Evidence based care in Medicaid

We want to do evidence based care.  We want to do things that work and avoid things that don’t work.  This sounds simple.  Let’s look at two very good natural experiments on unintended pregnancy rates:


    Since 2008, Colorado has successfully increased access to family planning services throughout the state, particularly for the most effective contraceptive methods, such as intrauterine devices (IUDs) and implants.

  • The Colorado Family Planning Initiative has increased health care provider education and training and reduced costs for more expensive contraceptive options, enabling more than 30,000 women in the state to choose long-acting reversible contraception….
  • When contraception, particularly the long-acting methods, became more readily available in Colorado between 2009 and 2013, the abortion rate fell 42 percent among all women ages 15 to 19 and 18 percent among women ages 20 to 24.
  • Colorado is a national leader in the use of long-acting reversible contraception, and reducing teen pregnancy and repeat pregnancies.

    • Teen birth rates in our state have declined more rapidly than in any other state or the nation as a whole.
  • The birth rate for Medicaid-eligible women ages 15 to 24 dropped sharply from 2010 to 2012, resulting in an estimated $49 million to $111 million avoided expenses in Medicaid birth-related costs alone.

More reliable and effective contraception was made available to Colorado women who had the choice to elect Long Acting Reverisble Contraception (LARC) or do something else.  A significant number of women elected to use LARC and the increased autonomy and reliability produced amazingly good results.



Reducing contraceptive availability led to higher abortion rates and higher unplanned pregnancies. Earlier live births have massively negative multi-generational repercussions for both the parents and kids.

The evidence strong suggests that significant improvements in quality of life can be made and significant expenditures reduced if contraception is made readily available.

And guess what Congress will consider to be a high priority:

House Speaker Paul Ryan announced Thursday that Republicans will move to strip all federal funding for Planned Parenthood as part of the process they are using early this year to dismantle Obamacare.

Wahoo… the evidence will strongly support the hypothesis that this policy will lead to more unintended pregnancies, more abortions and far worse outcomes for far more Americans.

Evidence based policy making — Hoo Yaa

Why we can’t have success

The kids these days…

They’re more than alright… they, as a cohort, engage in far less dumb, risk seeking behavior than my cohort did at the same point in my life.

There are two major components of the decline. The first is that kids these days are far less stupid and idiotic and risk taking thrill seekers compared to twenty years ago. This would be Kevin Drum’s Lead hypothesis. As teenagers grow up with far lower exposures to known neurotoxins that impede judgement and encourage short term gratification, they use more judgement and think about the future a little more. They’re still teenagers but they are not stupid. Compared to my teen years, teens are having less sex. However over the past nine years, the amount of sex teens are having is fairly constant.

The other major component of the decline is far more frequent and effective contraception use. Guttmacher found that the entire decline in pregnancy rates among teens was the uptake in effective birth control utilization:

Sexual activity in the last 3 months did not change significantly from 2007 to 2012. Pregnancy risk declined among sexually active adolescent women (p = .046), with significant increases in the use of any method (78%–86%, p = .046) and multiple methods (26%–37%, p = .046). Use of highly effective methods increased significantly from 2007 to 2009 (38%–51%, p = .010). Overall, the PRI declined at an annual rate of 5.6% (p = .071) from 2007 to 2012 and correlated with birth and pregnancy rate declines. Decomposition estimated that this decline was entirely attributable to improvements in contraceptive use.

So the question going forward is whether or not we’ll see those trend lines break?

I think we will. The Federal government will go all in again on ineffective abstinence based misinformation. Essential health benefits will be redefined to exclude most highly effective birth control methods (oral hormones, IUDs, implants etc). Awareness of what works will decrease while access will decline. If we hold the amount of sex being had constant, that means more pregnancies.

I also predict that the older teens will see a lower bounce in their age adjusted pregnancy risk than younger teens. Older teens have some money, they have some knowledge of how to work the system and most importantly, the women who know that they are at high risk of unplanned pregnancy have had the ability to get long acting and reversible contraception (IUDs) to control their risk and maintain their autonomy. Younger teens in the Trump administration won’t have those advantages. I expect births to mothers under the age of 15 to increase at a higher rate than births to mothers at age 18.

Teens these days

Via the Incidental Economist a fascinating study from the Journal of Adolescent Health that attempts to decompose the reasons behind the continual slow down in the teen birth rate. Teenagers are having just as much sex at the end of the study period as at the beginning. They are just having much smarter and safer sex.

They found that that sexual activity didn’t decline. What changed was contraceptive use. Use of the pill went up from 26% to 35%, as did IUDs (1.3% to 2.7%), condoms (49% to 56%), and even withdrawal (15% to 20%). The use of multiple methods increased from 23% to 34%. The percentage of kids reporting no contraceptive use dropped from 20% to 13%.

This led to the PRI dropping 5% every year from 2007 to 2012. Further, about 94% of the decline in the pregnancy risk index was attributable to contraceptive use.

I would love to see a follow-up once the 2014/2015 policy years are included as that is when IUD adaption has significantly increased. Given people tools to minimize risk, teaching them how to use those tools to minimize risk leads to lower risk.

And now I’m double dipping on The Incidental Economist and teen pregnancy prevention programs as they also flag a recent study on the baby simulator doll program:

A number of people, and programs, have decided that one way to combat teen pregnancy is to teach teens how hard it is to raise a baby. They sometimes force kids to “couple up” in school and pretend they have a child. Sometimes, they even give them a doll – one that cries, wakes up at night, etc. – to bring home the point…
And… more girls in the intervention group got pregnant. In the intervention group, 8% of the girls had at least one birth, compared to 4% of those in the control group. Even after adjusting for potential confounders, the intervention group had a more-than one-third higher relative risk of pregnancy in the teenage years.

So not only are those baby-doll-simulators likely a waste of time and money, they may be leading to an increase in teenage pregnancy.

Scaring them straight seldom works.

Kids these days… how will us old(er) people complain about the next generation when they are way less stupid than my cohort?

Well at least we had snow to walk through uphill both ways…..

Zubrick and not understanding insurance

The Supreme Court requested the Zubrick attorneys to file a supplemental brief to explain how employees of religiously affiliated groups could receive no cost sharing contraceptive coverage without the religiously affiliated do jack shit.  The goal is to see if their precious fee-fees won’t be offended while offering their female employees contraceptive coverage.  The brief is here and it shows an amazing lack of understanding of insurance and Congressional intent in the ACA design.

There are many ways in which the employees of a petitioner with an insured plan could receive cost-free contraceptive coverage through the same insurance company that would not require further involvement by the petitioner, including the way described in the Court’s order. And each one of those ways is a less restrictive alternative that dooms the government’s ongoing effort to use the threat of massive penalties to compel petitioners to forsake their sincerely held religious beliefs. Moreover, so long as the coverage provided through these alternatives is truly independent of petitioners and their plans—i.e., provided through a separate policy, with a separate enrollment process, a separate insurance card, and a separate payment source, and offered to individuals through a separate communication—petitioners’ RFRA objections would be fully addressed….

If commercial insurance companies were to offer truly separate contraceptive only policies along the lines envisioned in this Court’s order, then the employees of petitioners who selfinsure or use self-insured church plans could enroll in those separate contraceptive-only insurance policies as well. Those policies would obviously be separate from the coverage provided by the self-insured employers or the church plans, and petitioners’ employees would be free to enroll in those policies if they choose. Accordingly, among the many less restrictive alternatives available to the government is to require or incentivize commercial insurance companies to make separate contraceptive coverage plans (of the kind contemplated by the Court’s order for petitioners with insured plans) available to the employees of petitioners that self-insure or use selfinsured church plans, without requiring petitioners to facilitate that process or threatening them with ruinous fines unless they do so.

I’ll let the lawyers take a whack at the legal argumentation as I’ll take a whack at the mechanics.

Contraception as a cost center is overwhelmingly focused on females who have some idea if they will want to use contraception at some point during the policy’s active period.  Men don’t have to pay for prescription contraception, and women over a certain age don’t either.  Individuals whose partner(s) have had permanant sterilization or medical infertility don’t need contraception either.  Contraception is a near perfect case example of an adverse selection problem when it is unbundled from a larger medical insurance policy.

Requiring women who work for religious organizations to buy separate contraception only policies transforms part of their compensation (second question are the women getting a pay raise to make them whole?) from participation in an insurance scheme to participation in a discount buyer’s club.  Almost everyone who would buy a separate policy with a twelve month coverage period for contraception only will use contraception.  There is no risk pool.  It is just a bulk buyers’ pool.

Congress in the ACA advanced a strong federal interest that there would be no gender discrimination in premiums offered to women.  This was expressed as a significant interest for well over a generation in the group market and it is an expressed interest in PPACA for the individual market.  Congress also has a strong interest in bending the cost curve.  One of the major theories of change to bend the cost curve is to increase the use of evidence based preventative care.  The means to increase birth control utilization is to reduce the cost of birth control.   If all of a sudden secondary policies have to be created the monetary and the hassle/friction costs go up significantly for the people who would benefit the most from increased access to this form of preventative care.

update 1 This is the oh so onerous and oppressive form that must be filled out under the current accommodation for their fee-fees:

Texas, Jake


ETA: Annnnnndddd….always read the fine print.  I was taken in by a fake news story at a parody site.  Mea culpa.

I’ll leave this up as (a) a warning to self not to be an idiot, and (b) as a reminder of how hard it is (at least for me), in this election year of our discontent, to tell the difference between what should be obvious parody, and what is.


I’ll start by saying that no state could withstand a characterization drawn only from its most batsh*t crazy denizens.  So I apologize in advance for painting the great, diverse and fascinating state of Texas with a broad brush.

I’ll also note that it does matter a bit that so many of the most batsh*t insane Texans seem to end up in state government.  What this says about the too many of their fellow citizens* who put them there I’ll leave as an exercise for the reader.

Today’s Texan OMG S/HE SAID WUT???!!!! comes from TX state rep. Debbie Riddle (R-Planet Ten), who’s got a problem with the idea of one particular subset of her fellow double-X Americans doing their ladybusiness in public:

Rep. Debbie Riddle requested that the bill be modified to contain some conditions that not all mothers are going to like. Namely, the modified bill states, among other things, that “only women who possess the breast size C-cup or smaller shall be allowed to breastfeed in public areas.” Asked to comment on the discriminatory clause in the bill, Riddle simply stated, “Nature knows what it’s doing.”

I have to say that I really hope that this is somehow a hoax, that Riddle really didn’t say what she’s reported to said.  Because here’s where she is described as going next:

She also added, “It’s for the greater good. We already have more than enough distractions when walking the streets, and we don’t need this one as well.”


You know that old line, “when you hit bottom, stop digging?”  Riddle apparently does not:

“…everybody knows what happens when a woman with a D-cup size breasts starts breastfeeding her child in the park or on the street. Everybody immediately stops and starts staring.

Riddle also added that“studies have shown that women with bigger breasts are not commonly associated with modest behavior.”


Alright.  If the Texan legislator really did say all that (and more! — check out the link!) I got nuthin.  Or perhaps, as our legal beagle friends might say, res ipsa loquitur.

Ladles and Jellyspoons, have at it.  For me, I despair of the Republic.  Or at least that part of it that gave us the Honorable Riddle.

*Somewhere Rousseau — and Jefferson — are weeping.

Image:  Lucas Cranach the Elder, The Virgin Giving Suck c. 1515


Open Thread: Hash-ley, Made Them Some

The old saw is that men don’t pay hookers for the sex, they pay them to go away after the sex. If the green-mailers/8chan-lulz-seekers who dumped all those Ashley Madison files are correct, Avid Life Media’s most reliable source of income was not introducing lonely guys to suspiciously compliant young ladies, it was assuring those guys that the details of their online fantasies could be wiped clean from the internet afterwards. Welcome to the new age of no privacy, dudes!

As explained at NYMag‘s ladyblog, The Cut:

On Tuesday a group calling itself Impact Team made good on its promise to release a huge cache of customer data stolen from Ashley Madison, a website for people looking to cheat on their spouses that claims to have 37 million members. Parent company Avid Life Media was hacked last month, and the New York Times reports that 9.7 gigabytes of data has been posted, including log-in details, email addresses, payment details, and encrypted passwords for members of Ashley Madison and its companion site Established Men. (A third site, Cougar Life, was hacked as well, but data on ladies seeking younger men was not included in the dump — so thank you, Impact Team?) The information first appeared on the dark web, which means its beyond the scope of your typical internet browser, but searchable databases have appeared online and are currently being combed for famous names.

Of course, the hackers argue their theft and privacy breach is completely justified. Impact Team demanded that Ashley Madison and Established Men be taken offline permanently, and the group objected in its initial statement to ALM’s claim that customers could have their profile erased completely. ALM charged $19 for the service, but it allegedly kept the customer information on file. “Too bad for those men, they’re cheating dirtbags and deserve no such discretion,” the hackers wrote last month. “Too bad for ALM, you promised secrecy but didn’t deliver.”…

The Washington Post‘s techno-blog helpfully explains “How to search the Ashley Madison leak” (until Avid Life Media can get the info taken down, at least). But a different Post reporter warns us, “Don’t gloat… It’s about way more than infidelity“:

… Within minutes of the alleged leak, people began combing the data for information and posting their findings. Journalists and security experts quickly noted that there were 15,000 .mil or .gov e-mail addresses among those used for the site.

Under military rules, philanderers can be punished by a year in confinement and a dishonorable discharge, which means losing their pension, Slate reported

But the Internet soon turned its ire on other suspected Ashley Madison members, such as university professors and other “SJWs,” a derogatory acronym for “social justice warriors,” or people who speak out publicly against discrimination… Read more

OTC Birth control beneficiaries

UPDATE 1 Thanks to commenter MJ_Oregon who actually read the relevant portion of the law:

First, birth control medications will NOT become OTC in Oregon and all insurance coverage still applies. Drum didn’t bother to check the legislation for what it actually says. HB 2879 allows PHARMACISTS to prescribe birth control medications to women over 18 after they fill out a health questionnaire and are counseled by the pharmacist. There are other safeguards built into the language of the bill as well. AND Section 2 of the legislation contains this language: “(3) All state and federal laws governing insurance coverage of contraceptive drugs, devices, products and services shall apply to hormonal contraceptive patches and self administered oral hormonal contraceptives prescribed by a pharmacist under this section.”

Okay, this is just a massive expansion of the allowed prescriber universe without touching the prescribed vs. non-prescribed categorization of hormonal birth control.  This is a net win for women with current insurance, and women who want birth control but can’t easily get to a prescribing doctor.  Very different story.

My bad for not reading the source documentation.


Kevin Drum is commenting on a recent decision by Oregon to allow hormonal birth control to be sold over the counter:

I know there’s some disagreement about this among progressives these days, since prescription birth control is covered by Obamacare and OTC birth control isn’t. But I assume Oregonians who want a prescription can still get one, and allowing contraceptives to be sold OTC as well is the right thing to do. That decision should be made solely on safety grounds, not on grounds of political convenience. This is the same argument we make against things like forced ultrasounds for abortion patients, and it’s the right one

For people who are lucky enough to have access to decent insurance, this is a muddled win.  For women without access to decent insurance, this is a significant improvement to the status quo.

It definately lowers the barriers to accessing birth control for some more women which is a win as they won’t have to see their ObGyn or PCP to get a prescription.  However, if the drugs are being sold over the counter, most insurance companies won’t pay for over the counter medication of any sort.  Further more, women can’t use their tax advantaged health savings dollars to spend on over the counter medication of any sort.  Reimbursement for OTC medications only occur when their is a prescription.  OTC medications will be more costly than zero cost-sharing birth control for women with health insurance.  Once we start factoring in a prescription is needed for reimbursement, the cost barrier that reimbursement knocks down is replaced by accessing a provider to write the scrip.

The real winners of this policy would be women without health insurance, so that increasingly means immigrant women. Increased access to birth control for this group is a win.

The political downside is that putting hormonal birth control OTC gives anti-choice, anti-contraceptive politicians another angle of attack against including contraception as a core, Essential Health Benefit in any and all insurance policies as it is available over the counter.  Senator Gardner (R-Co) used making birth control OTC as a dodge against all of his anti-contraception policy views in the last election.  Getting a policy victory at the cost of a political club is the downside of the deal.  But it is a policy victory that benefits marginal members of the community while not harming others.

The other part of the policy change that stretches a birth control prescription from once per quarter to one per year is a pure policy win on cost, effectiveness, barrier lowering and efficiency grounds.