overcome recently, story i will tell, two years ago when arkansas was looking to, whether or not to expand medicaid under the affordable care act. and at the time we had a democratic governor and newly installed republican majority in the legislature and a lot of those republicans were elected, were elected on a pledge to oppose anything having to do with obamacare, but, once we got into the session and we started looking at it, the impact of not expanding medicare, that it would have on budget, we do have to balance the budget at state and local level which is something we all have in common, would have been tremendous. we're also looking at potential impact of closing rural hospitals. arkansas is a rural state. that is a lot of people going without access to health care and local communities going without access to major employer and major institution in the community. and so what ended up happening, and i'm summarizing because it was a long, involved process as you all can imagine, we came up

with a compromise and it was called the private option. to make a long story short, it was about taking the medicaid expansion dollars that were available but using them to purchase private insurance on the health insurance exchange. this was a really innovative approach. it didn't mean that it passed easily. i think we had to take about six or seven votes mainly because extremes on both sides we were just hear about were pretty dug in on the issue. i will tell you even though we were able to pass the private option, there were members of both parties who lost elections as a result afterwards, just in 2014. people were primaried, people instrumental passing that policy lost their elections but i'll tell you, i'm a democrat. i was for moving forward with the expansion from the beginning but part of, i think one. biggest things we had to do on our side was keep our mouth shut and not put the other side in two difficult of a position as well. again i see a lot of nodding

heads, but i respected the risks that my republican colleagues took in order to pass a policy that would be in the best interests of the people of arkansas. and now, the private option i think is very well-regarded as one of the most innovative public policies in the country and it is something a lot of states are looking at replicating. i think when you approach these public policy issues from a position of compromise and position of trying to solve problems rather than score political points the end result can be innovation in public policy and i think that is what we're all striving for and hope what we're able to achieve not only here today among ourselves but bring that message back up to washington and get them focused on things that really matter for our country. [applause] >> thank you, warwick. well, just, anybody can speak up on this, but i wonder which federal policy affects your

government, state or local government, the most and what would you tell us to tell congress to solve? >> i can give an example in iowa where this year for the first time in 30 years we invested in our roads, rivers, bridges and infrastructure by raising the gas tax and it was done in a bipartisan way. guess what? if congress doesn't put the highway road trust fund back on better path to solvency the rest of us in all the states will be left with that problem. we need them to be a federal partner. one of the ideas that no labels had was to repatriate taxes from overseas back to the united states, ruse some of that money to replenish highway trust fund. do a bond program. there -- >> we are going to leave this forum at this point and go live to a discussion on birth control and family planning featuring virginia's lieutenant governor, ralph northam.

with policy change by planned parenthood that they will no longer accept payment for fetal tissue. this is being held at brookings institution in washington. >> i will make some dictions. then we'll have belle review volume of future children to hear primarily about the volume i think is the best, if you want to go to one place to know about the status of research and thinking about marriage, this is it. it is extremely good volume. eight chapters or seven chapters of various aspects of marriage, including several chapters on folks on birth control. given our interest in birth control we decided to focus this event on birth control so that is what we're here to talk about. when belle finishes reviewing volume, i will review the policy brief. then we're very fortunate to have lieutenant governor that many here. i will talk -- northam here.

we'll give you a chance to ask him questions after we ask him some questions. we'll have a panel, magnificent panel of people experts on this great issue. i will ask them questions and hopefully have some disagreements and give audience a chance to stump the panel. in introducing belle, this wonderful book, i put a tag on here to remind myself which chapter, generation unbound, drifting with sex and parenthood without marriage. chapter 6 in this volume is something on this topic i think is about as good as you will get for short treatment. there is nothing better and belle is one of the great experts on this issue in this country. belle sawhill, doesn't get to talk about birth control, she gets to talk about marriage in the volume so thank you. >> thanks, ron. now, i want a little help here on the slides. oh, good, there they are. do we need for the --

>> that is the wrong one. >> oh, that is the wrong one. yeah. anyway, let me say a few words while we're sorting that out. thank you very much for being here by the way. really appreciate it. and there is a wonderful volume. we do this in conjunction with our partners at princeton university. editor-in-chief of that volume is sara mcclan hand. a number of our princeton colleagues are here today. i can't mention all of them but there are three or four of them here, particularly want to mention john wallace, who is the editor, managing editor of the volume. john, where are you? thank you. and it's been a wonderful partnership over about a decade's time now. and as ron suggested this volume i think is one of the best volumes we've ever done. we did a volume about 10 years

ago on marriage and were asked to sort of revise and update it this year. and we got a new set of authors and they were terrific people and they all wrote great chapters. i can't possibly do justice to the whole volume. i think there are copies outside and feel free to take one and read it at your leisure. i will show you the table of contents here. so you get a sense of what's in the volume and who contributed to it. so, i can't, as i say, do more than just give you the highlights and a few comments from me. so, let's start with just what's been happening. i think as you all know, marriage is in retreat. it has been declining, from about895% -- 85% in 1950 to 50

mers now. this is age group 30 to 44. you can look at this in different ways, but however you look at it you see these kind of declines. because marriage is declining doesn't mean people are not having children. they're having them outside of marriage instead of inside of marriage. here is the data on from the volume on that issue. as you can see we have very high rates of unwed child bearing in the u.s. right now. overall 40% of all kids are born outside of marriage. this varies both by class and by race. if you look at education, as a proxy for socioeconomic status or class, you can see that the rate declines sharply with more education but keep in mind that this last category here, where

the rates are quite low, the college educated, those with college degrees, is a small group still. it is only about 30% of the population. so the other lines here refer to the other 70%. and then with in each education category there are racial gaps and we had an entire chapter in the volume on the gaps by race and by class. we also had an entire chapter on same-sex marriage as we were preparing the volume. the supreme court was considering what to do and as you all know in june they finally legalized same-sex marriage. and that made this whole discussion very interesting and very timely. and part of the debate, leading up to all the court decisions was about whether same-sex couples are good for kids or not. whether this is a good

environment in which to raise kids? and there are a whole lot of research studies on that. not all of them of equal merit but our author did a nice review of that evidence and a lot of other evidence and background including the legal background on this movement to legalize same-sex marriage and he finally concludes, after looking at all the evidence that you really can't come to the conclusion that same sex relationships are not good for kids. some of the studies that the kids didn't do so well with same-sex coupleses were done with era, period of time and stigma and lack of legalization of marriage, the kids were born in unstable circumstances. they might have been product of opposite sex marriage and then

later that couple broke up and gay or lesbian parent moved into a same sex relationship and the children came with that parent and that led to instability in the lives of the children and that most researchers believe is actually not a good thing for kids. in the future it will be very different and my book, which ron was nice enough to mention, talks a lot about drifting into parenthood. i use the word drifting very consciously because i think that is a lot of what's happening. this is unplanned pregnancies and birth but, in the same sex world, by definition, when people have kids, they do it by choice. we had another very interesting chapter the extent which marriage matters for wild well-being. a child who grows up in a

two-parent family than a child that grows up in a child in one-parent family. are children better off in cohabiting families? this chapter adds to all the literature on those issues and basically all of that literature, of which there is a ton now, has led pretty much to a consensus on average, on average, growing up in a two-parent married family is better for kids than not. that said you have to then ask, well why should marriage matter? one it matters is simply because the people who marry are self-selected group. they have other charactertics, like education and more income, that is helpful to their kids. but there are other reasons as well. this author, david riber, goes through all those other reasons and in the end concludes that all of them have some evidence

of making a difference for childrens lives and if we wanted to replace, marriage, for example, with government programs that made up for the lost income of the second parent, or other things of that sort, we could do that but it wouldn't fully replace the benefits that children now derive from marriage itself. we had a lot of debate around the production of the volume and amongst the authors about whether or not, or why there has been this decline. everybody agreed there was a decline. the issue is why? and these are the usual factors that get debated and talked about. women's new opportunities have made them clearly less dependent on marriage. no longer something they need for their economic well-being and then there is the argument

that men especially less-educated men are not doing well in the labor market, less earnings and made them less marriageable. this lack of marriageable men is a factor in the contributing decline of marriage. there are arguments whether government programs are inhibiting marriage because if you marry somebody that has additional income, you may become ineligible for various programs and that may discourage marriage. and ron haskins in his chapter does a very nice job of reviewing that and other government programs including marriage education programs and some others we'll get to. there has been a huge change in culture and attitudes about marriage. i like to talk about how our language changed around these issues. used to be that we called someone who had a baby outside

of marriage, we called the child an illegitimate child. i mean as recently as three or four decades ago we used that term quite commonly. we wouldn't think of doing that today. we called people who were cohabiting, living in sin. imagine using that term today? that is just an illustration how much attitudes and cultures changed here. brad wilcox, who is big advocate how we need to change the culture, bring back civil institutions and religious institutions to support marriage wrote a very nice chapter with his coauthors on that issue. i would say there are some differences of opinion between the group of authors about the relative importance of all of these factors but everybody agreed you can't just say it is one or the other. you can't just say it is economics or culture, for example, it's both. this is probably my last and

most important slide here and one you're probably most interested in which is, well, is there anything we can do about these trends if we think they haven't been ideal or children? and the bush administration pioneered a set of marriage education programs and thanks to ron haskins and others those programs were very carefully evaluated and by the time we produced this volume we finally had the results and the results are not very encouraging. they didn't show that we were able to move the needle very much using marriage education programs. some people would say, well, we need to try harder. we need a new generation of such programs and that's a legitimate argument. other people argue that we need to reduce the so-called marriage penalties in both tax and benefit programs. we've done a fair amount of that already. it is very expensive to do it because it requires moving

eligibility for these programs quite far up the income stale and when you do that you're getting into the thicker part of the income distribution and costing you a lot of money and there isn't a huge amount of evidence that it moves the needle behaviorally. that is the issue but i don't think it is one that has got a lot of promise to it. finally we have here, not finally, but second to last we have improving mens or womens economic prospects, hoping that will help them to marry or form more stable unions at least. that's been a big issue of debate of late and one of the most interesting chapters to me is probably the most interesting chapter in this whole volume is the one by danny snyder, a professor at berkeley, who looked looked at 15 social experiments

designed to improve economic status of men and women, usually more disadvantaged men or women. they were all evaluated using randomized control trials. most of them were focused looking what happened to the economic status of the recipients compare to a control group. of them, 15 of them actually what happened to marriage. what he finds, that with two exceptions out of the 15, improving male economic prospects did not move the needle on marriage. for women it did. for women there was a lot more increase in marriage rates after a program improved their economic prospects. so i will let you mull over why that might be. final issue here is one that we're going to spend, hopefully the rest of the morning talking about or most of the morning.

that is reducing unplanned pregnancies. when you think about i started with, marriage is declining but people are still having kids and then you think about who is having kids, mostly younger women, women in their 20s. and 60% of those births to young, single women are unplanned according to the women themselves. that is from the government data with a sample of 20,000 people and so forth. so i think that's pretty solid, although we can debate about whether there is some nuances here, what does unplanned really mean? if that is the case, one way to improve the prospects of the children and help the women as well is to enable them to only have children when they really want to have children and feel ready. that would mean they would be older, more mature, more experienced and completed education and likely in a stable relationship with a stable

partner. so this is a very promising direction and one we're going to talk more about because what came out of this entire effort to produce this volume was this is one of the few areas that we saw where you could probably make some difference and you're going to be hearing now from some people who know a lot more about that. so i will stop and turn this back to ron. >> thank you, bell. so bell gave my introduction for me, if you're really interested in marriage and think marriage has big impact on children's well being and look around for interventions that have impact, good studies, pretty much the only thing that has consistently shown an impact is -- okay.

thank you. the only thing that consistently shown an impact is reducing non-marital births. there is some evidence. i would not say it is scientifically persuasive but woman who do not have out of wedlock births have a greater chance of subsequently marrying. there is also studies on women who without out of wedlock birth have more stable marriage. someone interested in marriage is something they focus on. not that they do in the real world and i will get into this as well as lieutenant governor. but this is strategy that makes a difference. in itself it makes a difference for several other things that i will talk about right now. that is why we selected in a volume on marriage we select ad topic of non-marital births and birth control. did i -- i think -- right. so first of all, we've had this enormous increase, bell talked about this a little bit, if you're like me forget stuff in

five minutes, five minutes is up and i will repeat it, message here is extremely important which is that we've had an onslaught of non-marital births. if there is something that results from non-marital births, not good for the country, not good for children, not good for couples, then it's a problem and getting worse and worse and worse. i would direct your attention, will not talk about this too much, there is certain amount of stability, over last, depends on what measure you use over the last decade, and in fact even more than that if you look at rate of non-marital births between 1000 women, i think the date is between 18 and 54, has been pretty stable for two decades. we still have these enormous rates. and as bell said, over 40% of kids are now born outside of marriage. it is a big problem but for some reason seems to have slowed down a little bit so that is a good

thing. here is aspect i think is often missed by people, who is having all these non-marital births? we always like to be politically correct and don't always like to point out act exactly who is doing something that could put their kids at risk or who could take actions, as a result of more government spending and so forth. so here you can see very clearly there are big ethnic differences across blacks, hispanics and whites in rates of non-marital births. many probably know the famous article that moynihan wrote about family composition and his thesis basically blacks are not going to be able able to take advantages of rights they're winning back in the 1960s because of results of the revolution because the black family has disintegrated that was extremely controversial. i don't know any academic fight, maybe over bell curve, only other academic fight i think of was so intense and nasty. it was legally ugly.

now i think we all have, harbin did a volume couple years ago. volume says moynihan was right. now what do we do? because it spread throughout the whole society. in fact the rate for white births now is higher than it was when moynihan wrote his alarmist report about impacts on blacks. but anyway, if it does bad things, there will be differences among ethnic groups. and equally bad, the same thing is true, the same thing is true of education levels. moms with less education are more likely to have a non-marital birth. moms with less education are less likely to have a non-marital birth. so we have the most disadvantaged groups in our society who are having more non-marital births. there is one impact on both the mother and children and perhaps the father as well that is undeniable. they are much more likely to live in poverty. i have not yet anybody that make as claim that poverty is good

for kids or adults. five times the rate. can you think of any intervention that produces an impact of five times in experimental group better than the control group? we don't have many like that. yet, kids are five times as likely to be poor if they're in the single parent family, which by every definition, every non-marital birth is in single parent family. there is clear impact on poverty. if you want to summarize, which is what i'm trying to do here, there are many, many other out comes, there is the least one i would call decent study. there is whole literature featuring random assignment study. you have reduced poverty rates. there is no question about that. a lot of evidence lower abortion rates. women who are pregnant outside of marriage more likely getting a abortion. a lot of evidence on better spacing for babies an kids and

mother. increasingly likelihood of prenatal care. kids, i think twice as likely prenatal care if they have a planned pregnancy, rather than unplanned pregnancy orbiter outside of marriage. there also is less postpartum depression among moms with planned pregnancies. reduced partner separation rates. more education for mothers. bell has written about almost all of these things. and there are a lot of studies for cost savings for government. i think maybe numbers are somewhat exaggerated sometimes but the very good review of the evidence shows that larks, the benefit cost ratio is $7 of benefits for every dollar of cost and that does not include any of the long-term benefits. and there is wonderful of review of literature by martha bailey at university of michigan shows big long-term impacts in fact the second generation. moms who avoid early births have

kids that do better than moms have early births. their kids do better. grow up. get more education. more income. less welfare and so forth. no one has taken those measures gone as far as i know, around definitely not including the seven to one figure. this is really a spectacular list of advantages. if we could do something about non-marital births, the mother would be better off, the child would be better off, the community they live in would be better off and nation would be better off and government would save money. that is a pretty good list of benefits. now, we have in the last decade or maybe a little more become increasingly to realize at large, long, lasting irreversible contraception which includes, which includes iuds and subdermal implants, and lasts up to 10 years, that they can have a huge impact on pregnancy rates for women who want to avoid pregnancy.

so this data is from one study, a st. louis study. as far as i know every study has shown roughly the same kind of thing. it is probability that a woman, would be pregnant if on various types of birth control. if a woman is on pill, patch or ring, she is nine times as likely to get pregnant as if she is taking a larc. i wouldn't focus on exact ratio here, but it is huge. many stud show this that larcs are very effective. birth control produces good out comes and larcs are best form of birth control to insure women don't get pregnant and we need to focus a lot of attention on larcs and that is what we'll do this morning. we mentioned barriers, we invited people to participate on the panel who are experts on these issues, reflect on these in more detail. i already talked about costs. in this case, initial cost of a

larc is more than initial cost of a pill, but in the long run, especially lasts for decade it actually saves money. then not to mention the impacts which also saves money. so in the long run this is typical thing government face, spend money now, you don't have to spend later. provider training is an issue. becoming addressed thanks in part to mark edwards here. there are a lot of administrative issues. for most effective you have to have it available on site and got to have people available on site and people coming in would like to have birth control, they would like a larc, come back in a week, that is a bad approach. we knee better patient education what various forms of birth control are. we do not want a situation where women are pressured into taking larcs or any other form of birth control. there are big socioeconomic and race issues i mentioned in the first place.

we have great opportunity. that is one of the main reasons to have the event. i think main factor behind bell's book, and definitely bell was involved in establishing campaign on non-planned pregnancy. they are a great organization. if we could measure these things accurately, major impact on decline especially among teens in non-marital birth rates. we're on the right track. the question is how can we do it more effectively. if we could, a lot of benefits would flow. the rest of our event we hope to elucidate that issue a little more clearly. . .

and then by coincidence the next week i met him because we were in a meeting come with israel focus is since he's been an elected official has been preschool. so it turned out well and he was able to clear schedule but he is a doctor. is a pediatric neurologist. yes undergraduate degree from virginia military institute and a medical degree from the university medical school and is not only lieutenant governor buddies practicing and teaching. he doesn't get a good night's sleep very often.

and as i said his political career began in 2008 when he was elected to the virginia state senate and he's been lieutenant governor since 2013 her since 2013 her i wanted to you and i know for sure he's a very open-minded individual and the reason i know that is that his son is doing his residency, thank you for that complicated term, residency at the university of north carolina at chapel hill which is not overly popular in virginia. so you can tell these are very open-minded generally. so lieutenant general -- lieutenant governor, thank you very much for coming. [applause] >> good morning, and ron, thank you so much for the kind introduction. and my son, we have two children. he's doing his neurosurgery training in chapel hill and that was not exactly his first choice but being a virginian any port in the store. he's enjoying it down there and

working hard and having a good expense. duel, thank you so much for your comments. i really appreciate the opportunity to be here this morning get it takes me away from norfolk which is why practice medicine in the city of richmond which is our capital in the virginia. so it's nice to get a day up in the nation's capital. i would like to also take this opportunity to thank the brookings institution as well as princeton for all of the great work that you all are doing. one might ask why is a pediatric neurologist before you this morning talking about contraception. and i will try to go through in the next maybe 10 to 15 minutes and explained that, but as a practitioner come as a pediatric neurologist and also as a policymaker in the commonwealth of virginia, the concept of contraception and as a way to decrease unintended or unplanned

pregnancies, also to decrease the number of abortions, not only in virginia but in this country and our society, and also to increase the health and well being of our children and their families. so it's an important concept from both a practitioner and a policymakpolicymak er but i want to just go through those steps would you a little bit this morning. as ron said a lot of people don't realize lieutenant governor at least on paper in virginia as a part-time job. so unless one is immediately wealthy, which ron, i am not, then -- i know you are. that's why wanted to clarify things. we continue to have another job and my job is being a pediatric urologist. about three or four days giving a what's going on in the schedule i see about 15 to 18 patients a day. a lot of my patients are

teenagers and we see teenagers from the 15 to 19 age range. we actually see patients after age 18 but most of my population is starting prenatally up until 18, 19. interestingly a lot of my patients are epileptics come as you may imagine, or perhaps have had migraines but are on medications that can affect the health and well being of a fetus. so we deal with individuals in that age group who become pregnant and those become interesting discussions and olympus a lot of these folks. so to be able to prevent those pregnancies, especially in that time of one's life is very important. a second, i would make is that we see a lot of individuals as pediatric neurologist in the

neonatal intensive care unit. we are able to maintain life in a 22, 23 week fetus newborns. for better or for worse that becomes somewhat of a challenge in a couple of ways. the morbidity as you may imagine any 22 or 23 week fetus is fairly high. there are some great outcomes but not all of them are good outcomes. and so if you look at financially what happens to take care of these babies, probably a conservative estimate would be a million dollars up to four or $5 million, up to a year plus in our neonatal intensive care units. and what i found in taking care of these individuals, because when you take care of babies you also take care of parents, in this case most of the time

mothers, but while that baby is in our hospital come in our nicu as we say, oftentimes a mother would become pregnant with her second or third baby. and so how can we stop the process cracks and i see these individuals in my offices. well, usually the mother's bring the families in, and the mother maybe less than 20 and have one, two or three children. and so i describe it as this kind of vicious cycle of poverty. and so as a physician i watched that during my 25 years of practice. and then that carries over into policymaking. now, so when we talk about ways that we can help these families, and i've been to home visits, and by the way, i probably won't talk about that a lot but if you

want to help these mothers and their children, we found a lease in virginia and i think in other places that if we can get into the home and help them get back on track, that this is one of our best investment that we are looking at that concept in the commonwealth of virginia. so how do we move this into policy area? that's my other life, and that is making laws in the commonwealth of virginia. so we have a diversity of two different concepts, if you will, that makes it somewhat challenging policy wise. and personally i feel that if we want to bend the curve of poverty, if you will, if we want to decrease the rate of unplanned pregnancies, if we want to decrease the number of

abortions, the best way to do that is through education and to access to health care, i.e., and this is why we are here this morning to talk about larcs. i wanted to talk about the reality of policymaking in virginia, and we are not here to throw stones but i did want to talk about what philosophy is or the approach of some other individuals who are policymakers. so if you've been keeping up with the news in virginia over the last couple of years, in 2012 we had the infamous vaginal ultrasound bill. and that was i think most people would agree to deter or to make it more difficult for women or children that have until to have abortions. on the way that ralph got in the middle of that discussion is that i'm the only practicing physician, only physician, period, in the senate.

so it can cover some to get up and debate the issue, what better person than a pediatric neurologist, right, to talk about vaginal ultrasound. it was a little bit of a learning curve for me but we made it through and we were able to educate folks and say that the purpose and the response from having about ultrasound really didn't add a whole lot. it's very costly. so we had that bill and we took care of that. then we have a deal those proposed by women that had miscarriages should report a miscarriage to the police. it was like, really? how about reporting it to your provider or your physician? we've also had the infamous personhood bill which is not only a state the but is also has been a nation piece of legislation. and the personhood bill says that conception, our life starts

with conception. and so the concern over the personhood bill, i don't know to get into it, how contraceptives work, but it possibly could make most forms of contraception unlawful in the commonwealth of virginia and it also would make in vitro fertilization unlawful. and then we had the trap laws that were intended to shut down some of the women's reproductive health clinics in virginia. so it's one approach, education and access to health care versus the other pieces of legislation. and the trick is how to bring these folks together, sit at the table and come up with a consensus. and so what happened in colorado and st. louis is just very powerful data. it over a five year period at least in colorado, and i will quote that study, the number of unplanned pregnancies went down

40% in the 15-19 year age group. and the number of abortions went down 42%. those are good numbers. i think the message that i try to give our colleagues enrichment is that let's at least agree that the last abortions a better. so if we can agree on that then we can move forward, and then i will start talk about some of the data from st. louis and colorado to hopefully make the case that this is actually a good direction to go in. so that's what we are involved in. to last point i'd like to me, and i certainly don't want to go over my time limit. i see these cards over here. one minute, three minutes, 50 i feel like i'm in a debate that i start having flashbacks but i did want to make -- >> we will be in a debate. [laughter] spent i promise you i don't want to do that. but we have come to our two issues i want to talk briefly.

the first is the affordable care act which as you know covers all forms of contraception and its come as part of the affordable many -- for the correct we have medicaid expansion which is an option for states. virginia has chosen not to expand medicaid, and what that does we have all paid in two our taxes through the federal system to support the affordable care act. road all the time to do is bring that money back to individual states, in this case, virginia, to provide coverage for up to 400,000 working virginians. and i would underline the word working. these are individuals who may have one, two, three jobs at the cost of health care have gone up much faster than their salaries so they don't have coverage. these folks who don't have coverage are women who end up not being able to make choices for larcs, for example. they are our mentally ill who don't have access to providers,

don't have access to the medications, end up in the emergency room or into jail and penitentiary system. and believe it or not our veterans. i know -- these are veterans coming home from afghanistan and iraq. and i tell people the least we can do is to provide those folks that are first their lives for our freedom the access to quality health care. and from a business perspective, just very quickly, about $4.5 million the commonwealth of virginia is contributing to surrounding states who we compete with over politics. and since january of 2014 when we had the option to expand medicaid, we've given away more than 2.8 billion dollars, and that's a lot of money that we could use for education and health care and transportation.

so finally what are we doing in virginia and then i will come to a close and take questions. we are very committed to the health and well being of our children and families and for the first time in administrations in virginia the governor form a children's cabinet. under several individuals that sit on that but within a children's cabinet we have come and i know this is a mouthful but the commonwealth council for childhood success. everybody at several areas. the first of which is pre-k education. we feel very strongly and that by the way is a nonpartisan issue. the chamber is very enthusiastic but we know there's a tremendous learning potential in our children before they ever reach kindergarten so we applied for a grant. we received a grant of about $70 million so we are using that to provide access to pre-k across the commonwealth of virginia. were also look at childcare. as you all know most parents are both working so it's important

to have accessible and affordable and quality child care for our families. and then we want to make sure that our children are healthy, that the initiations are up-to-date, that they have good nutrition so all of these issues are being looked at. one of the areas come and i will close on this, and i spoke about it just a minute ago our home visits. so when one goes into the home and sees a single mother who has perhaps two or three children, have gone into these homes, how can we hope that family. and again we have the that family through education and help them with access to medical care, i.e. contraception is, to try to get them out of that rut, if you will or that vicious cycle of poverty. and that's where the use of larcs comes in. when you talk about different types of contraception, whether

you use oral contraception, birth control pills, whether you use condoms, whether you use larcs, the data is clear these are very effective come up to 99% which in medicine you don't get to 99% very often. they are becoming more affordable. there is now an ied for $50 that will help with the cost of health care -- iad. help single mothers get on the path of helping take care of their current children become an educated, been able to obtain a job and be productive members of society. so the larc is a great concept. anyway, so that's kind of my background as a clinician, as a policymaker, and maybe just a few quick comments on what we're trying to do in the commonwealth of virginia to again, to think ron mentioned this, to decrease the number of unintended or

unplanned pregnancies, to decrease the number of abortions, and to make it healthier for our children and their families. so thank you for allowing me to say just a few words. i look forward to comments answer questions. thank you very much. [applause] >> [inaudible conversations]

>> thank you, lieutenant governor. that was very nicely done. i can do from talking before and knowing about your background and talking to people who know you and listening to presentations that you are a person of substantial reason, and you appear to be willing to give some credit to people who don't see things the way you do. in a couple of states including colorado and at the federal level, there appears to be politics that are extremely difficult, and people's minds are made up and they are in cement. in the case of colorado it resulted in not funding a problem that a pretty strong evidence of success. -- program. a private foundation for individual has picked up the slack but they may not do it permanently. here's my question to you. you on the front line to get you just described your involvement with several issues having to do

with birth. and so have you found it helpful? how do you approach people on the other side who are against policies that would spread birth control? >> that's a great question and it's a challenge that we have because in virginia we have 40 senators and 100 delegates, and they come from very diverse parts of the commonwealth of virginia and they bring with them different, i guess different attitude, different experience. i think that one of the ways we're going to plan to move forward with this is to use the data from colorado and st. louis, and look at what it's done for the well being of families and children, and also what it has done financially. and so sometimes when we talk to our federal legislators, they

don't always belief in science in which we talked about that a little bit earlier, but if you put it is in in an animal you talk about the data and also how it can be cost saving to the commonwealth of virginia, have virginia is a very conservative state. we balance our budget each year which is a good thing. so i want to keep a quick analogy of how i've done this or how we have done this before, but back in 2008 the governor asked me to patron a bill to eliminate smoking in restaurants. and if you can imagine virginia being very conservative, tobacco being a big part of our economy in the past, that was my first year in the senate, thank you very much, governor, for asking me to do that. but i talk about the size as a pediatrician about secondhand smoke, the ill effects of that, and also the cost to our health care, people that are exposed to

secondhand smoke. and so the first year it passed in as senator it was defeated in the house. the second year i reached out come like we are talking, continue to educate folks on both sides of the aisle. and we were able to get past the second year. one of the things that help with that, politicians like to be reelected as you all may realize. and so every two years in virginia the delegates run for reelection. every four years the senators. so we did some polling, talking to individuals across the commonwealth. and in that case 70% of the population said that they would like to be able to go into a restaurant and not be exposed to secondhand smoke. so we presented that data as well and so we were able to move forward. you use creative thinking perhaps maybe changing semantics when you have the opportunity,

but coming at it from different angles, and things happen in policymaking in small steps. you take one small step at a time but that's what i plan to do this you. i didn't mention, i don't mean to be so long winded, but part of our commonwealth council for childhood success, we've offered about 25 recommendations to the governor that we will be acting on this year in the general assembly. one of those recommendations is to increase funding for access to larcs across the commonwealth of virginia. so i will be taking this message on the road, if you will, and also to my fellow legislators. >> one of the arguments that when i first started understanding ayn rand studies -- let me say many of these studies are not random assignment so we always have to leave, the other bit cautious

about result but having said that, the big studies, iowa, colorado, st. louis and now a big study at the university of california at san francisco, it is random assignment, randomly assigned 40 clinics around the country, 20 controlled and larcs that the birth rate in half. i'm sorry, unplanned pregnancies come in half compared to the senators that didn't. so that's pretty good evidence. i don't know what they found pashtun they showed reduction in abortions and some of them were quite substantial. so do you think that's an effective argument? you would think that would be a leading argument. >> ron, i would hope it will be.

what they want to talk about gun control or gun violence or the number of abortions, i think that's the first up is yet to reach out to your colleagues and say do you agree with me that we have too many abortions, and the less abortions in the commonwealth of virginia would be better? and if you do come if we can agree on that, then how can we change that curve of that number? and so it's almost in my mind hypocritical if one says that they want to decrease the number of abortions but they are opposed to contraception. you can't have it both ways. so my first question would be let's decrease the number of abortions, and if so one of the best ways of doing that is to provide women with education as i said earlier that access to quality and affordable health care, to be able to make the decision whether they want to

take a long acting reversible contraceptive. that's the way we will move forward. >> go ahead. >> i just want to follow up on that, we are on the same wavelength which i think the other argument you might start with is what about the government cost? >> absolutely. >> i'm wondering, do you have any data in virginia even, you know, rough the data on how much you can save in medicaid and other programs if you can reduce unplanned pregnancies question mentioned that their high cost of these babies that are born at a very low birth weight, and that's very interesting but i'm wondering about bigger numbers on medicaid generally. >> we do have those numbers. you mentioned i think a great figure that i think people can hang their hat on, for every dollar that we invest in access

and education, you save $57 your that's a pretty -- $527. that would be a piece of data that we use. the point you made, and appointed articulate as well as i could have but to have let's say 20 to 25 week infant that has been in hospital for let's say five or six months that has cost the taxpayers several million dollars, that's just the start. we do the numbers of what it costs to take care of that individual, especially if you have problems like if they have epilepsy and cerebral palsy, all of those things are very costly and the other thing, morally, is it fair to a child and what does that do to a family? for all of these are i think strong facts that we can use to try to make our point. but the last point that i would

say is that, and we had this discussion all the time, it is the people that ultimately will make the decision. just like we did with the smoking ban in restaurants. it is the people who will tell their representatives this is the direction we want society to go in and do is going to be part of the plan or we're going to vote for someone else. that's a good thing about democracy. >> yes. i think one of the things that the national campaign to prevent teen and unplanned pregnancy has done is a very interesting -- andrea kane who will be speaking later may say more about this and i'm glad to see our new ceo jamie here. and if you ask republican women how they feel about these issues, especially younger republican women, they are in favor of birth control. they're issues they think is

already available. they don't see what the problem is. andrea how you can correct me but i think my summary of it, i think that fits in with what you were saying about, go to the public and find out what they want and what they think. >> audience, we have time for a couple of questions from our audience. would someone like to ask the lieutenant governor a question? yes, right near the back. please tell us your name. stand up and osha name and ask your question with a minimum common, okay? thank you. >> i'm wondering and lieutenant governor to talk about the importance of home visits. as a social worker's move into policy, i agree with you they are very important but what you think about increasing training edges education for the people that are going into the homes talking about this? it's often a really hard conversation. there's a lot of religious and moral objections to birth

control for teenagers such as wondering what to do for the people are actually providing that? >> i thank you for bringing it up because when we talk about going into homes, do we have the manpower if you will, the number of social workers and nurses and who ever we choose to take into their homes, and answer to that is no. we are very underfunded for that. judges to give an example, in hampton roads where we have a program, chip inside to the name of the program and that's a statewide program where we go into homes, for every one home that we visit, there are 10 others that need our help. so we are chipping away really by what we are doing right now. ..

those three legends didn't think that smoking was a sin and there are still a number of religions that think sex outside of marriage is wrong. so different political -- the question i would actually like to pose to you you said that people will alternately choose,

but the people are who ultimately vote who choose to come to local elections and state elections and not just national. and in the state of virginia, winning between the women between the ages of would say 21 and 35 do not necessarily come out to vote. i'm not i am not a politician pollster -- >> you are you're on the right track. >> i would ask you to comment on the need or the role for outreach to the voters who don't vote in local and state elections in states like virginia regarding issues like this point. >> your point is so well taken and i think a lot of us if we remember back to when we were 25-years-old, politics and policymaking was and high on their the radar screens so one of the things we are doing that

we are very active at least in virginia -- i can't speak for other areas but it's going to the colleges and universities or community college systems and talking to those individuals into talking about the use of areas issues just like with larc and legislators most of whom are men by the way should be telling women what they should and shouldn't be doing with their bodies. whether legislators should be telling people who they should love and live with. and so that is all part of the process as we move forward is to make our young folks -- and the reason i'm so interested in this as i have a 27 and a 24-year-old. and i see their friends and i see what's important to them and i know them working as hard as i can and other folks as well to make sure we do reach out to the population. when we do polling when i ran into a few 13 for lieutenant

governor we knew the people that would be voting for elderly and women. those were the two big areas and that's who was heavily targeted. does that mean we should ignore the rest of the folks? though so it's our job to make sure we get out in the next election it's not just the elderly and the women that it's the folks that are educated in colleges and universities so that's part of the overall plan but you make a great point. i don't know what your career is but politics and polling may be good for you. [laughter] >> another question over here in the middle up here. then the next and last one will be in the back. >> lieutenant governor, i'm also a virginia resident and a voter and i want to congratulate you on whatever role you had to turning turn down the focus regulations and clinics.

there have to be some challenges for the next several steps to make sure that it sticks so what do you see as the challenge where they are coming from and what is your approach going to be? >> you are referring to the trap laws and does change the structural regulations for the women's reproductive clinics and i won't get into a -- i certainly don't want to get off on a tangent about that was done in the guide is making us safer for women and the data isn't there to support it and my concern as a pediatric neurologist and physician we have people like me doing procedures for example we have gastroenterologists, those that are doing procedures that are much more dangerous than an abortion if you look at the data and so my question to them when they introduce and practice

legislation and my next if you are worried about the safety of the patients what's going to happen if you make this out so right now we have been able to kind of stop the progress of closing down. we need to change some of the seats in the legislature. but that's down the road we would need to do and hope to do good in a positive direction. and i would just tell you that a big part of my job as lieutenant lieutenant governor is an economic development. we want to bring businesses and

manufacturers and jobs to virginia because that is what pays for all of the things we like to talk about and if we need to do that we need the lights on and how come people. we don't want to detour women from coming to the commonwealth and folks like the lg bt community. we want to accept anybody that likes to come and live in virginia so that is the direction we need to go to move virginia forward. >> before the end of the panel i have a suggestion for you. this is a suggestion about how to advance the debate we mentioned the colorado situation where they had a big fight and republicans were opposed. despite the fact one of the worst conservative members.

i suggest that you invite to virginia to come invited to virginia to come down to talk to republicans in the legislature. join me in thanking the lieutenant governor. [applause] bear with us for a minute and we are going to bring out more. [inaudible conversations]

we have lots of views on these issues and i hope you will probably own right is my last slide. but if we are more successful in at least reducing the number of unplanned pregnancies and for almost every issue so i am hoping to dig into some of these issues. let me just introduce the whole panel and then we will proceed.

so this is interesting -- the head of the national campaign to -- i've worked with andrea for many years of and my typical response to her is yes ma'am. it's amazing how much she knows about what is going on. i really like people like that on the hill and i've been able to have contacts with lots of staffers because she tells me who to call. reflect things you've heard about. we wrote a wonderful paper about a -- i shouldn't say jost, but in issue that we are very concerned about that some women may feel come into the governor brought up the issue of mails telling women what they should

do. we could do things that are wrong. mark was on the board of directors of the national campaign to prevent teen unplanned pregnancy. so they started an organization called upstream and he now. they got the federal government to pay for birth control measures. is that right? [laughter] rachel's reaction was god. mark knows a lot about this because he teaches this data to set up clinics and to train the personnel.

i've asked them oldest day on the panel and i want to introduce her again. i will try to and then you will get a chance to. we will begin with mark. >> okay. that's fine. >> i really do want to thank you today for your incredible work. part of the story is true that we have inspired to change that to work on this important issue and i remember when we read the opportunity society which is an extraordinarily powerful book and of course the volume here is fabulous. i will admit my bias. helping women achieve their own goal and become pregnant when they want to is one of the most powerful things we can do to increase opportunity and mobility. upstream usa delivers assistance to health centers so they can

offer their patients the full range of methods particularly the most effective ones. we have done work at about half a dozen states around the country. and one thing we didn't talk about as much in the beginning is that the government, all that governing bodies in the medical field now are really behind these methods. so the cdc talked about how important it is to have access into the american college of ob/gyn and the american academy of pediatrics say that iud and implant should be the method of choice for all women including all adolescent. so this is the middle-of-the-road sort of modern contraceptive methods. as a part of what we do is acknowledge that there is a big gap between what the policy may say and then what actually happens at the health centers. what happens more often than not is women are given a false choice. you can get it until today and it will take two or three visits

to get one of the other fits of contraception. only in women's health health would've this kind of a false choice be available. if there was a really good student, if it was 20,000 more effect if there be lawsuits to get the methods in the same day but he day but he can't answer when women are faced with that choice, they will either use the pill and we know the failure rate is quite high or they will come back for one of the other methods if they don't come back and they come back pregnant. so we had a couple of examples that illustrate what can happen. the very first health center we did work and was in amarillo texas that have incredibly high rates of unplanned pregnancy, teen pregnancy, premature birth and this is a health center that wants to do best in class medicine for their patients which involves making sure the entire health center is allied to make them the same day that means not only training clinicians and providers but also to ensure they can build

for them and to schedule properly. they can be accounted for properly. too often patients aren't counseled and if they don't go to differences in the efficacy rates. so what the data shows is that utah patients about this and make them aware of the various efficacy rates they will often on the road choose iud and implant for themselves and so i think my colleague talks about coercion which is really important piece of this year. we shouldn't be forcing women to do anything. they should be given a true choice. the choice they have right now is not a true choice. but they are doing six times as many iuds and implants than they were before the training. what's interesting though is the revenue is up 400%, and that's largely because of word-of-mouth. when women know they can get these methods they also tell their friends, patient volume is way up, patient satisfaction is higher. as we ask patients who chose the method, did you choose it with

your provider or did your provider choose it for you and it's a really important question because we want to make sure that what we are finding is upwards of the full information they make great choices. another area that we are seeing a huge issue is the background piece of information that most of the planned pregnancy of course the women that were using a contraceptive method using a method that isn't working well for them these are accidental pregnancies that are often occurring in women that know this isn't a good time to get pregnant or when they want to get pregnant, but the pill as a method is simply not that effective unless you are good about taking it. so this is an opportunity to help women achieve their own goals. we are also seeing is that in many health centers women are not even being screened for pregnancy intention as a regular part of their welfare and so women are actually in the health centers for a whole range of

others health issues but no one is asking about pregnancy intention and so that becomes a standard part of their intake. so as a part of their standard of care and intake if the question is no family then we should have a conversation about a contraceptive counseling. if the answer is yes then let's get into the preconception care right away and folic acid and both vitamins but unfortunately that is a question that isn't a standard part of care. so we are doing a project in a large health center in massachusetts only 18% of the women are considered to contraceptive clients and the other 82% are there for a whole variety of other reasons but no one is asking about pregnancy and as a result of some of the same women are coming back just a few months later accidentally pregnant with a whole set of negative outcomes the lieutenant

governor was just speaking about because no one thought about this. this isn't a central piece of women's care as they should be. finally speaking to the notion of the cause, we are doing a new statewide project in delaware, delaware is interested is one of the highest rates of unintended pregnancy in the country. we crossed the medicaid data with the risk assessment monitoring system data and discovered 74.6% of the medicaid births per unplanned. three out of four is. and this is and what women want themselves. it is expensive for the state just in health outcomes allowed so this raises the opportunity to both help achieve their own goals and also save money. rachel is going to be talking about the central part of this we cannot force women to use any

method that the choice needs about to be offered the full range of methods in the same day and that is what it shows how critical it is not that they can get a method on sundays and two or three visits for another but all at the same day. second they are not a panacea. we know that isn't the solution as the lieutenant governor spoke about what we also know that there were 1.4 million unplanned births in this country. and by own view is if we that we want to increase opportunity and make sure that children achieve their full potential we really want to include this with what we think about as an opportunity we can't just simply start the conversation once children are born we have to insure they are born to parents who want them and plan for them and this is a good time to have them and finally i just want to say that this basic idea that women should be able to plan their pregnancies when they want them

in my view this is not about those women this is what i want for my own children. i have three college age girls. my new occupation has changed. i want them to become pregnant when they want to did not diminish before so why wouldn't i want them to have access to the most effective methods of contraception if those methods don't work then we can move onto something else. you know the failure rates are so different and i just get imported we have this conversation to recognize the pregnancy is actually going up. this is important and best class medicine for all women. [applause]

how tall are you? i couldn't agree more about the importance to make free judgment and decisions about their child. that is an absolutely critical role. i couldn't agree more about the potential. they have an amazing potential. if you look at the numbers and they have amazing potential. i hope that means we have an obligation to remove any and all their years for these methods and we have to make sure that when they can't afford them have to make sure that they are available and accessible in the places where men go for care. they have access that day and i think we need to pay a whole lot more attention to to the availability of the methods from

the women that just had an abortion. that is something that we don't talk about a whole lot or think about a whole lot. that is a really important missing piece of the whole state. having said all of that, i think we have to as we go down this road be mindful every minute of going too far to. in the guide is making sure that we are removing barriers and leveling the playing field, we absolutely cannot go too far and end up tilting the playing field in the other direction and end up being productive. it is something we have to constantly keep in our mind as we go forward. in that regard i think it is important to look at the history and learn the lessons of history. let's think about the history into some of it having to do upon perception of this country unfortunately isn't great and some of the history having to do with the larc methods in this

country isn't great. we have an opportunity to learn those methods within days of when the initial larc method, one of the initial methods, the contraceptive implant was approved by the fda in 1990 within days. there started to be proposals to offer financial incentives to win and if they agreed to get a contraceptive implant. that instantly and bridle of this method and an incredible controversy from which i don't think it ever recovered just within a couple of years in 13 states legislators have introduced provisions that were not adopted and they were not enacted that they were introduced offering women's financial incentives if they agreed to get a contraceptive implant. that was in 13 states. in seven states legislatures introduced mandating use of contraceptive implants for women on welfare, women that had recently given birth to the drug

and in one case mandating the use of compass of the implants to those that have a publicly funded abortion. again one of these were passed over adopted but they were proposed. we also in five invite states have judges handing down decisions or offering deals to people who have been convicted of child abuse. offering the sentences if they agreed to get a contraceptive implant. what this did is type the method that had such potential and completely engulfed in controversy and especially engulfed in controversy and those very communities that we were seeking to serve to make this method more from having an artist potential to be a source of controversy. it was an incredibly unfortunate event to and more unfortunate that we are starting to see ripples of this comeback. just this year there was a bill

proposed arkansas proposed, not adopted the proposed that would have offered a $2,500 to a woman on medicaid who already had a child, $2,500 payment if she agreed to a larc method and didn't go anywhere but it was considered by the committee and the district attorney in nashville tennessee. they banned the prosecutors reducing sentences to people who have been convicted of child abuse if they agreed to sterilization and appear according to media reports they took this action after the reports of the last five years being offered to people who. it's something we have to keep our mind constantly. while they have enormous potential and while we have an obligation to remove any and all

very years that could possibly stand in the way of women getting access to these methods. we need to be careful to remember these and we need to remember that the principle of giving women the voluntary and informed choice of the full range of contraceptive methods have been at the heart of family planning programs in this country for decades. that principle served as incredibly well and we need to remember that principle. i think frankly we need to remember the choice of a contraceptive method is not solely about efficacy. it's about what's choice this woman wants to make and what she feels is going to be best for her life because at the end of the day the method of a woman chooses is the one that will best fit into her life since the method that can be used to avoid the pregnancy she doesn't want

to have. [applause] i feel it when we talk about this issue we are talking about almost two levels. there's so much progress and momentum in the conversations we're having around the country and the research that's coming out of places are so exciting and there's so much potential and then there's also a lot of land lines and as rachel said what i want to do is put some of this in the policy and political context based on the experience of national campaign has had talking to a lot of people around the country and on the hill and state governments and local communities. one of the most encouraging things as there is potential for

sort of broad bipartisan support on this as the lieutenant governor said. if you look at the list of arguments that gone without for the potential outcomes there is something there for everyone and it happens to be true. reducing for the use of contraceptive does reduce abortion it saves money and improves outcomes and empowers women to achieve their goals and there is something there for everybody and i think what we can learn from from are some of the places people have come together to find ways to talk about this. it doesn't be not so perfect. colorado is worth spending a little bit of time because it is exciting but also a cautionary tale. the legislator who ron mentioned is a very conservative self-proclaimed redneck republican who saw the value of

making the implants available to women in the state they were not the only methods method available as rachel said that it made -- it reduced the barrier to the methods available for the extra counseling. so they were available when the barriers were removed and lots of additions of the methods. the state of colorado is to step up and continue the initiative at a very modest sum of $5 million. this was one of the champions and he -- you should look him up because the quotes are priceless but i want to just mention a couple cause for a state like virginia they could be very helpful.

he said if you are like im and do not support abortion you want to break the cycle of poverty and you want people to have a better life and save taxpayer dollars white but do not support this legislation? he thought the cost argument would be the way to bring some of his colleagues along. i think the fact that he was only able to get free republicans to join him is extremely telling and cautionary and i think the reason he gave her that is extremely important. behind the scenes this is very similar to what we hear on the hill and ron asked me to talk about that. behind the scenes most of the colleagues say i get it i love to support the bill. the research and arguments are there and it is fantastic policy but i'm afraid and i think that there is political liability for my doing that. the politicians don't give up the first time as the lieutenant governor said there is every expectation that other people in

colorado will come back at this next year. somethings about how to tweak the approach and talk about it but could be instructive. one of the other landmines is when we talk about iuds and implants in teams teenagers. some of the headliners coming of colorado they were giving them to teenagers. no, colorado was making iuds and implants available to women including teenagers but the headline of iuds has grabbed peoples attention and i don't think that it has been helpful so again it is a cautionary tale for how to talk about this and work on it and the political and policy states space and we definitely find that on the hill when we talk to republicans and talk about making a contraception available to women of all ages you get a very different response when you

focus on teens. it doesn't been teenagers have to be excluded but it's food you eat with and i think it's important. the cost argument is very powerful but also can be -- there are some landmines there i think the arkansas example is a good one. that legislator was very motivated by the idea of saving the government money and we can give people the sense of the which will help save money but perhaps that has some unintended consequences we have to be careful about. we definitely have to get the policies in line and i think that the affordable care act for the contraceptive coverage requirement allowing contraception methods available with no cost sharing to women who have private plans that we can't forget that there's still a number of states where people don't have access to medicaid including virginia and there's

still a lot of low income women who don't have that choice as rachel said and that is still a big policy barriers that barriers that we can't look just at the national picture unless we have to look at the specific states in the kind of work that mark is doing to help improve access from the state. even if we can get the financing of the policies all online and at the supply-side is perfect we have a lot of work to do politically and on the ground in terms of the demand side and education. if we want the voters to be the ones that help make the decision we have a lot of work to do to educate them about this and to educate the consumers and the patients that we are talking about. the national campaign recently finished qualitative research with the targeted audience with young women for 18 to 30 who would benefit from iuds and implants and we learned a lot how to talk about larc and the

first insight was to use the word larc and that's something we all have to learn from so we have to listen to the patients both as patients and as voters and look at what they want. and important research finding in the data knowledge about the iud and eggplant is very limited so what people know is often incorrect and out of date, confused. for example we found 77% of adults said they know little or nothing about the implant and 68% said they know little or nothing about iuds. so how can they communicate their desire to their elected officials that they don't even have good knowledge of these issues? we often talk about sex education for teenagers and that

is where the debate goes and it often does become a debate but we can't stop them thinking -- there was a fantastic policy initiative announced in new york city this week that i would encourage you to check out where they are now educating college students about the potential for iuds and they will move onto other methods at a time as well because this is a college completed strategy that is a way of framing this issue that is very inviting and and a feeling of powerful and happens to be true. maybe sort of in the surprising news we have seen great success around the idea of educating community college students and a planned pregnancy and sex education for college students which helps those students learn about the whole range of contraceptive methods and how that could help them achieve

their educational goals again that has partly happened to the conservative states because we are talking about adults and boss teams. as for talking about who people have in mind when we talk about these policy ideas. >> we will have more discussions now. >> [inaudible]

in the financing for birth control in general in march in particular is financing a big problem or can they figure that out and mostly get the federal government to pay their share? >> our experience to date has been the health centers and the states think they are losing money when they offered the methods but when they actually do the data and look at it they are not. they are making money because it is a procedure so the cost is less of a barrier. >> we've seen the data from the health benefits we have been working with southern ocean is that it is so expensive. >> can you tell that to the next group that you are working with

>> there are places that is not the case but in many cases the cost doesn't seem to be -- this is a lot of the policy which has been done. there are some important areas that we need to work on for example as you mentioned in the middle of the bell bell curve and most places that we have worked to cost is not the barrier one thing we hear from centers of apprentice in addition to cost it is being able to have that upfront money so that you can have that implanted in the closet waiting for a woman. so it's being able to have that upfront money to make that investment. we've made a lot of insurance

progress expanding medicaid in many states unfortunately not virginia although it's one of the states that has a specific medicaid extension specifically for family planning. then we made a lot of progress as was said on the affordable care act making sure that they have the choice contraceptive methods and product coverage. what we still have is the gap between medicaid and private coverage. and we have low income women who don't qualify for medicaid and low income women and we have immigrants who don't qualify so we can't just look at the insurance side, we have to make sure that there's a part of the funding available to provide coverage for people who are between or without insurance coverage and that is where the federal programs like the federal title x national family planning programs set in and to provide that sort of vague flexible funding to meet the needs of women that don't have insurance coverage on the day they come in.

>> that's where there is a perfect storm between the politics because the title x program that is often what provides the flexible funding and there is good research that shows went eight for nick gets clinic gets the title x funding it tends to provide better family care in the range of methods that program is proposed for elimination by the house appropriations bill and is cut by 10% in the senate really for political reasons which just makes no sense when it's been very clear that it helps reduce abortion and save money but again that is the political reality that we face. >> we talked talk about an important issue that is about the stop method. many centers don't realize you actually can get the terms for making that these methods and so one of the pieces of quality should print a proof and that we

do is to negotiate a contract so they can get 128 herbs and then get the cash flow to be able to have the methods right there. so i think there are ways we can work with them to ensure the cost is there. >> bringing up politics and politics are especially -- but they are kind of mysterious. there is the word fear that republicans have said in interviews they would ordinarily support this. i think he's a fantastic policy. but what exactly are they fearful about? after co- [laughter] >> i think they are fearful of challenges from primary challenges from bus far and they said that in the national

journal article. i'm not making this up and i certainly heard that from republicans on the hill that i've talked to. i don't know if it's true. i wish one of them would stand up and give it to his right and test the those are extreme views and it depends on where you're from and we often call this the walkable problem. there are different ways they are afraid of different things and i think that if they are talking about teens they are afraid of encouraging every 14 year old to go out and have sex if we make it available to them although there is absolutely no evidence that that is true or we are afraid that we are condoning it outside of marriage or we are afraid that we are doing something that is inconsistent with people's religious values or we are afraid certain methods of contraception may act as

abortifacients. or the argument just changes on different days but there is a lot a lot of their. >> the fact that mark udall lost in the senate after having talked about reproductive health and family planning and a huge amount into that being attacked. but the the post is a liberal newspaper for being the one issue candidate was probably a big element in colorado. don't you think? >> i also think it is fascinating he was beat by a republican who went out of his way to show that he supported contraception and that it is a very valuable thing for women to propose over-the-counter contraception which doesn't help at all.

so that was a very interesting election and one that has gotten more republicans. i don't think we have seen that yet in the implants to a number of republicans supported over-the-counter access. >> the other issue that i think comes in here is related to what you said about the number of adults that have very limited knowledge reminiscent of information. there has been very little use up until now. when i first started working on my book, the data sent by but even said that only 2% of all women using contraception were using long-acting. you probably know the data better than i do is up to like 12% out and it's higher than that among young women so the word is spreading very rapidly and i think that will play into

the politics because once more -- it goes back to your question about young women may be not devoting as much. but i think that as this becomes better known and is working were using it and the names are supported by the medical community that will make a difference politically. but we do have to be patient about that. >> maybe we haven't talked in that teen pregnancy. the teen pregnancy rate has declined every year since 1991 except for two years. and yet we have ten times that of japan -- there's room for a lot of progress here. this administration right at the beginning is getting the most thorough evaluation of any program that i know of and it is

an 102 places around the country. and we've already talked about all the potential damages of the more effective forms of birth control especially with young teenagers. yet the house killed it in the senate cut it by 80%. i don't understand why this is happening. >> first i want to be clear that program is not a program that provides contraception and it's often helpful to sort of divide educating people about why two to wait to have children and how to do that from the delivery contraceptive services that is an evidence-based program that you've written about and one of the evidence-based programs and it is mind boggling that it would have been proposed for elimination. everything that we've heard it's gotten caught up in politics,

shocking. and i think the larger politics around planned parenthood have shifted into putting the program unfortunately. we hope that it can get restored and that science and evidence will prevail. >> that has a ring to it. >> one time that i've been very pleased that it's not going to pass so we are continuing the resolution and maybe we will get the money because it is a really important program. so, here's the last question that we will open up to the audience briefly. what is one thing we can do that will make these reversible forms

>> i think that it's working as a service level and it's a lot of training and it's a lot of the staff at the sites that are older and like me are shopping around baggage from 20 years ago they are getting to the place where they are thinking that these methods are appropriate for teens and young adults as a young transition so it's the hands-on training of how to do it talking to people in helping people understand that this needs to be part and parcel of the service delivery package. >> what's the next thing we should do?

we should be going to health centers in the medicaid and the medicaid payments to meeting the guidelines i think that would be increasing because right now csic >> this is a version of training because we've put the guidelines in. this is the version of training with guidelines that. this is on the supply-side. especially young women getting knowledgeable about the fact that it's effective and so forth

is really important. i just want to comment on that. i get very uncomfortable when we have performance standards where they are essentially grading people on the report card and what the level is about pics of the methods added and and then they tie that to the payment which then can have the impact of giving providers a financial state of the methods you choose that makes me really uncomfortable. i'm all for the performance standards where we look at trying to spot load numbers and it may be a sign of the barriers of asset. i get nervous when you have performance standards that end up in this kind of world of pay-for-performance this kind of all the way and health care at the moment. i get nervous when we end up in a system where providers have a financial stake in what methods

women choose to. mark talked about having a screening question that's on every health care for for him when you go for an annual checkup and you are a woman of reproductive age there should be the screening on do you intend to get pregnant or wants to get pregnant in the last year and i think that could be a game changer but to get doctors and other providers to do that you might have to regulate or provide a financial incentive. would that be going too far in your view? >> when i get uncomfortable is when it affects the choice -- women should have the unfettered ability to choose the methods

that are best for them. >> you can't tell about your magnificent adoption study. >> dimension had no discussion about medical competitions of these methods and the media coverage because it seems to me the stories that ic tend to be very one-sided when they talk about the risks and do not end up at the end of the article saying these are the most effective contraceptive methods and part of what we need to do is balance what the journalists do it's a really good point to a lot of the side effects and the

problems we have to remember and i'm sure the doctors and governors would remind us of this the medical device. so the point is in counseling with him in to talk about that to talk very honestly about the benefits and the downside of these kids so they can make an informed choice and also in our sort of public messaging to those risks in context. the fine print in the ad on tv about all the side effects, does loom very large and that is often all they know so that's something we have a lot of work on. >> it makes it even more important. and there are a lot of risks. >> all the way in the back.

>> they were not that safe when they first came out they were the bad brand that came out and my mom was like why would you want to do that it's really unsafe. the '90s and then plant so what do you think about that. >> something mark already said which is the american college of ob/gyn and american academy of pediatricians have said that this is not only safe but should be the first line of defense for any woman who wants to avoid a pregnancy once more radical servitude can you get about safety now it is true and i'm sure you know more about this

than i do that a lot of providers out there including existing gynecologists that are in practice and are well receptive will tell a woman when she comes and i don't do that it's not safe. i have friends coming younger friends obviously. there is an education job in the training done to be done. >> it's so unfortunate that these are the evidence is clear what the research shows coming out of st. louis is when the women choose these methods they tend to like them much more than the pill and stay with them longer which is one of the reasons the lowest rate goes on and off and so they also returned to the original faster

than they do with other methods of contraception so lots of things about the methods that women liked better. [inaudible] i remember one of you said the test colleagues remain and experiencing the committee is in a the accordance where you talk of women's health what does it

seem as but doesn't seem as a hesitation talking about teens when we count the population out. >> repeats the question quickly. >> i think the question was if you talk about women which includes the teens they may not hear themselves on that they think of themselves as girls, not women they think it is a good point point and it's more just a political hesitation than anything else as we have heard from a medical point of view the american academy of pediatrics are perfectly appropriate and the first line option is more of a messaging issue in terms of the sort of political and policy discussion but i also feel like we are trying to have the conversation on two levels. there's how we talk about in the policy and political space and then there's how we talk about

it when we are trying to reach girls and women and those are nice and convenient and a lot simpler if we could use the same terms all the time that we do have to kind of take the methods and so i want to go back to the plate we are all using this term because it is a convenient way of packaging a couple of categories of contraception and the research that we have done makes no sense to them and they don't understand why you would treat something that goes in your arm and something that goes in your uterus as one category of things when they are so different. so we started to talk about them and it's a little bit more but that is an example where in the space like this we can talk about it in the long and short hand but if we talk about the actual young woman thinking about getting one of these methods that isn't the best way to talk about it. >> last question.

>> we tend to focus on teams that its single women in their 20s. it's important to keep in mind. >> un gender that they had a lot of great provider education with their membership. but what is being done on the primary care level is a lot of the women above see a gynecologist until they are 21-years-old and both of them at that point in time are already sexually active soap but is being done at the primary care provider level? >> not enough. that's why we are having the screening questions that we talked about. stick in the primary care settings it is a huge opportunity because that's where the volume of the patients are and it's a big gap between what is best and what is actually

happening. >> to add to that not to pick on the pediatrician in the audience that they think it's not just the primary care level i think we need to focus much more on the pediatricians and the adolescent care, the doctors are seeing women in their teens who can really set them up for being able to make responsible decisions going forward. ..