Wednesday, July 23, 2014

7 reasons birth control pills shouldn't require a prescription

Monday morning's Supreme Court ruling dealt a blow to contraceptive access. The ruling allows some for-profit corporations to provide insurance that doesn't cover birth control, essentially opting out of Obamacare's mandate.

In the short-term, political efforts will surely focus on bridging the coverage gap created by the decision. But in the long term, advocates for access to contraception should turn to something else: making birth control available over the counter.

1. Birth control is safe.

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"Oral contraceptives have been out for many, many years in this country. Although no drug is perfectly safe — even aspirin has its side effects — oral contraceptives are a relatively safe drug." says Gerald Joseph, a vice president at the American College of Obstetricians and Gynecologists. "The benefits far outweigh the risks."

Since the birth control pill became mainstream, the main change has been a trend toward "low-dose" formulations; most pills contain lower levels of hormones than earlier versions. The morning-after pill is a strong single dose of the same hormones, and it's available over the counter.

Blood clots are one of the chief medical concerns with birth control. But pregnancy itself comes with blood clot risk that's twice as high as the risk associated with contraceptives.

Health risks are higher among certain women — those who are obese or who smoke, for example. Doctors and pharmacists believe that women are capable of self-screening for risk factors, and they have data to back them up.

2. Moving the pill over the counter would improve access.

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Obamacare requires that plans cover birth control pills without a co-payment. That's a solid strategy for improving access, but it may not be enough: multiple factors influence whether a woman has access to contraception, and affordability is only one of them.

If a woman is unable to schedule a doctor's appointment - she can't get the time off of work, or find a babysitter, or she doesn't have access to a car or other transportation - that's a barrier to birth control, because a prescription is required to get the pill. Making insurance more generous can't fix that.

One of the primary problems with oral contraceptives is the "drop-out" rate. Women receive birth control and start taking it, but the need to fill a prescription every month (or every several months) and to get the prescription renewed after a year leads to women abandoning the pill — and may have more unintended pregnancies as a result.

Allowing women to buy birth control at the pharmacy without a prescription would broaden access. Drugstores typically keep longer hours than clinics and doctor offices, and they're often more conveniently located, too.

3. Doctor groups support over-the-counter birth control.

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Doctors used to require a pelvic exam to check for cervical cancer or sexually transmitted infections before prescribing contraceptives. Though these screenings are still important, medical guidelines no longer mandate these exams before a woman starts taking birth control.

And in 2012, the American College of Obstetricians and Gynecologists — an interest group representing women's physicians — declared public support for making birth control available over the counter.

"We have taken this step because of the unintended pregnancy rate in the United States," Joseph says. "Over the past 20 years the unintended pregnancy rate in our country has hovered around 50 percent and in all those years, we've done very little to improve that statistic."

Obstetricians and gynecologists aren't the only health care providers who support the move. A survey of over 2,700 pharmacists found that 85 percent were interested in providing contraceptive services and 98 percent considered it an important public health issue.

4. So do Republicans.

116779495Bobby Jindal (Jason Sullivan/Getty Images News)

Obamacare's mandate that all employers offering insurance must cover birth control for female employees has been controversial from the start. That controversy tended to break along partisan lines: Democrats endorse the rule as a win for women's health and Republicans condemn it as an infringement on religious freedom.

Over-the-counter birth control isn't plagued by the same problem.

Bobby Jindal, the Republican governor of Louisiana, wrote an editorial in favor of moving contraceptives over the counter in 2012, describing it as "common-sense" and a policy "that could yield a result everyone can embrace: the end of birth-control politics."

Given the Supreme Court decision, we probably won't declare the end of "birth-control politics" anytime soon. But last week, Rep. Cory Gardner, a GOP Congressman running for Senate in Colorado, also penned a column in support of making birth control accessible over the counter.

"Fewer unneeded doctors' appointments mean fewer missed workdays and child-care expenses, more productivity and more time with family," Gardner writes. "With over 50,000 pharmacies in America and no appointment required, the increase in convenience and access would aid every adult woman who uses oral contraceptives, whether it's the first time they get them or when they run out and need a refill far from home."

Among Republicans, over-the-counter birth control is seen as a palatable alternative to requiring employers and insurers to include contraceptives in their benefits — something that would stand in for the contraceptive mandate. But the existence of the contraceptive mandate doesn't change the merit of over-the-counter birth control policy.

5. Most other countries already offer birth control without prescriptions.

Screen_shot_2014-06-24_at_1.45.04_pmSource: K. Grindlay et al, Contraception 88 (2013)

Most of the world lives in countries that offer birth control without a prescription.

The nations where birth control is available over the counter tend to be low- and middle-income, but there's a trend toward expanding contraceptive access in high-income countries.

In 2009, the British National Health Service launched an initiative in London to make birth control pills available at pharmacies without a prescription to women over 16. The project was successful, and NHS recommended scaling it up nationally.

In Australia, pharmacists can dispense interim pills to women who need contraceptives but have expired prescriptions.

And in Washington state, a pilot program authorized pharmacists to provide birth control pills to women without a prescription from a physician. The effort was considered a success: both women and pharmacists thought it was a safe, effective, and acceptable.

6. Moving the pill over the counter should bring down prices.

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Right now, women aren't very sensitive to the price of birth control. Insurers cover some pills without a co-pay, as required by Obamacare. If a woman wants a brand that isn't in the "co-pay free" tier, she'll probably pay a flat fee for her prescription (which might be higher for brand-name pills compared to generics).

But, generally speaking, insured women don't need to worry about the price of individual pill brands, because most brand-name pills will be subject to the same copay (while generics may have a lesser copay). Allowing contraceptives to be sold over the counter would change all that. Contraceptive manufacturers would be required to compete for consumers on cost, which should bring down prices overall.

Lower prices would be good for women who want to buy contraceptives over the counter, good for women seeking contraceptives with a prescription, and good for the health care system as a whole.

7. "Over-the-counter" and "no co-pay" birth control don't have to be mutually exclusive.

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Obamacare made contraception available without co-pays, but that doesn't necessarily eliminate the need for oral contraceptives on drug store aisles. Even when health reform is fully implemented, some people will still be uninsured — consider, for example, the low-income women in states not expanding Medicaid. For the uninsured, the need for a prescription presents an access barrier.

Health insurance could continue to cover the birth control — including IUDs — without co-pay, while over-the-counter access gives women an option to purchase the pill on her own dime. There's actually some precedent for this. Obamacare makes therapeutic aspirin — when it's prescribed to reduce the risk of heart attacks, for example — available without co-pay. Of course, anyone can walk into a drugstore and buy a bottle of the exact same aspirin; the fact that some adults get it free with a prescription doesn't change that.

The morning-after pill works the same way: if prescribed, women can get it without a co-pay. Or, they can pick it up at the drugstore and pay for it themselves. Birth control pills should work the same way.

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