Evaluation of Medicaid Expansion Under the Affordable Care Act and Contraceptive Care in US Community Health Centers | Health Care Reform | JAMA Network Open | JAMA Network
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Figure 1.  Study Population Selection
Study Population Selection
Figure 2.  Adjusted Prevalence of Moderately Effective or Most Effective and Most Effective Effective Contraceptive Methods by Medicaid Expansion and Title X Status
Adjusted Prevalence of Moderately Effective or Most Effective and Most Effective Effective Contraceptive Methods by Medicaid Expansion and Title X Status

Standards for moderately effective or most effective contraceptive methods are as per National Quality Forum standard 2903, and standards for most effective contraceptive methods are as per National Quality Forum standard 2904.

Table 1.  Study Population Characteristics by Medicaid Expansion Status
Study Population Characteristics by Medicaid Expansion Status
Table 2.  Receipt of Contraception, Before Affordable Care Act Expansion (2013) vs Immediately (2014) and Longer (2016) After Expansion, by State-Level Medicaid Expansion Status
Receipt of Contraception, Before Affordable Care Act Expansion (2013) vs Immediately (2014) and Longer (2016) After Expansion, by State-Level Medicaid Expansion Status
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    Original Investigation
    Health Policy
    June 4, 2020

    Evaluation of Medicaid Expansion Under the Affordable Care Act and Contraceptive Care in US Community Health Centers

    Author Affiliations
    • 1Oregon Health & Science University, Portland, Oregon
    • 2OHSU-PSU School of Public Health, Portland, Oregon
    • 3National Institute of Public Health, Center for Population Health, Cuernavaca, Morelos, Mexico
    • 4OCHIN Inc, Portland, Oregon
    JAMA Netw Open. 2020;3(6):e206874. doi:10.1001/jamanetworkopen.2020.6874
    Key Points español 中文 (chinese)

    Question  Was Medicaid expansion under the Affordable Care Act associated with improvements in contraceptive use quality metrics in the US health care safety net?

    Findings  In this cross-sectional study including more than 500 000 women, Medicaid expansion was associated with an increase in use of the most effective contraceptive methods (long-acting reversible contraception) by 1.2 percentage points among women at risk of pregnancy in states that expanded Medicaid compared with nonexpansion states, controlling for other payers for contraceptive care (such as Title X and 1115 waiver programs).

    Meaning  Affordable Care Act–sponsored Medicaid expansion was independently associated with a small but meaningful increase in access to the most effective methods of contraception.

    Abstract

    Importance  Use of effective contraception decreases unintended pregnancy. It is not known whether Medicaid expansion under the Affordable Care Act increased use of contraception for women who are underserved in the US health care safety net.

    Objective  To evaluate the association of Medicaid expansion under the Affordable Care Act with changes in use of contraception among patients at risk of pregnancy at US community health centers, with the hypothesis that Medicaid expansion would be associated with increases in use of the most effective contraceptive methods (long-acting reversible contraception).

    Design, Setting, and Participants  This was a participant-level retrospective cross-sectional study comparing receipt of contraception before (2013) vs immediately after (2014) and a longer time after (2016) Medicaid expansion. Electronic health record data from a clinical research network of community health centers across 24 states were included. The sample included all female patients ages 15 to 44 years at risk for pregnancy, with an ambulatory care visit at a participating community health center during the study period (315 clinics in expansion states and 165 clinics in nonexpansion states).

    Exposures  Medicaid expansion status (by state).

    Main Outcomes and Measures  Two National Quality Forum–endorsed contraception quality metrics, calculated annually: the proportion of women at risk of pregnancy who received (1) either a moderately effective or most effective method (hormonal and long-acting reversible contraception) methods and (2) the most effective method (long-acting reversible contraception).

    Results  The sample included 310 132 women from expansion states and 235 408 women from nonexpansion states. The absolute adjusted increase in use of long-acting reversible contraceptive methods was 0.58 (95% CI, 0.13-1.05) percentage points greater among women in expansion states compared with nonexpansion states in 2014 and 1.19 (95% CI, 0.41-1.96) percentage points larger in 2016. Among adolescents, the association was larger, particularly in the longer term (2014 vs 2013: absolute difference-in-difference, 0.80 [95% CI, 0.30-1.30] percentage points; 2016 vs 2013: absolute difference, 1.79 [95% CI, 0.88-2.70] percentage points). Women from expansion states who received care at a Title X clinic had the highest percentage of women receiving most effective contraceptive methods compared with non–Title X clinics and nonexpansion states.

    Conclusions and Relevance  In this study, Medicaid expansion was associated with an increase in use of long-acting reversible contraceptive methods among women at risk of pregnancy seeking care in the US safety net system, and gains were greatest among adolescents.

    Introduction

    Unintended pregnancy is a key health indicator with multigenerational negative social, economic, and health consequences.1 The proportion of unintended pregnancies overall is declining, but disparities by race/ethnicity, income, and insurance status persist.2-4 Women with low incomes and a lack of insurance have double the burden of unintended pregnancy compared with women with incomes of 200% or more than the federal poverty level (FPL).5 Use of effective contraception is an essential intervention to reduce unintended pregnancy. Community health centers (CHCs), which include federally qualified health centers, rural health centers, and county health departments, receive federal funds to provide care regardless of insurance status or ability to pay and are key sources of care for women of reproductive age.6 In 2015, more than 6 million women in the US received publicly funded contraceptive services in CHCs or other safety net settings.7

    The Affordable Care Act (ACA) increased the number of adults receiving health insurance coverage, especially in Medicaid expansion states,8-10 and insurance coverage for preventive services, including contraception, without any out-of-pocket costs to patients.11 Recent studies suggest that the number of women receiving contraceptive services in primary care settings increased in Medicaid expansion states after ACA implementation,12-14 and more women in safety net clinics used insurance to pay for contraceptive services after Medicaid expansion.15 Research to date on publicly funded contraceptive services has focused on 1 of 3 mechanisms (Medicaid, single payers [eg, state family-planning programs],16 or federal programs [Title X]17-19) or has included only clinics with a reproductive health focus or those known to provide publicly funded contraceptive services.20-22 We have little evidence collected across the safety net system that also includes programs, such as Title X, that pay for contraceptive services in the safety net. Objective clinical data that capture the association of Medicaid expansion under the ACA with changes to the provision of contraceptive care across the safety net, regardless of insurance status or payer type, is lacking. Even small increases in the use of the most effective methods of contraception translate into a large outcome on unintended pregnancy, birth, and abortion rates,23,24 as well as public cost savings.

    The purpose of this study is to examine the association of the ACA with quality of contraceptive care across the safety net system, using 2 newly developed metrics endorsed by the Office of Population Affairs (OPA) of the US Centers for Disease Control and Prevention and the National Quality Forum (NQF).25,26 These metrics27 are calculated annually at the individual level among women at risk of pregnancy in each measurement year: (1) receipt of a most effective or moderately effective contraceptive method and (2) receipt of a most effective contraceptive method. We use a patient-level data source that includes more than 300 CHCs across the US and assess overall rates of contraceptive provision, relative changes associated with Medicaid expansion (both immediate and longer term), and the role of Title X. We hypothesized that controlling for other programs and payers, the ACA would have a modest association with access to the most effective contraceptive methods. We compare outcomes in the preexpansion year to 2 points: one immediately postexpansion (2014) and a point longer after expansion (2016).

    Methods

    We used electronic health record (EHR) data from a multistate network of CHCs and conducted a retrospective, cross-sectional, patient-level study. This analysis is part of the Reproductive Care in the Safety Net: Women’s Health after Affordable Care Act Implementation (EVERYWOMAN)30 study and estimates the association of ACA-sponsored Medicaid expansion with receipt of contraceptive care in the US safety net. This study follows the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.

    Data Source and Sample

    We used EHR data from the Accelerating Data Value Across a National Community Health Center Network (ADVANCE) clinical research network, a member of PCORnet, the National Patient-Centered Clinical Research Initiative.28 ADVANCE is a multicenter collaborative led by OCHIN Inc in partnership with Health Choice Network, Fenway Health, and Oregon Health & Science University. Outpatient EHR data from CHCs in the 3 data-sharing partner organizations (OCHIN Inc, Health Choice Network, and Fenway Health) are integrated and standardized into a common data model.29 ADVANCE data includes information from more than 5.6 million patients from CHCs across 30 states and is demographically similar to the national profile of patients in CHCs.6 ADVANCE data are collected under a waiver of authorization because of minimal risk to patients and the practical issues of getting consent from the number of patients included. More details on the data are in the previously published full study protocol.30 For this analysis, we included data from CHCs that were live (active) on their EHR and contributed data throughout the study period (2013, 2014, and 2016) and provided primary and preventive care services to women of reproductive age; these inclusion criteria resulted in CHC data from 20 states for analysis. The sample includes female patients aged 15 to 44 years old who were at risk of pregnancy.

    Dependent Variables: Receipt of Contraception

    Our 2 primary outcomes are binary measures of receipt of contraception, based on the OPA and NQF contraceptive quality metrics specification28 and calculated annually at the individual level among women at risk of pregnancy in each measurement year: (1) receipt of a most effective or moderately effective contraceptive method (NQF 2903), and (2) receipt of a most effective contraceptive method (NQF 2904). The NQF standard 2903 includes oral contraceptive pills, injections, patches, rings, diaphragms, incident sterilization, or a long-acting reversible contraceptive (LARC) method (intrauterine device or implant). The NQF standard 2904 includes LARC methods (existing sterilization is an exclusion). These metrics are percentages of an eligible population calculated annually for women ages 15 to 44 years and reported in 2 strata: ages 15 to 20 years (adolescents) and ages 21 to 44 years (adults). We compared 2013 (before Medicaid expansion) with 2014 (immediately after Medicaid expansion) and 2016 (a longer time after Medicaid expansion).

    Women were eligible for a given measurement year if they were aged 15 to 44 years at the end of the year, had 1 or more ambulatory visit at an included study clinic during the year, and were at risk for pregnancy in the year. Women were excluded if they had evidence of previous sterilization noted in their EHR, were infecund for noncontraceptive reasons, or were pregnant in the measurement year and had a live birth delivery date in the last 2 months of the year (following OPA measure specifications28). Because the postpartum period is a key time for contraceptive care and delivery dates were sometimes unknown in the EHR, women were included in the sample if they were pregnant in the measurement year but had had a nonlive birth, had had a live birth in the first 10 months of the year, or had had an unknown pregnancy outcome. Delivery dates were missing in the outpatient EHR data for about 85% of pregnant women (11.5% of the study sample); we used postpartum visit dates as a proxy when available (accounting for about 25% of pregnant women). The remaining 60% of pregnant women with unknown pregnancy outcome were included in the final analysis because most would have delivered in the first 10 months of the year. We conducted a sensitivity analysis excluding all women with a pregnancy in the measurement year; results were unchanged (eTable 3 in the Supplement). Metric inclusion criteria are detailed in Figure 1.

    Independent Variable

    Medicaid expansion status was our primary independent variable: our sample included patients from CHCs in 12 expansion states as of January 1, 2014 (California, Hawaii, Massachusetts, Maryland, Minnesota, New Mexico, Nevada, Ohio, Oregon, Rhode Island, Washington, and Wisconsin), and 8 nonexpansion states (Alaska, Florida, Indiana, Kansas, Missouri, Montana, North Carolina, and Texas). Wisconsin did not expand Medicaid eligibility to people with incomes of 138% FPL or less but opened adult enrollment up to those with incomes of 100% FPL or less, so it was categorized as an expansion state.27,31 Alaska, Indiana, and Montana implemented Medicaid expansion by January 1, 2016, and were reclassified as expansion states for the 2016 measurement year. Expansion vs nonexpansion status was based on the state location of each patient’s primary care facility.

    We included patient-level, clinic-level, and state-level covariates in our patient-level analysis. We hypothesized that clinic-level and state-level factors could be associated with both Medicaid expansion and study outcomes.

    Patient-Level Covariates

    We extracted patient-level covariates from the EHR, including age, race/ethnicity, and household income as a percentage of FPL. Hispanic ethnicity includes all patients with Spanish as a primary language, regardless of their coded ethnicities. Time-varying covariates (age and FPL) were assigned as of each patient’s last ambulatory visit in the given period. Where data elements were missing, we coded a separate missing/unknown category to not exclude these patients from our models.

    Patients were assigned to a primary CHC clinic according to the most frequently visited facility in a given period. Individual-level insurance type was excluded from the analysis because Medicaid expansion status and having Medicaid are highly correlated and Medicaid coverage is in an associative pathway. Sensitivity analyses with insurance included as a covariate can be found in eTable 4 in the Supplement. To control for difference in health care utilization, we computed mean annual visit rates per for each measurement year among eligible patients and included an indicator for new patient status, because new patients are hypothesized to use care differently than patients with established care. We also controlled for binary pregnancy status (ie, pregnant or not pregnant in measurement year), because this affects both health care utilization and access to contraception.

    Clinic-Level Covariates

    We identified patients who visited a Title X clinic32 within the measurement year because Title X clinics are known to provide broader range of contraceptive methods, including LARC.22,33-35 Title X funding status of the clinic was determined from data from the OPA.36 Urban vs rural status was assigned to each patient using Rural-Urban Commuting Area codes37 based on each patient’s primary clinic address. We also identified women who received care from a women’s health specialist.

    State-Level Covariates

    We measured whether states used a Medicaid 1115 Waiver or State Plan Amendment to expand family planning coverage. In our data, these included expansion states California, Massachusetts, Maryland, Minnesota, New Mexico, Oregon, Rhode Island, Washington, and Wisconsin and nonexpansion states Florida, Indiana, Montana, and North Carolina.38 Because nearly all of the women had visits in states with a state family-planning program (approximately 90%; Table 1), we conducted a sensitivity analysis excluding state family-planning programs from our models. Results were unchanged. Based on previous literature and the potential confounding role on Medicaid expansion and contraceptive care, we still chose to include state family-planning programs in our final models.

    Statistical Analysis

    We computed descriptive statistics for all eligible patients, stratified by expansion status and preexpansion and postexpansion periods. To assess whether patient samples differed substantially before vs after Medicaid expansion within the expansion group, we computed absolute standardized mean differences (ASMD). This effect size measure is used in observational studies to compare distributional differences between groups, with extensions to binary and multinomial variables.39 Importantly, ASMD is not affected by sample size (given our large sample size, most P values are highly significant) and can be used to compare distributions between overlapping (ie, nonindependent) groups as in this instance. To make comparisons between expansion status groups, we used ASMD to compare distributional differences in demographic and clinical measures. We considered an ASMD of more than 0.1 to denote marginal differences between the groups40 being compared.

    To estimate association of the ACA with quality of contraceptive care, we used a difference-in-difference model.41-44 This quasiexperimental approach compares changes in contraceptive care outcomes at different points over time in states that expanded Medicaid vs those that did not. We calculated unadjusted and covariate adjusted estimates of the proportion of eligible women who received a most effective or moderately effective contraceptive method or a most effective method in preexpansion and postexpansion periods, by expansion status. We also stratified both outcomes by age groups (15-20 years and 21-44 years) and visiting vs not visiting a Title X clinic in the year. Adults made up most of our sample, and adult results were thus nearly identical to overall results; we therefore only show overall and adolescent results. We then fitted separate generalized estimating equation (GEE) models45 for each outcome and stratified by age groups with an identity link to obtain adjusted absolute percentage point differences comparing postexpansion vs preexpansion differences in contraceptive provision within expansion status groups, and difference-in-difference (DID)46,47 estimates with 95% CIs to test postexpansion vs preexpansion changes between expansion status groups. The GEE models included an indicator for measurement year (2013, 2014, and 2016), Medicaid expansion status, and the interaction between these variables (the difference-in-differences estimator). To help clarify comparisons, we used the SAS statement LSMEANS and contrast statements to output within-group before and after expansion and difference-in-differences estimates comparing each postexpansion year to the 2013 baseline year. Models were adjusted for covariates described above. The GEE models implemented a robust sandwich standard error estimator with a working independent correlation structure to account for the clustering of patients within CHCs. This study was approved by the Western Institutional Review Board. Analyses were conducted from May 2019 to February 2020 using SAS version 9.4 (SAS Institute). Statistical significance was set at P < .05 using 2-sided tests.

    Results

    Our sample included 310 132 women from 315 CHCs in expansion states and 235 408 women from 165 CHCs in nonexpansion states. Compared with nonexpansion states, expansion states had a higher proportion of non-Hispanic white women (144 110 [46.5%] vs 63 455 [26.9%]; ASMD. 0.58), fewer patients with incomes greater than 138% of the FPL (36 741 [11.9%] vs 32 203 [13.4%]; ASMD, 0.48), and more patients with Medicaid (149 886 [48.3%] vs 81 520 [34.6%]; ASMD, 0.43; Table 1). Expansion states had more patients living in rural areas (32 617 [10.5%] vs 8593 [3.6%]; ASMD, 0.50) and more women with a Title X clinic visit (63 405 [20.4%] vs 17 120 [7.3%]; ASMD, 0.39). Within expansion groups, the populations who were eligible before and after ACA did not differ substantially, except on characteristics that would be expected to change (ie, ASMDs were >0.10 for age, insurance type, visit rates, and new patient status; Table 1 for all covariates and eTable 1 in the Supplement for full data before and after expansion by expansion status).

    Moderately Effective or Most Effective Contraception

    Women in expansion states had an adjusted 24.4% receipt of moderately effective or most effective contraceptive methods in the year after Medicaid expansion (Table 2), an increase from 23.7% before expansion. Use of most effective or moderately effective contraceptives remained stable through 2016 (24.3%). Women in nonexpansion states experienced a greater adjusted increase in the receipt of moderately effective or most effective contraceptive methods in the immediate postexpansion period, from 17.9% to 19.6%. By 2016, receipt of contraceptives increased further, to 20.4%. The increase in coverage was thus significantly greater among women in nonexpansion states relative to expansion states (absolute adjusted difference-in-differences, 2014 vs 2013: −1.10 [95% CI, −1.88 to −0.33] percentage points; 2016 vs 2013: −1.93 [95% CI, −3.63 to −0.23] percentage points).

    Most Effective Contraception (LARC)

    After Medicaid expansion, annual use of most effective methods among women in expansion states increased from 4.4% in 2013 to 5.3% in 2014 and 6.1% in 2016 (Table 2). Women in nonexpansion states also experienced an increase in LARC in the postexpansion period, from 1.8% to 2.2% in 2014 and 2.4% in 2016. The increase in the most effective methods was thus greater among women in expansion states, particularly comparing 2016 with 2013 (absolute adjusted difference-in-difference, 1.19 [95% CI, 0.41-1.96] percentage points; Table 2).

    Adolescents

    Among adolescents, use of moderately effective or most effective contraceptive methods did not change appreciably in expansion states (adjusted percentage receiving contraceptives in 2013, 28.9%; 2014, 28.4%; 2016, 27.8%; difference not significant). Adolescents in clinics in nonexpansion states experienced a small increase in use of moderately effective or most effective contraceptive methods in 2013, 2014, and 2016 (21.2%, 22.4%, and 24.1%, respectively). The increase in use of moderately effective or most effective methods was significantly larger among adolescents in nonexpansion states (2016 vs 2013: absolute difference-in-difference of −3.96 [95% CI, −6.07 to −1.85] percentage points; Table 2).

    Adolescent use of most effective contraceptive methods increased nearly 1 percentage point in the first postexpansion year (from 4.0% to 4.9%) and more than 2 percentage points by 2016 (to 6.1%) in expansion states (Table 2). Adolescents seen in clinics in nonexpansion states experienced no significant change in the use of most effective methods (from 1.8% to 2.1% in each measurement year). The change in use of most effective methods was significantly greater among adolescents seen in clinics in expansion states in both the year immediately after ACA implementation (2014 vs 2013: absolute difference-in-difference, 0.80 [95% CI, 0.30-1.30] percentage points) and 3 years after ACA implementation (2016 vs 2013: absolute difference-in-difference, 1.79 [95% CI, 0.88-2.70] percentage points).

    Title X

    Women who visited a Title X clinic in expansion states had higher percentages of receipt of both moderately effective or moderately effective and most effective contraceptive methods (Figure 2A). Compared with nonexpansion states, Medicaid expansion was significantly associated with an increase in the proportion of use of most effective methods use among women who were not seen in Title X clinics (Figure 2B), particularly 3 years after expansion (2016 vs 2013: adjusted difference-in-difference, 1.55 [95% CI 0.71-2.39] percentage points; eTable 2 in the Supplement).

    Discussion

    We present new evidence that Medicaid expansion under the ACA is associated with an increase in use of the most effective contraception (LARC; intrauterine devices and implants) among women at risk of pregnancy, both immediately after expansion and at 3 years. This increase in effective contraceptive use attributable to Medicaid expansion was larger among a uniquely vulnerable population: adolescents seeking care in CHCs (who had a 2.1 percentage point increase in 2016 over 2013). While women in nonexpansion states experienced and increase in the access to moderately effective or most effective methods, they remained at overall lower levels of effective contraceptive use than women seen in expansion states. Although the absolute increase in contraceptive use attributable to Medicaid expansion is small, this difference is meaningful from a population health perspective. Being without insurance is a known risk factor for unintended pregnancy48; interventions that improve access to contraception for this population have profound population-level outcomes.23,24 Our findings persisted when accounting for other safety net programs, such as Title X. Medicaid expansion did not replace the benefits observed with Title X programs and can help improve access for women unable to visit a Title X clinic. We found that Medicaid expansion was associated with a 0.8 percentage point increase in access to LARC in 2014 relative to 2013, and this was 1.6 percentage points greater in 2016 vs 2013 among women seen in non–Title X clinics compared with those seen in nonexpansion states.

    Unintended pregnancy disproportionately affects women with low incomes5; this is precisely the population included in our sample of CHCs that care for low-income and underserved populations. Previous work has reported conflicting results about provisions of the ACA, including the contraceptive mandate and Medicaid expansion, on contraceptive use.49-52 Our findings suggest that Medicaid expansion under the ACA improved access to the most effective contraception, LARC, among a population at high risk of unintended pregnancy. Furthermore, the observed increase in LARC in our sample of patients in safety net settings supports previous evidence that when cost barriers are removed, women choose LARC methods.53 Our findings that use of moderately effective methods decreased over time in expansion states is consistent with previous work using clinic-level reporting and survey data18 and may be explained by women switching to more effective methods. If this were the case, overall rates of use of moderately effective or most effective contraception would go down as most effective rates go up, given that most women in the group using moderately effective or most effective contraception are using moderately effective methods.

    Our results show that, after Medicaid expansion, women in expansion states seeking care in CHCs had higher adjusted proportion of use of most effective methods than women with commercial insurance. Overall annual use of most effective methods was 2.3% (in nonexpansion states) or 5.3% (in expansion states), compared with 3.2% in a commercially insured population.54 Even small increases in LARC use, such as we observed in this study, translate into large changes in unintended pregnancy, birth, and abortion rates,23,24 as well as public cost saving in the US.

    Adolescents who receive care in the safety net are at high risk for unintended pregnancy.55 In Medicaid expansion states, CHCs are providing adolescents better access to the most effective contraceptive methods compared with the commercially insured population. The adjusted proportion of provision of the most effective methods among adolescents was between 1.9% (in nonexpansion states) and 5.0% (in expansion states), compared with 2.4% among adolescents with commercial insurance in 2014.54

    Our findings suggest that Medicaid expansion did not replace the influence of Title X in contraceptive care access but did increase access to most effective contraceptive methods for women who did not visit a Title X clinic. Research using clinic-level data has demonstrated that Title X clinics provide better access to LARC methods than non–Title X clinics.22,56-58 Historically, Title X has been the most important payer for contraceptive services for women with low incomes,59 and the exit of Planned Parenthood and individual states from the Title X program34 may intensify the role of non–Title X CHCs as publicly funded contraceptive care providers.60

    Our results must be interpreted in the context of the goal of the OPA and NQF metrics; the intent of these metrics to track barriers to access to contraception. The moderately effective and most effective methods metric is useful to interpret in the context of published rates of use of these methods and estimates of the population at risk of unintended pregnancy. For example, we estimate that 24.3% of our adult sample received a moderately effective or most effective method in 2014. If we apply estimates of sexual activity and those actively seeking pregnancy from the National Survey of Family Growth,61 we calculate that 67.3% of contraceptive needs are met, leaving 32.7% opportunity for improvement. The LARC metric is intended to identify barriers to access, not to reach a threshold or promote use of LARC over other methods61; the National Survey of Family Growth comparisons are thus not used for this metric. We show that LARC use in the CHC population is similar to that of the commercially insured population but identify potential access gaps for women in this group who live in nonexpansion states compared with women with commercial insurance. Finally, this study focuses on 2 measures of access to contraceptive methods; while these are understood as quality metrics, the quality of contraceptive care is more than access to methods.62 New measures under review by the NQF assess the patient experience of care63 and will deepen our ability to assess the quality of contraceptive care across practice settings.

    Limitations

    Our study has limitations. First, the CHC sample may not be generalizable to all patients in CHCs, CHC clinics, or states. However, our objective patient-level data come from the largest national data set on patients who receive care in safety net settings, and the ADVANCE patient population is demographically and clinically similar to the overall CHC population.6 Second, we had incomplete pregnancy outcome data for a subset of our sample; however, our sensitivity analyses found no changes to the main results. Similarly, missing data for covariates could result in bias, but the percentage of records with missing data was low. Third, we may not be able to fully identify women who had undergone sterilization prior to the study period; we looked back in the EHR with data available, but our observed sterilization rate (approximately 5%; Figure 1) is less than that reported in the National Survey of Family Growth.61 Fourth, the OPA and NQF metrics may not completely capture women at risk of unintended pregnancy (eg, they do not include a measure of sexual activity or pregnancy intention); however, the use of standard metrics to measure contraceptive access is an advance over previous studies. For quality metrics to be broadly used, they must be feasible to collect using existing administrative or clinical data.64,65 Finally, additional studies are needed to understand whether gains under Medicaid expansion were sustained past 2016.

    Conclusions

    In conclusion, we found that ACA Medicaid expansion was associated with increased access to the most effective contraceptive methods across the safety net, especially for adolescents. Title X continues to play a vital role in contraceptive access for CHC populations.

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    Article Information

    Accepted for Publication: March 23, 2020.

    Published: June 4, 2020. doi:10.1001/jamanetworkopen.2020.6874

    Correction: This article was corrected on June 25, 2020, to fix incorrect wording in the Key Points.

    Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Darney BG et al. JAMA Network Open.

    Corresponding Author: Blair G. Darney, PhD, MPH, Department of Obstetrics & Gynecology, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Mail Code UHN-50, Portland, OR 97239 (darneyb@ohsu.edu).

    Author Contributions: Dr Darney and Ms Hoopes had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Darney, Hoopes, Rodriguez, Hatch, Templeton, Oakley, Cottrell.

    Acquisition, analysis, or interpretation of data: Darney, Jacob, Hoopes, Hatch, Marino, Templeton.

    Drafting of the manuscript: Darney, Jacob, Hoopes, Rodriguez, Hatch, Oakley.

    Critical revision of the manuscript for important intellectual content: Darney, Hoopes, Rodriguez, Hatch, Marino, Templeton, Oakley, Cottrell.

    Statistical analysis: Darney, Jacob, Hoopes, Marino.

    Obtained funding: Hatch, Marino, Cottrell.

    Administrative, technical, or material support: Jacob, Rodriguez, Hatch, Templeton, Oakley, Cottrell.

    Supervision: Darney, Hatch, Cottrell.

    Conflict of Interest Disclosures: Dr Darney consults for Ipas, a global nonprofit focused on safe abortion, and served as an expert in the Oregon Department of Justice’s litigation on proposed rule changes to Title X. Dr Rodriguez has served as a contraceptive trainer for Merck and the American Congress of Obstetricians and Gynecologists; served on an advisory board for Bayer; served as a consultant for the World Health Organization; and received research funding via her institution from the Laura and John Arnold Foundation/Arnold Ventures, the National Institutes of Health, Merck and the Robert Wood Johnson Foundation on projects for which she is the primary investigator. Ms Hoopes and Dr Cottrell reported grants from Agency for Health Care Research & Quality during the conduct of the study. No other disclosures were reported.

    Funding/Support: The EVERYWOMAN study is funded by the Agency for Healthcare Research and Quality (award 1R01HS025155-01) and conducted with the Accelerating Data Value across a National Community Health Center Network (ADVANCE) Clinical Research Network, a member of the People-Centered Research Foundation Consortium, an initiative of the Patient-Centered Outcomes Research Institute. The ADVANCE network is led by OCHIN Inc in partnership with the Health Choice Network, Fenway Health, Oregon Health and Science University, and the Robert Graham Center/HealthLandscape and funded through the People-Centered Research Foundation (contract number 1237).

    Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    Meeting Presentations: Portions of these findings were presented at the Population Association of America annual meeting; April 27, 2017; Chicago, Illinois.

    Additional Contributions: The authors thank Frances M. Biel, MPH, MS, OCHIN Inc, for her assistance with the revision of this manuscript and Carrie Tillotson, MPH, OCHIN Inc, for her assistance with figure creation. These individuals were compensated for their contributions.

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