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Figure.
Self-reported Change in Access to Health Care Services After Healthy Michigan Plan Enrollment
Self-reported Change in Access to Health Care Services After Healthy Michigan Plan Enrollment

Proportions are weighted to a population of 113 565 women.

Table 1.  
Characteristics of Female Respondents Aged 19 to 44 Years
Characteristics of Female Respondents Aged 19 to 44 Years
Table 2.  
Unadjusted Proportions and Adjusted Odds of Self-reported Improvement in Access to Family Planning Services
Unadjusted Proportions and Adjusted Odds of Self-reported Improvement in Access to Family Planning Services
2.
Ayanian  JZ.  Michigan’s approach to Medicaid expansion and reform.  N Engl J Med. 2013;369(19):1773-1775. doi:10.1056/NEJMp1310910PubMedGoogle ScholarCrossref
3.
Michigan Department of Health & Human Services. Healthy Michigan Plan. http://www.michigan.gov/mdhhs/0,5885,7-339-71547_2943_66797,00.html. Updated June 25, 2018. Accessed July 2, 2018.
4.
US Department of Labor, US Department of Health and Human Services, US Treasury. FAQs about Affordable Care Act implementation (part XXVI). https://www.dol.gov/sites/default/files/ebsa/about-ebsa/our-activities/resource-center/faqs/aca-part-xxvi.pdf. Published May 11, 2015. Accessed July 2, 2018.
5.
Gavin  L, Pazol  K.  Update: providing quality family planning services—recommendations from CDC and the US Office of Population Affairs, 2015.  MMWR Morb Mortal Wkly Rep. 2016;65(9):231-234. doi:10.15585/mmwr.mm6509a3PubMedGoogle ScholarCrossref
6.
Finer  LB, Zolna  MR.  Declines in unintended pregnancy in the United States, 2008-2011.  N Engl J Med. 2016;374(9):843-852. doi:10.1056/NEJMsa1506575PubMedGoogle ScholarCrossref
7.
Sonfield  A, Kost  K; Guttmacher Institute. Public costs from unintended pregnancies and the role of public insurance programs in paying for pregnancy-related care: national and state estimates for 2010. https://www.guttmacher.org/report/public-costs-unintended-pregnancies-and-role-public-insurance-programs-paying-pregnancy. Published February 2015. Accessed July 2, 2018.
8.
Forrest  JD, Singh  S.  Public-sector savings resulting from expenditures for contraceptive services.  Fam Plann Perspect. 1990;22(1):6-15. doi:10.2307/2135432PubMedGoogle ScholarCrossref
9.
Frost  JJ, Frohwirth  L, Zolna  MR. Contraceptive needs and services, 2013 update. https://www.guttmacher.org/sites/default/files/pdfs/pubs/win/contraceptive-needs-2013.pdf. Published July 2015. Accessed July 2, 2018.
10.
Jones  J, Mosher  W, Daniels  K.  Current contraceptive use in the United States, 2006-2010, and changes in patterns of use since 1995.  Natl Health Stat Report. 2012;(60):1-25.PubMedGoogle Scholar
11.
Kaiser Family Foundation. Women's Health Insurance Coverage. http://kff.org/womens-health-policy/fact-sheet/womens-health-insurance-coverage-fact-sheet/. Published October 31, 2017. Accessed July 2, 2018.
12.
Reeves  RB, Venator  J. Sex, contraception, or abortion? explaining class gaps in unintended childbearing. https://www.brookings.edu/research/sex-contraception-or-abortion-explaining-class-gaps-in-unintended-childbearing/. Published February 26, 2015. Accessed July 2, 2018.
13.
Trussell  J, Lalla  AM, Doan  QV, Reyes  E, Pinto  L, Gricar  J.  Cost effectiveness of contraceptives in the United States.  Contraception. 2009;79(1):5-14. doi:10.1016/j.contraception.2008.08.003PubMedGoogle ScholarCrossref
14.
Committee on Health Care for Underserved Women.  Access to contraception: Committee opinion No. 615.  Obstet Gynecol. 2015;125:250-255. doi:10.1097/01.AOG.0000459866.14114.33PubMedGoogle ScholarCrossref
15.
Hing  E, Decker  S, Jamoom  E.  Acceptance of new patients with public and private insurance by office-based physicians: United States, 2013.  NCHS Data Brief. 2015;(195):1-8.PubMedGoogle Scholar
16.
American Association for Public Opinion Research. Standard definitions. https://www.aapor.org/Standards-Ethics/Standard-Definitions-(1).aspx. Accessed July 2, 2018.
17.
US Department of Health & Human Services Office of Population Affairs. Performance measures: contraceptive care measures. https://www.hhs.gov/opa/performance-measures/index.html. Reviewed May 2, 2018. Accessed July 2, 2018.
18.
Centers for Medicare & Medicaid Services. Healthy Michigan 1115 demonstration. https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/mi/mi-healthy-michigan-ca.pdf. Published August 8, 2017. Accessed July 2, 2018.
19.
Centers for Disease Control and Prevention, National Center for Health Statistics. National Health and Nutrition Examination Survey. https://www.cdc.gov/nchs/nhanes/index.htm. Updated June 28, 2018. Accessed July 2, 2018.
20.
Center for Studying Health System Change. Health Tracking Household Survey, 2007 [United States] (ICPSR 26001). https://www.icpsr.umich.edu/icpsrweb/HMCA/studies/26001/version/1. Published April 15, 2011. Accessed July 2, 2018.
21.
Centers for Medicare & Medicaid Services. Consumer Assessment of Healthcare Providers and Systems (CAHPS). Rockville, MD: Agency for Healthcare Research and Quality. https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/CAHPS/. Modified March 15, 2018. Accessed July 2, 2018.
22.
US Census Bureau. American Community Survey (ACS). https://www.census.gov/programs-surveys/acs/. Accessed July 2, 2018.
23.
Dehlendorf  C, Park  SY, Emeremni  CA, Comer  D, Vincett  K, Borrero  S.  Racial/ethnic disparities in contraceptive use: variation by age and women’s reproductive experiences.  Am J Obstet Gynecol. 2014;210(6):526.e1-526.e9. doi:10.1016/j.ajog.2014.01.037PubMedGoogle ScholarCrossref
24.
Thiel de Bocanegra  H, Braughton  M, Bradsberry  M, Howell  M, Logan  J, Schwarz  EB.  Racial and ethnic disparities in postpartum care and contraception in California’s Medicaid program.  Am J Obstet Gynecol. 2017;217(1):47.e1-47.e7. doi:10.1016/j.ajog.2017.02.040PubMedGoogle ScholarCrossref
25.
Grady  CD, Dehlendorf  C, Cohen  ED, Schwarz  EB, Borrero  S.  Racial and ethnic differences in contraceptive use among women who desire no future children, 2006-2010 National Survey of Family Growth.  Contraception. 2015;92(1):62-70. doi:10.1016/j.contraception.2015.03.017PubMedGoogle ScholarCrossref
26.
Adams  EK, Galactionova  K, Kenney  GM.  Medicaid family planning waivers in 3 States: did they reduce unwanted births?  Inquiry. 2015;52:52.PubMedGoogle Scholar
27.
Lindrooth  RC, McCullough  JS.  The effect of Medicaid family planning expansions on unplanned births.  Womens Health Issues. 2007;17(2):66-74. doi:10.1016/j.whi.2007.02.012PubMedGoogle ScholarCrossref
28.
Kearney  MS, Levine  PB.  Subsidized contraception, fertility, and sexual behavior.  Rev Econ Stat. 2009;91(1):137. doi:10.1162/rest.91.1.137PubMedGoogle ScholarCrossref
29.
Thompson  KM, Rocca  CH, Kohn  JE,  et al.  Public funding for contraception, provider training, and use of highly effective contraceptives: a cluster randomized trial.  Am J Public Health. 2016;106(3):541-546. doi:10.2105/AJPH.2015.303001PubMedGoogle ScholarCrossref
30.
Carlin  CS, Fertig  AR, Dowd  BE.  Affordable Care Act’s mandate eliminating contraceptive cost sharing influenced choices of women with employer coverage.  Health Aff (Millwood). 2016;35(9):1608-1615. doi:10.1377/hlthaff.2015.1457PubMedGoogle ScholarCrossref
31.
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(9):811-817. doi:10.1097/MLR.0000000000000551PubMedGoogle ScholarCrossref
32.
Bearak  JM, Jones  RK.  Did contraceptive use patterns change after the Affordable Care Act? a descriptive analysis.  Womens Health Issues. 2017;27(3):316-321. doi:10.1016/j.whi.2017.01.006PubMedGoogle ScholarCrossref
33.
Antonisse  L, Garfield  R, Rudowitz  R, Artiga  S. The Effects of Medicaid Expansion under the ACA: updated findings from a literature review. http://files.kff.org/attachment/Issue-Brief-The-Effects-of-Medicaid-Expansion-Under-the-ACA-Updated-Findings-from-a-Literature-Review. Published March 2018. Accessed July 2, 2018.
34.
Fowler  C, Gable  J, Wang  J, Lasater  B. Family planning annual report: 2016 national summary. https://www.hhs.gov/opa/sites/default/files/title-x-fpar-2016-national.pdf. Published August 2017. Accessed July 2, 2018.
35.
Committee on Adolescent Health Care.  Committee opinion No. 699: adolescent pregnancy, contraception, and sexual activity.  Obstet Gynecol. 2017;129(5):e142-e149. doi:10.1097/AOG.0000000000002045PubMedGoogle ScholarCrossref
36.
Frost  JJ, Frohwirth  LF, Zolna  MR. Contraceptive needs and services, 2014 update. https://www.guttmacher.org/report/contraceptive-needs-and-services-2014-update. Published September 2016. Accessed July 2, 2018.
37.
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(3):125-132. doi:10.1363/46e1714PubMedGoogle ScholarCrossref
38.
Secura  GM, Madden  T, McNicholas  C,  et al.  Provision of no-cost, long-acting contraception and teenage pregnancy.  N Engl J Med. 2014;371(14):1316-1323. doi:10.1056/NEJMoa1400506PubMedGoogle ScholarCrossref
39.
Michigan Department of Health & Human Services. Healthy Michigan Plan health risk assessment. https://www.michigan.gov/documents/mdch/DCH-1315-Healthy_Michigan_Assessment-FINAL-WEB-COPY_452123_7.pdf. Accessed July 2, 2018.
40.
Biggs  MA, Harper  CC, Brindis  CD.  California family planning health care providers’ challenges to same-day long-acting reversible contraception provision.  Obstet Gynecol. 2015;126(2):338-345. doi:10.1097/AOG.0000000000000969PubMedGoogle ScholarCrossref
41.
Rubin  SE, Campos  G, Markens  S.  Primary care physicians’ concerns may affect adolescents’ access to intrauterine contraception.  J Prim Care Community Health. 2013;4(3):216-219. doi:10.1177/2150131912465314PubMedGoogle ScholarCrossref
42.
Greenberg  KB, Makino  KK, Coles  MS.  Factors associated with provision of long-acting reversible contraception among adolescent health care providers.  J Adolesc Health. 2013;52(3):372-374. doi:10.1016/j.jadohealth.2012.11.003PubMedGoogle ScholarCrossref
43.
Biggs  MA, Arons  A, Turner  R, Brindis  CD.  Same-day LARC insertion attitudes and practices.  Contraception. 2013;88(5):629-635. doi:10.1016/j.contraception.2013.05.012PubMedGoogle ScholarCrossref
44.
Vaaler  ML, Kalanges  LK, Fonseca  VP, Castrucci  BC.  Urban-rural differences in attitudes and practices toward long-acting reversible contraceptives among family planning providers in Texas.  Womens Health Issues. 2012;22(2):e157-e162. doi:10.1016/j.whi.2011.11.004PubMedGoogle ScholarCrossref
45.
Luchowski  AT, Anderson  BL, Power  ML, Raglan  GB, Espey  E, Schulkin  J.  Obstetrician-gynecologists and contraception: long-acting reversible contraception practices and education.  Contraception. 2014;89(6):578-583. doi:10.1016/j.contraception.2014.02.004PubMedGoogle ScholarCrossref
46.
Curtis  KM, Tepper  NK, Jatlaoui  TC,  et al.  US medical eligibility criteria for contraceptive use, 2016.  MMWR Recomm Rep. 2016;65(3):1-103. doi:10.15585/mmwr.rr6503a1PubMedGoogle ScholarCrossref
47.
Sonfield  A, Hasstedt  K, Kavanaugh  ML, Anderson  R. The social and economic benefits of women’s ability to determine whether and when to have children. https://www.guttmacher.org/report/social-and-economic-benefits-womens-ability-determine-whether-and-when-have-children. Published March 2013. Accessed July 2, 2018.
48.
Daniels  K, Mosher  WD.  Contraceptive methods women have ever used: United States, 1982-2010.  Natl Health Stat Report. 2013;(62):1-15.PubMedGoogle Scholar
49.
Peipert  JF, Madden  T, Allsworth  JE, Secura  GM.  Preventing unintended pregnancies by providing no-cost contraception.  Obstet Gynecol. 2012;120(6):1291-1297. doi:10.1097/AOG.0b013e318273eb56PubMedGoogle ScholarCrossref
50.
Frost  JJ, Zolna  MR, Frohwirth  L. Contraceptive needs and services, 2010. https://www.guttmacher.org/sites/default/files/report_pdf/contraceptive-needs-2010.pdf. Published July 2013. Accessed July 2, 2018.
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    Views 2,201
    Original Investigation
    Health Policy
    August 31, 2018

    Association of Access to Family Planning Services With Medicaid Expansion Among Female Enrollees in Michigan

    Author Affiliations
    • 1Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor
    • 2Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
    • 3School of Public Health, University of Michigan, Ann Arbor
    • 4Department of Internal Medicine, University of Michigan, Ann Arbor
    • 5Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor
    • 6School of Social Work, University of Michigan, Ann Arbor
    • 7Department of Pediatrics, University of Michigan, Ann Arbor
    • 8Veterans Affairs Ann Arbor Center for Clinical Management Research, University of Michigan, Ann Arbor
    • 9Department of Family Medicine, University of Michigan, Ann Arbor
    JAMA Netw Open. 2018;1(4):e181627. doi:10.1001/jamanetworkopen.2018.1627
    Key Points español 中文 (chinese)

    Question  Did Medicaid expansion in Michigan improve access to birth control and family planning services?

    Findings  In this survey study of 1166 female Medicaid expansion enrollees of reproductive age in Michigan (sample weighted to 113 565 women), 35.5% reported increased access to birth control and family planning services. Those most likely to report increased access were women aged 19 to 24 (39.8%) and 25 to 34 (41.4%) years, women without health insurance coverage in the year preceding Medicaid expansion enrollment (42.6%), and women with a recent visit to a primary care clinician (36.8%).

    Meaning  Results suggest that Medicaid expansion is associated with improved access to family planning services, which may enable low-income women to maintain optimal reproductive health.

    Abstract

    Importance  To date, 32 states and the District of Columbia have expanded Medicaid programs under the Patient Protection and Affordable Care Act. It is vital to understand whether expanded health insurance coverage of low-income individuals improves access to family planning services as a first step toward improving reproductive health outcomes.

    Objective  To evaluate the association of Medicaid expansion coverage with access to birth control and family planning services among women of reproductive age enrolled in the Michigan expansion plan.

    Design, Setting, and Participants  In a survey study, from January 13 through December 15, 2016, telephone surveys of a stratified sample of enrollees in Michigan’s Section 1115 Medicaid Expansion waiver program, the Healthy Michigan Plan (HMP), were conducted. Interviewers completed surveys for 4090 sampled enrollees, of whom 1166 were women aged 19 to 44 years. Surveys were conducted with a computer-assisted telephone interviewing system in English, Arabic, and Spanish. The sample was weighted to 113 565 women. Dates of data analysis were from January 27 through September 18, 2017.

    Main Outcomes and Measures  Self-reported change in access to birth control and family planning services through HMP (better, worse, about the same, or don’t know/doesn’t apply), compared with before enrollment.

    Results  Among the 1166 survey respondents aged 19 to 44 years (mean [SD] age, 31.0 [0.3] years) and the weighted sample of 113 565, 74.7% (95% CI, 72.2%-76.9%) lived in very-low-income households (<100% federal poverty level), 64.0% (95% CI, 60.5%-67.3%) reported at least 1 chronic medical condition, 23.5% (95% CI, 20.6%-26.6%) reported fair or poor health, and 17.7% (95% CI, 15.7%-19.9%) lived in rural settings. Overall, 35.5% (95% CI, 32.2%-39.0%) reported increased access to family planning services. After adjusting, those most likely to report increased access were women without health insurance coverage in the year preceding HMP enrollment (adjusted odds ratio [aOR], 2.02; 95% CI, 1.41-2.89) compared with women with health insurance for the full 12 months preceding enrollment; younger women (aOR for 19-24 years, 2.80 [95% CI, 1.75-4.50]; aOR for 25-34 years, 2.35 [95% CI, 1.60-3.45]) compared with women aged 35 to 44 years; and women with a recent visit to a primary care clinician (aOR 1.69; 95% CI, 1.03-2.76) compared with women without a primary care visit in the preceding 12 months.

    Conclusions and Relevance  One in 3 women of reproductive age reported better ability to access birth control and family planning services through HMP compared with before enrollment. This finding suggests that Medicaid expansion is associated with improved access to family planning services, which may enable low-income women to maintain optimal reproductive health.

    Introduction

    Michigan is among the 32 states and District of Columbia that have expanded their Medicaid programs under the Patient Protection and Affordable Care Act (ACA).1 Michigan’s Section 1115 Medicaid Expansion waiver program, the Healthy Michigan Plan (HMP), began enrolling patients in April 2014 and now provides health insurance to approximately 650 000 low-income adults, including approximately 200 000 Michigan women of reproductive age.2,3 It is critical to understand the effects of Medicaid expansion programs, which the ACA requires to cover birth control without cost-sharing, on access to care.4

    Contraceptive care is an essential health service for women of reproductive age.5 Approximately 45% of US pregnancies are unintended, with an even higher proportion (55.9%) classified as unintended among low-income women (<150% federal poverty level).6 Unintended pregnancies generate an estimated $5 billion in direct and indirect health care costs each year in the United States, and 68% of care associated with unintended pregnancies is funded through Medicaid and other public programs.7,8 Improving consistent use of effective contraceptive methods is the main approach to reducing unintended pregnancies and their consequences. An estimated 37.9 million women in the United States are currently at risk of unintended pregnancy—that is, they are sexually active, physically able to conceive, and not pregnant or trying to conceive.9 Contraceptive need is particularly acute among low-income women, who are more likely than high-income women to report nonuse of contraceptives, to use less effective contraceptive methods, and to experience a contraceptive failure.10-12

    What impedes contraceptive use? Most forms of birth control require a prescription (eg, contraceptive pills, patch, ring) or clinician administration or insertion (eg, contraceptive shot, intrauterine devices, contraceptive implant). The most effective contraceptive methods—including intrauterine devices, implants, and sterilization—are expensive but also cost-effective.13 Before Medicaid expansion, many low-income women had significant out-of-pocket costs for contraception, which left some women using less effective contraceptive methods or no method at all. Expanded health insurance coverage of low-income women may remove some critical barriers to contraceptive care, such as out-of-pocket costs for contraceptive methods and visits. However, expanded coverage may not translate into improved access to contraceptive services because of nonfinancial access barriers such as inadequate sources of reproductive health care, discomfort with health care clinicians, logistical barriers (eg, child care, time off work, transportation), distance to a trained reproductive health clinician, and misinformation or poor health literacy.14,15 It is critically important to understand whether expanded health insurance coverage of low-income individuals improves access to family planning services as a first step toward reducing unintended pregnancy and improving reproductive health outcomes. Our study aimed to evaluate the association of obtaining Medicaid expansion coverage with access to birth control and family planning services among women enrolled in Michigan.

    Methods
    Study Design

    We conducted a telephone survey of HMP enrollees as part of the formal evaluation of the Medicaid Section 1115 demonstration under contract with the Michigan Department of Health and Human Services. This study evaluating a public program followed the American Association for Public Opinion Research (AAPOR) reporting guidelines and was deemed exempt from review by the institutional review boards of the University of Michigan and Michigan Department of Health and Human Services and did not require informed consent.

    Survey Sampling and Administration

    From January 13 through December 15, 2016, a stratified sample of HMP enrollees was drawn each month; the sample was allocated proportionally to the overall HMP enrollment by geographic region (Northern Michigan, Central Michigan, Southern Michigan, and Detroit) and income (0%-35%, 36%-99%, and 100%-133% of the federal poverty level). Inclusion criteria were based on demographic characteristics available in the Michigan Department of Health and Human Services data warehouse at the time of sampling and included ages 19 to 64 years; initial HMP enrollment at least 12 months before sampling; enrollment in an HMP managed care plan for at least 9 months (because most HMP enrollees are in managed care, and those who are not are not representative of the typical HMP experience); preferred language of English, Spanish, or Arabic; and a complete Michigan address and telephone number. Sampled HMP enrollees were mailed a letter and brochure that described the project and indicated the project team would call to discuss the survey; enrollees were also given the option to indicate their preferred time of day for the survey via postage-paid postcard, email, or toll-free number. The letter and brochure included general descriptions of the survey project, using language such as:

    Healthy Michigan Voices is a phone survey conducted by the University of Michigan. It includes people like you, who are enrolled in the Healthy Michigan Plan or other health plan. The survey asks about doctor and dentist visits, health care costs, and ways in which the Healthy Michigan Plan is working for you.

    Project interviewers called sampled HMP enrollees on weekdays from 9 am to 9 pm or at the enrollees’ requested time. Surveys were conducted with a computer-assisted telephone interviewing system in English, Arabic, and Spanish. As an institutional review board–exempt project, written informed consent was not required, but interviewers provided potential participants with information about the survey, ability to stop at any time, and confidentiality of responses, and individuals could then choose whether to participate. Respondents received a $25 gift card incentive. Of the 9227 HMP enrollees who were mailed the initial recruitment materials, 4108 completed the survey (weighted response rate, 53.7% using the American Association for Public Opinion Research’s response rate formula 3).16 Eighteen surveys had more than 20% missing data and were excluded from further analysis. Of the remaining 4090 respondents, 1681 were men and 2409 were women. Of the 2409 women, 1166 were aged 19 to 44 years. The analytic sample for the present study was limited to these 1166 female survey respondents aged 19 to 44 years, based on national guidelines for monitoring access to contraceptive care.17 The respondents were weighted to a population of 113 565 women. Pregnant women seeking Medicaid coverage are not eligible for HMP, are enrolled in a different Medicaid program, and therefore are not included in our sample.

    Survey Instrument

    The survey was part of a larger evaluation of HMP, as required by the Centers for Medicare & Medicaid Services.18 To inform survey development, we conducted in-depth semistructured interviews with 67 HMP enrollees from April 1 through August 31, 2015. Interview participants with at least 6 months of HMP enrollment and who had used at least 1 HMP-covered health care service were recruited through community outreach efforts, and purposive sampling methods were used to select interviewees with a diversity of age, race/ethnicity, income, health conditions, geographic region, and urban or rural residence. Guided by findings from these interviews, the survey instrument was developed by the research team.

    The survey measured demographics, health status, insurance status, health care access, and use of health care services with established items and scales.19-22 When established measures were not available, new items were developed based on findings from the qualitative interviews. New items underwent cognitive testing and pretesting before being included in the survey instrument. Given the well-documented disparities in contraceptive access across racial/ethnic groups,23-25 we collected information on race/ethnicity. Respondents were asked “Are you Hispanic or Latino (yes/no)?” “Are you of Arab or Chaldean or Middle Eastern descent (yes/no)?” and “What race or races do you consider yourself to be?” (options defined by respondent). Primary care is an important and unique feature of Michigan’s Medicaid expansion. Enrollees in HMP are encouraged to schedule an appointment with their primary care clinician within 60 days of choosing or being assigned to a health plan. We therefore also collected information about use of primary care services (“Have you seen your primary care provider in the past 12 months?”).

    The final instrument also included 1 item addressing access to different categories of health care, including family planning services. Female respondents aged 19 to 44 years were read the following prompt:

    Next I’m going to ask about different categories of health care. Tell me if your ability to get that type of care through the Healthy Michigan Plan is better, worse, or about the same, compared to before you had Healthy Michigan Plan. You can also say if you don’t know, or if that type of care doesn’t apply to you. Would you say that your ability to get birth control/family planning services through the Healthy Michigan Plan is better, worse, or about the same, compared to before?

    Respondent replies were recorded as better, worse, about the same, or don’t know/doesn’t apply.

    Statistical Analysis

    We used descriptive statistics and Pearson χ2 analyses to describe self-reported changes in access to reproductive services by demographic and insurance characteristics. We also performed a logistic regression model that estimated a positive change in access to family planning services, including age, race/ethnicity, income, urbanicity, marital status, chronic disease, insurance coverage before HMP, and visit with a primary care clinician in the past 12 months as covariates. A sensitivity analysis was performed excluding those who responded “don’t know/doesn’t apply.” Adjusted odds ratios (aORs) and their 95% CIs were calculated. Item nonresponses were coded as missing. All analyses were weighted using the svy: command in Stata software (version 14.2; StataCorp). Survey selection weight, adjustments for nonworking numbers, ineligible cases, unknown eligibility, and nonresponse, as well as poststratification weights and sampling strata were applied to adjust for sample design and nonresponse. All statistics applied these weights, and the resulting statistics reflect the overall HMP population. Two-sided P < .05 was considered statistically significant.

    Results

    Our sample of 1166 female respondents (weighted population, 113 565 women) aged 19 to 44 years (mean [SD] age, 31.0 [0.3] years) broadly reflected the racial/ethnic composition of low-income nonelderly adults in Michigan (Table 1). Most women (74.7%; 95% CI, 72.2%-76.9%) lived in very-low-income households (<100% of the federal poverty level). At least 1 chronic medical condition was reported by 64.0% (95% CI, 60.5%-67.3%), and 23.5% (95% CI, 20.6%-26.6%) reported fair or poor health. Nearly 1 in 5 (17.7%; 95% CI, 15.7%-19.9%) lived in rural settings.

    Overall, 35.5% (95% CI, 32.2%-39.0%) of respondents reported better ability to access birth control and family planning services through HMP compared with before they enrolled in HMP, whereas 24.8% (95% CI, 21.8%-28.0%) reported about the same ability, and 1.4% (95% CI, 0.8%-2.5%) reported worse ability. An additional 38.3% (95% CI, 34.9%-41.8%) reported that they did not know whether HMP affected their ability to get birth control and family planning or that birth control and family planning access did not apply to them. The proportion reporting improved access to family planning services was lower than the proportion of women aged 19 to 44 years reporting improved access to primary care, specialist care, dental care, prescription medications, and help preventing health problems, but higher than the proportion reporting improved access to mental health, cancer screening, and substance use treatment (Figure).

    Significantly higher proportions of younger women aged 19 to 24 years (39.8%; 95% CI, 32.7%-47.4%) and aged 25 to 34 years (41.4%; 95% CI, 36.3%-46.8%) reported improved ability to obtain birth control and family planning services after acquiring HMP coverage compared with women aged 35 to 44 years (24.1%; 95% CI, 19.4%-29.6%; P < .001) (eTable in the Supplement). Improved access to birth control and family planning services was also more commonly reported by women without health insurance in the year preceding HMP coverage (42.6%; 95% CI, 37.7%-47.6%) compared with those who were insured all 12 months (27.5%; 95% CI, 22.3%-33.2%; P = .001). A difference in access to family planning services was observed for women who had seen a primary care clinician in the last 12 months, compared with those without a primary care visit, but the difference did not achieve significance (36.8% [95% CI, 33.1%-40.8%] vs 27.6% [95% CI, 19.9%-36.7%]; P = .06).

    In multivariable logistic regression analysis, better access to birth control and family planning services was significantly associated with age, having no health insurance coverage before HMP enrollment, and a recent visit with a primary care clinician (Table 2). Compared with enrollees aged 35 to 44 years, younger women had significantly higher odds of reporting better access to birth control and family planning services (aOR for 19-24 years, 2.80 [95% CI, 1.75-4.50]; aOR for 25-34 years, 2.35 [1.60-3.45]). Compared with women with health insurance for the full year before enrolling in HMP, women without any insurance in the preceding 12 months had twice the odds of reporting that HMP improved their access to birth control and family planning services (aOR, 2.02; 95% CI, 1.41-2.89). Enrollees who had visited a primary care clinician in the preceding 12 months also had significantly higher odds of reporting better access to birth control and family planning after HMP enrollment compared with those who had not (aOR, 1.69; 95% CI, 1.03-2.76). We did not observe differences in self-reported access across racial/ethnic groups, income categories, partnership status, urban or rural setting, self-reported health status, or presence of medical comorbidity. In the sensitivity analysis, after dropping responses of “don’t know/doesn’t apply,” women without health insurance in the past 12 months were significantly more likely to report improved access to family planning services (aOR, 3.11; 95% CI, 1.99-4.86).

    Discussion

    In this study examining health care access after Medicaid expansion in Michigan, more than 1 in 3 women of reproductive age reported better ability to access birth control and family planning services through HMP compared with before enrollment. Younger women, those without insurance coverage in the year preceding HMP enrollment, and those with a recent visit to a primary care clinician were significantly more likely to report increased access to family planning services.

    Although improved contraceptive access is a critical first step in improving contraceptive use and reducing unintended pregnancy rates, prior studies of the effects of expanded coverage on access to contraceptive services and reproductive health outcomes26-32 have had mixed results. Multiple studies26-29 suggest that Medicaid family planning waivers and state plan amendments to expand family planning coverage to women not otherwise eligible for Medicaid have been associated with increased contraceptive use and significant reductions in unintended pregnancy rates. However, early studies evaluating contraceptive use patterns among commercially and publicly insured women after implementation of the ACA’s contraceptive coverage mandate30-32 have documented no or only minimal change in contraceptive use patterns. Conflicting findings may be due to variation in women’s baseline contraceptive need at the time of expanded coverage. Our study of Medicaid expansion in Michigan suggests that expansion improves family planning access among low-income women, with the greatest association among young women and those without insurance coverage in the 12 months preceding HMP enrollment, populations that may have had a high unmet need for family planning care. Our findings are consistent with those of a recent literature review of 153 studies of Medicaid expansion33 that documents predominantly positive effects of Medicaid expansion on measures of access to health care.

    Fewer respondents reported improved access to birth control and family planning compared with some other health care services. This improvement was true even when comparing birth control with other prescription drugs. This finding has several possible explanations. Many low-income women may have already had access to free or low-cost birth control through publicly funded clinics. In 2016, for example, more than 4.0 million individuals were served at approximately 4000 sites funded by the Title X National Family Planning Program, the federal program that supports delivery of family planning care to low-income families.34 Some women may not have had a need for birth control or family planning care (eg, they had already received a sterilizing surgery or a long-acting contraceptive device, or they desired pregnancy). Another explanation is that some newly insured individuals may not have known they were eligible for no-cost family planning services.

    Young HMP enrollees were significantly more likely to report improved access to family planning services. Young women are at disproportionately high risk of unintended and short-interval pregnancies and associated adverse outcomes, including preterm birth, compared with older women.6 Young women face unique barriers to contraceptive access, including concerns about cost and confidentiality.35 Provision of no-cost contraception has been shown to decrease unintended pregnancy rates among young women.36-38 Our findings suggest that Medicaid expansion may help improve family planning access for this vulnerable population with often unmet family planning needs.

    Our findings also suggest that primary care clinicians may play an important role in translating insurance coverage into meaningful access to family planning care. Enrollees in HMP with a recent visit to a primary care clinician were significantly more likely to report better birth control and family planning access after HMP enrollment than their peers who had not recently seen a primary care clinician. One explanation is that women who have seen a primary care clinician may have more interest in family planning services. Alternatively, primary care clinicians may inquire about the need for contraception and prescribe birth control or refer new Medicaid enrollees to clinicians with family planning expertise. New enrollees in HMP are encouraged to have an early visit with a primary care clinician, which may be an important strategy for improving access to reproductive health services.39 States that have expanded Medicaid can also support clinicians in delivering high-quality family planning care by eliminating multivisit protocols, encouraging contraception access across health care settings, and disseminating the evidence-based guidelines from the Centers for Disease Control and Prevention regarding contraceptive use in women with chronic medical conditions.40-46

    We did not observe differences in reported improvement in access to family planning services across racial/ethnic, income, or urban and rural groups. This suggests that the benefits of Medicaid expansion for family planning access are being shared equitably by diverse enrollees.

    Limitations

    Our study has several potential limitations. First, we measured only self-reported access to services. Objective measures of appointment availability, service affordability, and clinician acceptability are important topics for future studies of reproductive health access after Medicaid expansion. Second, our survey included adult women of reproductive age. By not specifically excluding women not at risk of unintended pregnancy, we provide conservative estimates of the associations of coverage expansion with access to birth control and family planning services, likely underestimating the association among women at higher risk of unintended pregnancy. Third, the present study focuses on self-reported access to birth control and family planning services. Additional work is needed to understand whether improved access translates into enhanced contraceptive use and improved reproductive health outcomes. Fourth, because we examined Medicaid expansion in a single large state, findings may not be generalizable to all states. State-level evaluations, however, are the most robust method of evaluating Medicaid expansions, given unique implementation processes across states. Michigan’s early experiences may provide useful insights as Medicaid expansion continues to be debated and implemented in other states.

    Conclusions

    Our results suggest that Medicaid expansion is associated with improved access to family planning services, which may enable low-income women to maintain optimal reproductive health. States that have adopted or are considering adopting Medicaid expansion can use robust communication efforts to ensure optimal use of family planning services by interested enrollees. Facilitating access to family planning services may improve health outcomes and reduce health care expenditures, because each dollar spent on contraception has been estimated to save the health care system $6.47-50 Our findings provide supporting evidence that Medicaid expansion appears to effectively enhance access to family planning care in Michigan. Further research is required to assess how this increased access affects reproductive health among Medicaid expansion enrollees.

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    Article Information

    Accepted for Publication: May 28, 2018.

    Published: August 31, 2018. doi:10.1001/jamanetworkopen.2018.1627

    Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2018 Moniz MH et al. JAMA Network Open.

    Corresponding Author: Michelle H. Moniz, MD, MSc, 2800 N Plymouth Rd, Bldg 16, Room G222, Ann Arbor, MI 48109 (mmoniz@med.umich.edu).

    Author Contributions: Drs Goold and Chang had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Solway, Goold, Ayanian, Kieffer, Clark, Tipirneni, Kullgren, Chang.

    Acquisition, analysis, or interpretation of data: All authors.

    Drafting of the manuscript: Moniz, Kirch, Chang.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Kirch, Goold, Chang.

    Obtained funding: Ayanian, Tipirneni.

    Administrative, technical, or material support: Moniz, Solway, Clark, Kullgren, Chang.

    Supervision: Goold, Ayanian, Chang.

    Conflict of Interest Disclosures: The University of Michigan Institute for Healthcare Policy and Innovation is conducting the evaluation required by the Centers for Medicare & Medicaid Services of the Healthy Michigan Plan under contract with the Michigan Department of Health and Human Services (MDHHS). Mr Kirch reported receiving grant funding from MDHHS during the conduct of the study and compensation from the University of Michigan through a contract with the state of Michigan. Dr Solway reported receiving grant funding from MDHHS during the conduct of the study and compensation from the University of Michigan through a contract with the state of Michigan. Dr Goold reported receiving grants from MDHHS during the conduct of the study and compensation from the University of Michigan through a contract with the state of Michigan. Dr Ayanian reported receiving grants from MDHHS during the conduct of the study and compensation from the University of Michigan through a contract with the state of Michigan. Dr Clark reported receiving grants from the state of Michigan and MDHHS during the conduct of the study and compensation from the University of Michigan through a contract with the state of Michigan. Dr Tipirneni reported receiving grant funding from the state of Michigan and MDHHS during the conduct of the study and compensation from the University of Michigan through a contract with the state of Michigan. Dr Kullgren reported receiving grant funding from MDHHS during the conduct of the study; personal fees from HealthMine and AbilTo, Inc, outside the submitted work; compensation from the University of Michigan through a contract with the state of Michigan; and a Veterans Affairs Health Services Research and Development career development award at the Ann Arbor VA. Dr Chang reported receiving grant funding from MDHHS during the conduct of the study and compensation from the University of Michigan through a contract with the state of Michigan. No other disclosures were reported.

    Funding/Support: This study was supported by the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service (Dr Kullgren); grant K08 HS025465 from the Agency for Healthcare Research and Quality (Dr Moniz); and grant K08 AG056591 from the National Institute on Aging (Dr Tipirneni).

    Role of the Funder/Sponsor: The sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation of the manuscript; and decision to submit the manuscript for publication. The state of Michigan reviewed the draft publication and approved the draft accepted for publication, but the authors maintained final editorial control.

    Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs, the US government, or the Michigan Department of Health and Human Services.

    Additional Contributions: Adrianne Haggins, MD, MSc, Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, Ann-Marie M. Rosland, MD, MS, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, Sunghee Lee, PhD, University of Michigan Institute for Social Research, Ann Arbor, Erin Beathard, MPH, MSW, University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, and Erin Sears, MPH, Colorado Department of Health Care Policy and Financing, Denver, contributed to the study design and implementation of this study. All additional contributors’ efforts on this project were funded by a contract with MDHHS. The community leaders who participate on this project’s Steering Committee provided valuable insights.

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