摘要：Objectives. We estimated the number of women of reproductive age in need who would gain coverage for contraceptive services after implementation of the Affordable Care Act, the extent to which there would remain a need for publicly funded programs that provide contraceptive services, and how that need would vary on the basis of state Medicaid expansion decisions. Methods. We used nationally representative American Community Survey data (2009), to estimate the insurance status for women in Massachusetts and derived the numbers of adult women at or below 250% of the federal poverty level and adolescents in need of confidential services. We extrapolated findings to simulate the impact of the Affordable Care Act nationally and by state, adjusting for current Medicaid expansion and state Medicaid Family Planning Expansion Programs. Results. The number of low-income women at risk for unintended pregnancy is expected to decrease from 5.2 million in 2009 to 2.5 million in 2016, based on states’ current Medicaid expansion plans. Conclusions. The Affordable Care Act increases women’s insurance coverage and improves access to contraceptive services. However, for women who remain uninsured, publicly funded family planning programs may still be needed. The Patient Protection and Affordable Care Act (ACA) affects the availability of contraceptive and other preventive services for American women. 1 Preliminary evidence shows that insurance coverage expanded considerably since 2014, when the main ACA expansions began. 2,3 In addition, most insurers are now required to cover certain preventive services, including Food and Drug Administration–approved contraception, HIV and sexually transmitted infection (STI) services, breast and cervical cancer screening, and well-woman visits, with no cost sharing. These changes have raised questions about the need for publicly funded safety net programs 4 ; we explored this question with regard to Title X, the federal family planning grant program. The Title X program (of the Public Health Service Act) provides grants for family planning and related preventive health services, including contraception, breast and cervical cancer screening, and HIV and STI services. 5 Title X is designed to prioritize the needs of low-income individuals living at or below 250% of the federal poverty level (FPL), including those who are uninsured or underinsured or who seek confidential services, including adolescents. 5 It also funds personnel training, community education, and research and evaluation to enhance the quality of family planning services. 5 Title X has established a clinical network of approximately 95 grantees that deliver services through more than 4000 service sites nationwide, caring for 5 million clients annually. 6 Agencies can use Title X grants flexibly to support infrastructure, such as salaries and supplies, as well as services for uninsured individuals. The ACA, as modified by a 2012 Supreme Court decision, gives states the option to expand Medicaid coverage to nonelderly adults with incomes below 138% FPL. 7 As of March 2015, 28 states and the District of Columbia have expanded Medicaid, though states may elect to expand or to terminate an expansion at a later time. 8 Some states that are not expanding have adult income criteria as low as 23% FPL (in Alabama), and many do not cover childless adults. 9 Although Title X is a critical source of public funding for family planning, Medicaid has become an increasingly important source of revenue for Title X service sites, accounting for 40% of total revenue in 2013. 10 Title X complements Medicaid, covering costs Medicaid does not cover, such as serving low-income women ineligible for Medicaid, filling gaps between Medicaid reimbursement and actual costs of services, and funding infrastructure (e.g., provider training and community outreach). Another important option to expand family planning coverage exists under Medicaid. States may expand eligibility for family planning services through temporary federal waivers or permanent state plan amendments (SPAs). 11,12 Both family planning waivers and SPAs include coverage of contraceptive services. 11 As of 2014, 30 states extended Medicaid eligibility for family planning services to those who would otherwise be ineligible; 19 states operate under a family planning waiver, whereas 11 states have an SPA for family planning services. 13 Under these waivers and SPAs, family planning eligibility typically ranges from 185% to 250% FPL, well above the ACA levels of 138% FPL. Insurance coverage can increase access to and use of contraceptive services. 14,15 Analyses of the 2006–2010 National Survey of Family Growth found that women with any period without insurance coverage in a year were less likely to have used a family planning service. 16 As more women gain insurance coverage for family planning services, it is important to know the potential implications for Title X clients. After Massachusetts’ 2006 insurance expansions, the state’s extensive network of family planning clinics still found that a large fraction of Title X clients were uninsured. 17,18 Other analyses have found that, after health care reform, the use of safety-net facilities (e.g., community health centers) surged; patients continued to use these facilities even after they gained insurance, and newly insured patients flocked to them, partially because of difficulties accessing care in regular physicians’ offices. 17,19 We sought to determine the extent to which ACA could reduce the number of women of reproductive age who are in need of health care coverage, access to confidential contraceptive services, or both, and affect the need for Title X to address the unmet family planning needs. We focused on women of reproductive age in need, which consisted of the primary target population of Title X, adult women with incomes at or below 250% FPL and female adolescents in need of confidential care. 5 We restricted the target population to women who are “in need” of contraceptive services (i.e., at risk for an unintended pregnancy), defined as those who had ever had sexual intercourse and who were not pregnant, sterile, or seeking pregnancy. We projected the number of low-income women who would need contraceptive services after implementation of health insurance expansions, examined how that need would vary on the basis of state decisions whether to expand Medicaid, and estimated the level of funding that would be needed for Title X to deliver that level of direct services.
