Available online 11 February 2026, 103112

Expanding health insurance can either increase or decrease pregnancies and births, depending on how it affects access to contraception and the financial costs of childbearing. I study the Affordable Care Act’s Medicaid expansion using difference-in-differences models and state-level data on contraceptive provision, births, and abortions, synthesizing analysis of these outcomes to distinguish the role of subsidized contraception. The expansion led to a substantial increase in contraceptive provision, particularly for short-acting hormonal methods. Teen birth rates fell significantly by 5%, a reduction that owes to increased parental eligibility, while effects on overall birth rates are not distinguishable from zero. Estimated effects on abortion are imprecise but suggestive of reductions for teens. Simulations based on contraceptive provision imply that subsidized contraception led to reductions in the pregnancy and birth rate of approximately 1% to 2%. These findings indicate that Medicaid’s contraceptive subsidies modestly reduced pregnancies, abortions, and births, but also suggest that financial barriers to reproductive health care are not a primary driver of fertility behavior overall.

Contraception

Fertility

Public health insurance

© 2026 The Author. Published by Elsevier B.V.