Implications of Repeal of the ACA for American Fertility
By June Carbone | January 27, 2017
In considering the potential impact of the repeal of the Affordable Care Act, efforts to defund Planned Parenthood, and other actions that may affect women’s health, most of the discussion has appropriately been on the impact on individual women. Indeed, Texas demonstrates the risks. The state had operated a Medicaid financed family planning system that included funds for Planned Parenthood. In 2011, the state legislation cut family planning grants by 66%, and tried to redirect federal funds from Planned Parenthood to more general county-based programs. Although litigation initially prevented the switch, Texas eventually succeeded in replacing the federal funds with state money, and moving such funding away from family planning providers.
The result produced a shift in contraceptive use, and an increase in Medicaid funded childbirths. Between 2010 and 2012, as these results were taking effect, the state’s maternal death rate doubled, though no thorough study has yet to determine the causes.
Less examined is the potential impact on overall American fertility. The United States is unusual among developed nations both in its high birth rate and its correspondingly high rate of unintended pregnancies. Until the Great Recession, overall American fertility had been at 2.1, that is, an average of 2.1 children per woman, just above replacement levels. Since the Great Recession, however, that rate has fallen to 1.86, a rate that resembles Northern Europe. The potential implications are complex and potentially far-reaching. On the one hand, lower overall fertility, particularly in developed countries, can lead to lower economic growth. On the other hand, if the decline comes primarily from fewer unplanned births, it can lead to greater investment in children, and a narrowing of class-based disparities in the timing and number of children. The decline in unplanned pregnancies also tends to increase women’s autonomy and to reduce the incidence and importance of abortion.
Three big stories underlie the change in overall fertility. First, is the bifurcated nature of American fertility. Between 1990 and 2008, the best off Americans saw their unintended pregnancy rates fall by half, while they increased substantially for poorer women; those trends reversed after 2008. Second, the effect has been particularly marked among Latinas. They have had the higher fertility rates than any other segment of the American population leading into the Great Recession. Since 2008, however, Latina fertility, particularly in what had been the peak childbearing years between the late teens and early twenties has fallen off a cliff, explaining half of the overall American fertility drop. Third, the consensus among the few studies to date is that the increased efficacy of contraception has played an important role in the drop in fertility. While rigorous studies have yet to be undertaken, the evidence suggests that increased access through the Affordable Care Act, which mandates contraceptive coverage as part of private health insurance coverage and expands access through Medicaid, is an important part of the explanation.
The Bifurcated Nature of American Fertility
According to the Guttmacher Institute, between 1981 and 2008, unintended pregnancy became a product of class. For the wealthiest part of the population, unplanned births fell in half at the same time they increased substantially for the poorest part of the population. For the better off, the steady drop in unplanned pregnancies almost certainly reflected systematic use of contraception together with a small drop in sexual activity in the mid-teens. Better off teens have become more likely to use contraception before they begin sexual activity, and doctors (including Web M.D.) emphasize the advantages of the pill in controlling acne, regularizing menstrual periods, and alleviating cramps. Indeed, more than half of women who use the pill do so for reasons other than the prevention of pregnancy. During that same period, poorer women received less (and often no) information about contraception compared to the better off, and restrictions on immigrant women’s access to contraceptive services increased. Women without health insurance are thirty percent less likely to use prescription methods, which are more effective than the alternatives.
The Decline in the Latino Birth Rate
Since 2008, however, unintended pregnancies have declined for all groups, with the largest declines occurring among poorer women and Latinas. “Between 2006 and 2013, the Hispanic birth rate plummeted 25 percent. By comparison, the rate for non-Hispanics declined just 5 percent—though the latter was already much lower.” For Americans generally, the biggest decline in births has been among younger women, and that has been particularly true for Latinas. During the 2006—13 period, Latina birth rates declined by 45 percent among 15- to 19-year-olds and by 34 percent in the 20-24 year-old age range. Together with the decline in immigration, this has slowed the growth in the Latino percentage of the overall population.
The Factors Producing the Declines
The precipitous decline in births, with Latinas accounting for 50% of the total American decline and even more for teens, reflects a combination of factors. First, the decline in construction jobs, which have been particularly important for Latino men and which boomed during the housing bubble in the early 2000s, almost certainly played a role. Latinos constitute about a quarter of construction workers and were particularly hard hit during Great Recession. Partly as a result, Latina women have been staying in school longer and delaying pregnancy. Second, foreign-born Hispanics indicate greater support for teen births than do those born in the United States. In 2009, a Pew Research Center study found, for instance, that while 69 percent of first-generation Hispanic teens called teen pregnancy a bad thing for society, 86 percent of Hispanic teens who are third-generation and higher gave that response. As immigration declines, a higher percentage of Latinos are American born, which may contribute to changing attitudes.
While the recession and changing immigration patterns accounts for some of the drop in fertility, however, it is not the entire story. Since the onset of the Great Recession, poorer women have experienced the greatest drops in unplanned pregnancies – a reversal of the trends of the last quarter century. Colorado provides a particularly dramatic example. Between 2009 and 2013, the state provided free access to IUDs and long acting hormonal implants to teens and poor women. Birth rates for the group dropped by 40% (and abortion rates dropped by even more). Looking just at teen pregnancies between the ages of 15 and 19, which is the group with the greatest declines among Latinas, the largest factor appears to be a change in contraceptive use, with an increase in hormonal contraceptive use from 37% in 2006–2008 to 47% in 2008–2010 of sexually active teens nationally. There has been a similar change in increase in the use of long acting contraceptives generally, with large increases after adoption of the ACA, though the causal factors have not been established. What has been documented is the decline in costs: for women with private health insurance, the proportion who paid nothing out of pocket for birth control pills rose from 15% in 2012 — before the federal requirement took effect — to 67% in 2014 — after it was implemented.
In addition, while the Great Recession appears to have triggered the changing fertility patterns, the recovery has not produced more births to young women – the first three months of 2016 saw overall U.S. fertility rates fall to their lowest levels in recorded history, and between 2014 and 2016, the births to women under the age of twenty-five continued to fall.
Overall, greater use of contraception accounts for a large portion of the drops in unintended pregnancy, though individual state rates continue to vary substantially. The Guttmacher Institute concludes that both more use of contraception and greater use of more effective forms of contraception contribute to the changes; Pew, looking at just teen births, attributes a greater role to more effective forms of contraception. The most effective forms of contraception require a prescription and can be expensive. ACA mandates for their coverage make them accessible to a larger group of women, and Guttmacher ties at least some of the regional variations to insurance and Medicaid coverage. The declines in unplanned pregnancies have had beneficial effects on families, including increasing the percentage of births within marriage for the first time in decades and reducing the percentage of births to teens. Changes to the ACA mandate may reverse the recent trends, which have finally seen poorer women adopt some of the techniques that have long been available to better off women.
— June Carbone, Professor and Robina Chair in Law, Science and Technology, University of Minnesota, School of Law