Reproductive-health policy experts say making contraception available over the counter would not be a suitable alternative to the birth control benefit in the Affordable Care Act (ACA), though Sen. Bill Cassidy (R-LA) brought up the conservative myth just last week.
Cassidy was asked by host Marc Fisher during a Washington Post Live forum last Monday on the “Health Care Challenges Facing the 115th Congress” whether, like Trump’s pick for Health and Human Services secretary, Rep. Tom Price (R-GA), he would support eliminating contraceptives from the list of services that health insurers must cover.
“I favor making contraceptives over the counter,” replied Cassidy. “Now, the ‘American College of OB-GYN’ favors that as well.”
This is hardly the first time a member of the GOP has championed making some contraceptive methods available over the counter. It’s been a popular battle cry for Republicans seemingly hoping to counter their party’s general opposition to expanding reproductive health care. Trump similarly took up the cause in September when asked about the ACA’s birth control benefit, telling Dr. Mehmet Oz on Oz’s television program that contraceptives “should not be done by prescription. You have women that just aren’t in a position to go get a prescription.”
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As Cassidy referenced, making oral contraception available over the counter has long been supported by the American College of Obstetricians and Gynecologists, which says doing so could “improve contraceptive access and use, and possibly decrease unintended pregnancy rates.”
But there are some key problems with doing so as an alternative to the birth control benefit, especially as a stand-alone measure.
According to Laurie Sobel, senior policy analyst with the Kaiser Family Foundation’s Women’s Health Policy team, when people talk about making contraception available over the counter, “in most situations that means that you don’t need a prescription for oral contraception.” That would mean other methods would not be accessible to those who need them.
“We’ve heard this argument before. It’s not accurate in the slightest,” said Adam Sonfield, senior policy manager at the Guttmacher Institute, when asked whether making contraception available over the counter would be a suitable alternative to the ACA’s birth control benefit. “Moving oral contraceptives over the counter has a lot of potential benefits, certainly, for some women, but it’s one more tool that we need in the toolshed, not a replacement for all the other tools we have that we need.”
Sonfield explained that the ACA “requires not just coverage [of contraception], but coverage of the full range of methods, and coverage without any patient out-of-pocket costs,” or co-pays.
“Trying to replace them with just over-the-counter access for oral contraceptives would mean you would be reducing choice of methods, and you’d be increasing the price of methods,” he continued, adding that “both of those things would be major barriers to women’s ability to choose the method of contraception that works best for them at a given point in their life.”
Cassidy also claimed at the event that if oral contraceptives were available over the counter, those needing it could “go to a [Federally Qualified Health Center (FQHC)] and buy birth control pills for pennies a pill.”
But it wouldn’t be that simple. The FQHCs mentioned by Cassidy are required to work in underserved communities and areas, receive funding through the Health Resources and Services Administration, and provide services based on a sliding scale. In a subsequent email to Rewire, Sonfield explained that Cassidy’s suggestion “would mean forcing women to stop going to their regular primary care doctor or OB-GYN (from whom they get, for instance, their pap tests) and go somewhere separate for their contraception.”
Sonfield added that Cassidy apparently assumes that all FQHCs, which include community health centers, “actually provide birth control pills on site.” According to a 2014 nationwide survey of health centers’ family-planning practices, at the largest sites, just 62 percent of respondents offered oral contraceptives on site, and 36 percent of centers only made prescriptions instead of dispensing the pills.
He also pointed to “the difficulty FQHCs would have in filling in gaps in the safety net created by social conservatives,” specifically pointing to conservatives’ quest to defund Planned Parenthood. Planned Parenthood reports that 34 percent of all health-care services it offers are for contraceptives.
Cassidy himself has voted to defund Planned Parenthood.
Part of Cassidy’s pitch also included the argument that switching to over-the-counter contraception would “immediately lower a lot of costs” and that those who have a health savings account—an option pushed by many conservatives, including Trump, as part of an ACA replacement scheme—would simply be able to use those.
According to a 2015 analysis by the Guttmacher Institute’s Sneha Barot that looked at previous GOP pushes for over-the-counter contraceptives, however, suggestions like Cassidy’s rest “on the false assumption that switching a drug from prescription-only to OTC status will inevitably lower its costs” and ignore that those with low incomes can’t afford to put money away in health savings accounts.
“[S]upporters have ignored the only example of an OTC hormonal contraceptive, emergency contraception, the cost of which has remained high and barriers to access have thus persisted since the prescription requirement was removed,” wrote Barot. “To partially address the issue of cost, the bill looks to Health Savings Accounts and Flexible Spending Accounts—which allow people to put aside a tax-free pot of savings for health care expenses—to pay for OTC drugs without a prescription. Although this option might benefit some better-off women, it would be useless for lower income women who cannot afford to set aside those pre-tax earnings up front and who would save little from the tax deduction.”
Those who use other methods of contraception, such as the ring, the patch, or IUDs, were notably absent from Cassidy’s proposal. And moving oral contraceptives over the counter without the birth control benefit “doesn’t account for all the other methods that women need,” Sobel said. “So you’re essentially taking a plan where all methods are covered without cost sharing, including the doctor’s visit, to moving one method over the counter and without any specification about who is going to pay for it.”
“I’m not sure exactly what [Cassidy] was referring to, but obviously an IUD can’t move over the counter,” said Sobel. “It’s not something that a woman picks up at the pharmacy.”
“Women tend to use on average three to four different contraceptive methods over the course of their lives,” Guttmacher’s Sonfield noted. “They have different needs at different points. Women look at contraception and think about a lot of different factors: They think about effectiveness, they think about side effects, they think about whether or not they have hormones.”
“And having that choice matters for how effectively women use a method,” he continued. “Women who are satisfied with their methods are more likely to use it consistently and correctly, therefore, to avoid unintended pregnancy.”
“For all those reasons, choice of method really matters. So putting one method over the counter isn’t satisfactory for women,” Sonfield said.
Without the protections of the birth control benefit, all contraceptive methods can be costly. “There are some forms of birth control, for instance longer-acting contraceptives, that can run up to $1,000,” said Janel George, director of federal reproductive rights and health at the National Women’s Law Center in a Wednesday interview with Rewire. She noted that one study found that the ACA’s birth control benefit had saved women $1.4 billion in one year just on the birth control pill alone.
If oral contraceptives were available over the counter without a prescription, many insurers may not cover that method. And of course, without the birth control benefit, insurers wouldn’t be required to cover any methods at all, prescription or not. That would mean those who rely on their insurance to pay for it could be stuck footing a bill. “Outside of the ACA, let’s say the birth control requirement went away completely because either that provision goes away or the ACA is repealed altogether, then having birth control over the counter doesn’t account for who’s going to pay for it,” explained Sobel.
Whether the people who need it can actually afford to pay for their contraception seems to be of little concern to the looming Trump administration. The Republican president-elect’s choice for secretary of the Department of Health and Human Services (HHS), Rep. Tom Price (R-GA), claimed in a 2012 interview with ThinkProgress that “there’s not one” woman who would be “left should the benefit be eliminated. Now, as head of the department, he could lead the charge in rolling it back by choosing to redefine what qualifies as a preventive service.
“If past is prologue, then we know that Price has made clear his anti-abortion, anti-choice approach,” said George, when asked about what Price’s takeover could mean for reproductive rights and health. She pointed to the representative’s history of voting for legislation that “would undermine women’s access to care,” and his opposition to the birth control benefit in particular.
After a Rewire report on Price’s past comments about the benefit, “we actually reached out to our constituents and have asked them to weigh in,” George went on. “We have received thousands of responses from women saying that coverage of birth control under the ACA is really key and that they are unable to afford the high out-of-pocket costs related to birth control, which again, could range up to a thousand dollars.”
“That’s more than a minimum-wage worker makes in a month,” she continued. “So there are thousands of women who are unable to afford birth control.”
Shifting oral contraceptives over the counter could also come with other limitations. “A lot of the conservatives who have been trying to put this out there as a supposed alternative to contraceptive coverage have a lot of limitations of what they are thinking of when they say they want over-the-counter access,” said Sonfield. “A lot of the times they want age restrictions, for instance.”
Those age restrictions could be imposed by either the Food and Drug Administration (FDA)—which oversees what medication could be moved over the counter—or policy makers, according to Barot’s analysis. If imposed, they could restrict whether minors and young people have access to contraceptives and could especially affect people of color and undocumented immigrants.
“These age-groups face a greater risk of unintended pregnancy and more barriers to accessing contraceptives than older women—and therefore have the most to gain from an OTC status switch,” wrote Barot. “Additionally, an age requirement would, by definition, mean an identification requirement, which would be a disadvantage not only for adolescent and young women without government-issued photo IDs, but for immigrants as well, particularly those who are undocumented.”
Sonfield also noted that moving contraceptives over the counter is “not something that Congress could do,” as manufacturers would need to apply to the FDA and go through its processes for approval. Doing so “requires a substantial investment from the manufacturer to do the research necessary to prove that it’s effective over the counter …. And so far, no manufacturer has stepped up for that, let alone all the manufacturers of all the different oral contraceptives out there.” “None of this is an acceptable alternative to what women have now,” said Sonfield. Moving oral contraceptives over the counter would “be a great addition to” the birth control benefit, he said, “but it can’t replace it.”