Study reveals disparities in contraceptive access for Medicare enrollees with disabilities

Contraceptive use is low among reproductive-aged people with disabilities who are enrolled in Medicare, according to a new study from the University of Pittsburgh that highlights how lack of contraceptive coverage by Medicare may prevent disabled enrollees from accessing contraception.

Published today in the January issue of Health Affairs, the study provides the first national overview of contraceptive use among enrollees in Medicare, the government health insurance for people over 65 and for people with qualifying disabilities. The researchers say that policy changes are needed to expand contraception coverage in Medicare and to ensure more equitable health care for people with disabilities, who already face barriers to reproductive health care and have higher rates of pregnancy complications and deaths than nondisabled people.

The federal government requires that commercial insurers and Medicaid cover all contraceptive methods without cost sharing, but there is no similar requirement for Medicare, which means that disabled enrollees may not be able to access contraception or their preferred method of contraception. People with disabilities are already marginalized and experience barriers to accessing health care. It is unjust that they face additional cost-related barriers to receiving their contraceptive method of choice."

Jacqueline Ellison, Ph.D., M.P.H., lead author, assistant professor in the Department of Health Policy and Management at the Pitt School of Public Health

Medicare does not require coverage for contraception to prevent pregnancies but may cover certain contraceptives for clinical indications such as endometriosis. Oral contraception may also be covered by Part D, an optional drug coverage benefit that costs extra. Patients may also be covered for other contraceptive methods by enrolling in Medicare Advantage, which is provided by private companies that contract with Medicare, but the scope of coverage depends on the company.

This complicated insurance landscape means that people with disabilities may not be able to access contraception or may be forced to pay out of pocket to access their preferred method of contraception.

In 2019, Medicare was the primary health insurance coverage for about 1.38 million reproductive-aged females with disabilities: About 941,000 had traditional Medicare and about 444,000 had Medicare Advantage. To understand more about patterns of contraceptive use among this population, Ellison and her team used two databases of insurance claims to analyze a study sample representing 17.2% of traditional Medicare and 9.5% of Medicare Advantage populations.

The researchers found that contraceptive use was low among reproductive-aged females with disabilities. Just 14.3% of traditional Medicare enrollees and 16.3% of those with Medicare Advantage had an insurance claim for contraception in 2019. In comparison, another study found that about 25% of reproductive-aged females with Medicaid -; which is required to cover all forms of contraception -; had such a claim in 2018.

The analysis also showed variation in contraceptive methods by type of Medicare coverage. For example, Medicare Advantage enrollees were about four times more likely to use an intrauterine device and 10 times more likely to have tubal ligation than those with traditional Medicare.

"This variation isn't due to patient preference: There's no reason that people with Medicare Advantage would be so much more likely than those with traditional Medicare to prefer using the intrauterine device or undergoing tubal sterilization," explained Ellison. "This is a function of Medicare not requiring coverage for the full range of contraceptive methods."

Medicare enrollees with noncontraceptive indications -; such as acne, endometriosis, menstrual pain and irregular bleeding -; were nearly twice as likely to use contraceptives as those without such an indication. This finding may highlight the importance of contraceptives for reasons beyond pregnancy prevention, or it may reflect clinicians documenting such an indication to help their patients get contraception when they otherwise would not have coverage.

"People with disabilities are more vulnerable to interference by guardians and clinicians in their reproductive decision making," said Ellison. "It's critical that, while ensuring access to the full range of contraceptive methods, we protect people with disabilities against such interference by ensuring contraceptive care provided in the Medicare program is truly person-centered."

Other authors on the study were Sabnum Pudasainy, M.S., Deirdre Quinn, Ph.D., M.P.H, Sonya Borrero, M.D., M.S., Iris Olson, M.P.H., Qingwen Chen, M.S., and Marian Jarlenski, Ph.D., M.P.H., all of Pitt; and Meghan Bellerose, M.P.H., and Theresa I. Shireman, Ph.D., of Brown University.

This research was supported by the National Institute for Reproductive Health (5717077).