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Planning parenthood: the Affordable Care Act young adult provision and pathways to fertility


This paper investigates the effect of the Affordable Care Act young adult provision on fertility and related outcomes. The expected effect of the provision on fertility is not clear ex ante. By expanding insurance coverage to young adults, the provision may affect fertility directly through expanded options for obtaining contraceptives as well as through expanded options for obtaining pregnancy-, birth-, and infant-related care, and these may lead to decreased or increased fertility, respectively. In addition, the provision may also affect fertility indirectly through marriage or labor markets, and the direction and magnitude of these effects is difficult to determine. This paper considers the effect of the provision on fertility as well as the contributing channels by applying difference-in-differences type methods using the 2008–2010 and 2012–2013 American Community Survey, 2006–2009 and 2012–2013 Centers for Disease Control and Prevention abortion surveillance data, and 2006–2010 and 2011–2013 National Survey of Family Growth. Results suggest that the provision is associated with decreases in the likelihood of having given birth and abortion rates and an increase in the likelihood of using long-term hormonal contraceptives.

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  1. This channel would be less relevant to the extent that insurers raised premiums to offset the increased coverage of adult children, as found by Depew and Bailey (2015), and that parents passed these costs on to their dependents.

  2. While the NSFG also includes data on abortions, such data are known to be underreported and are not recommended for use in substantive research (U.S. Department of Health and Human Services 2014). Accordingly, the CDC abortion surveillance data are used in this analysis for examining effects of the provision on abortion outcomes.

  3. Specifically, California, Florida, New Hampshire, and Wyoming did not report in any of the sample years, and Delaware, the District of Columbia, Louisiana, Maine, Maryland, and Vermont did not report in all years.

  4. Specifications used in this analysis include state fixed effects to account for differences across states. These include differences in state mandates for young adult insurance coverage on parents’ private health insurance plans prior to the ACA young adult provision and state health insurance mandates for contraception coverage, as well as other policies and characteristics. Specifications including a control for whether the individual would have been eligible for dependent coverage on a parent’s private health insurance plan prior to the ACA young adult provision following the classification of state policies in Monheit et al. (2011) yielded qualitatively similar results. In addition, specifications including a control for whether the state had adopted a dependent coverage mandate prior to the enactment of the ACA young adult provision following the classification of state policies in Monheit et al. (2011) yielded qualitatively similar results.

  5. Including controls for family income as a percentage of the federal poverty line and its squared term resulted in qualitatively similar results.

  6. Incorporating information on parents’ insurance coverage into the analysis to identify individuals eligible for coverage through parents as a result of the provision was not used in this analysis investigating fertility because this methodology would limit the sample to only individuals living in the same household as their parents.

  7. These controls were included in individual-level specifications by Mulligan (2015); omitting potentially endogenous controls for employment status, education attainment, household income, and the number of own children in the household resulted in qualitatively similar results.

  8. Linear probability models are used in all regressions rather than probit models for ease of interpretation. Regressions using probit models yielded qualitatively similar results.

  9. The birth rate for 20–25-year-old women before provision enactment was 9.5%.

  10. A decrease in the birth rate of 0.95 percentage points on a basis of approximately 13 million women ages 20–25 would result in approximately 125,000 fewer births.

  11. Calculated as a 10 percentage point increase on a basis of approximately 13 million women ages 20–25.

  12. Barbaresco et al. (2015) and Abramowitz (2016) also consider a placebo treatment group of individuals at ages unaffected by the provision over the analysis period. I also performed such a placebo test, including only individuals ages 28–30 and 32–34, who are outside of the age range affected by the provision, and defined individuals ages 28–30 as the placebo treatment group. However, I could not rule out differential pre-treatment trends for the respective age groups.


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I am grateful to Ausmita Ghosh, Catherine Massey, and three anonymous referees for their invaluable comments and to Sara Zobl for excellent research assistance. I would also like to thank seminar participants at Dickinson College, the University of Michigan Survey Research Center, and the 2016 American Society of Health Economists Biennial Conference for their helpful feedback.

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Correspondence to Joelle Abramowitz.

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Responsible editor: Erdal Tekin

Any opinions and conclusions expressed herein are those of the author and do not necessarily represent the views of the U.S. Census Bureau. All results have been reviewed to ensure that no confidential information is disclosed.


Appendix 1

Table 9 ACS pre-trend regression results

Appendix 2

Table 10 CDC abortion surveillance and NSFG pre-trend regression results

Appendix 3

Table 11 Estimates of reductions in fertility associated with the young adult provision

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Abramowitz, J. Planning parenthood: the Affordable Care Act young adult provision and pathways to fertility. J Popul Econ 31, 1097–1123 (2018).

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  • Fertility
  • Affordable Care Act
  • Young adult provision
  • Health insurance

JEL classifications

  • I12
  • I13
  • I18
  • J13