Upstream USA

Ordinary unrestricted recipient donation. G=$10,000 is arithmetic normalization only. c uses full recipient expenses, including operations, grants, management and fundraising, per new partner population as a conservative planning anchor. It is not observed marginal cost, and no existing patient is assumed newly treated merely by being covered. Partner clinical resource costs paid by insurance are excluded from donor cost but require a separate social-cost sensitivity. No avoided public spending is netted from the donation.

The original return identifies domestic partnerships and no foreign operational activity. FreeBC currently operates in Colorado. g=.99 is an outcome-weighted residence allowance for incidental nonresident/foreign spillovers; range .98–1. No national benefit is allocated by headquarters, citizenship or share of states covered. All US states and DC count.

D(T)=sum[t=1..T](1.03)^(-t). N=(G/c)×b. Q_all=N×(d×D×q−h). Q_USA=Q_all×g. Price per 10=10G/Q_USA only when Q_USA>0. d is Upstream-attributable patient-desired pregnancy episodes avoided per newly covered person-year; q is net patient health per episode, not lives not born. h is incremental treatment/adverse-experience health burden per newly covered person over the intervention horizon, retained even when d=0.

G

10000 USD normalization (judgment). Arithmetic scale only, not a verified funding tranche.

FY2025 expense

47685527 USD (observed). Original Form 990 full functional expense. [up-99025]

New partner reproductive-age population

445000 patients in partner population (observed). 2025 accomplishment narrative; does not establish unique treated patients or causal health change. [up-99025]

c

107.15848764044944 USD/newly covered person (judgment). 47,685,527/445,000 planning ratio. Full current spending includes maintenance and expansion, so not a measured marginal cost. Favorable25, poor200; linked service-cost data required. [up-99025]

b

0.1 funding and capacity additionality (judgment). Large liquid investment base and nearly seven expense-years unrestricted net assets motivate a strong discount. Range0–.8 is sensitivity, not observed probability. [up-99025] [up-impact]

d

0.001 additional patient-desired pregnancies avoided/person-year (judgment). One per1000 newly covered people, net of patient selection, usual care and public/partner attribution. Far below the trial's7.5/100 person-years in selected young family-planning patients. Modest Delaware adult initiation effects caution against broad transfer. Stress0–.02. The private-insurance increase was0.3percentage points; substituting methods may yield less pregnancy change than new access. [up-access] [up-abortion] [up-rct] [up-private]

T

3 years of implementation effect (judgment). Same cohort, annual effect discounted3%; range1–5. No evidence verifies national persistence at this duration. [up-impact] [up-access]

q

0.01 patient QALYs/desired episode avoided (judgment). Illustrative0.02 health-utility improvement for0.5year=.01 QALY. This is a cautious patient-health prior, not a measured study effect: generic health utility differences in pregnancy-context studies are small and confounded, VAS much larger, and TTO/SG often near null. Range0–.05. No birth, abortion or child-life count is valued as health. [up-utility08] [up-utility17]

h

0.00001 incremental adverse patient QALYs/newly covered person (judgment). Allowance equivalent to1% experiencing.001 QALY of incremental pain, side effects or harmful pressure; this is not an observed adverse-event rate. Already relative to usual care. Poor.00002; no-harm0. Current pressure survey cannot establish causal excess. [up-impact] [up-coercion]

g

0.99 USA resident health share (judgment). Domestic operational footprint; allow incidental nonresident benefit. Range.98–1. [up-99025] [up-freebc]

Unrestricted net assets

332463472 USD (observed). 2025 Part X; nearly6.97times current annual expenses, not a commitment-adjusted runway. [up-99025]

Unmodeled FreeBC/symptom/autonomy pathway

null incremental QALYs/USD (unknown). Need allocation, additional completed care, clinical indication, utility change, and funding counterfactual; do not convert free-care availability or choice into QALYs automatically. [up-freebc] [up-impact]

Cautious current implementation and patient-health scenario: Cost: $10K; USA QALYs: 0.00016893904358000525; all-population QALYs: 0.00017064549856566188. c=107.15848764044944; b=0.1; d=0.001; T=3; D=2.828611354894681; q=0.01; h=0.00001; g=0.99. Discounted causal net patient-health pathway, not a valuation of births avoided.

Low-cost scalable access with sustained patient-desired benefit: Cost: $10K; USA QALYs: 1.462306299902251; all-population QALYs: 1.462306299902251. c=25; b=0.8; d=0.02; T=5; D=4.579707187194534; q=0.05; h=0.00001; g=1. Discounted causal net patient-health pathway, not a valuation of births avoided.

Little additional desired prevention and adverse burden: Cost: $10K; USA QALYs: -0.00001940970873786408; all-population QALYs: -0.000019805825242718447. c=200; b=0.02; d=0.0002; T=1; D=0.970873786407767; q=0.001; h=0.00002; g=0.98. Discounted causal net patient-health pathway, not a valuation of births avoided.

Already-funded expansion fully substitutes: Cost: $10K; USA QALYs: 0; all-population QALYs: 0. c=107.15848764044944; b=0; d=0.001; T=3; D=2.828611354894681; q=0.01; h=0.00001; g=0.99. Discounted causal net patient-health pathway, not a valuation of births avoided.

No prevention benefit but incremental treatment burden: Cost: $10K; USA QALYs: -0.00009238652222507681; all-population QALYs: -0.00009331971941926951. c=107.15848764044944; b=0.1; d=0; T=3; D=2.828611354894681; q=0.01; h=0.00001; g=0.99. Discounted causal net patient-health pathway, not a valuation of births avoided.

Central except no incremental treatment harm: Cost: $10K; USA QALYs: 0.00026132556580508206; all-population QALYs: 0.0002639652179849314. c=107.15848764044944; b=0.1; d=0.001; T=3; D=2.828611354894681; q=0.01; h=0; g=0.99. Discounted causal net patient-health pathway, not a valuation of births avoided.

Counterfactual: b isolates donor financing and implementation additionality given large reserves, committed expansion, other donors and capacity. d independently subtracts usual care, alternative contraception, public payment changes and other partners' contribution; it is not the combined Delaware program's observed initiation coefficient. Persistence covers the same new partner cohort, not repeated counting of cumulative reach. q excludes unwantedness labels that do not represent the patient's own preference and does not assume a delayed pregnancy eliminates lifetime maternity risk.

Attribution: The national implementation planning model includes all recipient spending in c and only a modest patient-health pathway in the numerator. Current funding allocations to FreeBC versus clinic implementation, recurrent support and advocacy are not observed. The central is a conditional cautious scenario, not a complete expected-value estimate or guaranteed lower bound. Unquantified symptom-treatment and autonomy gains could improve it; unwanted methods, removal barriers and side effects could worsen it.

Clinical trials support the access mechanism, but the geographic/patient transfer and marginal financing are judgments. Patient utilities are cross-sectional or hypothetical, not causal QALY measurements from Upstream patients. The range includes harm and zero; favorable/poor cases are joint stress tests, not confidence intervals. A patient-centered access program can have important autonomy value that a health-only QALY metric misses. That does not justify inventing a conversion.

Sensitivity

• At central c,b,q,T,h,g, the rate d needed for $100,000 per10 is3.827 patient-desired episodes avoided per covered person-year; for $1million it is.3830. These requirements are far above the central .001 and implausible as transferable population averages. This is a useful rejection threshold, not a forecast.
• At central effect settings, c would need to fall below about$0.018 per newly covered person for $100,000 per10, or$0.181 for $1million. Better funding additionality and larger causal health effects must accompany scale efficiencies to support high EV.
• With b=1 rather than.1, central price falls tenfold to about$59million per10; funding additionality alone does not make this narrow health pathway compelling.
• At central d and other inputs, q must be about38.27 QALYs per avoided episode for $100,000 per10 or3.83 for $1million. Those are not credible brief patient-health improvements and cannot be supplied by counting a child not born.
• The favorable case jointly assumes c=$25, b=.8, d=.02, five-year persistence and q=.05, yielding about$68,000 per10. It requires evidence for all these improvements, not simply choosing a high LARC uptake rate.
• Setting h=0 improves central price to about$383million per10. Setting d=0 while retaining incremental intervention burden produces negative health; harm is not discounted away by assuming no prevention.
• FreeBC could have a materially different direct-care cost and counterfactual, especially where alternatives disappear. No current service counts or marginal budget link it to the next ordinary recipient donation.
• Adding$15 per covered person of incremental partner clinical resource cost would increase central social cost by about14%, with no claimed public-cost savings; actual care utilization and reimbursements must replace this illustrative allowance.
• Generic health utilities and autonomy are not interchangeable. Counting educational attainment or public savings would require separate outcomes, not adding them to QALYs without a transparent bridge.

Unresolved inputs

• A current funding-contingent expansion budget explaining what does not happen with $332m unrestricted net assets absent new donations.
• Matched marginal national expenses, newly covered unique patients, actual preferred-method access, removals and care completion, including the FreeBC allocation.
• Causal changes in patient-desired pregnancy prevention or symptom relief relative to contemporary alternatives, with public/partner contributions separated.
• Repeated patient health-utility measurements with an appropriate comparator, duration and unwanted effects; current pregnancy-context utility differences are not causal treatment effects.
• Causal excess pain, side effects, removal barriers and pressure versus ordinary care, plus positive autonomy outcomes kept distinct from QALYs.
• Effect persistence, staff turnover and maintenance costs for the same partner cohort, not annual re-counting of stock reach.
• Outcome-weighted patient residence and payer/resource-cost data; no inference from the number of states.