Unintended consequences of health insurance: Affordable Care Act's free contraception mandate and risky sex

摘要

Abstract Health insurance is a primary driver of rising medical expenditures. Economic theory suggests that insurance induces an increase in risky behaviors, but previous empirical evidence is mixed. I use a mandate in the Affordable Care Act in which contraceptives were covered at zero cost to consumers to test for unintended effects of insurance on risky sex. Leveraging mandated zero cost‐sharing for contraception and pre‐policy insured rates as a measure of treatment intensity, I provide evidence that this 2012 policy reduced fertility but caused unintended consequences: a decline in condom use and a subsequent increase in sexually transmitted infections (STIs). I discuss shortcomings of controlling for nonparallel pre‐trends using state‐trends, and I suggest an alternative to control for pre‐trends directly in the context of dose‐response difference‐in‐differences. Finally, estimates based on the 2010 dependent coverage mandate indicate health insurance provides an overall net positive effect on insurance and STI prevention.