Fall 2019 Journal: Providing Free Contraceptives For Young People – Lessons From Colorado

October 7, 2019 bppj Health, Reproductive Justice, Uncategorized 0

This article is the first article featured in our Fall 2019 journal. For the complete journal, please see the “Journal Archive” tab above.

by Devan Shea

Edited by: Fiona McBride and Annie McDonald

As a highly effective method of pregnancy prevention, long-acting reversible contraceptives (LARCs) have recently become a critical component of reproductive justice and family planning programs for adolescents in the United States. However, LARC promotion must be viewed in the context of reproductive coercion and oppression of low-income and minority communities in the States. This article discusses successes to LARC programs, using the Colorado Family Planning initiative as a case study, while also providing recommendations to ensure that programs are balanced with patient-centered care and a respect for reproductive autonomy.

Introduction

Long-acting reversible contraceptives (LARCs) are the most effective, non-permanent methods for pregnancy prevention currently available. [1] LARCs are a critically important piece of the contraceptive method mix, providing a highly reliable, safe, and reversible option for long-term prevention. Adolescents and young people are thought to benefit especially from LARCs, [2] and a growing number of U.S. states have implemented LARC promotion programs aimed at adolescents and young people who seek services in publicly-funded clinics. [3]

However, this enthusiasm for LARCs warrants caution in the broader context of reproductive oppression and coercion. [4] Communities of color, low-income individuals, and young people in the United States have been historically targeted by coercive population policies and programs, including forced and coerced sterilization and LARC use. For these communities, LARCs carry a dark history.

Public investment in LARCs will benefit millions of adolescents and young people. The challenge for policymakers is balancing the public policy goal of expanding access to a highly effective but costly method of pregnancy prevention with the reproductive justice goal of ensuring young people have the resources, knowledge, and power to make decisions about their reproductive futures. [5]

To uncover the elements of a successful, patient-centered, rights-based LARC access program, I will review evidence showing that removing financial barriers to LARCs improves access for adolescents and young people, with a special focus on the Colorado Family Planning Initiative. I will also discuss several worrying elements of LARC policies and programs, which could unintentionally harm young people by restricting their autonomy and reproductive rights. Using a reproductive justice framework, I will offer recommendations for policymakers who wish to improve access to LARCs for adolescents and young people. If properly balanced with patient-centered care, comprehensive services, and respect for reproductive autonomy, publicly-funded LARC programs will help young people meet their sexual and reproductive health goals.

Background: LARCs and Adolescents

LARCs have been enthusiastically embraced by the reproductive health community as a first-line method for adolescents, recommended by both the American Academy of Pediatrics [6] and the American College of Obstetricians and Gynecologists. [7] LARCs include hormonal intrauterine devices (IUDs) and hormonal subdermal implants, effective for 3-7 years, and copper IUDs, effective for up to 12 years. [8]

LARCs are recommended as a first-line contraceptive method for adolescents because they have extremely low failure rates, are effective for several years, and require little maintenance. [9] However, LARCs remain inaccessible to many who might otherwise choose them. The high upfront cost of the device and insertion procedures; lack of awareness or accurate knowledge about LARCs and how they work; provider biases and misconceptions; clinic stock-outs; and lack of access to trained providers are all documented barriers. [10] Young people face additional challenges related to consent and confidentiality; provider biases and misconceptions about the suitability of LARCs for adolescents; and delays in LARC initiation. [11]

Publicly-Funded LARCs for Adolescents

Financial barriers are among the most significant impediments to LARC access for young people, especially those who are low-income, uninsured, or reside in low-resourced areas. Programs that lower the cost of providing LARCs in publicly-funded clinics have thus become an increasingly popular public policy intervention.

Growing evidence shows that reducing or removing financial barriers to LARCs increases levels of uptake, particularly among adolescents and young women, [12] and that increasing access to LARCs reduces adolescent pregnancy rates at the population level. [13] Indeed, research attributes the overall decline in pregnancy rates among adolescents in the U.S. since 2007 almost entirely to improved access to contraceptives, particularly highly effective contraceptives like LARCs. [14] By these measures, Colorado’s Family Planning Initiative is a paradigm for success in public health interventions designed to increase the use of LARCs.

Case Study: Colorado Family Planning Initiative

In 2007, a private donor invested $27 million in the Colorado state government to reduce unplanned pregnancies by expanding family planning services. In 2009, the Colorado Department of Public Health and the Environment (CDPHE) launched the Colorado Family Planning Initiative in Title X-funded family planning clinics across the state. [15] Title X of the Public Health Service Act provides federal funding for reproductive health services reaching low-income, uninsured clients.

The anchoring strategy of the initiative was to expand access to all contraceptive methods by removing cost barriers to the most effective methods, LARCs. Donor funding allowed clinics to purchase LARC devices at little to no cost and paid for provider training and capacity building in the clinics that provided them. [16]

According to the CDPHE, between 2009 and 2014 the initiative helped cut the unintended pregnancy rate by 40 percent for young women aged 15-19 and 20 percent for young women aged 20-24; and helped reduce birth rates and abortion rates by nearly half for young women aged 15-19, and by about 20 percent for women aged 20-24. [17] University of Colorado economists estimated that the program saved between $66.1 and $69.6 million in public program costs over the five year period. [18]

Several aligning factors made Colorado’s initiative a success. Two of these factors are especially relevant to policy makers: Title X and Medicaid expansion, which are critical sources of public funding for contraceptive services.

Title X clinics are vital sources of reproductive health care for many communities in the United States. According to the Guttmacher Institute, Title X-funded clinics serve 14 percent of all women who receive any contraceptive care, 25 percent of poor women receiving contraceptive services, and 36 percent of uninsured women receiving services. [19] Evidence from California suggests that Title X-funded clinics are associated with an increase in LARC use. [20] In Colorado, an already robust Title X network with a statewide model of reproductive health services facilitated the distribution of funds, expansion of programs, and growth of clinic capacity. [21]

However, the future of Title X is uncertain. The Trump administration issued new regulations for federal Title X family planning funding. [22] The regulations block funding to providers that also offer abortion services, and restrict abortion counseling and referrals, which Title X clinics were previously allowed to provide. [23] These restrictions could significantly reduce the number of providers that qualify for funding, with serious consequences for the communities that rely on Title X clinics for care, [24] such as the adolescents and young people served by Colorado’s Title X network.

Medicaid is also a major source of funding for providers who care for low-income communities. Medicaid accounted for 75 percent of total public expenditures on family planning in FY2015. [25] In Colorado, Medicaid proved significant for the success and sustainability of the Family Planning Initiative. [26] During the Initiative, the Affordable Care Act (ACA) was implemented, and Colorado expanded Medicaid. The ACA and Medicaid expansion together not only increased the population of insured patients, it facilitated a change in the business models of Title X clinics. [27]

Critically, the Family Planning Initiative dedicated program funding for technical assistance to support clinics as they navigated a new, post-ACA world. It supported providers to correctly bill payers, conduct enrollment outreach activities, and ultimately change their business model from “free” clinics to operations with diverse revenue streams comprised of multiple payers. [28]

LARCs and Reproductive Coercion

Colorado received national attention for its success at reducing the adolescent pregnancy rate and for the state’s projected cost savings in public program expenditures. [29] However, this success, like any family planning program aimed at low-income communities, should be met with caution. If not carefully designed, LARC promotion programs could invite bias and coercion.

Though Colorado garnered headlines for its program successes, the state’s basic approach is not unique: providing free, highly effective contraceptive methods to reduce adolescent pregnancy. Governments and advocates have long heralded family planning investment for its potential to lower fertility rates and thus reduce poverty and improve health, economic, and educational outcomes for poor women and their families. [30] These attitudes reveal a widespread acceptance of fertility control as a legitimate anti-poverty strategy.

However, the logic of this approach is unsettling in light of sterilization and population control policies that historically targeted communities of color and Native Americans. Evidence about the direct effect of early pregnancy and parenthood on educational and economic outcomes is unclear, [31] yet governments continue to invest in teen pregnancy prevention efforts as a poverty intervention. This line of thinking positions poor, young women, and their fertility as the source of a social problem, while overlooking the economic, social, and cultural institutions and public policies that perpetuate poverty and racism.

Coercive sterilization was practiced throughout the United States at least until the 1970s, [32] targeting women with disabilities or serious mental illness, and low-income women of color, especially Black, Latina, and Native women. [33] Reversible methods have also been wielded coercively. When the contraceptive, Norplant, was approved in 1990, some state lawmakers attempted to pass legislation that would incentivize or even mandate Norplant use among women who received public assistance. [34]

The targeted control of low-income women’s fertility continues today in insidious, and no less racialized, forms. For example, “welfare family caps”—state-level policies which deny benefits to families who have additional children while receiving public assistance—still existed in 17 states as of 2016. [35] Reproductive health policies and programs that emphasize “public costs averted” through pregnancy prevention—a success that Colorado’s initiative celebrated—further stigmatize low-income women who rely on public assistance programs to support themselves and their families.

LARC Promotion Pitfalls: Discrimination, Directive Counseling, and Removal

Publicly-funded contraceptive initiatives, particularly those centered around LARC methods, explicitly target populations at “high-risk” for unintended pregnancy (low-income young people and people of color). But Gomez, Fuentes, and Allina warn that targeting “high-risk” populations could lead to statistical discrimination, by “using epidemiologic data or previous clinic experiences to estimate a particular woman’s risk, without consideration of her unique history, preferences and priorities.”36 Black and Latinx people report experiencing racial discrimination when seeking reproductive health care; for instance, they are more likely to be pressured or advised to use contraceptives or restrict their fertility. [37]

Furthermore, directive counseling could undermine patient choice. By promoting LARC methods over other contraceptive measures or emphasizing the effectiveness of LARCs above other criteria for choosing a contraceptive, providers risk infringing on reproductive autonomy, especially for patients who belong to communities historically targeted for fertility control. [38]

Finally, access to LARC removal is of increasing concern to reproductive health and justice advocates. Patients face provider resistance when they wish to discontinue their LARC method early, while clinicians report mixed or negative feelings, even feeling they have “failed,” when a patient requests early removal. [39] Young people of color and low-income young people, whose fertility and childbearing are highly stigmatized, could be at particular risk of facing resistance from providers if they wish to discontinue their LARC method. [40]

The removal problem is also embedded in public policy. In a study of state-level Medicaid policies, Vela et al. found that most state payment policies did not cover the costs of counseling, device removal, or follow-up care. [41] Moreover, several state payment policies impose medical necessity restrictions on reimbursement for removal procedures. [42] Reimbursement restrictions effectively make early removal inaccessible for patients who rely on Medicaid. This is an unacceptable limit on reproductive autonomy. Young people who request early removal due to side effects, plans to use a different method, a desire to discontinue contraceptive use, or any other reason are effectively unable to do so in these states. [43]

Recommendations

The potential for bias and coercion is not theoretical, but rather ingrained in public policies and program designs, however well-intentioned. Bridging lessons from the Colorado Family Planning Initiative—which leveraged a large private donation into a sustainable, statewide public investment in LARC access—with careful analysis of some of the problematic foundations of publicly-funded family planning, I offer broad recommendations for policymakers who may wish to replicate Colorado’s success.

1) Policies and programs aiming to increase access to LARCs must include strategies to facilitate LARC removal. States should ensure that their Medicaid payment policies capture the costs of all LARC-related services, including follow-up care and removal, without restrictions. Pilot initiatives providing no- or low-cost services to uninsured and low-income communities should budget resources for early removal. Health departments should support safety-net providers to provide high-quality care and counseling that includes information about LARC removal procedures and costs. These added program costs may prove challenging to safety-net providers’ capacities and budgets. Therefore, reproductive health funders should consider increasing their investments. Still, providers with limited resources must consider the potential trade-off between providing truly comprehensive care and serving the greatest number of people.

2) Policy and program goals should center patients. LARC uptake as the “default outcome” [44] or the measure of successful service provision could fuel biased counseling. Policy and program goals should aim to improve LARC access and meet each patient’s sexual and reproductive health needs regardless of which contraceptive they choose. Policymakers should avoid setting potentially coercive and stigmatizing targets such as increasing uptake, lowering adolescent birth rates, and averting the “costs” of young people’s fertility. Anti-poverty strategies should tackle the holistic health, economic, social, and educational needs of young people, including young parents.

3) Policymakers and advocates should defend public funding for sexual and reproductive health. Title X and Medicaid are critical sources of funding for safety-net clinics and the patients that rely on them. Policymakers should push back against proposed Title X funding restrictions and defend public health insurance for low-income, disabled, and undocumented immigrant communities. In states that have not adopted Medicaid expansion, advocates should explore new advocacy tools, including grassroots ballot initiatives, following recent successes in Nebraska, Idaho, and Utah. State governments should also search for innovative and sustainable financing mechanisms to maintain and increase funding for safety-net sexual and reproductive health programs. 

4) Decision makers should engage young people in policy and program design. Policymakers should survey the community they intend to serve—especially young people—to understand specific unmet needs, goals, and values of clients, rather than inferring them only from population-level data. Policies and programs should facilitate respect for young people’s goals, values, and decisions about their reproductive lives and contraceptive choices. Program designers should link contraceptive access programs with programs that support pregnant and parenting young people, integrating reproductive health and social services.

Conclusion

Evidence shows that removing financial barriers to LARC methods dramatically improves access for young people. However, LARC promotion programs must properly balance public policy goals with reproductive justice values. Policymakers who are concerned about improving access to sexual and reproductive health for young people must approach LARC initiatives from a patient-centered and rights-based perspective. 

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Devan Shea (MPP ’19) is an alumna of the Goldman School of Public Policy.

Endnotes

  1. Amy Stoddard, Colleen McNicholas, and Jeffrey F. Peipert, “Efficacy and Safety of Long-Acting Reversible Contraception:,” Drugs 71, no. 8 (May 2011): 969–80, https://doi.org/10.2165/11591290-000000000-00000.
  2. American College of Obstetricians and Gynecologists, “Adolescents and Long-Acting Reversible Contraception: Implants and Intrauterine Devices,” Obstetrics & Gynecology, ACOG Committee Opinion No. 735, 131, no. 5 (May 2018): e130–39, https://doi.org/10.1097/AOG.0000000000002632.
  3. Throughout this paper, I will attempt to use gender-inclusive terms (e.g. adolescents, young people, communities, patients, clients, etc.) to describe people who may experience pregnancy or wish to prevent pregnancy, which includes cisgender women, transgender men, and non-binary and gender-nonconforming people. In some cases, I will use the term “women” to describe population and public health policies that specifically aimed to reach or target women or subgroups of women.
  4. Anu Manchikanti Gomez, Liza Fuentes, and Amy Allina, “Women or LARC First? Reproductive Autonomy And the Promotion of Long-Acting Reversible Contraceptive Methods,” Perspectives on Sexual and Reproductive Health 46, no. 3 (September 2014): 171–75, https://doi.org/10.1363/46e1614; Jenny A. Higgins, “Celebration Meets Caution: LARC’s Boons, Potential Busts, and the Benefits of a Reproductive Justice Approach,” Contraception 89, no. 4 (April 2014): 237–41, https://doi.org/10.1016/j.contraception.2014.01.027.
  5. Rachel Benson Gold, “Guarding Against Coercion While Ensuring Access: A Delicate Balance,” Guttmacher Policy Review 17, no. 3 (2014): 7; Gomez, Fuentes, and Allina, “Women or LARC First?”
  6. American Academy of Pediatrics, Committee on Adolescence, “Contraception for Adolescents,” Pediatrics 134, no. 4 (October 1, 2014): e1244–56, https://doi.org/10.1542/peds.2014-2299.
  7. American College of Obstetricians and Gynecologists, “Adolescents and Long-Acting Reversible Contraception: Implants and Intrauterine Devices.”
  8. Stoddard, McNicholas, and Peipert, “Efficacy and Safety of Long-Acting Reversible Contraception.”
  9. American College of Obstetricians and Gynecologists, “Adolescents and Long-Acting Reversible Contraception: Implants and Intrauterine Devices”; American Academy of Pediatrics, Committee on Adolescence, “Contraception for Adolescents.”
  10. Megan L. Evans et al., “Revolving Loan Fund: A Novel Approach to Increasing Access to Long-Acting Reversible Contraception Methods in Community Health Centers,” Journal of Public Health Management and Practice 23, no. 6 (2017): 684–89, https://doi.org/10.1097/PHH.0000000000000607; Gina M. Secura et al., “The Contraceptive CHOICE Project: Reducing Barriers to Long-Acting Reversible Contraception,” American Journal of Obstetrics and Gynecology 203, no. 2 (August 2010): 115.e1-115.e7, https://doi.org/10.1016/j.ajog.2010.04.017.
  11. American College of Obstetricians and Gynecologists, “Adolescents and Long-Acting Reversible Contraception: Implants and Intrauterine Devices”; Natasha Kumar and Joanna D. Brown, “Access Barriers to Long-Acting Reversible Contraceptives for Adolescents,” Journal of Adolescent Health 59, no. 3 (September 2016): 248–53, https://doi.org/10.1016/j.jadohealth.2016.03.039.
  12. Sue Ricketts, Greta Klingler, and Renee Schwalberg, “Game Change in Colorado: Widespread Use Of Long-Acting Reversible Contraceptives and Rapid Decline in Births Among Young, Low-Income Women,” Perspectives on Sexual and Reproductive Health 46, no. 3 (September 2014): 125–32, https://doi.org/10.1363/46e1714; Secura et al., “The Contraceptive CHOICE Project”; Gina M. Secura et al., “Provision of No-Cost, Long-Acting Contraception and Teenage Pregnancy,” New England Journal of Medicine 371, no. 14 (October 2, 2014): 1316–23, https://doi.org/10.1056/NEJMoa1400506.
  13. Ricketts, Klingler, and Schwalberg, “Game Change in Colorado”; Secura et al., “Provision of No-Cost, Long-Acting Contraception and Teenage Pregnancy.”
  14. Laura Lindberg, John Santelli, and Sheila Desai, “Understanding the Decline in Adolescent Fertility in the United States, 2007–2012,” Journal of Adolescent Health 59, no. 5 (November 2016): 577–83, https://doi.org/10.1016/j.jadohealth.2016.06.024.
  15. Colorado Department of Public Health and Environment, “Taking the Unintended out of Pregnancy: Colorado’s Success with Long-Acting Reversible Contraception,” January 2017, https://www.colorado.gov/cdphe/cfpi-report.
  16. Colorado Department of Public Health and Environment.
  17. Colorado Department of Public Health and Environment.
  18. Colorado Department of Public Health and Environment.
  19. Jennifer J Frost, “U.S. Women’s Use of Sexual and Reproductive Health Services: Trends, Sources of Care and Factors Associated with Use, 1995–2010” (Guttmacher Institute, May 2013), https://www.guttmacher.org/report/us-womens-use-sexual-and-reproductive-health-services-trends-sources-care-and-factors.
  20. Hye-Youn Park et al., “Long-Acting Reversible Contraception Method Use among Title X Providers and Non-Title X Providers in California,” Contraception 86, no. 5 (November 2012): 557–61, https://doi.org/10.1016/j.contraception.2012.04.006.
  21. Colorado Department of Public Health and Environment, “Taking the Unintended out of Pregnancy: Colorado’s Success with Long-Acting Reversible Contraception.”
  22. The rule is under temporary injunction pending legal challenges as of April 2019.
  23. Laurie Sobel et al., “Proposed Changes to Title X: Implications for Women and Family Planning Providers,” The Henry J. Kaiser Family Foundation (blog), November 21, 2018, https://www.kff.org/womens-health-policy/issue-brief/proposed-changes-to-title-x-implications-for-women-and-family-planning-providers/.
  24. Sobel et al.
  25. Kinsey Hasstedt, Adam Sonfield, and Rachel Benson Gold, “Public Funding for Family Planning and Abortion Services, FY 1980–2015” (Guttmacher Institute, April 2017), https://www.guttmacher.org/report/public-funding-family-planning-abortion-services-fy-1980-2015.
  26. Colorado Department of Public Health and Environment, “Taking the Unintended out of Pregnancy: Colorado’s Success with Long-Acting Reversible Contraception.”
  27. Colorado Department of Public Health and Environment.
  28. Colorado Department of Public Health and Environment.
  29. Sabrina Tavernise, “Colorado’s Effort Against Teenage Pregnancies Is a Startling Success,” The New York Times, July 5, 2015, https://www.nytimes.com/2015/07/06/science/colorados-push-against-teenage-pregnancies-is-a-startling-success.html.
  30. Martha J Bailey, “Reexamining the Impact of Family Planning Programs on US Fertility: Evidence from the War on Poverty and the Early Years of Title X,” American Economic Journal: Applied Economics 4, no. 2 (April 2012): 62–97, https://doi.org/10.1257/app.4.2.62.
  31. Melissa S Kearney and Phillip B Levine, “Why Is the Teen Birth Rate in the United States So High and Why Does It Matter?,” Journal of Economic Perspectives 26, no. 2 (May 2012): 141–66, https://doi.org/10.1257/jep.26.2.141.
  32. A new class action lawsuit against the Canadian government alleges sterilization abuses against Indigenous women as recently as 2001. Anna Kusmer, “Sterilized Without Consent: Indigenous Women in Canada File Class Action Lawsuit,” Rewire News, December 3, 2018, https://rewire.news/article/2018/12/03/sterilized-without-consent-indigenous-women-in-canada-file-class-action-lawsuit/.
  33. Rachel Benson Gold, “Guarding Against Coercion While Ensuring Access: A Delicate Balance,” Guttmacher Policy Review 17, no. 3 (2014): 7.
  34. Gold.
  35. Center on Reproductive Rights and Justice, “Bringing Families out of ’Cap’tivity: The Path Toward Abolishing Welfare Family Caps,” November 2016, https://www.law.berkeley.edu/article/new-study-welfare-family-caps-emboldens-anti-poverty-advocates/.
  36. Anu Manchikanti Gomez, Liza Fuentes, and Amy Allina, “Women or LARC First? Reproductive Autonomy And the Promotion of Long-Acting Reversible Contraceptive Methods,” Perspectives on Sexual and Reproductive Health 46, no. 3 (September 2014): 171, https://doi.org/10.1363/46e1614.
  37. Gomez, Fuentes, and Allina, “Women or LARC First?”
  38. Gomez, Fuentes, and Allina; Jenny A. Higgins, “Celebration Meets Caution: LARC’s Boons, Potential Busts, and the Benefits of a Reproductive Justice Approach,” Contraception 89, no. 4 (April 2014): 237–41, https://doi.org/10.1016/j.contraception.2014.01.027.
  39. Jennifer R. Amico et al., “‘She Just Told Me to Leave It’: Women’s Experiences Discussing Early Elective IUD Removal,” Contraception 94, no. 4 (October 2016): 357–61, https://doi.org/10.1016/j.contraception.2016.04.012; Jennifer R. Amico et al., “‘I Wish They Could Hold on a Little Longer’: Physicians’ Experiences with Requests for Early IUD Removal,” Contraception 96, no. 2 (August 2017): 106–10, https://doi.org/10.1016/j.contraception.2017.05.007; Julia Strasser et al., “Access to Removal of Long-Acting Reversible Contraceptive Methods Is an Essential Component of High-Quality Contraceptive Care,” Women’s Health Issues 27, no. 3 (May 2017): 253–55, https://doi.org/10.1016/j.whi.2017.04.003.
  40. Gomez, Fuentes, and Allina, “Women or LARC First?”; Strasser et al., “Access to Removal of Long-Acting Reversible Contraceptive Methods Is an Essential Component of High-Quality Contraceptive Care.”
  41. Veronica X. Vela et al., “Rethinking Medicaid Coverage and Payment Policy to Promote High Value Care: The Case of Long-Acting Reversible Contraception,” Women’s Health Issues 28, no. 2 (March 2018): 137–43, https://doi.org/10.1016/j.whi.2017.10.013.
  42. Strasser et al., “Access to Removal of Long-Acting Reversible Contraceptive Methods Is an Essential Component of High-Quality Contraceptive Care”; Vela et al., “Rethinking Medicaid Coverage and Payment Policy to Promote High Value Care.”
  43. Notably, Colorado does reimburse for device removal. The Centers for Medicare and Medicaid Services issued a letter in June 2016 to state health officials which explicitly instructs states to reimburse for both insertion and removal, however, state policies still vary (Strasser, Borkowski, Couillard, Allina, & Wood, 2017).
  44. Gomez, Fuentes, and Allina, “Women or LARC First?”