By Katie Kerwin McCrimmon
A Colorado birth control program that has cut unintended pregnancies and abortions by nearly half since 2009 will stay alive for at least one more year thanks to $2 million in donations from private foundations.
The rescue of the highly-touted program comes after Republican lawmakers earlier this year killed a bill that would have provided $5 million in public funding for IUDs and other long-acting reversible contraceptives for low-income teens and young women. Colorado health officials estimate that the IUDs and other devices have saved at least $79 million in Medicaid costs for unintended births, but some opponents claimed that IUDs are abortifacients and refused to approve funding in the Republican-controlled Senate.
From mid-2009 to mid-2015, the Susan Thompson Buffett Foundation funded a pilot effort in Colorado with a $25 million grant. The Colorado Family Planning Initiativeprovided teens and young women with more than 36,000 free or low-cost IUDs or other long-acting birth control devices.
The newest data from the Colorado Department of Public Health and Environment show a 48 percent drop statewide in unintended pregnancies and abortions. Births among teens ages 15 to 19 fell from 6,201 in 2009 to 3,361 in 2014, while abortions declined from 1,711 to 939 in the same period.
The 48 percent reduction is up from a 40 percent drop through 2013.
Teens and young women get the free and low-cost devices at 68 family planning clinics across Colorado. The Affordable Care Act requires health insurance companies to pay for birth control, but some plans don’t cover implants since they’re more expensive up front. State Medicaid programs increasingly are covering IUDs and implants, but patients who are uninsured or don’t qualify for Medicaid often need help paying for birth control. The Colorado Family Planning program has been essential to safety-net clinics. Managers used the grant funds to pay for the devices in advance, then worried about reimbursements later.
The lack of public funding for the IUD program in Colorado comes as health leaders across the country are racing to expand access to long-acting contraceptives. The most popular device in Colorado now is an arm insert called the Nexplanon. About 50 percent of Colorado patients request that device since it’s so easy for doctors to insert. Other patients opt for traditional vaginal IUDs known as the ParaGard and the Mirena.
At least 15 states are working on some kind of boost to the use of IUDs or implants, according to leaders at the Association of State and Territorial Health Officials. A study from the U.S. Centers for Disease Control and Prevention earlier this year found that more teens are waiting to have sex and that Colorado is far ahead of the rest of the country in teen use of long-acting contraceptives.
As funding withered for the Colorado program at the end of June, some county health agencies were creating waiting lists, while others were trying to stockpile IUDs for the neediest patients.
This week, foundations rode in to the rescue with pledges to keep the program alive until the middle of next year. Their money will pay for an additional 6,000 devices.
“I feel fortunate that we have that community to turn to in what I considered an emergency situation,” said Dr. Larry Wolk, Colorado’s top health official.
While he celebrated the program’s survival through private funding, Wolk said that he and Democratic Gov. John Hickenlooper plan to keep fighting for taxpayer support. The governor will include funding for the birth control program in Colorado’s budget, Wolk said.
“We’ve made the case for a public benefit and we need public investment,” said Wolk, chief medical officer and executive director of the Colorado Department of Public Health and Environment. “That’s where ultimate sustainability lies.”
IUDs and other long-acting forms of contraception cost more initially than birth control pills, but they last from three to 10 years. The up-front cost for an implant or IUD is about $325 for clinics that get federal discounts or about $800 to $900 at full cost. By comparison, the discounted price for birth control pills is about $23 a month and the full price is about $70 a month. Without help affording birth control, some teens struggle to pay the initial cost of an implant. If they’re on the pill, they must get refills every couple of months and have to remember to take the pill every day. Imperfect use cuts effectiveness.
Since the Colorado legislature torpedoed funding, the evidence of success has only improved.
“We’re going to go back with our even more remarkable results,” said Wolk, a pediatrician with a specialty in treating teens.
County health officials celebrated the news that the program will survive for at least one more year.
In Jefferson County, Colorado’s fourth largest, health officials started creating waiting lists earlier this summer to be sure that they would have some IUDs on hand each month.
Kelly Conroy, nurse manager for clinic services for Jefferson County Public Health, said the program’s popularity is surging.
“The word is definitely getting out. We have a lot of patients who come in and specifically ask for the devices by name. A lot of it is word of mouth, friends and family. A friend will be on Mirena (an IUD). They will know which one they want — hormonal or non-hormonal. People are coming in way more educated,” Conroy said.
Since Conroy and her colleagues knew funding from the state was in jeopardy, they started hunting for funds elsewhere to be sure they could have IUDs and other devices on hand. They worked to bill insurance companies or Medicaid for devices they were implanting so they could recoup as much money as possible to pay for other devices. On average, she said, patients were having to wait about three weeks.
Now health officials should be able to stop creating a waiting list and provide devices for those who want them right away.
“We’re absolutely thrilled,” Conroy said. “We are a safety net for a lot of clients who are uninsured and underinsured. We don’t want to put any obstacles in their way. We certainly don’t want anyone to have an unintended pregnancy.
“Our ultimate goal is empowering not just women, but families with the ability to know that they can make the choice (to have a baby) when they’re ready,” Conroy said.
Evidence shows that cutting teen pregnancy rates also reduces high school dropout rates. Along with direct savings for Medicaid — births costs about $11,000 each — supporters of the IUD program liked the idea that better birth control can dramatically improve outcomes for girls. Those who get a good education go on to earn higher incomes, thus reducing poverty rates and cutting reliance on Medicaid and other programs for people living in poverty.
Health officials across the country have been meeting with Colorado leaders for about a year to learn about the IUD program.
“Other states are very excited about the results from Colorado,” said Lisa Waddell, chief of community health and prevention for the Association of State and Territorial Health Officials. “All states are results-oriented and want the best outcomes for adolescents, women and families.
“There’s a tremendous amount of energy around learning from Colorado and other states and looking at that return on it investment. What does it take (to start this program)? How do you leverage different partners?”
Waddell said many states are much more interested in IUDs for several reasons. They’ve seen the success in Colorado and are paying more attention to long-term benefits, not just up-front expenses. IUDs are much safer now after having had a tarnished reputation decades ago. The Affordable Care Act requires coverage for birth control, and research is showing that IUDs and other long-acting devices work much better than other birth control methods. At the same time, increased transparency in health costs is driving much greater attention to getting the best bang for the buck.
“In the last couple of years, there’s been this convergence of this best evidence coming out and this drive to make sure we’re purchasing the best health care,” Waddell said. “These are highly effective devices…You’re seeing a systems change.”
According to the CDC, the failure rate with IUDs and other long-acting devices is less than 1 percent, while birth control pills fail at a 9 percent rate and condoms don’t work 18 percent of the time.
Nationally, only 7 percent of women use IUDs or other long-acting devices.
Waddell’s group represents Dr. Wolk and his colleagues. Because of the extensive interest in the issue, they convened a “learning community” on long-acting contraception. The group met in person last year and holds regular virtual sessions.
Six states that have already changed their policies on long-acting birth control led the way. They are Colorado, Georgia, Iowa, New Mexico, Massachusetts and South Carolina. Six more states are slated to join the group shortly and leaders from the 12 states will meet in person again in October.
Waddell says 50 percent of pregnancies in the U.S. are unintended. One of the programs that has been most popular in other states is to offer women who have just given birth an IUD or other long-acting device while they’re still in the hospital after having had a baby. Medicaid will pay for those devices and health officials say it makes great sense to implant the device while the woman is in the hospital.
“They’re generally pretty motivated to get a contraceptive device that would allow their body to recover,” Waddell said.
Along with postpartum use of IUDs, South Carolina health officials have been focusing on using long-acting birth control as a method for driving down stubbornly high infant mortality rates. Premature births that can put babies in jeopardy are higher among teens and others who get pregnant unexpectedly.
Driving down the number of unwanted pregnancies should also result in fewer infant deaths, Waddell said.
Consumer demand is also central to the growth in popularity of IUDs and other long-acting devices, said Ellen Pliska, director of family and child health programs for the health officials’ group.
“Since the momentum has gotten started, more women are aware that it’s a viable option. We’ve been hearing that word of mouth has been incredible, particularly among teens. If one ‘influencer’ gets involved, they’re going to tell everybody about it,” Pliska said.
Among the groups that so far have pledged support for the Colorado effort are:
· The Ben and Lucy Ana Walton Fund of the Walton Family Foundation
· Buell Foundation
· Caring for Colorado Foundation
· Chambers Family Fund
· The Colorado Health Foundation
· The Colorado Trust
· Community First Foundation
· The Community Foundation Serving Boulder County
· Global Health Foundation
· Kaiser Permanente Colorado
· The Women’s Foundation of Colorado
Wolk said some of the money will be used to expand training so that many more providers will know how to insert IUDs and other devices.
While Wolk supports efforts to give IUDs to teens and women who have already had babies, he thinks it’s much better to reach out to them and provide the most reliable contraception before they get pregnant the first time. He’d like to set up a system comparable to the public funding for vaccines, which, like IUDs, cost a lot for providers to keep on hand. A steady stream of funding would provide two options. If a woman has private or public insurance, providers can give them IUDs and get reimbursed. If they don’t have coverage and still want long-acting contraception, they can still get help.
“We’d have (devices) for uninsured on one side and insured on the other,” said Wolk. “That’s my vision.”