How Will Improved Pregnancy Care Coverage and Family Planning Access Under the ACA Medicaid Expansions Affect Fertility?

Background and Purpose: Determining the impact of Medicaid expansions under the Affordable Care Act on fertility and identifying which groups are most affected can improve understanding of unmet reproductive healthcare needs among women, and guide future planning to address meeting healthcare needs for women of reproductive age. Insurance expansions increase access to maternity care for pregnant women while also increasing access to pregnancy prevention through improved coverage for contraception and family planning. Past analyses of insurance expansions have found varied effects on women giving birth, with some expansions increasing births, some decreasing births, and some increasing births for some groups and decreasing births for other groups, with differences by race/ethnicity, maternal age, educational attainment, and marital status. The ACA Medicaid expansions improved coverage for millions of reproductive-aged women, improving coverage prior to pregnancy as well as increasing family planning access and decreasing unintended pregnancies. This study aims to evaluate the effects of the Medicaid expansions on fertility, and if these effects vary by race/ethnicity, marital status, maternal age, and educational attainment.

Methods: This study uses difference-in-difference and difference-in-difference-in-difference (triple-difference) models with wild cluster standard errors by state and a one-year lag to examine the relationship between Medicaid expansion and fertility. This research uses data for reproductive-aged women 19-44 from the American Community Survey for all states for the time period 2008-2017. Stratified and triple-difference models include by race/ethnicity; maternal age; educational attainment; and marital status. The sample size for women at or below 138% of the federal poverty level (FPL) is 1,122,304.

Results: Overall, the Medicaid expansions were not associated with a significant change in women reporting giving birth in the past year, or a significant difference in the association between Medicaid expansion and fertility among women who were Medicaid-eligible compared to women who were 139-250 percent FPL. Medicaid expansion was associated with a 2.6 percentage point decrease (p=0.003) in fertility among American Indian or Alaska Native women, a 0.4 percentage point (p=0.045) decrease among unmarried women, and a significant decrease in fertility by 1.7 percentage points (p=0.001) among women 25-29 years old. In triple-difference models, fertility effects were significantly lower among Asian women and American Indian or Alaska Native women compared to non-Hispanic White women and significantly lower among women 25-29 compared to women 40-44 years old.

Conclusions and Implications: Overall, Medicaid expansion under the ACA was not associated with a change in fertility. Decreases in fertility were present for among American Indian or Alaska Native women, unmarried women, and women 25-29 years old, and differences were significantly different among some racial groups and by maternal age. These findings suggest that Medicaid expansions are decreasing fertility for some women, indicating that the increased access to contraception and family planning services and the decreases in unintended pregnancies associated with Medicaid expansion are associated with decreased fertility for some groups. This research sheds light on which groups are most affected by improving low-income women’s access to reproductive health services, and could inform future policy decisions that target women’s reproductive healthcare needs.