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Commentary| Volume 25, ISSUE 6, P612-615, November 2015

Policy Barriers to Best Practices: The Impact of Restrictive State Regulations on Access to Long-acting Reversible Contraceptives

DOI:https://doi.org/10.1016/j.whi.2015.09.001
Policy Barriers to Best Practices: The Impact of Restrictive State Regulations on Access to Long-acting Reversible Contraceptives
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      Scientific evidence supports long-acting reversible contraceptive (LARC) methods for first-line use as birth control. Studies have shown that LARC methods, which include the intrauterine device (IUD) and subdermal implant, are highly effective, very safe, preferable to women, and cost effective. Despite these data, low rates of LARC use persist in the United States; LARCs were selected by 8.5% of all birth control users, and 4.5% of teens in 2014 (

      Guttmacher Institute. (2014). Fact sheet: Publicly funded family planning services in the United States. Available: www.guttmacher.org/pubs/fb_contraceptive_serv.pdf. Accessed August 24, 2015.

      ). A prescription contraceptive method is chosen by a woman with her health care provider. This choice is shaped by the knowledge and beliefs of these two parties and by the policy environment in which this decision is made (
      • Bird C.E.
      • Rieker P.P.
      Gender and health: The effects of constrained choices and social policies.
      Cambridge University Press, New York2008
      ). State contraceptive policies do not consistently support LARC use, and can create both direct and indirect barriers to the use of these most effective contraceptive methods. We consider three types of state policies affecting LARC use—those impacting insurance coverage, those regulating which providers can initiate these methods and where, and those affecting LARC eligibility in special populations. Illustrative examples of each are provided. Addressing these policy barriers to LARC initiation will encourage the uptake of more reliable contraception.

      The Evidence for LARC Methods

      Four U.S. Food and Drug Administration (FDA)–approved LARC methods are currently available in the United States: three types of IUDs and one subdermal implant. These devices effectively prevent pregnancy for 3 to 10 years, depending on the type, and their contraceptive effects are completely and rapidly reversible upon removal. In contrast to estrogen-containing birth control methods, there are few medical contraindications to LARC use (
      • Stoddard A.
      • McNicholas C.
      • Peipert J.F.
      Efficacy and safety of long-acting reversible contraception.
      Drugs. 2011; 71: 969-980
      ). IUDs and implants have been shown to be safe in virtually all patient populations (
      Centers for Disease Control and Prevention (CDC)
      United States medical eligibility criteria for contraceptive use.
      MMWR Recommended Reports. 2010; 59: 1-86
      ).
      Effectiveness is a LARC's principal advantage. A contraceptive's “perfect use” failure rate refers to the probability of pregnancy with consistent and correct use while its “typical use” failure rate accounts for user error. For example, male condoms are 98% effective in preventing pregnancy with perfect use, but can be as little as 18% effective with typical use. LARC methods have typical—and perfect—use failure rates of less than 1% (

      Guttmacher Institute. (2015d). Fact sheet: Contraceptive use in the United States. Available: www.guttmacher.org/pubs/fb_contr_use.pdf. Accessed August 24, 2015.

      ). LARC methods differ from, and are more effective than, other forms of birth control in part because they are “user independent”; once a health care provider inserts a LARC, no further user adherence, visits or refills are required (
      American College of Obstetricians and Gynecologists (ACOG)
      ACOG Committee Opinion #450, increasing use of contraceptive implants and intrauterine devices to reduce unintended pregnancy.
      Author, Washington, DC2011
      ). Many studies have also shown LARC methods to have the highest rates of user satisfaction and continuation across women of all ages (

      Salganicoff A., Ranji U., Beamesderfer A., & Kurani N. (2014). Women and health care in the early years of the ACA: Key findings from the 2013 Kaiser Women's Health Survey. Available: https://kaiserfamilyfoundation.files.wordpress.com/2014/05/8590-women-andhealth-care-in-the-early-years-of-the-affordable-care-act.pdf. Accessed August 24, 2015.

      ).
      LARCs are highly cost effective at the population level. A cost model using 2013 data estimated that if just 10% of U.S. women 20 to 29 years of age switched from oral contraceptive pills to LARC methods, health care costs associated with unintended pregnancy could be reduced by $288 million annually (
      • Trussell J.
      • Henry N.
      • Hassan F.
      • Prezioso A.
      • Law A.
      • Filonenko A.
      Burden of unintended pregnancy in the United States: Potential savings with increased use of long-acting reversible contraception.
      Contraception. 2013; 87: 154-161
      ). A 2009 cost–benefit analysis estimated that each dollar spent on LARC methods yields a $5 return on investment in public insurance expenditures for unintended births (
      • Foster D.G.
      • Biggs M.A.
      • Malvin J.
      • Bradsberry M.
      • Darney P.
      • Brindis C.D.
      Cost-savings from the provision of specific contraceptive methods in 2009.
      Women's Health Issues. 2013; 23: e265-e271
      ).

      Policies Impacting LARC Coverage and Payment

      Patient contraceptive selection is sensitive to copayment. A 2010 analysis confirmed that employer-based plans display significant variation in copayments by contraceptive method, with LARC methods being the most expensive in terms of upfront costs to patients (
      • Pace L.E.
      • Dusetzina S.B.
      • Fendrick A.M.
      • Keating N.L.
      • Dalton V.K.
      The impact of out-of-pocket costs on the use of intrauterine contraception among women with employer-sponsored insurance.
      Medical Care. 2013; 51: 959-963
      ). The Medicaid program has always required that family planning services be fully covered for patients without cost sharing (
      • Dusetzina S.B.
      • Dalton V.K.
      • Chernew M.E.
      • Pace L.E.
      • Bowden G.
      • Fendrick A.M.
      Cost of contraceptive methods to privately insured women in the United States.
      Women’s Health Issues. 2013; 23: e69-71
      ). The Patient Protection and Affordable Care Act (ACA) similarly required new private health plans to provide no-cost coverage for all FDA-approved contraceptives (

      National Women's Law Center. (2015). Fact sheet: Contraceptive coverage in the health care law: Frequently asked questions. Available: www.nwlc.org/sites/default/files/pdfs/contraceptive_coverage_in_the_healh_care_law_frequently_asked_questions.pdfv3_.pdf. Accessed August 24, 2015.

      ).
      Despite ACA stipulations, cost sharing for contraception is still in place. A 2013 survey of Medicaid managed care members revealed that one-fifth of women with public insurance reported paying some amount out of pocket for contraceptives (
      • Sonfield A.
      Making Medicaid managed care work for family planning coverage and services.
      Guttmacher Policy Review. 2015; 18: 8-13
      ). Cost sharing is being implemented by new ACA insurance plans under the guise of “reasonable medical management” controls on prescribing (

      78 Fed. Reg. 39, 873 (July 2, 2013).

      ,

      Salganicoff A., Ranji U., Beamesderfer A., & Kurani N. (2014). Women and health care in the early years of the ACA: Key findings from the 2013 Kaiser Women's Health Survey. Available: https://kaiserfamilyfoundation.files.wordpress.com/2014/05/8590-women-andhealth-care-in-the-early-years-of-the-affordable-care-act.pdf. Accessed August 24, 2015.

      ) These management practices include categorizing contraceptive drugs or devices into tiers by cost, requiring prior authorization, placing limits on available quantities of drugs or devices, and allowing copayments where generics are unavailable (as with IUDs and implants). These policies run counter to federal regulations, and shift contraceptive costs from plans to patients. In response, California enacted a state policy (The Contraceptive Coverage Equity Act) ensuring that the total costs of all birth control methods would be fully covered (
      • Moy A.
      • Mossburg K.
      SB 1053-The Contraceptive Coverage Equity Act of 2014.
      California Family Health Council and the National Health Law Program, Los Angeles2014
      ). In May 2015, the U.S. Department of Health and Human Services issued a statement reiterating that FDA-approved contraceptive methods were to be covered without cost sharing in ACA plans, and that reasonable medical management processes had to be transparent and efficient (

      Department of Health and Human Services (HHS). (2015). FAQs about affordable care act implementation (part XXVI). Available: https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/aca_implementation_faqs26.pdf. Accessed August 24, 2015.

      ). The impact of this clarification of federal policy on state insurance plan practices remains to be seen.
      State policies also impact access to LARC methods by allowing plans to “opt out” of covering contraceptives. The ACA provided a “religious exemption” from contraceptive coverage for a narrowly defined group of religious entities (

      78 Fed. Reg. 39, 873 (July 2, 2013).

      ). By design, these criteria did not exempt religiously affiliated universities, hospitals, or corporations from having to provide insurance plans covering contraceptives. The backlash to these stipulations led—via litigation such as Burwell v. Hobby Lobby, Inc.—to a “special case accommodation” for “non-exempt employers with religious objections.” These employers were given a year's “safe haven” to work with stakeholders to determine contraceptive coverage in each state (
      • VanSickle-Ward R.
      • Hollis-Brusky A.
      An (un)clear conscience clause: The causes and consequences of statutory ambiguity in state contraceptive mandates.
      Journal of Health Politics, Policy, and Law. 2013; 38: 683-708
      ). In this way, control over religious exemption policies for contraceptive coverage has been devolved to individual states. Policies in California and New York, for example, mirror the narrow criteria for religious exemption outlined in the original ACA language (

      Guttmacher Institute. (2015b). State policies in brief: Insurance coverage of contraceptives. Available: www.guttmacher.org/statecenter/spibs/spib_ICC.pdf. Accessed August 24, 2015.

      ). In contrast, Florida and Texas have no official policies on exemption, making it easier to refuse coverage on religious grounds (

      Florida Statutes. § 381.0051 (2015).

      ,

      Texas Insurance Codes § 1369.108.

      )

      Policies Affecting LARC Initiation

      LARC methods can be easily initiated by a physician, nurse, or allied health professional in the outpatient setting. However, inadequate mechanisms of reimbursement for inpatient LARC insertion are a significant barrier to accessing LARC methods during hospitalization. Immediate postpartum LARC initiation (i.e., IUD placement immediately after a vaginal or cesarean delivery, or implant placement before discharge) is supported by clinical practice guidelines for preventing rapid repeat unintended pregnancy (

      Health Management Associates. (2013). Medicaid reimbursement for post-partum LARC. Available: https://www.acog.org/∼/media/Departments/LARC/HMAPostpartumReimbursmtResource.pdf. Accessed August 24, 2015.

      ). Women may be highly motivated to initiate contraception immediately postpartum. Even among women interested in LARC methods after delivery, delaying insertion until a separate postpartum visit can be a significant obstacle to timely LARC use (
      • Zerden M.L.
      • Tang J.H.
      • Stuart G.S.
      • Norton D.R.
      • Verbiest S.B.
      • Brody S.
      Barriers to receiving long-acting reversible contraception in the postpartum period.
      Women's Health Issues. 2015; (Advance online publication. http://dx.doi.org/10.1016/j.whi.2015.06.004)
      ). Surveys of Medicaid patients demonstrate that only about one-half of postpartum women who request an IUD actually obtain one after delivery; immediate postpartum insertion could address this gap in care (
      • Rodriguez M.I.
      • Evans M.
      • Espey E.
      Advocating for immediate postpartum LARC: Increasing access, improving outcomes, and decreasing cost.
      Contraception. 2014; 90: 468-471
      ). New York has adopted guidelines to allow providers to bill for the initiation of an IUD or implant immediately after delivery (

      American College of Obstetricians and Gynecologists (ACOG). (2014). Medicaid reimbursement for postpartum LARC by state. Available: www.acog.org/About-ACOG/ACOG-Departments/Long-Acting-Reversible-Contraception/Coding-and-Reimbursement-for-LARC/Reimbursement-Resources-for-Postpartum-LARC-Initiation/Medicaid-Reimbursement-for-Postpartum-LARC-By-State. Accessed August 24, 2015.

      ). Similar policies expanding Medicaid delivery-related care bundles to include inpatient LARC initiation are now being considered in other states (

      Association of State and Territorial Health Officials (ASTHO). (2014). Long acting reversible contraception (LARC) learning community launch report. Available: www.astho.org/Programs/Maternal-and-ChildHealth/Long-Acting-Reversible-Contraception-LARC/. Accessed August 24, 2015.

      ).
      State policies also influence which providers can serve women seeking contraceptive services—including LARC methods. Several states have attempted to exclude providers who perform abortions from participating in Medicaid altogether, although these exclusions run counter to federal law (
      • Sonfield A.
      Making Medicaid managed care work for family planning coverage and services.
      Guttmacher Policy Review. 2015; 18: 8-13
      ). Texas enacted such a ban in 2012, cutting Medicaid funding to community health centers and many Planned Parenthood affiliates. Consequentially, 30% fewer women are now served by publicly funded family planning sites in that state (

      National Abortion and Reproductive Rights Action League (NARAL). (2015). Fact sheet: Affiliation bans would devastate states’ family-planning systems. Available: www.prochoiceamerica.org/media/fact-sheets/abortionbirthcontrol-family-planning-state-government-affiliation-bans.pdf. Accessed August 24, 2015.

      ). These policies decrease access points for women seeking LARC and other contraceptive methods.

      LARC Access in Vulnerable Populations: Minors and Women Living in the United States without Legal Permission

      In 2012, 42% of U.S. adolescents reported engaging in intercourse; teens contribute disproportionately to the United States unintended pregnancy rate (

      Guttmacher Institute. (2015a). Fact sheet: Unintended pregnancy in the United States. Available: www.guttmacher.org/pubs/FBUnintendedPregnancy-US.pdf. Accessed August 24, 2015.

      ). Sexually active adolescents who use contraception are more likely than adults to select contraceptive methods with high typical use failure rates such as withdrawal, condoms and birth control pills. (
      American College of Obstetricians and Gynecologists (ACOG)
      ACOG Committee Opinion #539, adolescents and long-acting reversible contraception: implants and intrauterine devices.
      Author, Washington, DC2012
      ). However, adolescents who receive comprehensive counseling and face no cost barriers preferentially select LARC methods and continue to use them long-term (
      • Mestad R.
      • Secura G.
      • Allsworth J.E.
      • Madden T.
      • Zhao Q.
      • Peipert J.F.
      Acceptance of long-acting reversible contraceptive methods by adolescent participants in the Contraceptive CHOICE Project.
      Contraception. 2011; 84: 493-498
      ). A no-cost contraceptive program in Colorado demonstrated an impressive 29% decrease in teen pregnancies among LARC users compared with those relying on other methods (
      • Ricketts S.
      • Klingler G.
      • Schwalberg R.
      Game change in Colorado: Widespread use of long-acting reversible contraceptives and rapid decline in births among young, low-income women.
      Perspectives on Sexual and Reproductive Health. 2014; 46: 125-132
      ).
      Contraceptive choice among adolescents is particularly sensitive to the availability of confidential reproductive health services for minors. Title X of the 1970 Public Health Service Act provides funds to support contraceptive access for low-income Americans, with a mandate for confidential services for all patients served by these funds, including minors. (

      Office of Population Affairs. (2014). Program requirements for Title X Funded family planning projects. Available: www.hhs.gov/opa/pdfs/ogccleared-final-april.pdf. Accessed August 24, 2015.

      ). Unsurprisingly, a state's acceptance of Title X funds has been linked to improved contraceptive access amongst its adolescents (
      • Mead K.H.
      • Beeson T.
      • Wood S.F.
      • Goldberg D.G.
      • Shin P.
      • Rosenbaum S.
      The role of federally qualified health centers in delivering family planning services to adolescents.
      Journal of Adolescent Health. 2015; 57: 87-93
      ). However, with only 95 grantees nationally, the reach of Title X is insufficient to overcome restrictions on minors across all states. No federal law explicitly protects the rights of minors to receive contraception without parental notification—this has been left up to the states to decide. To date, 21 states and the District of Columbia have enacted legislation identifying which minors may receive confidential contraceptive services. For example, whereas California state law explicitly allows minors to consent for contraceptives, a minor in Illinois may only do so if she is married, a parent, has been previously pregnant, or if pregnancy would pose a “health hazard” (

      Guttmacher Institute. (2015c). State policies in brief: Minors' access to contraceptive services. Available: www.guttmacher.org/statecenter/spibs/spib_MACS.pdf. Accessed August 24, 2015.

      ). Advocates of parental notification argue that it may deter or delay sexual activity among adolescents, but research has not borne this out. The literature in this area shows no clear association between parental notification and safer sex practices; such regulations seem instead to inhibit the use of effective birth control methods (
      • Jones R.K.
      • Boonstra H.
      Confidential reproductive health services for minors: the potential impact of mandated parental involvement for contraception.
      Perspectives on Sexual and Reproductive Health. 2004; 36: 182-191
      ).
      Women living in the United States without legal permission comprise a second vulnerable population whose access to LARC methods has been restricted by state policies, albeit less directly. In the United States, 60% of low-income, non-citizen immigrant women are uninsured—twice the rate of their U.S.-born counterparts (

      Planned Parenthood Action Fund. Immigration reform. (2015). Available: www.plannedparenthoodaction.org/issues/immigration-reform/. Accessed August 24, 2015.

      ). The ACA did not extend coverage to immigrants who are in the United States illegally. Women who fall into this category do not qualify for coverage for birth control under Medicaid expansions, nor can they purchase insurance through state or federal marketplaces. (
      • Hasstedt K.
      Toward equity and access: Removing legal barriers to health insurance coverage for immigrants.
      Guttmacher Policy Review. 2013; 16: 2-8
      ,

      Henry J. Kaiser Family Foundation. (2015). State profiles: How will the uninsured fare under the Affordable Care Act? Available: http://kff.org/stateprofilesuninsured-under-aca/. Accessed August 24, 2015.

      ). A few states have developed solutions to provide contraceptives to immigrant women regardless of legal status. For example, the Family Planning Access, Care and Treatment (Family PACT) program covers all FDA-approved contraceptives for Californians living at or below 200% of the federal poverty level, regardless of immigration status (

      University of California, San Francisco Bixby Center for Global Reproductive Health, California Department of Public Health, & California Department of Health Care Services–Office of Family Planning. (2012). Fact sheet on Family PACT: An overview. Available: www.familypact.org/Providers/Factsheets/AccessToFamilyPlanningServics_ADA.pdf. Accessed August 24, 2015.

      ). Family PACT's broad eligibility criteria purposely make family planning services available to all Californians at risk of unintended pregnancy. This program can serve as a model for other states seeking to expand services to immigrant women within the current federal constraints.

      Conclusion

      Existing policies create direct and indirect barriers to LARC use; eliminating these barriers can increase women's access to and use of effective contraception. Promoting the use of LARC methods has emerged as a “best practice” in reproductive health, yet this practice is not supported by some states' contraceptive policies. Quantitative studies can provide insight into the links between specific policy approaches to LARC access, reproductive health outcomes, and potential cost savings. Such research can inform evidence-based policies and further improve access to reliable contraception.

      References

        • American College of Obstetricians and Gynecologists (ACOG)
        ACOG Committee Opinion #450, increasing use of contraceptive implants and intrauterine devices to reduce unintended pregnancy.
        Author, Washington, DC2011
        View in Article
        • American College of Obstetricians and Gynecologists (ACOG)
        ACOG Committee Opinion #539, adolescents and long-acting reversible contraception: implants and intrauterine devices.
        Author, Washington, DC2012
        View in Article

      3. American College of Obstetricians and Gynecologists (ACOG). (2014). Medicaid reimbursement for postpartum LARC by state. Available: www.acog.org/About-ACOG/ACOG-Departments/Long-Acting-Reversible-Contraception/Coding-and-Reimbursement-for-LARC/Reimbursement-Resources-for-Postpartum-LARC-Initiation/Medicaid-Reimbursement-for-Postpartum-LARC-By-State. Accessed August 24, 2015.

        View in Article

      4. Association of State and Territorial Health Officials (ASTHO). (2014). Long acting reversible contraception (LARC) learning community launch report. Available: www.astho.org/Programs/Maternal-and-ChildHealth/Long-Acting-Reversible-Contraception-LARC/. Accessed August 24, 2015.

        View in Article
        • Centers for Disease Control and Prevention (CDC)
        United States medical eligibility criteria for contraceptive use.
        MMWR Recommended Reports. 2010; 59: 1-86
        View in Article
        • Bird C.E.
        • Rieker P.P.
        Gender and health: The effects of constrained choices and social policies.
        Cambridge University Press, New York2008
        View in Article

      7. Department of Health and Human Services (HHS). (2015). FAQs about affordable care act implementation (part XXVI). Available: https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/aca_implementation_faqs26.pdf. Accessed August 24, 2015.

        View in Article
        • Dusetzina S.B.
        • Dalton V.K.
        • Chernew M.E.
        • Pace L.E.
        • Bowden G.
        • Fendrick A.M.
        Cost of contraceptive methods to privately insured women in the United States.
        Women’s Health Issues. 2013; 23: e69-71
        View in Article

      9. 78 Fed. Reg. 39, 873 (July 2, 2013).

        View in Article

      10. Florida Statutes. § 381.0051 (2015).

        View in Article
        • Foster D.G.
        • Biggs M.A.
        • Malvin J.
        • Bradsberry M.
        • Darney P.
        • Brindis C.D.
        Cost-savings from the provision of specific contraceptive methods in 2009.
        Women's Health Issues. 2013; 23: e265-e271
        View in Article

      12. Guttmacher Institute. (2014). Fact sheet: Publicly funded family planning services in the United States. Available: www.guttmacher.org/pubs/fb_contraceptive_serv.pdf. Accessed August 24, 2015.

        View in Article

      13. Guttmacher Institute. (2015a). Fact sheet: Unintended pregnancy in the United States. Available: www.guttmacher.org/pubs/FBUnintendedPregnancy-US.pdf. Accessed August 24, 2015.

        View in Article

      14. Guttmacher Institute. (2015b). State policies in brief: Insurance coverage of contraceptives. Available: www.guttmacher.org/statecenter/spibs/spib_ICC.pdf. Accessed August 24, 2015.

        View in Article

      15. Guttmacher Institute. (2015c). State policies in brief: Minors' access to contraceptive services. Available: www.guttmacher.org/statecenter/spibs/spib_MACS.pdf. Accessed August 24, 2015.

        View in Article

      16. Guttmacher Institute. (2015d). Fact sheet: Contraceptive use in the United States. Available: www.guttmacher.org/pubs/fb_contr_use.pdf. Accessed August 24, 2015.

        View in Article
        • Hasstedt K.
        Toward equity and access: Removing legal barriers to health insurance coverage for immigrants.
        Guttmacher Policy Review. 2013; 16: 2-8
        View in Article

      18. Health Management Associates. (2013). Medicaid reimbursement for post-partum LARC. Available: https://www.acog.org/∼/media/Departments/LARC/HMAPostpartumReimbursmtResource.pdf. Accessed August 24, 2015.

        View in Article

      19. Henry J. Kaiser Family Foundation. (2015). State profiles: How will the uninsured fare under the Affordable Care Act? Available: http://kff.org/stateprofilesuninsured-under-aca/. Accessed August 24, 2015.

        View in Article
        • Jones R.K.
        • Boonstra H.
        Confidential reproductive health services for minors: the potential impact of mandated parental involvement for contraception.
        Perspectives on Sexual and Reproductive Health. 2004; 36: 182-191
        View in Article
        • Mead K.H.
        • Beeson T.
        • Wood S.F.
        • Goldberg D.G.
        • Shin P.
        • Rosenbaum S.
        The role of federally qualified health centers in delivering family planning services to adolescents.
        Journal of Adolescent Health. 2015; 57: 87-93
        View in Article
        • Mestad R.
        • Secura G.
        • Allsworth J.E.
        • Madden T.
        • Zhao Q.
        • Peipert J.F.
        Acceptance of long-acting reversible contraceptive methods by adolescent participants in the Contraceptive CHOICE Project.
        Contraception. 2011; 84: 493-498
        View in Article
        • Moy A.
        • Mossburg K.
        SB 1053-The Contraceptive Coverage Equity Act of 2014.
        California Family Health Council and the National Health Law Program, Los Angeles2014 (Available:http://cfhc.org/sites/default/files/sb1053-contraceptivecoverageequity-fact-sheet.pdf. Accessed August 24, 2015.)
        View in Article

      24. National Abortion and Reproductive Rights Action League (NARAL). (2015). Fact sheet: Affiliation bans would devastate states’ family-planning systems. Available: www.prochoiceamerica.org/media/fact-sheets/abortionbirthcontrol-family-planning-state-government-affiliation-bans.pdf. Accessed August 24, 2015.

        View in Article

      25. National Women's Law Center. (2015). Fact sheet: Contraceptive coverage in the health care law: Frequently asked questions. Available: www.nwlc.org/sites/default/files/pdfs/contraceptive_coverage_in_the_healh_care_law_frequently_asked_questions.pdfv3_.pdf. Accessed August 24, 2015.

        View in Article

      26. Office of Population Affairs. (2014). Program requirements for Title X Funded family planning projects. Available: www.hhs.gov/opa/pdfs/ogccleared-final-april.pdf. Accessed August 24, 2015.

        View in Article
        • Pace L.E.
        • Dusetzina S.B.
        • Fendrick A.M.
        • Keating N.L.
        • Dalton V.K.
        The impact of out-of-pocket costs on the use of intrauterine contraception among women with employer-sponsored insurance.
        Medical Care. 2013; 51: 959-963
        View in Article

      28. Planned Parenthood Action Fund. Immigration reform. (2015). Available: www.plannedparenthoodaction.org/issues/immigration-reform/. Accessed August 24, 2015.

        View in Article
        • Ricketts S.
        • Klingler G.
        • Schwalberg R.
        Game change in Colorado: Widespread use of long-acting reversible contraceptives and rapid decline in births among young, low-income women.
        Perspectives on Sexual and Reproductive Health. 2014; 46: 125-132
        View in Article
        • Rodriguez M.I.
        • Evans M.
        • Espey E.
        Advocating for immediate postpartum LARC: Increasing access, improving outcomes, and decreasing cost.
        Contraception. 2014; 90: 468-471
        View in Article

      31. Salganicoff A., Ranji U., Beamesderfer A., & Kurani N. (2014). Women and health care in the early years of the ACA: Key findings from the 2013 Kaiser Women's Health Survey. Available: https://kaiserfamilyfoundation.files.wordpress.com/2014/05/8590-women-andhealth-care-in-the-early-years-of-the-affordable-care-act.pdf. Accessed August 24, 2015.

        View in Article
        • Sonfield A.
        Making Medicaid managed care work for family planning coverage and services.
        Guttmacher Policy Review. 2015; 18: 8-13
        View in Article
        • Stoddard A.
        • McNicholas C.
        • Peipert J.F.
        Efficacy and safety of long-acting reversible contraception.
        Drugs. 2011; 71: 969-980
        View in Article

      34. Texas Insurance Codes § 1369.108.

        View in Article
        • Trussell J.
        • Henry N.
        • Hassan F.
        • Prezioso A.
        • Law A.
        • Filonenko A.
        Burden of unintended pregnancy in the United States: Potential savings with increased use of long-acting reversible contraception.
        Contraception. 2013; 87: 154-161
        View in Article

      36. University of California, San Francisco Bixby Center for Global Reproductive Health, California Department of Public Health, & California Department of Health Care Services–Office of Family Planning. (2012). Fact sheet on Family PACT: An overview. Available: www.familypact.org/Providers/Factsheets/AccessToFamilyPlanningServics_ADA.pdf. Accessed August 24, 2015.

        View in Article
        • VanSickle-Ward R.
        • Hollis-Brusky A.
        An (un)clear conscience clause: The causes and consequences of statutory ambiguity in state contraceptive mandates.
        Journal of Health Politics, Policy, and Law. 2013; 38: 683-708
        View in Article
        • Zerden M.L.
        • Tang J.H.
        • Stuart G.S.
        • Norton D.R.
        • Verbiest S.B.
        • Brody S.
        Barriers to receiving long-acting reversible contraception in the postpartum period.
        Women's Health Issues. 2015; (Advance online publication. http://dx.doi.org/10.1016/j.whi.2015.06.004)
        View in Article

      Biography

      Priya Batra, MD, MS, is an obstetrician/gynecologist and health services researcher in the Robert Wood Johnson Foundation Clinical Scholars Program at the University of California, Los Angeles. Her research focuses on public policy that impacts women's health care delivery.

      Biography

      Chloe E. Bird, PhD, is Senior Sociologist at RAND and Professor at Pardee RAND Graduate School. Her recent research focuses on women's health and addressing gender gaps in health and heath care. She is Editor-in-Chief of Women's Health Issues.

      Article info

      Publication history

      Accepted: September 2, 2015
      Received in revised form: August 26, 2015
      Received: August 5, 2015

      Footnotes

      Funding Statement: Dr. Batra's time is funded by the Robert Wood Johnson Foundation (Clinical Scholars Program, grant number 71897).

      Identification

      DOI: https://doi.org/10.1016/j.whi.2015.09.001

      Copyright

      © 2015 Jacobs Institute of Women's Health. Published by Elsevier Inc. All rights reserved.

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