Melissa Weiler Gerber didn’t need a front page New York Times story to tell her that long-acting reversible contraceptives—like IUDs and implants—can reduce the rate of teen pregnancy. The president and CEO of AccessMatters, a Philly sexual health network, has followed the science about these contraceptives—known as LARCs—for years, waiting for public perception and public policy to catch up to the research that shows they are the most effective, most convenient and safest way for women to decide when or if they want to have a baby. Still, even Weiler Gerber was stunned by the scale of what happened in Colorado over the last several years.
In 2009, Colorado had one of the highest rates of teen pregnancy in the country, with half of all first babies born to women under the age of 21. After a six-year effort to make LARCs accessible to mostly poor young women in the state, the teen birthrate fell by 40 percent, and abortions by 42 percent. Funded by Warren Buffett’s foundation, posthumously named for his late wife Susan Thompson Buffett, the $23 million experiment helped 30,000 teens and women get free LARCs, which would otherwise have cost around $900 each.
“To those of us working in the field, this is a game-changer kind of moment,” says Weiler Gerber, who was already scheduled to testify about this issue before the city’s health commission two days after the Colorado success hit the news. “The science has been really far out in front of the public perception and comfort around this. The fact that this is getting so much attention is great.”
Nationally, around half of pregnancies in the United States are unplanned, although the number of teenage births has been on the decline. This is true in Philadelphia, too, though it has not made much of a dent: In 2012, 2,500 babies were born to teenagers aged 15 to 19, a rate of 46.6 per 1,000 teenage girls—around double the state and national rate. Among American big cities, Philadelphia has the highest number of teens who are sexually active and who have had four or more partners, making them at high risk for disease and pregnancy. It also has the highest poverty rate of any big city in America, making it harder for young women to access healthcare—and effective birth control, especially LARCs. Statewide, in 2013 just 3 percent of teenagers at public family planning clinics had an IUD or implant. In Colorado, for comparison, 20 percent of women now have LARCs.
“To those of us working in the field, this is a game-changer kind of moment,” says Melissa Weiler Gerber, CEO of AccessMatters, a Philly sexual health network. “A lot of these changes were funded by one progressive billionaire. That’s not how we should sustain these things.”
The Colorado program—as well as a smaller research study in St. Louis—proved that young women, if counseled about the benefits and offered long-acting reversible birth control for free, will overwhelmingly choose to use a LARC. More than that, they are choosing to avoid what social scientists have observed for generations: That poor, young single mothers stay poor, a legacy they pass on to their children, and one of the leading causes of continuing financial inequality in America.
Instead, they can finish school, start careers and plan their futures, before needing to care for a baby.“This was not difficult, and the outcomes are just so high that they can’t be ignored,” says Dayle Steinberg, CEO of Planned Parenthood of Southeastern Pennsylvania. “Access to family planning and reproductive care are directly related to the ability to succeed in school and beyond that.”
LARCs come in two different forms: Intrauterine devices, small t-shaped plastic rods inserted into the uterus; and implants, a plastic rod about the size of a matchstick inserted into the arm that prevents ovaries from releasing an egg. To reach its 99 percent success rate, the birth control pill must be taken every day, at the same time of day, without fail—which is a lot to ask of any woman, especially teenagers. This is why IUDs are the most common form of birth control in the world. But fewer than nine percent of American women have them. Blame this on the Dalkon Shield, which, before it was pulled from the market in 1974, caused 17 deaths, thousands of infections, and some cases of infertility in American women. Smaller, safer versions of IUDs—as well as implants—have hit the market subsequently, but LARCs have remained an unpopular choice for teens partly because of a lingering misconception that they are unsafe for women who have not yet had children. (Numerous studies have shown this is not the case.)
There’s another barrier to LARCs in the United States: They are, by far, the most expensive method of birth control—around $900, compared to $50 a month for the pill. “After less than two years, women end up saving money with a LARC,” Weiler Gerber says. “But it’s like the down payment on a house. It has a big upfront cost that makes it hard.”
The Affordable Care Act was supposed to take care of this, by guaranteeing women access to FDA-approved contraception. But until recently, insurers often refused reimbursement on the more expensive devices in favor of cheaper, less-effective contraceptives. Doctors, who have to cover the upfront costs of stocking LARCs, have often been unable to recoup their money, so many can’t afford to offer them to their patients. In May, the government clarified that one of every kind of birth control must be available under the ACA—including LARCs. Weiler Gerber says it will still take several months for the changes to trickle up to insurers and down to providers. And, she says, advocates still are working to convince insurers that different types of providers—like pediatricians and family doctors—can also give LARCs to their patients.
Colorado’s chief medical officer Larry Wolk says the state used the $23 million grant for clinics in the poorest areas of the state funded by the federal Title X family planning program, which serves low-income women. The money allowed the providers to counsel women about LARCs and covered the cost of insertion for more women in every year of the program. In 2009, Medicaid and other insurers paid $500,000 to cover LARCs for women in these clinics. In 2014, after the Affordable Care Act took effect, the clinics were reimbursed $3.5 million. That number—especially after the May guidelines—should continue to go up.
The Colorado program proved that young women will overwhelmingly choose to avoid what social scientists have observed for generations: That poor, young single mothers stay poor, a legacy they pass on to their children, and one of the leading causes of continuing financial inequality in America.
But change is slow, and the ACA and Medicaid still won’t cover the cost of implants for everyone, including women who don’t have insurance, or teenagers who don’t want to alert their parents, or women in abusive relationships, for whom the invisible IUDs are a way to control their own bodies. It also doesn’t pay for training of doctors, or for outreach to educate women. In Colorado, the Buffett grant ran out this year, and despite the dramatic results of the program, the state legislature refused to approve $5 million to fund it for another year. Wolk says his department will try for state funding again next year, and in the meantime is relying on foundations and other sources to continue the efforts. “We went from having one of the highest rates of teen pregnancy in the country, to being in the middle and on our way down,” he says. “We’re not going to give that up.”
What would it take to get these results in Philadelphia? Actually, not that much: Weiler Gerber says AccessMatters could “substantially reduce the number of unintended pregnancies” in the city for $3.2 million—that’s in a city budget of roughly $4 billion. That would go towards outreach to the public and providers at health centers, schools and community-based organizations about the need for effective birth control; to purchase LARCs for AccessMatters’ 68 clinics; to educate providers on how to counsel women, and how to insert the devices; and to advocate for better public and insurance policies to ensure long-term coverage for patients.
AccessMatters could “substantially reduce the number of unintended pregnancies” in the city for $3.2 million—that’s in a city budget of roughly $4 billion.
Weiler Gerber says the city’s health department—led by James Buehler, who trained as a pediatrician—has been supportive of AccessMatters’ efforts to reduce teen pregnancy, and of the idea of increasing access to LARCs. But so far, no government entity here—or elsewhere—has accomplished as much as the privately-funded program in Colorado. Title X, the federal family planning program that helps fund AccessMatters and other women’s health clinics, has seen its budget steadily decrease; it is, again, vulnerable to be cut altogether in some Republican budget plans.
“We should be able look to our elected officials to help with this,” says Steinberg. “They should be able to see how successful the program was in Colorado, and be champions for it.”
In the meantime, Weiler Gerber says progress is crawling along. Advocates around the state have been pushing for a change to Medicaid rules that would allow women in Pennsylvania to get LARCs immediately after giving birth, to prevent another unplanned pregnancy and help them space out their babies (which studies show is healthier for them and their children). Currently, Medicaid will only pay for LARCs as an outpatient procedure. But Weiler Gerber says some 45 percent of women fail to show up for their first postpartum appointment, and may go months without seeing a doctor for birth control. That can make the difference between a temporary setback and a lifelong struggle. “When a teen has had one baby, we can’t just give up,” she says. “With one child, we can still intervene and help them stay on track for career and education. ” Several states in the country have already made this rule change—including conservative South Carolina. In Pennsylvania, Governor Corbett put up roadblocks to a statewide change; Weiler Gerber says Governor Wolf’s administration has promised to consider it.
And change is coming by way of the private sector, too. The FDA in the spring approved Lileta, an IUD that is specifically designed to be available for women who are uninsured. Lileta will have two fees—one for insurance companies and one for public health facilities, which will allow them to offer the LARC to women at a cost to clinics of just $55. Again, Lileta has been funded by the Buffett Foundation.
“A lot of these changes around the country were funded by one progressive billionaire,” Weiler Gerber says. “This shows that we’re trying to find private solutions to public policy problems. But that’s not how we should sustain these things as a country. We’re saying, let’s fix the problem at a policy level, so it works for everyone. We should have policy that supports the science.”
Header Image: “Flying IUD” by chuck b, via Flickr.