Do you want to become pregnant in the next year?
It’s a telling question, and one that women of reproductive age in Delaware will be asked at doctor’s appointments going forward, even at primary care providers.
“If the answer is yes, then great; we can get them into preconception care right away, which is fabulous,” says Mark Edwards, co-founder of Upstream USA, a nonprofit that trains healthcare providers on how to prescribe the full range of birth control, including how to place and remove intrauterine devices and implants. “But if the answer is no, then it kicks off a conversation about contraception.”
If a woman wants an IUD or an implant, she’ll be able to get it inserted during that visit from the stock that all trained doctors will be required to keep on hand. It doesn’t work like that now: Women who want such long-acting reversible contraceptives have to see a gynecologist and come back for the procedure after a device is ordered and when there’s time in the doctor’s schedule.
This new contraceptive world will be the result of a collaboration called Delaware CAN. Upstream USA will train providers at publicly-funded clinics as well as 30 to 40 of the largest healthcare providers across the state. The goal is for all women, whether they have insurance or not, to be asked about their pregnancy plans and given birth control if they want it, at no cost. Billing staff will also be trained on how to code for procedures not usually done in these offices so that they’re reimbursed properly.
Delaware governor Jack Markell asked the group to develop a plan to lower the state’s unintended pregnancy rate: about 57 percent of pregnancies are unintended, higher than the national average, Edwards says. It’s an ambitious-sounding effort, but Markell told the Cut he sees preventing unintended pregnancy as an opportunity issue that must be addressed.
“So many women, and for that matter, a lot of men, see their life trajectory change dramatically as a result of an unintended pregnancy that leads to a birth,” Governor Markell says, noting that people often put education plans on hold or get a second or third job or drop out of the workforce entirely. “Then of course there’s the impact on so many children who, because of these circumstances, may get off to a rougher start. I really do believe that getting this right, the project with Upstream, could be perhaps the most important thing we do to help more people achieve their full potential.”
Delaware CAN won’t be fully implemented until the end of 2017 (though there are already some participating providers), and it will take an additional two years to complete an evaluation. A public awareness campaign will launch this fall.
A similar program in Colorado has made headlines in recent years for providing free IUDs and implants to teens and low-income women at nearly 70 family planning clinics across the state. Yes, birth control is free under the Affordable Care Act for those with non-grandfathered health plans, but that doesn’t cover people who remain uninsured, or teens who want birth control but don’t want to tell their parents.
The Colorado effort not only lowered the teen birth rate and abortion rate by 40 and 42 percent respectively, but the state saw a similar decline in the number of unintended pregnancies in unmarried women under 25. Colorado’s six-year initiative was funded by a $23.5 million grant from the Susan Thompson Buffett Foundation, though the state added $2.5 million to the 2016-2017 family planning budget to keep it going.
Delaware, on the other hand, is financing its program by reallocating about $1.75 million from the public health budget — the project is also supported by significant private funding — and the governor expects it will result in Medicaid savings that will then be reinvested into Delaware CAN. (After three years, Colorado saw Medicaid savings of about $5.85 for every $1 invested. The state’s Medicaid program covers more than 75 percent of teenage pregnancies and births.)
This is why Markell describes the initiative as “win-win-win:” He believes it will help expand opportunity and improve the quality of birth outcomes as well as save some money in the long run. And he doesn’t even have to ask the state legislature for a budget increase. “This is one of these things where I’m highly confident that there will be significant savings to make it sustainable,” he says.
The partnership with Upstream has helped identify other areas where the state can improve women’s access to care, like the fact that Medicaid payments for labor and delivery didn’t cover the placement of contraceptive devices while the mother is still in the hospital. “If a woman delivers a baby it’s not a bad time to have the conversation. And until we changed our policy a few months ago in Delaware, and this is true in many places, they’d have to schedule a follow-up appointment,” Markell says.
All told, Edwards says there will be 80 to 90 Upstream-trained offices in the state, which is home to about 950,000 people — nearly 200,000 of whom are women of reproductive age. Both he and Markell hope that other states will take a closer look at contraception. “Our aim is to bring reproductive health into the center of women’s health,” Edwards says. “All women should be asked this question as a standard part of their care.”
If they are, Edwards will need to find another gig; but that’s the point. “Our goal is that, over the next 15 years, we can take this work around the country. We hope that in doing so we will ultimately be out of business.”
