Later this year, California will become the first state in the country where women can skip the trip to their doctor and go straight to the drugstore for their birth control pills. Passed in 2013 amid concerns about a growing shortage of primary care doctors, the new law gives pharmacists the authority to prescribe hormonal contraception, such as the pill, patch, and ring.
The California law is going into effect just as national interest in fully over-the-counter oral contraception has increased—with two bills in favor of the idea, one from each side of the aisle, now pending in Congress.
According to an analysis published earlier this year, if birth control pills were available over the counter and covered by insurance, the rate of unintended pregnancies could drop by up to 25 percent.
Making the pill available over the counter is actually not very controversial, from a public health perspective. Globally, women in the majority of countries outside of North America and Europe can get oral contraception without a prescription—either officially or through de facto channels. The pill’s risk of serious side effects is very low—lower than other common over-the-counter drugs like, say, aspirin—and it easily meets the FDA’s criteria for medications eligible for over-the-counter status: It has no risk of toxic overdose or addiction. Its instructions are easy to follow. Research has found that women are capable of using a simple checklist to determine if they have any contraindications. And having pill packs readily available—whether by having over-the-counter access or obtaining many months’ supply at a time—may make women more likely to keep using them consistently.
Perhaps the most commonly voiced concern is that if women don’t need to see the doctor to get their birth control, they’ll be less likely to come in for their annual pelvic exam and get screened for cervical cancer and sexually transmitted diseases. But this just underscores the problem with the current system. Medically, a pelvic exam doesn’t have anything to do with whether a woman can safely take hormonal birth control. And yet, despite medical guidelines discouraging it, many doctors still require one before prescribing the pill—essentially holding contraception hostage to coerce women into getting check-ups. It’s a punitive move that doesn’t do anything to ensure better access—to either effective contraception or preventive care—for women who face barriers.
Take, for example, a study conducted by the reproductive health research organization Ibis Reproductive Health that compared women living in El Paso, Texas, who get their birth control pills over-the-counter in Mexican pharmacies to women who get them from family planning clinics state-side. The former group was slightly less likely to get preventative care, like breast exams and Pap smears, but screening rates in both cohorts were fairly high. And, as Dan Grossman, the study’s co-author and the vice president for research at Ibis, explains to me, “The reasons they were not getting screenings were similar to why they chose to get pills OTC—they couldn’t afford to go to a clinic, or weren’t eligible for financial assistance programs, or didn’t know where to go.”
Many reproductive health advocates have been pushing to “free the pill” for more than a decade. And, in the last few years, the American College of Obstetricians and Gynecologists and the American Medical Association have both come out in support of the idea.
Still, it’s a bit of a surprise that Republicans in Congress have recently jumped on board. Last month, Republican Senators Cory Gardner and Kelly Ayotte introduced a bill aimed at encouraging pharmaceutical manufacturers of oral contraceptives to seek FDA approval for over-the-counter status. However, given that these same Republican lawmakers have also sought to overturn the Affordable Care Act’s requirement that insurers cover birth control without a co-pay, reproductive health advocates called foul. If the pill became available sans prescription but with no guarantee that insurers still cover it without one, women would be forced to pay the out-of-pocket cost, which could reach $600 a year. “We cannot support a plan that creates one route to access at the expense of another, more helpful route,” ACOG’s president explained.
After calling the GOP proposal a “sham bill” and “nothing but political pandering,” Planned Parenthood and NARAL Pro-Choice America have now thrown their support behind a competing over-the-counter birth control bill—introduced yesterday by Senator Patty Murray and other Democratic lawmakers—that would ensure the pill remains fully covered by insurance if the FDA approves over-the-counter sales.
The cost concern is well-founded. While some middle- and upper-income women may be willing and able to pay out-of-pocket for the convenience of picking up their birth control without visiting a pharmacy window, the real benefit of over-the-counter oral contraception would come from increasing access among low-income women for whom a trip to the doctor is a hurdle. According to an analysis published earlier this year by Ibis, if birth control pills were available over the counter and covered by insurance, the rate of unintended pregnancies could drop by up to 25 percent. The drop would be attributed to low-income women switching from less effective methods or no birth control to the pill.
The California law, for its part, side-steps the cost dilemma. Since birth control will still be prescribed—by a pharmacist rather than a physician—it should still be covered fully by insurers under Obamacare. Grossman says the law is “a big step in the right direction,” but he still sees “OTC access to oral contraceptives as the ultimate goal.”
For one thing, unnecessary barriers remain under the California model: Women are restricted to picking up their pills during pharmacy hours and must still deal with a middle man, one who may be poorly trained or refuse to prescribe birth control due to his or her own personal moral objections—which has been a problem when it comes to emergency contraception. There’s also a potential reimbursement issue. When Washington state launched a similar pilot project in 2003, it ultimately failed—despite being popular with women—because insurers refused to reimburse pharmacists for their time. And while other states may follow California’s lead if this model proves successful—in fact, Oregon is considering a similar bill right now—winning over-the-counter status would expand access in every state in one fell swoop.
Of course, despite the dueling bills now in Congress, only the FDA has the power to make that change. And first, the agency needs a pharmaceutical company to conduct the required research on its particular pill—which would take a couple years—and submit an official application. “That is expensive,” Grossman explains, “and many of the big pharmaceutical companies that have several oral contraceptive products don’t see much potential for financial gain since they will just be competing with themselves.” Still, he notes, part of their hesitancy may be due to concerns that lawmakers will inject politics into the regulatory process, as they did in the protracted battle to make Plan B available without a prescription.
If so, hopefully these companies will see the relative consensus in Congress as a green light. The GOP’s sudden interest in birth control may indeed be little more than an end run around Obamacare and a cynical attempt to distract from their committed record of voting to destroy women’s access to contraception, abortion, and affordable health care generally. But if the effort helps get the pill on the open shelves, that’s the kind of political pandering I’ll accept.
The Gender Gap explores the persisting gender inequalities of the modern age and society's unwillingness to grapple with them.