Analyzing the impact of state level contraception mandates on public health outcomes.

AuthorNew, Michael J.

ABSTRACT

The recent mandate by the U.S. Department of Health and Human Services requiring private health insurance plans to cover all FDA-approved contraceptive drugs has generated a considerable amount of controversy. Much of the commentary and analysis has discussed whether this mandate violates the conscience rights of religious employers; however, there has been considerably less discussion as to whether these contraception mandates offer any significant public health benefit. Since the late 1990s, approximately thirty states have required that privately bought health insurance plans cover contraception. A time series cross-sectional analysis of state level public health data offers important insights as to what impact these contraceptive mandates have on public health outcomes. Results indicate that state contraception mandates have little impact on either unintended pregnancy rates or abortion rates.

INTRODUCTION

Contraception has become a prominent political issue in recent years. Since 2010, abortion opponents have successfully stopped several states from funding Planned Parenthood.

In response, during the 2012 election cycle, various media outlets, President Obama, and other Democratic political candidates argued that Republican efforts to stop federal funding for Planned Parenthood would limit the availability of contraceptives and amount to a "War on Women." (1) Also, in February 2012, the Department of Health and Human Services (HHS) required that private health insurance plans cover all FDA-approved contraceptive drugs by August of 2012. (2)

After the Health and Human Services mandate was handed down, much of the subsequent public debate centered on whether religious groups or employers with strong religious beliefs could be exempted from the contraception mandate. The original HHS mandate did include a religious exemption; however, many felt the exemption was too narrow because it only applied to religious institutions that served those of the same religion. (3) For instance, a Catholic school that enrolled a non-trivial percentage of non- Catholic students would likely be ineligible for an exemption. (4)

Religious institutions filed a number of lawsuits arguing that the HHS contraception mandate violated their conscience rights. (5) Many specifically objected to the fact that the HHS mandate required employers to cover contraceptives, which work as abortifacients. (6) Plaintiffs included a range of religious groups and employers including Notre Dame University, Little Sisters of the Poor, and Priests for Life. (7) On June 30, 2014, in Burwell v. Hobby Lobby Stores, Inc., the Supreme Court struck down the HHS mandate as applied to closely held corporations with religious objections. (8) As such, Hobby Lobby would not be compelled to provide contraception under their healthcare plans. The ruling was reached on statutory grounds, citing the Religious Freedom Restoration Act, because the mandate was not the "least restrictive" method of implementing the government's interest. (9) Other litigation is still pending. (10)

The debates about exemptions for employers with religious convictions have certainly been interesting and informative. That said, there has been relatively little public discussion about the public policy implications of the 2012 HHS mandate. Specifically, there has been little research as to whether contraception mandates have positive implications for public health. As such, new research on this area has the ability to usefully inform ongoing public policy debates about not only the HHS mandate, but also contraception policies in general.

Between 1995 and 2010, twenty-eight states instituted mandates requiring that privately sold health insurance plans cover various forms of contraception. (11) These mandates differ from state to state. Some states require that all health insurance plans cover contraceptives. (12) Other states only require those plans which cover pharmaceuticals and/or outpatient services to cover contraceptives. (13) Overall, the states that have implemented some kind of contraceptive mandate tend to be ideologically and demographically diverse. Additionally, a range of public health data from these states is publicly available. (14) As such, an analysis of both unintended pregnancy rates and abortion rates in these states should lend important insights as to whether or not contraception mandates offer any public health benefit.

In Section I, therefore, I will provide a literature review on the impact of contraception on unintended pregnancies and abortions. In Section II, I will explain the methodology used to analyze the impact of the twenty-eight state contraceptive mandates on public health outcomes. Section III presents the results, followed by a brief conclusion.

  1. LITERATURE REVIEW

    Abortion opponents receive a considerable amount of criticism from various media outlets for not being more supportive of contraception. (15) That being said, research on the efficacy of programs to promote contraceptive use paints a mixed picture of its effectiveness. The Guttmacher Institute, which up until 2007 was Planned Parenthood's research arm and still receives significant funding from Planned Parenthood, frequently publishes studies and analyses that argue contraception programs are effective; (16) however, a closer look at their research and other research that has appeared in peer- reviewed journals raises serious questions about the efficacy of contraceptive programs.

    1. Theoretical Reasons Why Contraceptive Programs May Be Ineffective

      The Guttmacher Institute has published a number of studies advocating for the effectiveness of various contraceptive programs; however, several of their studies are theoretical in nature and do not analyze hard data on either contraceptive spending or unintended pregnancy rates. (17) They simply assume that if more money is spent, more people will have access to contraception, and unintended pregnancy rates will decline. (18)

      These studies, however, often fail to take into account that there is a substantial body of research that finds that increasing the availability of contraception may result in more sexual activity. (19) This will reduce the effectiveness of any program designed to distribute contraceptives more widely or encourage contraceptive use. (20) Even an analysis of teen sexual activity by a scholar affiliated with the Guttmacher Institute found that the availability of the birth control pill in the early 1960s resulted in teens engaging in sexual activity at an earlier age. (21)

      The Akerlof, Yellen, and Katz study, which appeared in The Quarterly Journal of Economics in 1996, was especially interesting. (22) The authors designed an economic model of mating and sexual behavior. They argued that before the advent of the birth control pill, the effective price of pre- marital sex was high because there was a substantial risk of an unintended pregnancy; (23) however, the advent of the birth control pill in the early 1960s had two important implications. First, it lowered the effective price of sex by reducing the risk of an unintended pregnancy. (24) This resulted in more pre- marital sexual activity. (25) Second, since a higher percentage of women were engaging in pre-marital sexual activity--other women felt compelled to engage in pre-marital sex in order to make themselves more attractive to potential mates. (26) The end result was more sexual activity and more unintended pregnancies. (27)

      Now it is certainly possible that gains in contraception use may offset the risks involved with increased sexual activity; however, there is another important reason to question the efficacy of contraception programs. Namely, research shows that very few women forego contraception due to high cost or lack of availability. (28) This is unsurprising considering how widely available contraception is. In 2002, the Guttmacher Institute surveyed over 10,000 sexually active women who were not using contraception. (29) The most frequently cited reasons for not using contraceptives included a perceived low risk of pregnancy, concerns about contraceptive methods, and ambivalence about contraception. (30) Only twelve percent cited high cost or lack of availability. (31) Additionally, in 2012 a study conducted by the Centers for Disease Control (CDC) of 5,000 teenage girls who gave birth after unplanned pregnancies found that only a small percentage had difficulty accessing contraception. (32)

      Case studies provide additional evidence that few women forego contraception due to cost or availability. In the book Unmarried Couples with Children, sociologists Kathryn Edin of Harvard University and Paula England of Stanford University conducted an intense study of seventy-six low-income couples from Milwaukee, Chicago, and New York who had just given birth. (33) The fertility patterns of all of the women in the study were carefully studied for four years. (34) Edin and England found that only a very small percentage of these women wanted contraception but were unable to afford it. (35) Specifically, all of the women surveyed were asked whether they had been in a situation where they wanted birth control but could not afford or find it. (36) Tellingly, all said no. (37) In fact, according to Edin and England, "[s]ome laughed when we asked this question, pointing out how hard clinics and schools in their communities push contraceptives." (38)

    2. U.S. Trends in Contraception Use, Abortion Rates, and Unintended Pregnancy Rates

      An analysis of trends in contraception use, abortion rates, and unintended pregnancy rates in the United States also raises questions about the efficacy of contraception programs. Many commentators give increased contraception use much of the credit for the fairly consistent decline in the U.S. abortion rate since the early 1980s and the approximately twenty-five percent decline in the number of abortions performed since...

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