EXAMINING THE DIRECT AND INDIRECT EFFECTS OF CONTRACEPTIVE ACCESS
Creators: name: Castleberry, Neko Michelle
Publisher: name: American University
Year: 2023
Subjects: classificationCode: 4206
subject: Public health
classificationCode: 440709
subject: Public policy

description: Contraceptive access is vital for women to be able to participate equally within economic life. Studies have shown that access to contraceptives increases women’s labor force participation, increases college enrollment among women, decreases the gender wage gap, and decreases the likelihood of children growing up in poverty (Bailey, 2006; Bailey et al., 2012, 2018). While contraceptives have become legally accessible across the U.S., affordability is a common barrier to contraceptive access, especially for low-income women (K. Jones &amp; Bernstein, 2019). Focusing on state and federal policies that eliminate the contraceptives costs for users, this dissertation examines the direct effects of no-cost contraceptives on contraceptive usage and rates of unintended pregnancy, as well as the indirect effects of mothers having access to no-cost contraceptives on the health of young children. This dissertation takes advantage of time and state policy variations to examine the direct and indirect effects of contraceptive access. First, to examine the direct effect of the expansion of Medicaid eligibility under the Affordable Care Act’s (ACA) on contraceptive prescription rates among reproductive-aged women at or below 138% federal poverty level (FPL) over time, I use both a difference-in-differences approach and an event study model to compare the rate of prescription contraceptives reimbursed by Medicaid in expansion and non-expansion states, pre- and post-expansion of Medicaid eligibility. My findings show an increase of 45% for contraceptive prescriptions, with a greater increase among long-acting reversible contraceptives (LARCs) than among short-acting methods (60% vs. 48%, respectively). Second, I investigate whether the ACA’s mandate for private health insurance to cover contraceptives with no copays decreased the likelihood of a woman being pregnant and, among those who recently gave birth, the likelihood that their pregnancy was unintended, using a difference-in-differences strategy to compare the likelihood that the birth was unintended in states lacking a contraceptive mandate prior to the ACA to those in states with mandates, pre-/post-implementation of the ACA mandate in 2013. I find that ACA’s mandate resulted in relative declines in the likelihood of currently being pregnant among young women (ages 18 to 24 years) and low-income women in states that had no prior state-level contraceptive mandate compared to similar women in states with a pre-existing mandate. Finally, I examine whether the Colorado Family Planning Initiative (CFPI), a state-level program that provided funding for LARC access to low-income women at reduced or no cost, affected child health outcomes. I use a difference-in-differences strategy to compare health care utilization, outcomes, and quality time with family for children under age 12 who live in households at or below 150% FPL, the targeted population for the CFPI, in Colorado compared to children in all other states without similar contraceptive initiatives, before and after CFPI implementation. My findings show that children in Colorado are 3.7% more likely to have had at least one preventive visit post-CFPI, compared to children in other states, with greater effects among Colorado children living with a single mother. This dissertation has meaningful implications for a variety of health and social policies: these chapters infer how effective mandates that require health insurers to cover products and services are in increasing usage and how effective expanded Medicaid eligibility is on increasing prescription drug usage, while having broader inferences for policies that focus on increasing contraceptive access. More broadly, this dissertation has policy implications regarding women’s participation within the labor force, the health of American families, and reproductive policy overall.