Colorado's free IUD program is one of the most successful public health measures of all time, but it's as controversial as it is effective.
For the past six years, Colorado has been the country’s secret birth control utopia, conducting one of the largest and craziest contraceptive experiments in history: The Colorado Family Planning Initiative.
In an effort to decrease unwanted pregnancies in teenagers and poor women, study participants in those groups were offered free long-acting birth control methods such as intrauterine devices (IUDs) and implants as state officials probed the question: Would women still choose to use these contraceptive methods over more common ones like the pill or condoms, even if they weren’t free?
The plan turned out, and in a big way. Following program implementation, the birth rate among teenagers across the state plunged by 50 percent from 2009 to 2017, while their rate of abortions fell by a the same rate, according to the Colorado Department of Public Health and Environment. There was a similar decline in unwanted pregnancies for another particularly vulnerable group of women: those under 25 who had not finished high school.
“Our demographer came into my office with a chart and said, ‘Greta, look at this, we’ve never seen this before,’” said Greta Klingler, the family planning supervisor for the public health department to the New York Times in a 2015 article on the program's success. “The numbers were plummeting.”
This is a huge deal for two reasons. First, a 50 percent decrease is no joke. Rarely is a health measure so universally effective at setting out to do what it was meant to, which, in this case was curb unplanned pregnancies. Second, these changes were particularly conspicuous in the poorest, most uneducated areas of the state, cities where jobs are scarce and many disadvantaged young women have unplanned pregnancies.
This success with free IUDs and implants proves some glaring facts: When people are provided with free or affordable reproductive healthcare choices, poverty and inequality can be dealt with in a direct, efficacious way, and we can give people a chance at life they might not have had otherwise.
More broadly, properly implemented free birth control programs can change both individual lives and improve the wellbeing of society.
Take the example of Michelle, a young woman who participated in the study from Montrose, Colorado. “All the women in my family had kids young,” she told us. “My mom wanted to be a doctor, but when she had us, she knew she wouldn’t be able to afford medical school or have time to go, so she cut hair for money instead. Her sister had my cousin when she was 18 and she’s still in the same town she was born in. I love them but I was afraid I’d turn out like them. I feel like having my IUD made me feel like I could accomplish something, then have a family when I’m ready.”
The program is credited with helping a huge number of young women like Michelle wait until they’re a little older to have children, giving them time to finish their education and get a foothold in the working world first. And while teen pregnancy is on the decline nationwide, an estimated 37 percent of all pregnancies in the U.S. are unintended, something that can have serious health ramifications for mother and baby, as well as high economic and social costs for the new family.
By and large, the financial impact of unintended pregnancies are the most significant for low-income women with poor educational achievement. According to a 2008 nationwide study by the Guttmacher Institute, unplanned pregnancies were five times as likely for those at or below the federal poverty level, meaning poor, young families often don’t have the monetary resources to give a new child or her mother the healthcare, education and attention they need.
It’s no difference in Colorado. Findings from the federal government’s Consumer Expenditure Survey reveal that the average cost to raise a child in Colorado from infancy to age 18 in 2014 was $261,000 — not an insignificant sum for a family below the federal poverty line … or even on it … or even right above it. Even when you’re prepared and financially able to have a child … that’s still an absurd amount of cash.
And then there are economic consequences of unplanned pregnancies for taxpayers: A 2011 study from the Brookings Institution found that healthcare costs for unintentional births total about $12 billion in taxpayer dollars each year through government-subsidized medical-care programs like Medicaid and Children’s Health Insurance Program (CHIP). That means you, the taxpayer, are forfeiting a portion of your income each year to support the astronomical costs incurred by young women who just weren’t emotionally or financially ready for children.
Looking past the personal and societal economic consequences of unplanned pregnancies, studies have also found that they can negatively impact educational attainment for mothers. This is something Michelle mentioned in her description of her mother’s changing career trajectory, but also something much observed in the ivied world of academia; a 2010 paper from Boston University suggests that unplanned pregnancies and births can be harmful to a woman’s economic status and income, and can reduce the probability of labor-force participation by as much as 25 percent.
This potential compromisation of societal productivity is something Isabel Sawhill, an economist at the Brookings Institution, is very alarmed by, simply because it’s so preventable. In her book “Generation Unbound: Drifting Into Sex and Parenthood Without Marriage,” she makes the case that young, unwanted pregnancy is a major driver of socioeconomic inequality and the best tool we have to prevent it is affordable, long-acting birth control.
“If we want to reduce poverty, one of the simplest, fastest and cheapest things we could do would be to make sure that as few people as possible become parents before they actually want to,” she writes.
Well … Viva la free IUD.
But poverty and missed educational opportunities aren’t the only consequences suffered by a lack of free or affordable birth control for young women; women who unintentionally become pregnant have the highest rate of abortions as well.
Regardless of what your stance on abortion is, the following numbers are significant. Women who took part in Colorado’s free contraceptive program had a titanic 42 percent drop in abortion rate, making it clear that easily accessible birth control neutralizes the need for abortions at all. A separate study published in the New England Journal of Medicine found that sexually active women ages 14-19 who were using IUDs or implants underwent 25 percent less abortions than their counterparts who were not using these methods. Those numbers sure look like a powerful case for making birth control free to everyone.
Not all birth control is created equal though. IUDs and implants are miles more efficacious at reducing unplanned pregnancies than cheaper, more common birth control options like condoms or the pill.
“The difference in effectiveness is profound,” said Dr. Jeffrey Peipert, a professor of obstetrics and gynecology at Washington University in St. Louis, again to the New York Times. The failure rate for the pill was about 5 percent, compared with less than 1 percent for implants and IUDs. The latter are popular and effective because, unlike the pill or condoms, they don’t require conscious thought or planning to work; you can zone out, drool pouring from your face in the neon glow of your Netflix screen, and not get pregnant.
This is particularly salient considering that the CDC estimates that 62 percent of women of reproductive age are currently on the pill, and just over half of women use condoms to prevent pregnancy. That means that while these two methods are more popular, they don’t necessarily work better at preventing pregnancy. This is one of the most valuable lessons learned from Colorado’s IUD study, that we should be focusing on making long acting contraceptives, not condoms or the pill, more affordable for young women.
And despite the fact that older models of IUDs had disastrous results, IUD technology has come a long way. Just last fall, the American Academy of Pediatrics published guidelines that for the first time singled them out as a “first-line” birth control option for adolescents, citing their “efficacy, safety and ease of use.” Good thing that, thanks to the program, about 20 percent of women ages 18 to 44 in Colorado now use a long-acting method.
The surge in Colorado has far outpaced the growing use of such methods nationwide, which answers the study’s initial probe: women will absolutely chose these methods over others.
So, that answers that. But we still had an aching question: If free birth control is so effective, why haven’t programs like these been implemented before?
In short, because there was no precedent; rather, the Colorado study is the precedent. No other study has shown that free long-acting contraceptives are so effective, because no other study like this one has been allowed to take place.
This has largely been a funding issue; if there is no precedent, there’s not a good argument for private investors or the government to spend millions of dollars on supplies and medical care in order to make them free. That’s why the Colorado study is so unique; it had significant backing from a private source, the Susan Thompson Buffet Foundation. Named for the billionaire investor Warren Buffet’s late wife, it floated the contraceptives and medical care young Colorado women in the program needed for six years.
But despite the efficacy of these methods and the overwhelming success of the program, funding is running out to keep it afloat. The hope was that the state legislature would help the young women of Colorado to live better, more economically successful lives by voting to fund the program itself, but the Republican-run legislature decided against it.
Why? Because it benefits opponents of free contraceptives to keep sex dangerous in the hope that danger will stop girls and women from having sex in the first place. This was clear in the debate over the program’s funding.
“I hear the stories of young girls who are engaged, very prematurely, in sexual activity, and I see firsthand the devastation that happens to them,” Republican state Rep. Kathleen Conti argued. “I’m not accrediting this directly to this program, but I’m saying, while we may be preventing an unwanted pregnancy, at the same time, what are the emotional consequences that could be coming up on the other side?”
Similarly, some religious conservatives believe that IUDs are forms of “abortifacients,” even though that’s at odds with the available science. They’d prefer the devices not be used and they certainly don’t want to pay for them indirectly, whether it’s through taxes or through insurance premiums.
Plus, argue opponents of free birth control, the program is redundant now that Obamacare offers “free” birth control.
… Except it doesn’t. Obamacare does not offer free birth control. Obamacare requires that insurance plans cover birth control without a copay, but you either have to buy the insurance or earn it as an employment benefit in order to get that coverage. That’s not cheap. Obamacare insurance plans can run anywhere between $200-$300 per month or more. As a result, many of the young women and girls who are eligible for the Colorado program don’t have insurance or the money to get it. For women without insurance, both IUDs and hormonal implants can cost up to $800 to insert (not including the costs of the doctor’s exam).
Nevertheless, miraculously, the program was able to secure funding through 2016. But after that, whether Colorado’s young women will have the same access to birth control they have for the last six years is a total crapshoot. And that’s something that should concern you if you’re a fan of the following things: progress in women’s reproductive rights, empowering young women with life options, and giving them a chance at escaping poverty.
That’s all the more reason to keep long-acting contraceptives like IUDs and implants free, and as Colorado’s example proves, to keep programs like the Colorado Family Planning Initiative afloat. How can you do this? Not easily; you have be willing to play the legislative game by electing officials to Colorado’s government who’re willing to fight for women’s reproductive rights. Short of that, there’s always private funding, petition signing, Kickstarter-ing, writing to create awareness and good ol’ fashioned lobbying. None of this is quick or effortless to do, but as the data has shown, it’s a lot easier than dealing with the personal and societal burden of unplanned pregnancies.
Because when you have a large population of women who’re capable of choosing when to start a family like you do in Colorado, you also have a large population of people willing and ready to contribute productively to society in ways that they’ve always dreamed of doing. That’s a big effect for such a small change, and in today’s environment of ever-changing public health measures, that’s a rare, really good thing.