Gina Millan was 30 years old when she had her daughter. At the time, Millan, an immigrant from Morelos, Mexico, worked at a factory in Denver, Colorado, where she had no health insurance coverage. Her husband was also uninsured. She asked the doctor to perform a surgery that would prevent future pregnancies, but the doctor refused. Instead, he offered her an intrauterine device for birth control, which she accepted despite her wishes. She kept it for five years before having it removed.
That was the beginning of a long personal health care saga that included periods of no contraception at all. At one point, she became pregnant, but it ended in a natural miscarriage. When she visited the hospital, she received low-quality care, she said. Later, she saved up enough money to buy a second IUD, but it became embedded in her uterus. All the available options were expensive for Millan; none were what she wanted.
“It makes me mad,” said Millan, 51, now an animated community organizer with short, purple hair. “I’m frustrated at how immigrants are treated in America. We make this country wealthier, but we are not guaranteed health care coverage.” She wasn’t only frustrated on her own behalf. All around her, she saw immigrants in her community, many undocumented, who struggled to get the family health services they needed.
In the state of Colorado, that changed in July. The Colorado General Assembly passed a package of five bills that will help immigrants like Millan, and people all across the state, by expanding access to contraception and other reproductive care. This landmark legislation has made the state a model, by enacting sweeping reform to insurance coverage for family planning services that surveys show are overwhelmingly popular nationally.
“When we talk about contraception, the ability to plan a family — to decide if and when to have children — is fundamental to human dignity,” said Jack Teter, regional director of government affairs for Planned Parenthood of the Rocky Mountains (PPRM), an organization that advocated for the new laws.
Policies Under Attack
Advocates like Teter say these services are essential to the autonomy, well-being, and opportunity of individuals and families. But, despite their popularity, policies supporting contraceptive access have been under attack in recent years. Nineteen million women in the U.S. today lack access to the full range of birth control methods. This lack of access is a special problem for communities of color, who frequently face discrimination when seeking family planning services, as well as for youth and people who are low-income, uninsured, or live in “contraceptive deserts,” including rural areas.
Number of women in the U.S. who lack access to the full range of birth control methods
The legislative wins set a playbook for advocates and policymakers across the country who seek to make contraception more widely available. In Colorado, a unique and broad-based coalition of reproductive rights organizations, grassroots social justice nonprofits, and public health practitioners — including PPRM, the Colorado Children’s Campaign, the Colorado Organization for Latina Opportunity and Reproductive Rights (COLOR), and Elephant Circle — came together to drive a unified campaign. At a moment when the COVID-19 pandemic and other factors have caused more people to delay having children, the coalition’s success inspires hope for those promoting greater contraceptive choice.
The story of that success began with a shared recognition by these groups that it is up to states to set policy on access to contraception. At the federal level, the Affordable Care Act created a requirement that Medicaid and most private insurers cover a wide variety of contraception without cost-sharing. But there are gaps in the law, as well as leeway for insurers to provide coverage for some types of birth control, and some populations, while excluding others. Meanwhile, a 2020 report from Colorado’s Maternal Mortality Review Committee recommended that the state provide greater access to family planning services through broader insurance coverage and provision of culturally competent care. The coalition aimed to address these issues at the state level, working closely with each other and policymakers to draft a slate of five bills that would fill these gaps.
What the Bills Did
The Colorado General Assembly passed all five bills, providing new coverage for a range of contraceptive choices. “We decided to pursue legislation that says that insurance needs to cover all contraception for all people,” Teter said. “It also applies to both private insurance and Medicaid, so that people are able to get the care they need.” Led by PPRM, Colorado SB16 ensures that Medicaid and private insurers remove barriers to contraceptive access, eliminate surprise billing for family planning services, and provide coverage for testing and prevention of sexually transmitted infections, among other measures. The Medicaid change alone has the potential to improve care for more than 110,000 uninsured women of reproductive age in Colorado today (not all pregnancy-capable people identify as women).
The Colorado Children’s Campaign led the charge for Colorado SB25, which extends coverage for family planning services to people who make slightly too much income to qualify for Medicaid. The bill includes voluntary sterilization and basic fertility services, options the organization saw provided by other states’ plans. “We had data on hand to say that once fully implemented, it’s projected to save the state $3 million a year,” said Erin Miller, vice president of health initiatives for the Colorado Children’s Campaign. “But the primary reason to do this is that it lets people choose how to run their own lives.” The bill received bipartisan sponsorship in both chambers of the General Assembly.
Through Colorado SB9, COLOR advocated to create a new health insurance program under Medicaid that grants access to family planning services for undocumented immigrants. “We really believe that access to contraception allows our communities to achieve their personal, professional, and educational ambitions,” said Katherine Riley, interim policy director for COLOR. Latino people in Colorado are uninsured at 27 percent, the highest rate in the state. Millan, who works today as a community organizer for COLOR, helped to build community support for the new program, which will provide more choice about family planning and care for immigrant communities who often face disproportionate barriers to accessing care.
Elephant Circle pushed for two bills, SB193 and SB194, both of which expand health care access in the periods surrounding pregnancy. In particular, SB193 requires that the state provide better access to perinatal care providers and health education for incarcerated people, including those who are pregnant. Indra Lusero, director of Elephant Circle, said the new laws represent an important measure toward reproductive justice: “There’s no justice if people can’t control the timing of their pregnancies.”
Presenting a unified front was crucial to winning all the laws at once, advocates agreed. “We had this really broad coalition of folks who all came to the table with their own goals, but with a shared vision of continuing to improve access to contraceptives and supporting Colorado families in planning their own futures,” Miller said.
There’s no justice if people can’t control the timing of their pregnancies.Indra Lusero director of Elephant Circle
The Power of Many
Advocates for family planning services often find themselves in competition with each other — and with other policy-focused social justice organizations — for both state dollars and policymaker attention, several coalition members said. In this case, however, they banded together, put all the proposed new measures on one sheet of paper, and pushed it as a single agenda.
The members of the coalition each took ownership over one specific area of legislation, supported one another in drafting the bills, and committed to a consistent message that all five bills support the same communities and must run together. This made it possible to pass legislation for which it has been challenging to gain support in the past, such as COLOR’s proposal to provide contraceptive access to undocumented communities. “When social justice organizations with similar missions get pitted against each other, it’s really challenging for everyone to make their case,” Riley explained. “This year was really different.” She added, “We would not have been able to pass SB9 without the incredible support of the coalition we built.”
Now that the bills are Colorado law, coalition members have turned to the massive task of implementing the systems that will support new services and educating the public about them. “With policy advocacy, the bill signing is not the last step,” Miller said. “It’s the first step of the real work.”
Most of the new laws take effect in July 2022. For brand new programs, like those created under SB25 and SB9, the organizations must coordinate with multiple state agencies — including the Department of Public Health, Health First Colorado (the state’s Medicaid program), and the Division of Insurance — to carry out the rule-writing, coding, and regulatory processes that make service provision possible. At the same time, they have begun to communicate to the public about the expanded coverage for contraception, so that people can gain access.
For other programs, like those under SB16 that guarantee insurance coverage for long-standing services, there is the bureaucratic but important work of updating billing codes and manuals, so that no one ends up surprised by unexpected out-of-pocket costs. “In areas around insurance barriers to care, if policy is working well, nothing happens,” Teter said. “You go to the doctor, say you want birth control, and your insurance covers it.” He added, “Fulfilling the promise of the Affordable Care Act means ensuring that no one is getting a surprise bill for birth control.”
The Fight Is Not Over
Millan is enthusiastic about the new laws, which she sees as a victory for the organizing work that she has increasingly devoted her life to over the past 15 years. She is less concerned, she said, about how the new laws will affect her personally than the benefit they will provide to those in her community — for example, her coworker’s 21-year-old daughter, the undocumented people she knows, and many in rural parts of the state with scant access to contraceptive options. And the fight is not over. She is determined to keep educating, organizing, and pushing back against opponents of birth control, so that others can enjoy the rights that she was denied.
Millan asks others in her community to join her in this fight. “Something I tell people all the time is that it doesn’t matter if a certain policy is going to impact you personally,” Millan said. “Don’t just focus on your personal benefit. If it’s going to help your community, it matters to you as well.”