title: Implications of employer coverage of contraception: Cost-effectiveness analysis of contraception coverage under an employer mandate.
abstract: Mandatory employer-based insurance coverage of contraception in the US has been a controversial component of the Affordable Care Act (ACA). Prior research has examined the cost-effectiveness of contraception in general; however, no studies have developed a formal decision model in the context of the new ACA provisions. As such, this study aims to estimate the relative cost-effectiveness of insurance coverage of contraception under employer-sponsored insurance coverage taking into consideration newer regulations allowing for religious exemptions.
  
  
  
  A decision model was developed from the employer perspective to simulate pregnancy costs and outcomes associated with insurance coverage. Method-specific estimates of contraception failure rates, outcomes and costs were derived from the literature. Uptake by marital status and age was drawn from a nationally representative database.
  
  
  
  Providing no contraception coverage resulted in 33 more unintended pregnancies per 1000 women (95% confidence range: 22.4; 44.0). This subsequently significantly increased the number of unintended births and terminations. Total costs were higher among uninsured women owing to higher costs of pregnancy outcomes. The effect of no insurance was greatest on unmarried women 20-29 years old.
  
  
  
  Denying female employees' full coverage of contraceptives increases total costs from the employer perspective, as well as the total number of terminations.
  
  
  
  Insurance coverage was found to be significantly associated with women's choice of contraceptive method in a large nationally representative sample. Using a decision model to extrapolate to pregnancy outcomes, we found a large and statistically significant difference in unintended pregnancy and terminations. Denying women contraception coverage may have significant consequences for pregnancy outcomes.
authors.affiliation: University of Washington School of Pharmacy, Seattle, WA 98195, USA.
authors.forename: W
authors.initials: W
authors.lastname: Canestaro
authors.affiliation: University of Washington School of Pharmacy, Seattle, WA 98195, USA. Electronic address: evodicka@uw.edu.
authors.forename: E
authors.initials: E
authors.lastname: Vodicka
authors.affiliation: University of Washington School of Pharmacy, Seattle, WA 98195, USA.
authors.forename: D
authors.initials: D
authors.lastname: Downing
authors.affiliation: Princeton University, Princeton, NJ 08544, USA.
authors.forename: J
authors.initials: J
authors.lastname: Trussell
mesh_terms: D000293:Adolescent; D000328:Adult; D017677:Age Distribution; D000367:Age Factors; D003267:Contraception / Q000191:economics* / Q000379:methods; D003362:Cost-Benefit Analysis; D017049:Employer Health Costs / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D019458:Insurance Coverage; D017533:Marital Status; D017057:Medically Uninsured / Q000706:statistics & numerical data*; D058991:Patient Protection and Affordable Care Act; D011247:Pregnancy; D011256:Pregnancy Outcome / Q000191:economics; D049168:Pregnancy, Unplanned; D014481:United States; D055815:Young Adult
keywords: Cost-effectiveness; Employer mandate; Health outcomes; Insurance coverage