Bellerose Meghan, Ellison Jacqueline, Steenland Maria W, Meyers David J, Mitra Monika, Shireman Theresa I
Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island.
Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania.
JAMA Netw Open. 2025 Jun 2;8(6):e2517718. doi: 10.1001/jamanetworkopen.2025.17718.
Medicare is the primary health insurance payer for 1.5 million reproductive-aged women with disabilities, yet it is the only major form of US health insurance that is not required to cover contraceptives for pregnancy prevention.
To evaluate whether Medicare's contraceptive coverage gaps were associated with reduced use of contraceptives by enrollees with disabilities.
DESIGN, SETTING, AND PARTICIPANTS: In this national, cross-sectional study, traditional Medicare (TM), Medicare Advantage (MA), and Medicaid claims from female enrollees aged 20 to 49 years receiving Social Security Disability Insurance or Supplemental Security Income from January 1, 2016, to December 31, 2020, were linked. The propensity score-weighted probability of contraceptive use by public insurance type was estimated, then the association between gaining contraceptive coverage through a transition from Medicare to dual Medicare-Medicaid enrollment and contraceptive use was evaluated using a staggered-entry difference-in-differences design. Data were analyzed from December 3, 2024, to April 5, 2025.
Public insurance enrollment in TM, MA, dual TM-Medicaid, dual MA-Medicaid, or Medicaid.
Monthly use of permanent contraceptives, long-acting reversible contraceptives (intrauterine device and implant), and short-acting contraceptives (injectable and oral contraceptives, patch, and ring).
A total of 51 501 303 monthly observations from 1 606 129 women were included in the analysis. Mean (SD) age was 35.93 (8.58) years; 1.8% of monthly observations were from Asian women, 30.7% from Black women, 13.0% from Hispanic women, 52.6% from White women, and 1.9% from multiracial women or women identifying as another race and ethnicity not reported on previously. Those enrolled in TM and MA were more often older and non-Hispanic White compared with those dual enrolled or enrolled in Medicaid. The estimated monthly probability of use of any contraceptive method was lowest among TM (4.9%; 95% CI, 4.9%-4.9%) and MA (6.6%; 95% CI, 6.5%-6.6%) enrollees, followed by Medicaid (11.0%; 95% CI, 11.0%-11.0%), dual MA-Medicaid (11.3%; 95% CI, 11.3%-11.4%), and dual TM-Medicaid (13.1%; 95% CI, 13.0%-13.1%) enrollees. Gaining contraceptive coverage through dual enrollment was associated with an increase of 3.9 (95% CI, 3.5-4.3) percentage points (35%) in use of any contraceptive method, with the largest increase in use of short-acting methods at 2.6 (95% CI, 2.3-3.0) percentage points (45%).
In this cross-sectional study of contraceptive use in the Medicare program, gaining contraceptive coverage through dual Medicare-Medicaid enrollment was associated with increased contraceptive use among disabled Medicare enrollees, suggesting that Medicare's coverage gaps pose a financial barrier to desired contraceptive use. Given these findings, Medicare should be required to cover all US Food and Drug Administration-approved contraceptive methods without cost-sharing. Doing so would align Medicare's coverage requirements with those of Medicaid, private insurance plans, and TRICARE.
医疗保险是150万育龄残疾妇女的主要医疗保险支付方，但它是美国唯一一种无需涵盖避孕措施以预防怀孕的主要医疗保险形式。
评估医疗保险的避孕覆盖范围缺口是否与残疾参保者避孕措施使用减少有关。
设计、背景和参与者：在这项全国性横断面研究中，将2016年1月1日至2020年12月31日期间领取社会保障残疾保险或补充保障收入的20至49岁女性参保者的传统医疗保险（TM）、医疗保险优势计划（MA）和医疗补助索赔数据进行了关联。估计了按公共保险类型使用避孕措施的倾向得分加权概率，然后使用交错进入差异中的差异设计评估了从医疗保险过渡到医疗保险 - 医疗补助双重参保从而获得避孕覆盖与避孕措施使用之间的关联。数据于2024年12月3日至2025年4月5日进行分析。
参保TM、MA、TM - 医疗补助双重参保、MA - 医疗补助双重参保或医疗补助。
永久性避孕措施、长效可逆避孕措施（宫内节育器和植入物）以及短效避孕措施（注射用和口服避孕药、避孕贴片和避孕环）的月度使用情况。
分析纳入了1606129名女性的51501303条月度观察数据。平均（标准差）年龄为35.93（8.58）岁；月度观察数据的1.8%来自亚洲女性，30.7%来自黑人女性，13.0%来自西班牙裔女性，52.6%来自白人女性，1.9%来自多种族女性或属于未在此前报告过的其他种族和族裔的女性。与双重参保或参保医疗补助的女性相比，参保TM和MA的女性年龄通常更大且为非西班牙裔白人。估计任何避孕方法的月度使用概率在TM参保者中最低（4.9%；95%置信区间，4.9% - 4.9%），在MA参保者中次之（6.6%；95%置信区间，6.5% - 6.6%），其次是医疗补助参保者（11.0%；95%置信区间，11.0% - 11.0%）、MA - 医疗补助双重参保者（11.3%；95%置信区间，11.3% - 11.4%）和TM - 医疗补助双重参保者（13.1%；95%置信区间，13.0% - 13.1%）。通过双重参保获得避孕覆盖与任何避孕方法的使用增加3.9（95%置信区间，3.5 - 4.3）个百分点（35%）相关，其中短效方法的使用增加最多，为2.6（95%置信区间，2.3 - 3.0）个百分点（45%）。
在这项关于医疗保险计划中避孕措施使用的横断面研究中，通过医疗保险 - 医疗补助双重参保获得避孕覆盖与残疾医疗保险参保者避孕措施使用增加相关，这表明医疗保险的覆盖缺口对期望的避孕措施使用构成了经济障碍。鉴于这些发现，应要求医疗保险涵盖美国食品药品监督管理局批准的所有避孕方法且无需分担费用。这样做将使医疗保险的覆盖要求与医疗补助、私人保险计划和军人家属医疗保险（TRICARE）的要求保持一致。
