The XX Factor

Delaware Is Following Colorado’s Lead on Long-Acting Birth Control

Delaware Governor Jack Markell wants to bring down Medicaid costs by increasing IUDs.

Mandel Ngan/AFP/Getty Images

When Iowa and Colorado launched statewide programs in the late aughts to make long-acting reversible contraception—intrauterine devices and hormonal implants—available for free to women of reproductive age, they hoped that other states would note the many benefits and follow along. About a year after the initiatives were first covered widely in the mainstream press (due to a budget fight in Colorado over the program), it appears they have a new convert: In Tuesday’s New York Times, Delaware Governor Jack Markell pledged, “By the end of 2017, we will ensure that the nearly 200,000 women of reproductive age in our state have access to the full range of methods” of birth control, including implants and IUDs.

Providing “low or no cost” long-acting contraceptives may sound like a small-scale initiative of fringe importance, but public health researchers increasingly see birth control in general, and IUDs and implants in particular, as among the best ways to tackle the central dynamics of economic inequality. As Markell wrote, “Enabling women to become pregnant only when they want to is a shortcut to prosperity.”

Nearly half of the more than six million pregnancies that occur in the U.S. every year are unplanned—a fact that has far-reaching social consequences. As the Brookings Institution has summarized the issue, “[W]omen who experience unintended pregnancies have a higher incidence of mental-health problems, have less stable romantic relationships, experience higher rates of physical abuse, and are more likely to have abortions or to delay the initiation of prenatal care. Children whose conception was unintentional are also at greater risk than children who were conceived intentionally of experiencing negative physical- and mental-health outcomes and are more likely to drop out of high school and to engage in delinquent behavior during their teenage years.”

Long-acting reversible contraceptives, or LARCs, fail less than one percent of the time, about 20 times less often than the contraceptive pill, patch, or ring; IUDs and implants also score higher satisfaction and continuation rates among users than other forms of birth control. Though the devices are expensive—up to $1,000 each—most insurance companies are required to cover them. In many cases, it’s not cost, but providers’ lack of familiarity with these methods, that keeps them out of women’s hands.

The Colorado program—established with a $23.6 million grant from the Susan Thompson Buffett Foundation (which also paid for a similar, now defunct project in Iowa)—aimed to change that by flooding the state with the best birth control methods, creating a culture in which women knew to ask for them, and doctors were comfortable prescribing and inserting them. Now, Colorado’s purple legislature seems to be on the cusp of agreeing to continue the initiative with state dollars—something Republicans originally refused to do when the Buffett money dried up last year. The most compelling argument for many legislators has been the overwhelming evidence that the program not only drastically reduced the teen pregnancy and abortion rates, but also managed to save the state money: $5.85 in Medicaid costs for every $1 spent, according to the most recent math.

In January, Virginia put $9 million into providing birth control to women with inadequate or no insurance; that program will also emphasize the benefits of LARCs. Now, Delaware—where 57 percent of pregnancies are unintended—has come up with its own plan to tackle the issue. It’s partnering with the healthcare nonprofit Upstream USA, and focusing on training providers, and smoothing out insurance reimbursement practices to make sure that doctors’ offices can afford to stock implants and IUDs.

If Colorado is any indication, Delaware should be able to create a positive cycle, in which the more women and providers learn about LARCs, the more they’ll seek out and select these most effective methods. Markell seems confident in the results. In the Times, he pledges that the initiative “will be subject to a rigorous evaluation process that will not only track pregnancy and birth outcomes, but also assess its impact on birth-related spending in Medicaid and private insurance plans,” and urges that “others should consider initiatives like this.” Hopefully, if Delaware’s program works as well as Colorado’s did, it won’t be long before they will.