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The Over-the-Counter Birth Control Debate

March 31, 2016
Early this year, new laws in Oregon and California have enabled women to get hormonal contraceptives–such as the pill, patches and rings–directly from the pharmacy, with several other states planning to follow. What are the details and implications of these new laws? How have politicians and medical experts responded? Wonk Tank’s Health, Education and Welfare team will address these questions in our report this week on over-the-counter birth control.

Background

 

Since the FDA approved the use of the pill and other hormonal contraceptives in 1960, women’s access to such hormonal contraception has faced several barriers. Currently, in addition to “Zygote Personhood Bills”[1] and other congressional measures to make birth control less accessible, the traditional path to obtaining hormonal birth control involves going to an appointment at a clinic or doctor’s office, getting a physical examination, and then taking the prescription to a pharmacy. Several medical and political groups, such as the American College of Obstetricians and Gynecologists, have argued against this current method of obtaining birth control and have endorsed full over-the-counter access.[2]

 

On January 1 of this year, women in Oregon are now able to get the birth control pill, patch or ring without a trip to the gynecologist, although not completely over-the-counter either. In this law, women over 18 can visit their pharmacies to get a prescription directly from their pharmacist after a short screening process that consists of a 20-question self-assessment. Pharmacists also have to complete a training protocol in order to issue prescriptions. Moreover, prescriptions can include up to a year’s worth of the pill, a significantly longer time than most prescriptions from doctors.[3] In California, a similar practice has begun to occur early this month, although with no age restriction. The law in California also requires pharmacists to take women’s blood pressure. Plans to implement similar practices have arisen in the states of Washington, Hawaii, Arizona and Alaska.[4]

 

Under the Affordable Care Act, all prescription hormonal birth control will be covered by insurance, albeit with a possible additional cost of $25 for the pharmacist’s services. Both the law in California and in Oregon has received bipartisan support, with the political purpose of reducing rates of unintended pregnancy and abortion. Rep. Knute Buehler, a Republican who sponsored Oregon’s law, explained his decision to the New York Times by stating that it will “have repercussions for decreasing poverty because one of the key things for women in poverty is unintended pregnancy.”[5]

 

Debate

 

In other states, like North Carolina and Colorado, the debate on over-the-counter birth control has taken a strange twist, with a group of Republicans pushing the option while Democrats resist.[6] Politicians who oppose these bills have insisted that there is no guarantee of over-the-counter birth control being covered by insurance, the absence of which would widen economic disparities among women. Even Planned Parenthood, which has a typically positive view of options that provide access to women’s health services, has taken contradictory action.[7] Although the organization opposes mandatory office visits for birth control, they’ve released ads targeting the Republican candidates who support over-the-counter birth control, accusing them of driving up healthcare costs for women. Other critics point out that birth control methods available over-the-counter would be the less effective options, with less variety for women.[8]

 

Meanwhile, Republicans argue that their plan–unlike the Democrats’–encourages the manufacture of over-the-counter birth control and eliminates restrictions on contraceptives mandated by the Affordable Care Act.[9] But the same politicians support doing away with the Affordable Care Act entirely, which would leave women’s access to contraceptives incredibly vulnerable, especially for the poor.

 

The partisan conflict over birth control has been subsumed into rhetoric that places Democrats and Republicans on clearly opposite sides of women’s health issues. But the underlying problem is a less politicized question: that of screening guidelines.[10] In 2012, recommendations for cervical cancer screening were shifted from once per year to once every three years, drastically lowering the rate at which women see their gynecologists and making visits for birth control prescriptions less likely. That decision was a product of public health experts’ attempts to match concerns of overspending with medically-informed estimates of proper screening times. Studies found that there was little difference in outcomes between women screened every two years and women screened every three years, but a significant difference in cost.[11] Interestingly, the group which instituted the new screening guidelines (the American College of Obstetricians and Gynecologists) has come out in support of over-the-counter birth control.

 

The Potential Economic Consequences

 

Offering women the opportunity to purchase the pill without requiring a doctor’s prescription, not only breaks down another barrier for a woman to control her own sexual reproduction and protects young (teenage) girls from having unintended (teen) pregnancy, but it also has the potential to be a cost-savings solution for the public sector.  

 

Reproductive health researchers from the University of California, San Francisco released a study that estimates how making oral contraceptives available over-the-counter may affect 1) contraceptive use, 2) unintended pregnancies, and 3) associated contraceptive and pregnancy costs among low-income women.[12]  Based on previous data, the researchers estimated two possible scenarios to compare (e.g. low over-the-counter use v. high over-the-counter use) amongst the proportion of low-income women likely to switch to an over-the-counter pill.  From there, the researchers predicted the rate at which these over-the-counter pills would be readily adopted by these women considering the costs per pill pack.  Finally, the researchers estimated the cost-savings of each scenario by comparing the total public sector cost of providing over-the-counter pills and medical care for unintended pregnancy.[13]

 

From this study, the researchers found that about 21% of low-income women at risk for unintended pregnancy are very likely to use birth control pills if they were available to them without a prescription (over-the-counter).[14]  However, the use of such over-the-counter pills varies, depending on the cost of the pill pack.  

Source: Foster et al.Source: Foster et al.

Represented in the figure above is a scenario in which the researchers assumed that with no out-of-pocket costs for the over-the counter pill, an additional 11-21% of low-income women will use the pill, resulting in a 20-36% decrease in the number of women using no method or a method less effective than the pill, and a 7-25% decrease in the number of unintended pregnancies, depending on the level of use and any effect on contraceptive failure rates. [15] Thus, the researchers concluded from these findings that if such out-of-pocket costs for the pill are low, over-the-counter access to birth control could have a significant effect on the use of effective contraceptives and potentially reduce the number of unintended pregnancies.  By having low-cost over-the-counter birth control available so that all women could access it, the researchers argue that there could be savings on public expenditures that were allocated to public health plans that focus on pregnancy and contraceptive health care services.  

 

Conclusion

 

The issue of women’s reproductive health, and the autonomy women have to decide what to do with their bodies, will always be a contentious issue, particularly when religious (political) issues come into play.  However, removing the prescription barrier to the birth control pill comes at a low or zero out-of-pocket cost and its benefits of potentially increasing the use of effective contraception methods and reducing unintended pregnancy as well as healthcare costs making the case that this policy should be enacted at the federal level.  Maybe after more research is undertaken after a few years of the policy’s implementation in Oregon and California, policymakers will have a better idea on the effectiveness of this policy on not only women’s health, but also its potential economic



  [1] Baumann, Nick. 2016. “Congressional GOP Pushes Zygote Personhood Bills”. Mother Jones. http://www.motherjones.com/politics/2011/11/mississippi-personhood-zygote-federal-law.

 

  [2]“Over-The-Counter Access To Oral Contraceptives - ACOG”. 2016. Acog.Org. http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Gynecologic-Practice/Over-the-Counter-Access-to-Oral-Contraceptives.

 

  [3]Belluck, Pam. 2016. “Birth Control without Seeing a Doctor: Oregon Now, More States Later.” The New York Times. http://www.nytimes.com/interactive/2016/01/04/health/birth-control-oregon-contraception.html?_r=0

 

  [4]Karlamangla, Soumya. 2016. “Birth control pills without prescriptions, coming soon to California under new law.” Los Angelos Times. http://www.latimes.com/health/la-me-birth-control-pharmacies-20160214-story.html.

 

  [5]Caplan-Bricker, Nora. 2015. “Women Want Over-the-Counter Birth Control: California and Oregon are listening.” Slate Magazine. http://www.slate.com/articles/double_x/doublex/2015/11/over_the_counter_birth_control_in_california_and_oregon.html.

 

  [6]Libby, Sara. 2014. “The Weird Bipartisan Consensus On Over-The-Counter Birth Control”. The Atlantic. http://www.theatlantic.com/politics/archive/2014/09/birth-control-consensus/380584/.

 

  [7]Hohmann, James. 2016. “Planned Parenthood’s Ad Buy”. POLITICO. http://www.politico.com/story/2014/09/planned-parenthoods-colo-nc-ad-buy-110891.

 

  [8]“Should Birth Control Be Over The Counter?”. 2014. Women’s Health. http://www.womenshealthmag.com/health/over-the-counter-birth-control.

 

  [9]“Colorado Discovers A Way To Reduce Abortion”. 2016. The Huffington Post. http://www.huffingtonpost.com/2015/07/06/birth-control-abortion_n_7738894.html.

 

  [10]Alter, Charlotte. 2015. “Why Over-The-Counter Birth Control Is Stalled”.TIME.Com. http://time.com/4132835/why-over-the-counter-birth-control-is-stalled/.

 

  [11] “New Guidelines Put Pap Smear Screening Test For Cervical Cancer At Every 3-5 Years”. 2016. Cleveland.Com. http://www.cleveland.com/healthfit/index.ssf/2012/10/new_guidelines_put_cervical_ca.html.

 

  [12]Foster, Diana G., M. Antonia Biggs, Kathryn A. Phillips, Kate Grindlay, and Daniel Grossman. 2015. “Potential Public Sector Cost-Savings From Over-The-Counter Access To Oral Contraceptives”. Contraception91 (5): 373-379. doi:10.1016/j.contraception.2015.01.010.

 

  [13] Ibid.

 

  [14]Ibid.

 

  [15]Ibid.
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