Medicaid Expansion and Contraceptive Use Among Female High-School Students

Abstract

Introduction: Access to effective contraception prevents unintended pregnancies among sexually active female youth. Potentially impacted by the Affordable Care Act's Medicaid-related policies, contraception use increased among sexually active high-school students from 2013 to 2019.

Methods: Analyses conducted in 2021 assessed state-level Youth Risk Behavior Survey data among female students in grades 9-12 who reported being sexually active. States that expanded Medicaid were compared with other states in 2013 (baseline) and 2019 (after expansion). Measured outcomes included self-reported use of moderately effective or highly effective, long-acting reversible contraception at last sex. Long-acting reversible contraception included intrauterine devices and implants. Moderately effective contraception included birth control pills, injectables, patches, or rings. Results were weighted and adjusted for age and race/ethnicity.

Results: Students in Medicaid expansion states (n=27,564) did not differ significantly from those in nonexpansion states (n=6,048) at baseline or after expansion with respect to age, age at first sex, or the number of sexual partners in the past 3 months; however, race/ethnicity population characteristics changed over time. Postexpansion increased use of intrauterine devices/implants was greater in Medicaid expansion states than in nonexpansion states (238.1% increase vs 120.0% increase, adjusted p=0.047). For those aged 16-17 years, Medicaid expansion states had a 283.3% increase in intrauterine device/implant use compared with an increase of 69.7% in nonexpansion states (adjusted p=0.004).

Conclusions: Medicaid expansion was associated with a greater population-level increase in intrauterine device/implant use among sexually active female high-school students aged 16-17 years. These findings point to the possibility that the Affordable Care Act's Medicaid-related policies played a role in young women's use of intrauterine devices/implants.

Figure 1.

Changes in the use of different types of highly or moderately effective contraception^a by Medicaid expansion status.^b Note: Change from 2013 to 2019 include the following: +238.1% in expansion states and +120.0% in nonexpansion states for intrauterine devices or implants; +7.8% in expansion states and +24.4% in nonexpansion states for birth-control pills; and −32.9% in expansion states and −42.7% in nonexpansion states for injectable, patch, or ring. Expansion states (18) included Arkansas, Arizona, Connecticut, Washington, District of Columbia, Hawaii, Illinois, Kentucky, Massachusetts, Maryland, Michigan, New Hampshire, New Jersey, New Mexico, Nevada, New York, Ohio, Rhode Island, and West Virginia. Nonexpansion states (11) included Alabama, Florida, Kansas, Missouri, Mississippi, Nebraska, Oklahoma, South Carolina, South Dakota, Texas, and Wisconsin. ^aUsed before last sex among female high-school students who had sex in the 3 months before the survey. ^bExcluding states that did not have data available in both 2013 and 2019. ^cSignificant difference between 2013 and 2019 after adjusting for age and race (p<0.05). ^dChange significantly different between expansion and nonexpansion states after adjusting for age and race (p<0.05).