The impact of medicaid expansion on contraceptive use in neighborhoods of racialized socioeconomic deprivation and privilege

Objectives Health outcomes in the US vary by neighborhoods, but Medicaid research expansion may miss local heterogeneity. We assessed if state Medicaid expansion impacted contraceptive use differentially by neighborhood-level context. Methods Using restricted data from the National Survey of Family Growth, we identified state Medicaid expansion status in January 2014 and compared pre-expansion (2011–2013) data with post-expansion data. Neighborhood racialized socioeconomic deprivation/privilege was defined using respondents’ census tract Index of Concentration at the Extremes (ICE). We used a difference-in-differences approach with multivariable linear probability and multinomial logistic regression models with region fixed effects to estimate the impact of Medicaid expansion on contraceptive use and method type, by neighborhood ICE tertile. Results Of 13,224 respondents, 45% lived in non-expansion states, and a larger proportion of respondents lived in neighborhoods of concentrated deprivation. In adjusted models, living in an expansion state was associated with significant increases in contraceptive use, reduction in short-acting method use, and increases in use of long-acting reversible contraception (LARC). By neighborhood context, contraceptive use significantly increased in the most deprived neighborhoods (8.1 percentage points (95% CI, 0.6–15.6) by 2015–2017). Use of no method or barrier/coital methods declined 17.5 percentage points (95% CI, -26.3– -8.7) and LARC use increased by 7.6 percentage points (95% CI, 0.6–14.7) by 2017–2019. The impact of expansion was not significant in the middle or most privileged neighborhoods in fully adjusted models. Conclusions Changes in contraceptive use from Medicaid expansion were largest in neighborhoods of concentrated deprivation. Further expanding Medicaid would facilitate access to the full range of reproductive healthcare and advance population health equity. Health outcomes in the US vary by neighborhoods, but Medicaid research expansion may miss local heterogeneity. We assessed if state Medicaid expansion impacted contraceptive use differentially by neighborhood-level context. Using restricted data from the National Survey of Family Growth, we identified state Medicaid expansion status in January 2014 and compared pre-expansion (2011–2013) data with post-expansion data. Neighborhood racialized socioeconomic deprivation/privilege was defined using respondents’ census tract Index of Concentration at the Extremes (ICE). We used a difference-in-differences approach with multivariable linear probability and multinomial logistic regression models with region fixed effects to estimate the impact of Medicaid expansion on contraceptive use and method type, by neighborhood ICE tertile. Of 13,224 respondents, 45% lived in non-expansion states, and a larger proportion of respondents lived in neighborhoods of concentrated deprivation. In adjusted models, living in an expansion state was associated with significant increases in contraceptive use, reduction in short-acting method use, and increases in use of long-acting reversible contraception (LARC). By neighborhood context, contraceptive use significantly increased in the most deprived neighborhoods (8.1 percentage points (95% CI, 0.6–15.6) by 2015–2017). Use of no method or barrier/coital methods declined 17.5 percentage points (95% CI, -26.3– -8.7) and LARC use increased by 7.6 percentage points (95% CI, 0.6–14.7) by 2017–2019. The impact of expansion was not significant in the middle or most privileged neighborhoods in fully adjusted models. Changes in contraceptive use from Medicaid expansion were largest in neighborhoods of concentrated deprivation. Further expanding Medicaid would facilitate access to the full range of reproductive healthcare and advance population health equity.