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

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Abstract

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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Notes

  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.

References

  • Abramowitz J (2016) Saying, “I don’t”: the effect of the Affordable Care Act young adult provision on marriage. J Hum Resour 51(4):933–960

    Article  Google Scholar 

  • Akosa Antwi Y, Moriya A, Simon K (2013) Effects of federal policy to insure young adults: evidence from the 2010 Affordable Care Act’s dependent-coverage mandate. Am Econ J Econ Pol 5(4):1–28

    Article  Google Scholar 

  • Akosa Antwi Y, Moriya A, Simon K (2015) Access to health insurance and the use of inpatient medical care: evidence from the Affordable Care Act young adult mandate. J Health Econ 39:171–187

    Article  Google Scholar 

  • Apostolova-Mihaylova M, Yelowitz A 2017 Health insurance, fertility, and the wantedness of pregnancies: evidence from Massachusetts. Contemp Econ Policy. https://doi.org/10.1111/coep.12235

  • Bailey J, Chorniy, A 2016 Employer-provided health insurance and job mobility: did the Affordable Care Act reduce job lock? Contemp Econ Policy 34(1):173–183

  • Barbaresco S, Courtemanche C, Qi Y (2015) Impacts of the Affordable Care Act dependent coverage provision on health-related outcomes of young adults. J Health Econ 40:54–68

    Article  Google Scholar 

  • Bertrand M, Duflo E, Mullainathan S (2004) How much should we trust differences-in-differences estimates? Quart. J Econ 119(1):249–275

    Google Scholar 

  • Braveman P, Bennett T, Lewis C, Egerter S, Showstack J (1993) Access to prenatal care following major Medicaid eligibility expansions. J Am Med Assoc 269(10):1285–1289

    Article  Google Scholar 

  • Burns ME, Wolfe BL (2016) The effects of the Affordable Care Act adult dependent coverage expansion on mental health. J Ment Health Policy 19(1):3–20

    Google Scholar 

  • Cantor J, Monheit A, DeLia D, Lloyd K (2012) Early impact of the Affordable Care Act on health insurance coverage of young adults. Health Serv Res 47(5):1773–1798

    Article  Google Scholar 

  • Centers for Disease Control and Prevention (2017) Effectiveness of contraceptive methods. https://www.cdc.gov/reproductivehealth/contraception/unintendedpregnancy/pdf/contraceptive_methods_508.pdf. Accessed 1 Mar 2017

  • Collins S, Rasmussen P, Doty M, Beutel S (2015) The rise in health care coverage and affordability since health reform took effect: findings from the Commonwealth Fund biennial health insurance survey, 2014. The Commonwealth Fund, New York

    Google Scholar 

  • Colman G, Dave D (2017) It's about time: effects of the Affordable Care Act dependent coverage mandate on time use. NBER Working Paper 21725

  • Culwell KR, Feinglass J (2007) The association of health insurance with the use of prescription contraceptives. Perspect Sex Reprod Health 39(4):226–230

    Article  Google Scholar 

  • Currie J, Gruber J (1997) The technology of birth: health insurance, medical interventions, and infant health. NBER Working Paper 5985

  • DeLeire T, Lopoo LM, and Simon KI 2011 Medicaid Expansions and Fertility in the United States. Demography 48(2):725-747

  • Dennis A, Córdova D, Blanchard K, Wahlin B (2009) Low-income women’s access to contraception after Massachusetts health care reform. IBIS Reproductive Health and MDPH Family Planning Program

  • Dennis A, Clark J, Córdova D, McIntosh J, Edlund K, Wahlin B, Blanchard K (2012) Access to contraception after health care reform in Massachusetts: a mixed-methods study investigating benefits and barriers. Contraception 85(2):166–172

  • Depew B, Bailey J (2015) Did the Affordable Care Act's dependent coverage mandate increase premiums? J Health Econ 41:1–14

    Article  Google Scholar 

  • Egerter S, Braveman P, Marchi K (2002) Timing of insurance coverage and use of prenatal care among low-income women. Am J Public Health 92(3):423–427

  • Golberstein E, Busch SH, Zaha R, Greenfield SF, Beardslee WR, Meara E (2015) Effect of the Affordable Care Acts young adult insurance expansions on hospital-based mental health care. Amer. J Psychiatry 172(2):182–189

  • Gold R (2009) Family planning centers meet health care reform: lessons from Massachusetts. Guttmacher. Pol Rev 12(3). https://www.guttmacher.org/gpr/2009/08/family-planning-centers-meet-health-care-reform-lessons-massachusetts. Accessed 6 Nov 2017

  • Hahn Y, Yang H (2013) Do work decisions among young adults respond to extended dependent coverage? Monash University working paper

  • Heim B, Lurie I, Simon K (2017) The impact of the Affordable Care Act young adult provision on childbearing, marriage, and tax filing: evidence from tax data. NBER Working Paper 23092

  • Jatlaoui TC, Ewing A, Mandel MG, Simmons KB, Suchdev DB, Jamieson CJ, Pazol K (2016) Abortion surveillance—United States, 2013. Morb Mortal Wkly Rep Surveill Summ 65(12):1–44

    Google Scholar 

  • Joyce T, Grossman M (1990) Pregnancy wantedness and the early initiation of prenatal care. Demography 27(1):1–17

    Article  Google Scholar 

  • Joyce T, Kaestner R (1996) The effect of expansions in Medicaid income eligibility on abortion. Demography 33(2):181–192

    Article  Google Scholar 

  • Joyce T, Kaestner R, Kwan F (1998) Is Medicaid pronatalist? The effect of eligibility expansions on abortions and births. Fam Plan Perspect 30(3):108–127

    Article  Google Scholar 

  • Kaestner R (1999) Health insurance, the quantity and quality of prenatal care, and infant health. Inquiry 36(2):162–175

    Google Scholar 

  • Kearney M, Levine P (2009) Subsidized contraception, fertility, and sexual behavior. Rev Econ Stat 91(1):137–151

    Article  Google Scholar 

  • Leibowitz A (1990) The response of births to changes in health care costs. J Hum Resour 25(4):697–711

    Article  Google Scholar 

  • Look KA, Kim NH, Arora P (2016) Effects of the Affordable Care Act's dependent coverage mandate on private health insurance coverage in urban and rural areas. J Rural Health. https://doi.org/10.1111/jrh.12183

  • Ma J (2015) Health insurance and fertility decisions: evidence from Affordable Care Act young adult provision. Unpublished manuscript

  • Mellor JM (1998) The effect of family planning programs on the fertility of welfare recipients: evidence from Medicaid claims. J Hum Resour 33(4):866–895

    Article  Google Scholar 

  • Miller JA, Graefe DR, De Jong GF (2013) Health insurance coverage predicts lower childbearing among near-poor adolescents. J Adolesc Health 53:749–755

    Article  Google Scholar 

  • Monheit A, Cantor J, DeLia D, Belloff D (2011) How have state policies to expand dependent coverage affected the health insurance status of young adults? Health Serv Res 46(1):251–267

    Article  Google Scholar 

  • Mulcahy A, Harris K, Finegold K, Kellermann A, Edelman L, Sommers B (2013) Insurance coverage of emergency care for young adults under health reform. N Engl J Med 368(22):2105–2112

    Article  Google Scholar 

  • Mulligan K (2015) Contraception use, abortions, and births: the effect of insurance mandates. Demography 52(4):1195–1217

    Article  Google Scholar 

  • O’Hara B, Brault M (2013) The disparate impact of the ACA-dependent expansion across population subgroups. Health Serv Res 48(5):1581–1592

    Google Scholar 

  • Oberg CN, Lia-Hoagberg B, Skovholt C, Hodkinson E, Vanman R (1991) Prenatal care use and health insurance status. J Health Care Poor Underserved 2(2):270–291

    Article  Google Scholar 

  • Peipert J, Madden T, Allsworth J, Secura G (2012) Preventing unintended pregnancies by providing no-cost contraception. Obstet Gynecol 120(6):1291–1297

    Article  Google Scholar 

  • Slusky DJG (2017) Significant placebo results in difference-in-differences analysis: the case of the ACA’s parental mandate. East Econ J 43(4):580–603

  • Smith JC, Medalia C (2015) Health insurance coverage in the United States: 2014. U.S. Census Bureau, Washington

    Google Scholar 

  • Sommers B, Kronick R (2012) The Affordable Care Act and insurance coverage for young adults. J Am Med Assoc 207(9):913–914

    Google Scholar 

  • Sommers B, Buchmueller T, Decker S, Carey C, Kronick R (2013) The Affordable Care Act has led to significant gains in health insurance and access to care for young adults. Health Aff 32(1):165–174

    Article  Google Scholar 

  • Sonfield A, Gold RB (2011) Medicaid family planning expansions: lessons learned and implications for the future. Guttmacher Institute, New York

    Google Scholar 

  • U.S. Census Bureau (2014) Annual estimates of the resident population by single year of age and sex for the United States: April 1, 2010 to July 1, 2013. http://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?src=bkmk. Accessed 7 Feb 2015

  • U.S. Census Bureau (2015) Frequently asked questions: I'm using the American Community Survey (ACS) Public Use Microdata Sample (PUMS) files. Why don't my estimates match what's published on American factfinder (AFF)? https://ask.census.gov/faq.php?id=5000&faqId=911. Accessed 3 Mar 2015

  • U.S. Department of Health and Human Services (2014) Public use data file documentation: 2011–2013 National Survey of Family Growth. https://www.cdc.gov/nchs/data/nsfg/nsfg_2011-2013_userguide_maintext.pdf. Accessed 14 Apr 2017

  • U.S. Department of Labor, Employee Benefits Security Administration (2013) Frequently asked questions, young adults and the Affordable Care Act: protecting young adults and eliminating burdens on businesses and families. http://www.dol.gov/ebsa/faqs/faq-dependentcoverage.html. Accessed 14 Nov 2013

  • Zavodny M, Bitler MP (2010) The effect of Medicaid eligibility expansions on fertility. Social Science & Medicine 71(5):918-924

  • Ziller EC, Coburn AF, Anderson NJ, Loux SL (2008) Uninsured rural families. J Rural Health 24(1):1–11

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Acknowledgements

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.

Appendices

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). https://doi.org/10.1007/s00148-017-0676-6

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