Use of Health Insurance Among Clients Seeking Contraceptive Services at Title X–Funded Facilities in 2016

Abstract

portion of individuals covered by some type of health insurance. Notably, the ACA's contraceptive mandate guarantees coverage of the full range of contraceptive methods and services without cost sharing for the individual. Between 2013 and 2015, the overall proportion of reproductive-aged women who were uninsured declined by 36%; the change has been attributed to increases in both Medicaid and private insurance coverage. 4 During this same period, a similar decrease in the proportion of clients who were uninsured was documented in a small sample of family planning providers across the United States. 5 However, limited evidence exists to describe detailed patterns of insurance coverage among clients seeking reproductive health care since implementation of the ACA. The Family Planning Annual Report, released by the federal Office of Population Affairs, shows that in 2016, some 55% of clients seeking care at Title X-funded facilities were covered by either public or private insurance, but it does not document the extent to which these individuals used their coverage to pay for services. 1 Prior to implementation of the ACA, a key reason for adolescents' not using existing health insurance to cover their services was confidentiality concerns, 6 and these concerns may have become relevant to other age-groups following the ACA, which expanded coverage for young people on their parents' insurance plans up to age 26. A The national network of nearly 4,000 health care centers supported by Title X funding provides access to family planning and related preventive health care to about four million clients annually. 1 The Title X program was created in 1970 to help ensure that regardless of income, women and couples can obtain high-quality contraceptive services and related care, and remains the sole federal grant program dedicated to family planning in the United States. Title X funds are critical to providers' ability to offer free or reduced-cost care to family planning clients who do not have health insurance coverage, or who are unable to use their coverage. Sites supported by Title X funds represent a diverse set of providers, ranging from affiliates of the Planned Parenthood Federation of America, and others that focus on sexual and reproductive health, to health departments and federally qualified health care centers (FQHCs), which provide family planning care as part of a broader range of primary health care services. These sites must meet high standards in the delivery of family planning care, ensuring that services are affordable, comprehensive, nonjudgmental, confidential, voluntary, evidence-based and respectful. 2 The contraceptive services provided by Title X-funded clinics in 2015 helped women avert nearly two million unintended pregnancies. 3 Broad implementation of most of the health insurance reforms of the Affordable Care Act (ACA) in 2014 changed the landscape of health care nationally, increasing the pro-CONTEXT: As federal initiatives aim to fundamentally alter or dismantle the Affordable Care Act (ACA), evidence regarding the use of insurance among clients obtaining contraceptive care at Title X-funded facilities under ACA guidelines is essential to understanding what is at stake. METHODS: A nationally representative sample of 2,911 clients seeking contraceptive care at 43 Title X-funded sites in 2016 completed a survey assessing their characteristics and insurance coverage and use. Chi-square tests for independence with adjustments for the sampling design were conducted to determine differences in insurance coverage and use across demographic characteristics and facility types. RESULTS: Most clients (71%) had some form of public or private health insurance, and most of these (83%) planned to use it to pay for their services. Foreign-born clients were less likely than U.S.-born clients to have coverage (46% vs. 75%) and to use it (78% vs. 85%). Clients with private insurance were less likely than those with public insurance to plan to use their insurance (75% vs. 91%). More than one-quarter of clients not planning to use existing insurance for services indicated that the reason was that someone might find out.