October 24th, 2017

The availability of family planning and other health services in Colorado continues to be threatened by various changes in federal policies.

Photograph by Marc Piscotty for The Washington Post via Getty Images

By Michael Booth

Colorado's family planning and teen pregnancy funding has suffered recent setbacks and faces even tougher challenges in coming months, as emerging federal policy changes threaten years of gains in reproductive health access.

The federal government ended one category of teen pregnancy grants, dooming highly regarded Colorado Youth Matter and its family planning and sexual health education programs.

The administration also transformed Title X grants—one of the largest sources of family planning money in Colorado and nationwide—from three-year to one-year grants, with little information about how or when recipients can try to renew their multimillion-dollar awards.

Family planning advocates cite a handful of other looming threats:

  • In early October, the U.S. Department of Health & Human Services reversed Affordable Care Act (ACA) rules requiring employers to include free contraception services for women in their health insurance plans.
  • Congressional budget negotiations and ACA repeal efforts continue to threaten Medicaid expansion funding that brought women's health services to hundreds of thousands of Colorado women.
  • Rocky Mountain Planned Parenthood closed clinics in Longmont and Parker, as well as four more in Wyoming and New Mexico, in late spring, citing too-low Medicaid reimbursement for its services.
  • A University of Colorado study revealed more than half of pharmacies surveyed are flouting rules requiring that the "Plan B" morning-after contraceptive pill be sold over the counter and with no age restrictions, instead setting up barriers that make women's access harder than intended by the U.S. Food and Drug Administration (FDA).

“The unfortunate reality is that reproductive health and rights are under an unprecedented threat right now,” said Kinsey Hasstedt, senior policy manager for the Guttmacher Institute in Washington, D.C., a left-leaning reproductive research and advocacy organization. “We’re talking about undermining access to health care for people who, without these providers, wouldn’t have anywhere to go. And that’s just not okay.”

The program closures, changes to grant cycles and constant threat of more drastic cuts leaves some women’s health advocates in limbo even as they continue to deliver vital services.

“We’re living in constant fear of what they’re going to do,” said Ashley Wheeland, legislative and political director at Rocky Mountain Planned Parenthood (RMPP), of the Trump administration and socially conservative opponents of women’s health funding.  

“We serve 70,000 folks. We have concerns about whether they will even let us service Medicaid patients,” Wheeland added. One third of RMPP’s patients are enrolled in Medicaid.

A Colorado Health Institute analysis after the recent Trump Administration decision to loosen rules on employer-covered contraception estimated that 30,000 Colorado women could lose such coverage. The institute (a Colorado Trust grantee) made the estimate based on the percentage of women of child-bearing age whose employers did not offer coverage before the ACA.

Numerous studies, including those by Guttmacher, have shown that access to family planning and contraception allows more women to finish high school, attend college, close the pay gap with men and better control their economic destiny. Economists have gone a half-century back to study the impact of family planning services on the economic lives of families, with The Atlantic highlighting a report that “provides new evidence linking family planning programs of the 1960’s and 70’s with a decrease in the share of U.S. children and adults living in poverty today.”

Moreover, cuts to such services would fall more heavily on women and families of color, according to national and state statistics.

One of the great public health success stories of the past decade in Colorado is the steep decline in unplanned teen pregnancies, largely attributed to a statewide program offering long-acting reversible contraception (LARC) for free or at very low cost. (The Colorado Trust was among more than a dozen funders to provide short-term bridge funding for the program in 2015.)

Denver Health notes that Colorado’s LARC program was key to lowering the birth rate by 65 percent for Hispanic teens and 60 percent for African American teens since 2004. Researchers have disproven assumptions that differences in teen pregnancy rates were a cultural issue, said Lucy Loomis, MD, MSPH, director of family medicine at Denver Health. Within similar income groups, Loomis said, there is not much difference in pregnancy rates by ethnicity or race.

“The reason you see higher rates of pregnancy at lower incomes is because of lack of access to birth control methods,” Loomis said. “It’s not that they are irresponsible or don’t care. They do. It’s a huge equity issue.”

A Colorado Department of Public Health and Environment (CDPHE) report said 77 percent of women who received Title X family planning services at Colorado clinics in 2014 had incomes at or below the federal poverty level. The department said 47 percent of clients that year were of Hispanic ethnicity—far higher than the overall state population.

“The intent of the Colorado family planning program is for families to space the births of their children, giving them a chance to thrive,” said Jody Camp, the family planning unit section manager at CDPHE. “It’s also about a woman’s choice if and when to start a family, accessing basic public health screenings such as breast and pelvic exams, and for women and men to gain the chance for economic self-sufficiency, and to complete their education by spacing and timing their families as they choose.”

And on a purely economic note, public health officials say, family planning spending has saved hundreds of millions of dollars in Colorado Medicaid and other social program costs by avoiding pregnancies and other health issues in vulnerable populations. A 2011 New England Journal of Medicine study estimated that for every $1 spent on public family planning programs, $3.74 is saved in costs related to unintended pregnancies and births.

Family planning cuts are already being felt in communities like Sterling, in northeastern Colorado, where the Family Resource Center received grant funding via Colorado Youth Matter, which will shutter its operations at the end of the year. The family center used the money to fund Wyman's Teen Outreach Program, a combination of community service hours, meals and classes on pregnancy risk, healthy choices and lifestyles.

Family Resource Center clients “hear some of this information from their friends, but it’s important for them to hear it from people who are trained,” said Yvonne Draxler, the center’s executive director. “And a lot come from families where parents are working so much, they may not have the time or the energy to do things the way we did. We were providing a safe space for these kids.”

The senior citizens who received technology lessons from the teens as part of the community service have already been asking when the program will resume, Draxler said.

“I’ll have to start looking elsewhere for funding,” Draxler said. “It’s getting harder and harder to find support out here in the rural areas. I know there’s need everywhere.”

Colorado Youth Matter (CYM) received about $750,000 per year from the federal teen pregnancy prevention grants ended in September by the Trump administration. That was about three-quarters of the group’s funding, and leadership decided to close the doors rather than scramble to fill the huge hole with other grants.

Urban and rural family planning advocates said CYM was unique in that it went statewide, to cities and small towns and school districts, to train local staff in talking with youth about sexual health and healthy relationships. There’s also a misperception that school-based clinics are now handling contraceptives and sexual health information for all students, when each district does things differently, said CYM Executive Director Andrea Miller. Many students still don’t have financial resources to pay for effective birth control.

“We’ve worked all over the state—Grand Junction, Durango, Denver, Adams County, Sterling,” Miller said. “The comfort levels are very different [in each place] and that’s what we excelled at—we knew how to have those conversations in a conservative district or a progressive district, whether they needed more time to talk or were ready to go all in.”

Larger pots of family planning money are at stake with potential changes to the Title X women’s health funding that flows from the federal government to local clinics. Conservative lawmakers have tried to eliminate the budget item for years, and some current proposed budgets in Congress continue that threat, according to Guttmacher.

What the federal administration was able to do without congressional action was shorten the grant cycle from three years to one year. In Colorado, the Title X grant goes to CDPHE, which in turn makes grants to local health centers. (RMPP does not participate in the Title X funding with its Colorado clinics.)

For Colorado, that means losing the third year of its current grant—funding that was meant to cover the fiscal year beginning July 1, 2018. The administration may or may not intend to offer the same funding for 2018, but the state has been given “zero information” about the future, Camp said: “So now, we have funding through June 30 of next year.”

The good news for Colorado, Camp said, is that state lawmakers stepped up to add general fund money to the Title X federal funds for local clinics. The state now adds $4.1 million to the $3.6 million federal grant, allowing expansion of the successful LARC program. Medicaid expansion has also increased reimbursements to family planning services at clinics from $500,000 before the ACA to about $4 million in 2016, Camp said.

Practically speaking, the change to Title X means the state and local clinics are “tapping the brakes” on strategic expansion plans in family planning services, Camp said: “We haven’t flat-out said ‘no,’ but we are encouraging our folks to wait and watch a little before they expand.”

Title X money and Medicaid expansion reimbursement has allowed Denver Health to hire staff and expand reproductive services at its multiple clinics, Loomis said. In Denver and at other health organizations, she noted, “If staff on grants are threatened with a cut every year, they may just find other jobs. It’s tough to live and work in that situation.”

Recent research has identified another potential equity barrier in family planning and women’s health, through uneven access to those seeking the emergency contraception pills known as Plan B.

After years of changes, the FDA currently says there are no age restrictions or ID requirements for buying the drug, which can be placed in accessible shelves next to cold remedies and aspirin. Yet University of Colorado researchers contacted hundreds of pharmacies across the state to check on access to the Plan B drugs, and found 87 percent of the pharmacies kept it behind the counter. More than half of the pharmacies stocking Plan B also said they required ID for proof of age, counter to the access rules.

Plan B “should be easily available for purchase, yet our research identified numerous barriers to access within pharmacies. These restrictions not only affect adolescents, who may not have identification, but they affect all individuals who may find interacting with a store employee about his or her reproductive health embarrassing. The psychological discomfort can lead to delays or avoidance of purchasing a product with clearly proven effectiveness,” the researchers wrote.

The study suggests better education for pharmacy staff, and amplification of current FDA policy to improve access, but did not specify who should work toward those solutions.

While the researchers found similar access issues between urban and rural pharmacies, they also noted that of 64 Colorado counties, 18 rural counties have no phone listings for any pharmacy.

Colorado family planning providers say they will continue their work while advocacy groups keep a close eye on Washington budget negotiations and federal administration actions. They know that some of the most vocal sentiment has been for further cuts, even as the programs pile up more evidence of success.

“We’d be naive,” said Guttmacher’s Hasstedt, “to think we’re ever out of the woods.”

Michael Booth
Denver, Colorado