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.”
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.
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.
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.)
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.
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?”
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.
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.)
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?”
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.”