptives in women ages 20-25.
        Popul Health Manag. 2018; 21: 231-234https://doi.org/10.1089/pop.2017.0050
        • Pace LE
        • Dusetzina SB
        • Keating NL
        Early impact of the Affordable Care Act on uptake of long-acting reversible contraceptive methods.
        Med Care. 2016; 54: 811-817https://doi.org/10.1097/MLR.0000000000000551
        • Mulligan K
        Contraception use, abortions, and births: the effect of insurance mandates.
        Demography. 2015; 52: 1195-1217
        • Gariepy AM
        • Simon EJ
        • Patel DA
        • et al.
        The impact of out-of-pocket expense on IUD utilization among women with private insurance.
        Contraception. 2011; 84: e39-e42https://doi.org/10.1016/j.contraception.2011.07.002
        • Peipert JF
        • Madden T
        • Allsworth JE
        • Secura GM
        Preventing unintended pregnancies by providing no-cost contraception.
        Obstet Gynecol. 2012; 120: 1291-1297https://doi.org/10.1097/aog.0b013e318273eb56
        • Postlethwaite D
        • Trussell J
        • Zoolakis A
        • et al.
        A comparison of contraceptive procurement pre- and post-benefit change.
        Contraception. 2007; 76: 360-365https://doi.org/10.1016/j.contraception.2007.07.006
        • Ricketts S
        • Klingler G
        • Schwalberg R
        Game change in Colorado: widespread use of long-acting reversible contraceptives and rapid decline in births among young, low-income women.
        Perspect Sex Reprod Health. 2014; 46: 125-132https://doi.org/10.1363/46e1714
        • Secura GM
        • Allsworth JE
        • Madden T
        • et al.
        The Contraceptive CHOICE Project: reducing barriers to long-acting reversible contraception.
        Am J Obstet Gynecol. 2010; 203: 115.e1-115.e7https://doi.org/10.1016/j.ajog.2010.04.017
        • Secura GM
        • Madden T
        • McNicholas C
        • et al.
        Provision of no-cost, long-acting contraception and teenage pregnancy.
        New Engl J Med. 2014; 371: 1316-1323https://doi.org/10.1056/NEJMoa1400506
        • Terrizzi S
        • Mathews-Schultz AL
        • Deegan MM
        State versus federal health insurance marketplaces: a bigger deal for Medicaid and a smaller deal for the individual mandate.
        Health Policy OPEN. 2022; 3100059https://doi.org/10.1016/j.hpopen.2021.100059
        • Li J
        • Pesko MF
        • Unruh MA
        • Jung HY
        Effect of the Medicaid primary care rate increase on prenatal care utilization among Medicaid-insured women.
        Matern Child Health J. 2019; 23: 1564-1572https://doi.org/10.1007/s10995-019-02804-6
        • Swartz JJ
        • Meskey J
        • Stuart GS
        • Rodriguez MI
        Pregnancy Medicaid improvements in a nonexpansion state after the Affordable Care Act.
        Ann Fam Med. 2021; 19: 38-40https://doi.org/10.1370/afm.2615
      4. Casey Jr R: Hyde Amendment Codification Act. 2013. Accessed October 4, 2019. https://www.govtrack.us/congress/bills/113/s142/text

      5. Salganicoff A, Beamesderfer A, Kurani N, Sobel L: Coverage for abortion services and the ACA. The Henry J. Kaiser Family Foundation. Published September 19, 2014. Accessed October 4, 2019. https://www.kff.org/womens-health-policy/issue-brief/coverage-for-abortion-services-and-the-aca/

        • Dennis A
        • Henshaw SK
        • Joyce TJ
        • et al.
        The Impact of Laws Requiring Parental Involvement for Abortion: A Literature Review. Guttmacher Institute, 2009: 44
        • Friedman SH
        • Hendrix T
        • Haberman J
        • Jain A
        Judicial bypass of parental consent for abortion: characteristics of pregnant minor “Jane Doe's.
        J Nerv Ment Dis. 2015; 203: 401-405https://doi.org/10.1097/NMD.0000000000000298
        • Committee on Adolescence
        The adolescent's right to confidential care when considering abortion.
        Pediatrics. 2017; 139e20163861https://doi.org/10.1542/peds.2016-3861