Impacts of British Columbia's free contraception policy on out-of-pocket payments and contraception costs: an interrupted time series analysis with other provinces as controls

BackgroundCost is a key driver of inadequate, unequal contraception access. Without a national public pharmacare plan, Canadians use a mix of private or public prescription insurance plans to pay for drugs or devices. High deductibles, copayments, and/or exclusion of contraception from insurance formularies can result in access gaps. In April 2023, the western-most Canadian province (British Columbia (BC)) introduced universal, first-dollar coverage for prescription contraception. We estimated the effect of this free contraception policy on prescription contraception payer type and costs. MethodsUsing a national prescription database, we measured the monthly proportion of all dispensed contraception to reproductive-aged females (15-49y) in BC according to majority payer (out-of-pocket (patients), private, and public) and estimated costs per capita by payer type. We used a controlled interrupted time series analysis to compare outcomes in BC to expected trends if the policy had not been introduced and compared with synthetic controls derived from other Canadian provinces. FindingsPre-policy in BC, 39% of prescription contraception was paid out-of-pocket, 49% by private insurance, and 12% by public insurance. When BCs policy was introduced, out-of-pocket payments immediately decreased (-24.3% 95%CI -24.8 to -23.7). At 2-years post-policy, 5.4% (95% CI 4.5% to 6.4%) of on-formulary contraceptives were paid out-of-pocket and 8.4% (7.5% to 9.3%) was paid by private insurance. Total monthly per capita out-of-pocket costs in BC were 86% lower than expected if the policy had not been implemented. Time trends pre-and post-policy were similar in BC and controls. InterpretationUp to 40% of contraceptives were previously paid out-of-pocket in BC compared to prior studies showing 20% of all drugs in Canada were paid out-of-pocket. Contraception may be uniquely sensitive to inadequate insurance coverage as with a mix of public and private drug plans. The implementation of a public drug plan providing universal, first-dollar coverage policy for contraception substantially reduced out-of-pocket payments for dispensed contraception. Key pointsO_LIBefore policy implementation, 40% of contraception prescriptions in BC were paid out-of-pocket - double the national average for all prescription drugs - highlighting major gaps in coverage and inequitable access to contraception. C_LIO_LIA universal, first-dollar contraception policy reduced out-of-pocket costs by 86% within two years, with only 5% of on-formulary contraceptive prescriptions still paid out-of-pocket C_LIO_LIFirst-dollar public coverage effectively removes financial barriers and supports equitable access to contraception, providing timely evidence to inform national pharmacare implementation. C_LI