Usually when a public health agency makes a front-page article in the New York Times, it is not good news for the public’s health. Not true for this week’s NYT feature on the Colorado Department of Public Health and Environment and its six-year “experiment” with providing free long-acting reversible contraceptives (LARCs) to low-income teenagers. The article touts a 40% decline in the teen birth rate and a 42% reduction in the teen abortion rate since Colorado’s innovative Family Planning Initiative began in 2009. But how much of this decline can be attributed to the program?
It turns out this question is not so easy to answer because—contrary to the implication in the opening sentence of the New York Times article—a true experimental research design was not used in Colorado. Attribution is clouded by the fact that teen births have fallen across the country during this time period, partly due to the economic downturn. Fortunately, we have a new study by Jason Lindo and Analisa Packham at Texas A&M that provides strong quasi-experimental evidence about program impact, which surprisingly was overlooked in the NYT article. But this blog will give the researchers their due along with the good people in Colorado’s public health agency.
To derive estimates of causal impact, Lindo and Packham identify all the U.S. counties outside of Colorado with an operational Title X family planning clinic, and use these settings as a nonequivalent contemporaneous comparison group for the Colorado counties where the program was implemented. Colorado’s program steered resources to the state’s 37 Title X clinics to deliver LARCs free of charge to eligible clients. The researchers use difference-in-difference (DND) estimation to control for any systematic differences between the Colorado and non-Colorado settings that might otherwise confound the results. Even better, the empirical specification allows the program’s effects to vary across years while also controlling for state-specific trends in teen births, further reducing the risks of bias due to confounding.
The results suggest that Colorado’s program reduced the teen birth rate by approximately 5% in the four years following implementation. This effect size is much smaller than the 40% reduction touted in the New York Times article, but it is nevertheless a very impressive result that strongly confirms the health and economic benefits of improving financial access to long-acting contraceptives. The estimates imply a cost per teen birth avoided of around $25,000, which is a very good buy considering that the lifetime Medicaid and social services spending associated with teenage births are considerably higher. Moreover, this result probably gives us a more realistic projection of what impact we might expect from full implementation of the ACA’s mandate for first-dollar health insurance coverage of all evidence-based contraceptive options.
The disappointing news is that Colorado’s legislature so far has failed to pass a bill that would provide continued funding for the Colorado Family Planning Initiative, which has been supported to date through private philanthropy. The patchwork of federal, state, and local funding mechanisms for family planning services generally does not pay for LARCs despite their effectiveness and their beneficial economic spill-overs on other publicly-funded health and social programs. Medicaid coverage and reimbursement policies discourage many private providers from offering LARCs to their Medicaid patients, and insurer exemption and compliance issues continue to blunt the impact of the ACA’s private health insurance coverage mandate for LARCs. So for now, the sustainability and spread of Colorado’s innovation in family planning remain to be seen.