The impact of the Affordable Care Act contraceptive mandate on fertility and abortion rates
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Background: There are a variety of public health and social welfare motivations to reduce unintended pregnancies. Despite efforts to address this issue, approximately 45 percent of US pregnancies are unintended. The Affordable Care Act (ACA) contraceptive mandate increased the availability of prescription contraceptives and reduced copayments starting in August 2012. Previously, 30 states had mandates requiring contraceptive coverage but without price reductions comparable to the ACA. Current literature has not determined the effect of the ACA contraceptive mandate on fertility and abortion rates. Methods: Fixed effects models were used to estimate the impact of the ACA contraceptive mandate on fertility and abortion rates, utilizing NCHS public-use Birth Files from 2007-2017 and CDC Abortion Surveillance Reports from 2008-2015. Models included variables to test the effect of state-specific mandates alone and interacted with the ACA. The fertility and abortion analyses included 50 and 15 regression subpopulations, respectively, allowing modeling by age group, race/ethnicity, or combined. Tests were run for model specification and robustness. Results: The best fit fertility model estimated a decrease of 4.277 births/1,000 women (95% CI [-6.86, -0.22]) with an additional decrease in fertility of 0.844 births/1,000 women (95% CI [-1.20, -0.49]) in states with mandates, equivalent to a 6.8 and 8.1 percent decrease from the 2012 fertility rates, respectively. This translates to an estimated 299,179 births averted annually. Twenty-nine of the 50 subpopulations also estimated a statistically significant decrease in fertility. The final abortion model estimated a decrease of 4.677 abortions/1,000 women (95% CI [-6.055, -3.299]) and an additional decrease of 0.877 abortions/1,000 women (95% CI [-1.347, -0.406]) for states with mandates. This estimated decrease represents a 37.1 and 44.1 percent reduction from the mean 2012 abortion rate and translates to roughly 325,219 averted abortions annually. Fourteen of the fifteen regression subpopulations estimated a statistically significant decrease in abortion rates. Conclusion: The ACA contraceptive mandate decreased fertility and abortion rates for nearly all subpopulations in the analysis, with greater effects for younger and minority populations. Future federal, state, or insurance company policy should ensure free access to prescription contraceptives to improve health outcomes and reduce unintended pregnancy.