Data Sources

Our data included all pharmacy and medical claims from January 1, 2011, to December 31, 2014, under public fee-for-service family-planning insurance programs in Texas. We also accessed all claims for childbirth covered by Medicaid using unique identifications for two cohorts of women who use injectable contraceptives. We retrieved data regarding women’s counties of residence from the eligibility and billing system. We also used administrative records from the Texas Department of State Health Services and from Planned Parenthood to categorize counties as either having or not having providers affiliated with Planned Parenthood at the beginning of the study.

In keeping with the eligibility criteria of the programs, all women who were receiving services were fertile, legal Texas residents between the ages of 18 and 44 years with incomes at or below 185% of the federal poverty level. Using billing records, we identified the women on the basis of the presence of a medical claim that included one or more of the Current Procedural Terminology codes for a valid family-planning service or a pharmacy claim that included an appropriate national pharmacy code for a contraceptive method. For each quarter, we categorized contraceptive methods into three groups: long-acting reversible contraceptives (LARC; contraceptive implants and intrauterine devices), an injectable contraceptive (depot medroxyprogesterone acetate), and short-acting hormonal methods (oral contraceptive pills, transdermal contraceptive patches, and contraceptive rings). We then separated each set of claims into those that were filed in counties that had a Planned Parenthood affiliate in 2011 and those that were filed in counties without such an affiliate at that time.

Of the 254 counties in Texas, only 23 had clinics affiliated with Planned Parenthood. We first compared the group of counties that had a Planned Parenthood–affiliated clinic with those that did not with respect to the number of women between the ages of 18 and 44 years who had household incomes that would qualify them for the program (≤185% of the federal poverty level), the number of childbirths to legal residents covered by Medicaid, and the proportion of women between the ages of 18 and 44 years who did not have health insurance. We obtained these indicators from the American Community Survey, using 5-year averages centered on 2012, and from Texas Medicaid billing records.6

We also assessed the quarterly volume of program claims for contraceptives, according to method, for counties with Planned Parenthood affiliates and those without such affiliates during the 16 observed quarters (8 before and 8 after the exclusion). Among women using an injectable contraceptive in counties with Planned Parenthood affiliates and those without such affiliates in the fourth quarters of 2011 and 2012, we also measured the proportion of women who returned to the program for any service, who returned for an on-time subsequent injection, and who underwent childbirth covered by Medicaid during the following 18 months.

Study Oversight

The institutional review board at the University of Texas at Austin determined that the study was exempt from human-subjects review; therefore, no informed consent was required. The authors designed the study, and the funder had no role in the analysis or interpretation of the data, the writing of the manuscript, or the decision to submit the manuscript for publication. All the authors vouch for the integrity and completeness of the data and analyses.

Statistical Analysis

We used the difference-in-differences method and regression discontinuity to compare the number of claims for each contraceptive method in counties with Planned Parenthood affiliates and in those without such affiliates before and after the exclusion on January 1, 2013. This approach accounted for the influence of time-invariant differences between counties with affiliates and those without affiliates and for statewide trends over time that could influence service provision.7

On the basis of the quarterly number of claims for each contraceptive method, we calculated the difference in provision between counties with Planned Parenthood affiliates and those without such affiliates for each quarter and each method. We fitted local linear regression models to summarize the differences in volumes for each method.8 In these models, we allowed the slopes and intercepts to vary before and after the exclusion by using an indicator that was equal to 1 after the exclusion and 0 before the exclusion and an interaction between this indicator and time. We estimated the discontinuity in the differences at the point of the exclusion with the indicator for post-exclusion. Finally, we computed the relative change in provision by dividing this discontinuity by the estimated provision in counties with Planned Parenthood affiliates at the point of exclusion (as estimated by means of linear regression).

In order to assess changes in the rates of contraceptive continuation and subsequent childbirth covered by Medicaid associated with the exclusion of Planned Parenthood affiliates, we focused on women who were using an injectable contraceptive. Unlike other forms of contraception, this method requires regular provider visits and has a relatively short span of contraceptive effectiveness (3 months). These features of the method allowed us to observe changes in the rate of childbirth within 18 months after the claim, which would not be possible with LARC methods (which last longer) or oral contraceptive pills (which may be dispensed for a single month or up to 12 months per claim).

We included two cohorts in our comparison. The first cohort received an injection in the fourth quarter of 2011 and thus had a year to continue receiving services before the exclusion of Planned Parenthood affiliates took effect. The second cohort received an injection in the fourth quarter of 2012 and thus was subject to the influence of the exclusion before the due date for the next injection. For each cohort and county group, we computed the proportions of women who received a service covered by the program in the following quarter, who received an injection in that quarter, and who underwent childbirth covered by Medicaid in the following 18 months. We calculated the difference in differences between the two cohorts and groups of counties.

In order to determine the probability that women would return to the program during the next quarter, would receive an on-time subsequent injection, and would undergo childbirth covered by Medicaid within 18 months, we used generalized linear models for the response frequencies in the respective tables. In each model, we used an indicator equal to 1 after the exclusion and 0 before the exclusion, an indicator equal to 1 for the group of counties with Planned Parenthood affiliates and 0 for those without Planned Parenthood affiliates, and an interaction between these indicators to provide a direct statistical test of the difference in differences in the probability of each outcome. The assumed distribution of the frequencies (either binomial or Poisson) did not substantially change the significance of the tests. We report P values from the Poisson models because they were larger and thus more conservative.