Birds, Bees, and IUDs: Why Colorado’s Successful Experiment with Long Term Contraception is Poised to Fail

When something in politics sounds too good to be true, that’s probably because it is. But the Colorado Family Planning Initiative might just be an exception to that rule. Started in 2009 with a five-year grant of $23 million from the Susan Thompson Buffett Foundation, the Initiative undertook a bold new strategy to tackle the issue of teen pregnancy. Colorado used the grant money to distribute long-acting reversible contraceptive methods (LARCs) such as intrauterine devices (IUDs) to low-income women at no cost and with relatively few restrictions. The program was a rousing success and seemed palatable to everyone — lowering both the rates of teenage pregnancy and teenage abortion by about 40 percent over four years and saving the state millions of dollars.

Unfortunately, too good to be true doesn’t last long in politics, and the Colorado Family Planning Initiative program is now at risk of termination. This summer, members of the Colorado State Senate rejected a measure to use state funding to continue the program. The Initiative will continue for another year due to a flurry of last-minute donations from nonprofit organizations. However, the Senate’s decision raises questions over why such an effective program didn’t receive state funding. A parallel Buffett Foundation effort in Iowa was never even put up for a reauthorization vote. While conservative sexual mores and abortion worries are surely at the heart of the matter, the failure to fund long-term contraception methods — even in left-leaning states won twice by President Obama — also demonstrates the lopsidedness of advocacy efforts to shape the birth control debate.

The Colorado Family Planning Initiative’s focus on IUDs and long-term prevention methods represents a revolutionary approach to birth control in the United States. IUDs, though woefully underused, are the most effective form of birth control available. According to the Centers for Disease Control and Prevention, 9 in 100 women will get pregnant within their first year on the pill in part because of imperfect use. For those who rely on male condoms, the number is 18 in 100 women. That figure is less than 1 in 100 women for IUDs. But ever since a prominent IUD brand was linked to ovarian cancer in the 1970s, IUDs have been deeply unpopular in the United States, although they are by far the most common form of birth control in Europe. In recent years, as the American medical community realized that the United States lags in contraceptive coverage, IUDs and other forms of LARCs began to make a comeback. While only about 1.5 percent of women used LARCs in 2002, that figure has since more than quadrupled. However, until 2009, government initiatives had done little to promote these methods to the general public.  

That’s where the Buffett Foundation, which has a long history of supporting women’s health causes and organizations like Planned Parenthood, came in. According to the National Journal, the Buffett Foundation saw an opportunity to destigmatize long-term contraception and find an effective political middle ground that would please both abortion opponents and women’s health advocates. The Foundation chose Colorado and Iowa as “laboratories of democracy” in which to create a model for other states to copy. The programs were largely independent of established advocacy networks and sought to prove that LARCs were an effective policy that conservatives and liberals could unite behind.

The experiments worked like a charm, even if the political machinations didn’t. After advertising the new campaign, Colorado began distributing LARCs at zero or low cost, depending on patient income. As of July, the state had provided 30,000 contraceptive implants or IUDs. Almost one-fifth of young and middle-aged Colorado women now use long-acting birth control, compared to about 7 percent of women nationwide. Colorado health officials estimate that for every dollar spent on LARCs the state saved $5.85 on Medicaid. With precipitous drops in the teenage abortion rate to boot, it’s no wonder the New York Times labeled the program a “startling success.” Though Iowa’s program wasn’t quite as successful, the state also experienced an unprecedented drop in the abortion rate, and its rate of LARC usage nearly tripled.

Still, something else happened between 2009 and 2014 — a conservative tidal wave. The 2010 midterms were a catastrophe for Democrats around the country, and Colorado and Iowa were no exception. So when the grants from the Buffett Foundation began to expire in 2014, it was up to legislators from both parties to replace the lost funding. The hope that LARCs could secure bipartisan support didn’t hold up. Iowa Democrats concluded that between the Republican-controlled General Assembly and governorship it would be impossible to secure funding and preemptively gave up. Colorado Democrats, on the other hand, decided to take on mounting conservative opposition and attempted to build the advocacy apparatus that the Buffett Foundation’s grant had not created.  

The opposition to the Colorado Family Planning Initiative is a complex beast, much of which comes wrapped in the veil of fiscal conservatism. “If you look at the Affordable Care Act (ACA), it is now mandated that health care insurance include IUDs,” the president of the Colorado Senate, Republican Bill Cadman, said. “I don’t believe the state is in a position to subsidize federal programs, nor should we.” Other conservatives have pointed out that the benefits of the program may not have been as large as proponents said they were, since the rates of unplanned pregnancy and abortion fell nationwide — not just in Colorado — over the 2009-2015 period.  

But these fiscal arguments are, for lack of a better term, misleading. Colorado’s declining teen pregnancy rates have far outpaced those in other states, and studies from the Guttmacher Institute and the Colorado Health Department indicate that the program played a causal role in the decline. And while the ACA does require insurers to pay for IUDs and the like, those forms of birth control are often associated with higher upfront costs that even patients with health insurance may not be able to afford. Supposing half of the state’s spending on the program was redundant — which it wasn’t — the amount of money Colorado saves on Medicaid and welfare would still exceed the costs of the program. Republican State Representative Don Coram, the bill’s only Republican co-sponsor, put it best: “If you’re anti-abortion and also a fiscal conservative, I think this is a win-win situation for you.”

As with most women’s health issues, however, the heart of the opposition isn’t fiscal at all — it boils down to religious attitudes toward sex and abortion. The abortion argument is tricky; most of the time, IUDs are used to inhibit fertilization or prevent sperm from reaching an egg. But in some cases, IUDs may prevent fertilized eggs from attaching themselves to the uterus or can be inserted after unprotected sex to prevent a pregnancy. For certain religious conservatives who believe that life begins at conception — a view widely rejected by the medical community — these effects are tantamount to abortion. “This crosses a line,” said Republican Kevin Lundberg, the chair of the Senate Health Committee in Colorado. “The state constitution says no direct or indirect funding from the state shall go towards abortion.” And these abortion arguments often come coupled with worries about increased female promiscuity and sexual activity. Republican Colorado State Representative Kathleen Conti, for example, asked, “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?”

These minority views should not have enough political clout to cripple programs like the Colorado Family Planning Initiative. Polls from Gallup and Reuters indicate that 89 percent of all Americans think that birth control is morally acceptable and that 78 percent believe the federal government should subsidize birth control and other family-planning services, excluding abortion, at government-funded clinics. But the problem for programs like the one in Colorado isn’t the breadth of support — it’s that the support only goes so deep, in part because of advocacy groups’ weak involvement.

In the debate over state funding, it’s hard to shake the feeling that the Colorado Family Planning Initiative’s supporters brought a knife to a gunfight. Supporters of the bill mounted a last-ditch and rather passive public relations campaign compared to the intense, organized pressure Republicans faced from their constituencies. Colorado’s abortion opponents whipped up a dedicated opposition and applied intense pressure to Republican representatives. In fact, the lone Republican co-sponsor, Representative Coram, believes half of his Republican colleagues would have voted for the bill but feared attacks in their primary elections. Compare that with Democrats’ preemptive surrender in Iowa, and it’s clear that liberal advocacy groups are unwilling or unable to put up the same caliber effort as their conservative counterparts.

The Buffett Foundation thought it would be enough to prove that LARCs work and then hope for the best. It wasn’t. But it’s not their fault that women in Colorado and Iowa may no longer be able to count on effective contraception — the onus shouldn’t be on independent foundations to ensure reproductive rights. Liberals have a grassroots advocacy and messaging deficit, and until it’s remedied, these programs won’t be politically viable. In particular, women’s health groups and politicians need to sharpen the messaging directed toward moderate abortion opponents. That means publicizing the effectiveness of LARCs and forcefully addressing them in debates over abortion and women’s health. Moreover, liberals need to build a coalition of voters that will consistently turn out to vote on these issues — one that will be just as reliable as those of anti-abortion groups. Liberal legislators must receive the same pressure that their conservative counterparts do. This may result in some partisan bickering and stalemates, but at least it will prevent Democrats from taking steps backward when the going gets tough.

LARCs are no laughing matter — for low-income and teenage women, they can be the difference between living the life they choose and struggling to feed and clothe unwanted children. Moderate conservatives deserve blame for failing to support economically efficient programs, as do the cultural conservatives who hold extreme religious and cultural views. But proponents of LARCs cannot accept the fact that they’re losing the moral high ground on a program that prevents unplanned pregnancy and prevents abortion. Liberals must organize around access to care like it’s the political imperative that it is. Until they do, unfettered access to contraception will remain too good to be true.

Art by Rebecca Andrews