The IUD Capital of the U.S.

In Colorado and Iowa, a pilot program shows that IUDs and implants can dramatically reduce teen pregnancies and abortions. But policy results and politics don’t always mix.

Nora Caplan-Bricker
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Nora Caplan-Bricker
April 24, 2015, 1:01 a.m.

Don Coram is not ex­actly your ste­reo­typ­ic­al birth-con­trol cham­pi­on. A ranch­er, born and bred, the 66-year-old Re­pub­lic­an Col­or­ado state rep­res­ent­at­ive still raises cattle in Mon­trose, on the dusty West­ern Slope. He’s a big man, with a big, white mus­tache and side­burns, though his hair’s still steely gray. When we meet in his of­fice in the State Cap­it­ol Build­ing, he’s wear­ing black cow­boy boots and khaki-colored jeans with his blazer and tie—look­ing, as he says with rel­ish, like a true “red­neck Re­pub­lic­an.” He typ­ic­ally votes ac­cord­ingly: Coram op­posed Col­or­ado’s Medi­caid ex­pan­sion and stood against civil uni­ons—even though his only son, who is gay, im­plored him to change his mind.

In this year’s ses­sion, however, Coram is the un­likely co­spon­sor of an in­nov­at­ive pro­gram to in­crease wo­men’s use of long-term birth-con­trol meth­ods like the in­trauter­ine device (bet­ter-known as the IUD) and hor­mon­al im­plants. He’s con­vinced that these meth­ods re­duce teen preg­nan­cies and abor­tions, and mount­ing evid­ence backs him up. Ac­cord­ingly, his ward­robe has fea­tured an un­usu­al ad­di­tion: a pin in the T shape of an IUD, right next to the Amer­ic­an flag on his lapel. A “gal in Ohio,” he says, was mak­ing IUD-shaped ear­rings and selling them on the web­site Etsy, and “any­way, I took the ear­ring and made a lapel pin out of it.” He de­lighted in the re­ac­tions he got: “I would guess that 95 per­cent of people in the build­ing didn’t know what it was. A lot of people would laugh and shake their heads and then say, ‘OK, what is it?‘“Š”

Coram be­came aware of the so­cial ills of un­in­ten­ded preg­nancy when he was elec­ted to his loc­al school board in the early 1980s. Mon­trose County had one of the state’s highest teen-preg­nancy rates, and the board was at a loss for how to keep girls from drop­ping out of school. The prob­lem was so com­mon at Mon­trose High School, Coram says, the stu­dents joked that the “M” stood for “Ma­ter­nity.” The is­sue brings out the wonky side of Coram: He reels off the cur­rent stat­ist­ics every chance he gets: “80 per­cent of teen moth­ers that be­come preg­nant will be on wel­fare with­in a year. At age 30, of these teen girls, only 1.5 per­cent of them will have earned a [col­lege] de­gree. Daugh­ters of teen moth­ers are 22 per­cent more likely them­selves to be­come teen moth­ers. Sons of teen moth­ers are 13 per­cent more likely to be in­car­cer­ated.”

(RE­LATED: Re­pub­lic­ans’ Con­tra­cep­tion Puzzle)

Last fall, of­fi­cials at Col­or­ado’s Pub­lic Health and En­vir­on­ment De­part­ment told Coram about a policy ex­per­i­ment aimed at re­du­cing abor­tions and un­planned preg­nan­cies—one that had been op­er­at­ing quietly since 2009 and had shown stag­ger­ing res­ults. The Col­or­ado Ini­ti­at­ive to Re­duce Un­in­ten­ded Preg­nancy was the fruit of a $23.6 mil­lion grant from the Susan Thompson Buf­fett Found­a­tion, an Omaha-based char­it­able out­let for in­dus­tri­al­ist War­ren Buf­fett’s vast wealth. For five years in Iowa and six years in Col­or­ado—long enough to gauge the ef­fect—the Buf­fett Found­a­tion made IUDs and hor­mon­al im­plants, which are tiny rods that go in a wo­man’s arm, free and widely avail­able. These are long-act­ing, re­vers­ible meth­ods, with zero main­ten­ance and a fail­ure rate of less than 1 per­cent, far bet­ter than birth-con­trol pills or con­doms—but they are ex­pens­ive, to the tune of as much as $1,200. (In the long run, IUDs and im­plants can be more cost-ef­fect­ive than oth­er forms of birth con­trol—they last between three and ten years, de­pend­ing on the mod­el, while pills can cost about $50 a month—but the up-front price can be pro­hib­it­ive.) The found­a­tion hoped that high­er use of the devices in Col­or­ado and Iowa would re­duce abor­tions and un­wanted preg­nan­cies, and also spur na­tion­al in­terest in bol­ster­ing the use of long-term devices.

As Coram pored over the ini­ti­at­ive’s res­ults, he found him­self agree­ing with the state Pub­lic Health De­part­ment’s con­clu­sion—that these forms of birth con­trol were the best an­swer avail­able to the so­cial prob­lem he had been mulling for dec­ades. Since the pro­gram began, use of long-term con­tra­cep­tion had gone from 5 per­cent of wo­men seen in clin­ics tracked by the ini­ti­at­ive to 24 per­cent, and the teen birth rate had dropped by 40 per­cent. The fisc­ally con­ser­vat­ive side of Coram lit up when he saw an­oth­er num­ber: The state es­tim­ated the ini­ti­at­ive had saved $5.85 in short-term Medi­caid costs for every dol­lar spent (over the long term, the sav­ings might be great­er).

The IUD may be the best con­tra­cept­ive in the view of most health ex­perts, but it’s also the most con­tro­ver­sial in the eyes of the pub­lic.

But the fu­ture of the ex­per­i­ment was un­cer­tain; the fund­ing was set to run out in June, and re­pla­cing it with state dol­lars would take bi­par­tis­an sup­port in Col­or­ado’s di­vided le­gis­lature. (The House is ma­jor­ity Demo­crat­ic; the Sen­ate, ma­jor­ity Re­pub­lic­an.) So Coram signed on as the lone GOP co­spon­sor of one of the ses­sion’s top Demo­crat­ic pri­or­it­ies: a $5 mil­lion ap­pro­pri­ation to keep the pro­gram go­ing, en­thu­si­ast­ic­ally backed by Demo­crat­ic Gov. John Hick­en­loop­er. The Re­pub­lic­an teamed up on the bill with KC Beck­er, a lib­er­al Boulder rep­res­ent­at­ive who made an un­likely ally, to say the least: An en­vir­on­ment­al law­yer who spent years work­ing for the In­teri­or De­part­ment, she’s Coram’s lead­ing ad­versary on the Ag­ri­cul­ture, Live­stock, and Nat­ur­al Re­sources Com­mit­tee. Coram owns urani­um mines, which Beck­er has pushed to reg­u­late. Last year, when Beck­er ran a ma­jor wa­ter-ef­fi­ciency bill, Coram was part of the op­pos­i­tion that pres­sured Hick­en­loop­er in­to veto­ing it. This year, she tried once more, “and again, he at­tacked it to no end,” she says. “We were sit­ting in com­mit­tee one mo­ment hav­ing a strong dis­agree­ment on this bill, and at the same time, we knew we were both spon­sor­ing this IUD bill,” Beck­er adds with a laugh.

(RE­LATED: How the House GOP’s Abor­tion Bill Fell Apart)

Coram sees noth­ing con­tra­dict­ory about a con­ser­vat­ive call­ing for spend­ing mil­lions on IUDs and im­plants. To him, it’s plain com­mon sense. “If you are like I am, and you do not sup­port abor­tion, you want to break the cycle of poverty, you want young people to have a bet­ter life, you want to save tax­pay­er dol­lars—why would you not sup­port this le­gis­la­tion?” he asks, star­ing me down across a desk cluttered with stacks of pa­per and framed pho­tos of Coram with his wife and son (an al­lit­er­at­ive trio: Don, Di­anna, and Dee, their smil­ing faces turned out to­ward the door).

Of course, the polit­ics of birth con­trol are nev­er that simple. That’s es­pe­cially true of the IUD; it may be the best con­tra­cept­ive out there in the view of most health ex­perts, but it’s also the most con­tro­ver­sial in the eyes of the pub­lic. The dan­ger­ous side ef­fects of a pop­u­lar brand man­u­fac­tured in the 1970s gave IUDs a repu­ta­tion for be­ing un­safe. The fact that wo­men with IUDs can have “worry-free” sex—with no need to sched­ule a shot or re­mem­ber to take a pill—strikes some so­cial con­ser­vat­ives as an in­vit­a­tion to more pre­marit­al sex (and dis­ease). Oth­ers be­lieve that be­cause IUDs can pre­vent a fer­til­ized egg from im­plant­ing on the uter­ine wall, their work­ings are tan­tamount to abor­tion.

(Neil Webb)

Coram knew full well that his and Beck­er’s pro­pos­al faced both cul­tur­al and polit­ic­al hurdles. But he figured he could bring some fel­low Re­pub­lic­ans around by em­phas­iz­ing its fisc­al po­ten­tial—those Medi­caid sav­ings—and the fact that the pro­gram was re­du­cing abor­tions. “I run a lot of le­gis­la­tion,” he says, “and, policy-wise, this may be the best piece of le­gis­la­tion I’ve ever worked on.” He be­lieves it could be a power­ful mod­el for oth­er states to fol­low. But first, he and his co­spon­sor would have to con­vince skep­tic­al con­ser­vat­ives—and a few wary lib­er­als to boot—that they should keep Col­or­ado’s pi­on­eer­ing pro­gram from grind­ing to a halt.

AMER­ICA’s LARGE-SCALE re­jec­tion of long-act­ing birth con­trol can be traced back to a single, dis­astrous IUD. The devices first hit the U.S. mar­ket in the mid-‘60s, and by the early ‘70s, al­most 10 per­cent of con­tra­cept­ive users had them—a high­er pro­por­tion than today. Then the most pop­u­lar IUD, the Dalkon Shield, was pulled from the mar­ket in 1974, after it was linked to a high risk of pel­vic in­flam­mat­ory dis­ease—a ser­i­ous con­di­tion that can lead to in­fer­til­ity, or even prove fatal—and to the deaths of 18 wo­men. About 200,000 wo­men filed claims of in­jury, and the en­su­ing law­suits bank­rup­ted the IUD’s man­u­fac­turer, the A.”ŠH. Robins Com­pany. Com­pet­it­ors swiftly stopped pro­duc­tion of sim­il­ar devices, fear­ing they’d be next. “The in­terest in the IUD plummeted,” says Jeff Peipert, a clin­ic­al re­search­er in ob­stet­rics and gyneco­logy at Wash­ing­ton Uni­versity in St. Louis, “be­cause of what I think of as one bad act­or.” (Im­plants also gained a sketchy repu­ta­tion in the early 1990s, when an early mod­el, Nor­plant, proved dif­fi­cult to re­move and rid­den with side ef­fects; more law­suits and an­oth­er round of fright­en­ing head­lines en­sued.)

(RE­LATED: In­surers Cov­er Some Con­tra­cept­ives, But Not All)

Throughout the 1980s and ‘90s, most Amer­ic­an med­ic­al stu­dents nev­er learned to in­sert an IUD—even as a host of stud­ies from European coun­tries, where IUDs had re­mained pop­u­lar, sug­ges­ted the new mod­els were safe. If doc­tors did re­com­mend them for wo­men, it was for a nar­row cat­egory who were “older, mar­ried, with sev­er­al chil­dren,” says Eve Es­pey, chair of the Long-Act­ing Re­vers­ible Con­tra­cep­tion Work Group at the Amer­ic­an Col­lege of Ob­stet­ri­cians and Gyneco­lo­gists. In part, pro­viders couldn’t shake their fear, after the Dalkon Shield, of leav­ing young wo­men in­fer­tile—and of in­vit­ing law­suits as a con­sequence.

State Rep. Don Coram, a self-de­scribed “red­neck Re­pub­lic­an,” has be­come Col­or­ado’s most un­likely cham­pi­on of long-act­ing con­tra­cep­tion (Kath­ryn Scott Osler/The Den­ver Post)

But in the mid-2000s, med­ic­al re­search­ers star­ted to ask why Amer­ica’s stance on long-act­ing birth con­trol hadn’t changed with the times. “I think that re­search­ers and pub­lic-health prac­ti­tion­ers in­ter­ested in con­tra­cep­tion be­came in­creas­ingly aware of data that sup­por­ted the safety and ef­fect­ive­ness of IUDs,” Es­pey says. “With a meth­od that had been used a lot in the past and was used so much in oth­er coun­tries, at some point it be­came in­ev­it­able that people would say, ‘Why not in the U.S.?‘“Š”

As the med­ic­al com­munity began to em­brace im­plants and IUDs, the ques­tion be­came how to make them ac­cess­ible and af­ford­able for the young wo­men who have more un­planned preg­nan­cies and thus could be­ne­fit the most. They of­ten hadn’t heard of long-act­ing birth con­trol, or couldn’t af­ford it if they had. Many clin­ics found the price too high as well. (Ima­gine stock­ing your shelves with ten $900 devices and only us­ing, and be­ing re­im­bursed for, half.) These were big obstacles—but a land­mark study in St. Louis vin­dic­ated many re­search­ers’ hopes when it showed that, if those road­b­locks were re­moved, long-act­ing birth con­trol could quickly lower the teen birth rate. From 2007 to 2011, the Con­tra­cept­ive Choice Pro­ject, fun­ded by an an­onym­ous found­a­tion and run by Wash­ing­ton Uni­versity in St. Louis, offered groups of wo­men and teens any con­tra­cept­ive, free of charge. Where­as wo­men have typ­ic­ally been offered the cheap­er, less-ef­fect­ive meth­ods first, the St. Louis pro­ject counseled pa­tients on their op­tions by start­ing with the most ef­fect­ive and list­ing oth­ers in or­der of re­li­ab­il­ity. Three-quar­ters of par­ti­cipants chose IUDs and im­plants. A year later, those who had op­ted in­stead for the pill, patch, or NuvaR­ing had got­ten preg­nant at a rate 20 times high­er than those us­ing long-act­ing birth con­trol.

While the St. Louis pro­ject was un­der­way, the Susan Thompson Buf­fett Found­a­tion launched its more wide-scale ex­per­i­ment in Col­or­ado and Iowa. In ad­di­tion to fund­ing col­lege schol­ar­ships and oth­er edu­ca­tion pro­grams, the found­a­tion has a his­tory of sup­port­ing ac­cess to abor­tion. Ac­cord­ing to IRS fil­ings, it has giv­en mil­lions to Planned Par­ent­hood and the Na­tion­al Abor­tion Fed­er­a­tion Hot­line Fund, among oth­ers. (The found­a­tion does not speak to the press about its re­pro­duct­ive work and would not com­ment for this art­icle, though I did speak with lead­ers of the Iowa and Col­or­ado ef­forts.) In 2006, Buf­fett hired a lead­ing fam­ily-plan­ning ex­pert and tasked her with shift­ing its fo­cus from abor­tion ac­cess to abor­tion pre­ven­tion. The ini­ti­at­ive would be cent­ral to that ef­fort.

(RE­LATED: Wo­men Aren’t the Prob­lem in Polit­ics)

The ul­ti­mate goal, along with cut­ting the rate of un­wanted preg­nan­cies and abor­tions, was to use Col­or­ado and Iowa as clas­sic “labor­at­or­ies of demo­cracy”: If the pro­grams worked, they could be rep­lic­ated in oth­er states or on a na­tion­al level. The found­a­tion looked for re­l­at­ively small states where its re­sources could have the greatest pos­sible im­pact, says Sally Ped­er­son, who led the Iowa Ini­ti­at­ive to Re­duce Un­in­ten­ded Preg­nancy. It tar­geted states that were un­der Demo­crat­ic con­trol—which, at the time, Col­or­ado and Iowa were—to in­crease the chances of the pro­gram even­tu­ally win­ning state fund­ing. It also wanted each pi­lot pro­gram to be in “a middle-of-the-road state—phys­ic­ally and polit­ic­ally,” says El­len Mar­shall of the con­sult­ing firm Good Works Group, whom the found­a­tion hired to over­see the Col­or­ado ini­ti­at­ive. If it could work in Iowa and Col­or­ado, the think­ing was, it could work any­where.

The Buf­fett ini­ti­at­ive launched in Iowa in 2007 and in Col­or­ado two years later. Eliza­beth Romer, dir­ect­or of the Fam­ily Plan­ning Clin­ic at Chil­dren’s Hos­pit­al Col­or­ado, de­scribes the be­gin­ning of the pro­gram as an elec­tri­fy­ing con­flu­ence: Just as she and oth­er Col­or­ado pro­viders star­ted to wish that they could af­ford to ex­per­i­ment with the pos­sib­il­it­ies of IUDs and im­plants, “here was an op­por­tun­ity with fund­ing. What the ini­ti­at­ive gave us was the op­por­tun­ity to dream big.”

The first step was chan­ging the way long-act­ing birth con­trol was viewed. The ini­ti­at­ive edu­cated pro­viders about the be­ne­fits of IUDs and im­plants, and trained the ones who didn’t know how to in­sert the devices. Pub­lic-re­la­tions cam­paigns en­cour­aged wo­men to think anew about birth con­trol and drew them in­to clin­ics where they could learn about the long-term meth­ods they could now get for free. The mas­cot of Iowa’s “Avoid the Stork” cam­paign—a shaggy white Big Bird fig­ure with yel­low eyes and a baby doll buckled to his front—went to uni­versity cam­puses, NAS­CAR races, and county fairs to hand out the ini­ti­at­ive’s branded lip balm along with in­form­a­tion about con­tra­cept­ives. In Col­or­ado, city buses bore ads that read, “Safe is sexy,” and “Do you have a rain­coat for your sail­or?”

(RE­LATED: Pho­tos: The Real “Rosie the Riv­eter” Wo­men)

Demo­crat­ic law­maker KC Beck­er, who’s fight­ing for state fund­ing to pro­mote long-term birth con­trol, sports ear­rings fash­ioned after an IUD. (Craig F. Walk­er / The Den­ver Post)

Once the word star­ted to spread, in­terest seemed to speed up ex­po­nen­tially; at the clin­ics I vis­ited in the Den­ver sub­urbs of Au­rora and Long­mont, health pro­viders had stor­ies of teen­agers leav­ing with long-term birth con­trol, then com­ing back a week later, their friends in tow. The res­ults were more dra­mat­ic than any­one had an­ti­cip­ated. Ac­cord­ing to num­bers provided by the Col­or­ado Pub­lic Health and En­vir­on­ment De­part­ment, use of long-act­ing birth con­trol by wo­men at ini­ti­at­ive-af­fil­i­ated clin­ics was twice what the de­part­ment had hoped for.

As of Ju­ly 2014, the ini­ti­at­ive had provided more than 30,000 IUDs and im­plants to Col­or­ado wo­men. Last sum­mer, when Gov. Hick­en­loop­er an­nounced the 40 per­cent drop in the teen birth rate, he also said the abor­tion rate among teens had gone down by 35 per­cent since 2009. (The state at­trib­utes about three-quar­ters of that de­cline to the pro­gram; the na­tion­al teen preg­nancy rate has also been fall­ing, though much more slowly.) The ripple ef­fects of the ini­ti­at­ive have also been im­press­ive. Col­or­ado’s Wo­men, In­fants, and Chil­dren pro­gram, which gives food and oth­er ser­vices to low-in­come wo­men with young chil­dren, saw a 23 per­cent re­duc­tion in its in­fant case­load from 2008 to 2013. The gov­ernor’s of­fice es­tim­ates that, all in all, the ini­ti­at­ive saved the state $42.5 mil­lion in 2010 alone.

(RE­LATED: The “War on Wo­men” Isn’t Over Yet)

Iowa saw sim­il­ar out­comes: Re­search­ers found that long-act­ing birth-con­trol us­age more than tripled statewide over the course of the pro­gram, and the abor­tion rate de­creased by 25 per­cent. But by the time the state’s ini­ti­at­ive reached the end of its fund­ing in 2012, Iowa had tilted Re­pub­lic­an. Pro­ponents didn’t even try to get fund­ing from the state le­gis­lature; the pro­gram quietly fol­ded up shop. “When the fund­ing went away, it was very dif­fi­cult for the pro­viders to ad­just,” says Penny Dickey of Iowa’s Planned Par­ent­hood of the Heart­land. “We knew it wasn’t forever, but it was really dif­fi­cult to have to go back to the old way of man­aging the re­sources,” with an em­phas­is on cheap­er, short­er-term birth con­trol.

That left Col­or­ado as the sole hope for cre­at­ing a state-fun­ded mod­el that oth­er states could rep­lic­ate. “I think a lot of people are look­ing at wheth­er we’re go­ing to be able to get the pending le­gis­la­tion through our le­gis­lature,” says Stephanie Teal, fam­ily-plan­ning dir­ect­or for the Col­or­ado Pub­lic Health and En­vir­on­ment De­part­ment. “Here we are in Col­or­ado, this is our data, and if we’re un­able to get our le­gis­lature to con­tin­ue something like this, where we already have in­fra­struc­ture in place and we’ve proved the be­ne­fit, it’s go­ing to make it that much harder for oth­er states to be in­ter­ested.”

THE COL­OR­ADO STATE HOUSE is a mess. It’s after 7 p.m. on a Wed­nes­day in early April, and the House is still de­bat­ing amend­ments to its an­nu­al budget, aptly known as the “Long Bill.” The cham­ber is littered with the de­trit­us of a mara­thon day: An enorm­ous, mostly empty tub of Red Vines on a desk par­tially ob­scures my line of sight from the lobby; ther­moses and wa­ter bottles line every desk; and a lone crutch leans pre­cari­ously in­to the cent­ral aisle, propped against one of the forest-green chairs. At the po­di­um, Re­pub­lic­an Rep. Patrick Neville is ar­guing against Don Coram and KC Beck­er’s pro­pos­al to keep the long-term birth-con­trol pro­gram op­er­at­ing. But as he ges­tures to the pro­ject­or screen be­hind him, ex­pect­ing to see an amend­ment he wrote to block fund­ing for IUDs and im­plants, he finds in­stead a meas­ure to com­bat cy­ber­bul­ly­ing. A flurry of activ­ity fol­lows as aides try to find the cor­rect slide. “Let’s let the con­fu­sion be­gin,” in­tones the House speak­er pro tem­pore.

Like IUDs, im­plants gained a bad repu­ta­tion from an early mod­el’s highly pub­li­cized fail­ure. (GARO/phanie/Phanie Sarl/Cor­bis)

When the de­bate fi­nally com­mences in earn­est, mor­al and re­li­gious ar­gu­ments are scarcer than the ini­ti­at­ive’s pro­ponents had ex­pec­ted. Re­pub­lic­an House mem­bers have settled on a more prag­mat­ic line of at­tack: The fund­ing, they ar­gue, is un­ne­ces­sary be­cause the Af­ford­able Care Act re­quires in­surers to cov­er all forms of con­tra­cep­tion—IUDs and im­plants in­cluded. “We don’t need to spend this money on the same pro­gram, which is avail­able oth­er­wise,” Rep. Janak Joshi, a Re­pub­lic­an from so­cially con­ser­vat­ive Col­or­ado Springs, as­serts. “We can use this money for some bet­ter use—maybe edu­ca­tion, maybe roads, but not du­plic­at­ing the same ser­vices which are avail­able.”

In the Sen­ate, the only Re­pub­lic­an in the le­gis­lature to vote for Col­or­ado’s Medi­caid ex­pan­sion in 2013, Coram’s good friend Larry Crowder, had told me earli­er that this line of ar­gu­ment had led him to op­pose the pro­pos­al—though at first it seemed he might be the lone GOP sen­at­or to back it. “Nobody wants less un­in­ten­ded preg­nancy more than I do,” he said, “but am I will­ing to go in and ask tax­pay­ers to fund this? I think there’s ad­equate fund­ing out there.”

Pro­ponents counter that while it’s true in the­ory that all con­tra­cept­ives are covered un­der the Af­ford­able Care Act, in prac­tice, many in­surers are dis­cour­aging use of the long-term meth­ods by twist­ing Medi­caid rules that are sup­posed to pro­tect con­sumers. The gov­ern­ment al­lows in­surers to prac­tice what it calls “reas­on­able med­ic­al man­age­ment” to keep costs down, ex­plains Susan Berke Fo­gel of the Na­tion­al Health Law Pro­gram. This could mean cov­er­ing a cheap­er gen­er­ic in­stead of a pricey name-brand drug, or fol­low­ing what’s known as “step ther­apy,” which means pro­viders try less-ex­pens­ive treat­ments first and only re­sort to more ex­pens­ive ones when the cheap­er al­tern­at­ive fails. (This is sup­posed to keep you from hav­ing to, for ex­ample, shell out for a PET scan every time you have a head­ache. Ap­plied to birth con­trol, however, it means that some wo­men have to show that a less-ex­pens­ive op­tion, like the pill, has failed to pre­vent a preg­nancy or has made them sick be­fore the in­surer will cov­er an im­plant or IUD.)

(RE­LATED: Want More Wo­men in Of­fice? Look to Re­pub­lic­ans.)

Fo­gel says plans are tak­ing these guidelines too far in the case of long-act­ing birth con­trol. There are no gen­er­ic ver­sions of the devices on the mar­ket, she points out, and dif­fer­ent birth-con­trol meth­ods (some re­l­at­ively cheap, some not) work best for dif­fer­ent wo­men and life­styles. But that hasn’t stopped some in­sur­ance com­pan­ies from “group­ing” birth con­trols (so they might of­fer just one long-act­ing meth­od, and not the one you want), mak­ing doc­tors’ of­fices go through an ar­du­ous pre­approv­al pro­cess, or re­quir­ing a ver­sion of “step ther­apy” to prove that a long-term device is needed. (Clare Krus­ing, the com­mu­nic­a­tions dir­ect­or for the trade or­gan­iz­a­tion Amer­ica’s Health In­sur­ance Plans, says the in­surers’ rules are both leg­al and good for con­sumers. The Af­ford­able Care Act may cov­er con­tra­cep­tion, but “that be­ne­fit still has an im­pact on the over­all cost of cov­er­age” and the premi­ums people pay, she wrote in an email. “If plans were re­quired to cov­er every single birth con­trol op­tion, the costs to con­sumers would be sig­ni­fic­ant. … It’s why the guid­ance stresses the use of plans’ med­ic­al man­age­ment tools, so con­sumers have af­ford­able choices.”)

But there’s an­oth­er factor, pro­ponents of the Col­or­ado ini­ti­at­ive say: Teen­agers are the people least likely to get IUDs and im­plants through in­sur­ance. At Chil­dren’s Hos­pit­al Col­or­ado, Romer says, around half of the teens who come in for birth con­trol haven’t told a par­ent they’re there. No par­ent of­ten means no in­sur­ance—even if the fam­ily has it, the daugh­ter can’t use it without mom or dad find­ing out.

As the House de­bate makes clear, at least some of the law­makers ar­guing that fund­ing birth con­trol is re­dund­ant have deep­er ob­jec­tions. Re­pub­lic­an Rep. Kath­leen Conti, for in­stance, leads with the fin­an­cial ar­gu­ment: “We’re not de­fund­ing birth con­trol. We’re de­fund­ing the Ca­dillac of birth con­trols. Something that on av­er­age is about a $900”… ” She pauses and grasps at the air with her right hand, search­ing for the right word. “Equip­ment”… pro­ced­ure”…” But that’s not what she’s really come to the po­di­um to talk about. “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,” Conti says, wav­ing her hand with rising ur­gency. “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?”

(RE­LATED: Are Abor­tions Re­vers­ible?)

Coram tut-tuts at this line of ar­gu­ment. “That word, ‘sex,‘“Š” he says. “It seems to scare people.” His co­spon­sor, wear­ing sparkly ear­rings in the shape of IUDs, steps up to the mic to re­spond to Conti. “I think that there are lots of stresses that teens have in their lives,” Beck­er says. “I think that hav­ing an un­wanted preg­nancy is ab­so­lutely a stress that can lead to de­pres­sion. When you have a child when you’re not ready, it can be the hard­est, hard­est time in your life. Even when you are ready to have a child”—she gives a small laugh—”it can be one of the hard­est things you ever go through. So the more that we en­able “… girls to stay in school longer, to be self-suf­fi­cient, to not end up on wel­fare—the bet­ter their lives are go­ing to be, and the bet­ter the people of Col­or­ado are go­ing to be.”

Later that night, the House votes to in­clude the ini­ti­at­ive’s fund­ing in the Long Bill. But Coram and Beck­er know the battle has only just be­gun. The ma­jor­ity-Re­pub­lic­an Sen­ate has already killed the same amend­ment, with zero Re­pub­lic­an sen­at­ors sup­port­ing it. After the House vote, the amend­ment would head in­to a Joint Budget Com­mit­tee con­fer­ence the fol­low­ing week, where it would need a vote from one of the three Re­pub­lic­ans to pass; it would get none.

With three weeks left in this year’s ses­sion, and the clock run­ning out on the Buf­fett Found­a­tion’s fund­ing, Coram and Beck­er de­cided to try a stand-alone bill for the ini­ti­at­ive; they knew it would be harder to pass than the budget amend­ment, but it was their only shot. The meas­ure has cleared the House but faces long odds in the Sen­ate. The pro­spects for con­tinu­ing Col­or­ado’s long-term birth-con­trol pro­ject next year, as Coram ad­mits, are vir­tu­ally nil.

The morn­ing after the budget de­bate, I ask Coram what he thinks it would take to change the polit­ics of long-act­ing birth con­trol. “Spine!” he barks. He es­tim­ates that al­most half of his Re­pub­lic­an col­leagues sup­port the pro­gram, but only three of 48 are openly for it. Again and again, he says, they told him: “”Š’I would love to sup­port this bill, but I’m afraid of a primary from a group that’s in op­pos­i­tion.‘“Š” In oth­er words, he says, “It’s per­fect policy to do it, but it could be polit­ic­ally dam­aging to do it.’”

He’s not giv­ing up, though. “At­ti­tudes change,” Coram told me over the phone last week, as he drove west from Den­ver to­ward Mon­trose. “Ten years ago, if you wanted to talk about same-sex mar­riage, that cer­tainly did not have any sup­port. “… I think without a doubt this will be one of those things. Just be­cause this bill is go­ing to die doesn’t mean the con­ver­sa­tion is over.” 

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