The real way to improve contraceptive access

Conservative rhetoric about contraception is often negative and out of step with the opinions and experiences of most Americans. So it’s been surprising to hear a number of Republicans voice support for moving the birth control pill over the counter, in itself a laudable idea. However, it’s less surprising when one realizes it’s a political maneuver to circumvent the contraceptive coverage guarantee under the Affordable Care Act, which was recently eroded by the Supreme Court’s Hobby Lobby decision to exempt for-profit corporations from covering all forms of contraception without cost sharing in their employee insurance plans. 

Louisiana Gov. Bobby Jindal (R) announced his support for over-the-counter birth control pills in 2012, and Rep. Cory Gardner (R-Colo.) recently joined him, making this an issue in his bid for the Senate against incumbent Sen. Mark Udall (D-Colo.). Senate Republicans have also proposed legislation asking the FDA to study whether contraceptives can be sold safely without a prescription.  But their proposals miss the point: Just removing the prescription barrier to birth control is a narrow fix and doesn’t address the barriers women face accessing contraception that can lead to inconsistent or nonuse of contraception and high rates of unintended pregnancy. Without insurance coverage, cost will continue to be an obstacle for many women, especially for those who want highly effective, long-term methods, which have a higher up-front cost and often require a clinic visit.

The evidence in support of over-the-counter access to the birth control pill is solid. The pill has been around for over 60 years, and today’s low-dose formulations are unquestionably safe. There are some conditions that might make it less safe to use the pill or might reduce its effectiveness, but studies show that women can identify these conditions on their own using simple checklists.  Research we conducted in El Paso, Texas, found that women obtaining the pill over the counter in Mexico stayed on it longer than those getting it by prescription at public clinics in Texas. 

American women are very interested in using an over-the-counter pill, and a national survey found that use of birth control would likely increase if the pill were available without a prescription. But that survey also found that women were concerned about the cost of a future over-the-counter pill:  If it cost more than $20 per month, few women were interested. This is consistent with a large body of evidence demonstrating that cost can be an important barrier to birth control: The more women have to pay, the less likely they are to use it.

For an over-the-counter pill to have the most positive impact on access to contraception, it must be covered by insurance. More and more insurers are already covering some over-the-counter medications because it can save them money. And several state Medicaid programs cover over-the-counter emergency contraception without a prescription, as do the Indian Health Service and TRICARE, the insurance for active-duty military personnel and their dependents. But unfortunately, while the Affordable Care Act requires that over-the-counter contraceptive methods approved by the FDA be covered without a copay, the insurer may require women to have a prescription to get that coverage. This obviously undermines any improvement in access afforded by over-the-counter availability.

Of course the other problem with replacing the contraceptive coverage guarantee with a focus on moving birth control over the counter is that some methods require a doctor or nurse to provide them. The contraceptive implant and the IUD, as well as sterilization procedures, are the most effective methods—but they’re also the most expensive. Insurance coverage without cost sharing is a critical strategy to help women who want very effective, long-term or permanent birth control.

The movement to bring an oral contraceptive over the counter, which has been gaining support in recent years, is about increasing access to contraception for all women, not taking contraception out of the political arena or excluding it from insurance coverage. Women need access to the full range of methods so that they can choose what is best for them, whether that means getting their pills off the shelf at their local drugstore or visiting their doctor to get an IUD or a prescription for another hormonal method such as the patch or the ring. But whatever method a woman chooses and wherever she gets it, her insurance should cover it. 

The authors are from Ibis Reproductive Health, which coordinates the Oral Contraceptives Over-the-Counter Working Group.