Pill Popping

The debate over whether oral contraceptives should be covered by insurance misses the real point.

Women who have been struggling to get birth control pills paid for by their employers now have something that even the best insurance can't buy: legal precedent. Recently, a federal court ordered a pharmacy in Seattle, Washington, to cover oral contraceptives in its employee health plans. Failure to do so, argued U.S. District Judge Robert Lasnik, would be a violation of the federal Pregnancy Discrimination Act.

Whether or not Lasnik is right, the decision is an unexpected boon to working women. But the battle to make reproductive choice more varied and economical need not be fought in such constitutionally dubious territory. Reproductive-rights activists should instead ask themselves a more fundamental—and more controversial—question: Why should women have to get a physician's permission to take the Pill? After all, if it really is a woman's body, a woman's right, why do they have to defer to a doctor?

"Too dangerous!" say most gynecologists, when taking a break from the rigorous schedule of 15-minute breast and pelvic exams that they require for a prescription. These exams can cost hundreds of dollars, effectively pricing many women out of the market. "Too dangerous!" say many on the left, who demonize pharmaceutical companies as outfits that would just as soon poison consumers as help them. "Too dangerous!" say many on the right, who are uncomfortable with female sexuality, especially when unshackled from "nature's" strictures.

There's not much anyone can do to get conservatives to stop fretting about sexually active single women (or non-procreative sex, for that matter). But there's substantial evidence suggesting that the current prescription practices in the United States are far more stringent than any reasonable standard of public safety requires.

For instance, community-based clinics in the Third World have doled out the Pill without pelvic exams for years. That's not quite the same as over-the-counter status in the First World, but it's a step in the right direction. Additionally, in January, the Alan Guttmacher Institute, a nonprofit that studies reproductive health, analyzed data of a 1996-1997 government program that provided contraception without exams to low-income women in seven locations in central and southern California. The authors concluded that "participants valued the program's services, many chose to use more effective contraceptives than they had previously used and most kept referral appointments that introduced them to preventive reproductive health care." In May, the Journal of the American Medical Association published a study arguing that requiring breast and pelvic exams may "reduce access to highly effective contraceptive methods, and may therefore increase women's overall health risks."

Dr. Malcolm Potts, a professor of population and family planning at the University of California at Berkeley, argues adamantly that the pill should be freely available in any drug store. "Once the pill was beside Extra Strength Tylenol, users would know it was safe to use and begin to lose the misplaced fear many people still have in this method of contraceptive," he says. He also notes that a doctor's exam can't diagnose whether a person is at higher risk of the rare side effects associated with the Pill. In fact, diagnosis is based on "one simple question: 'Are you over 35 and do you smoke more than a pack of cigarettes a day?' Such warnings can be put on the packet."

Even apart from the issue of required doctor's exams, the economics of prescriptions reduces access to drugs. History shows that the price for medicine plummets dramatically when it becomes an over-the-counter pharmaceutical. This could make oral contraceptives—which today cost up to $40 a month—far more affordable, helping even those workers who aren't insured. This could slash budgets at women's health clinics and substantially reduce women's out-of-pocket expenses.

As important, it would underscore a key point in debates over contraception: Women should have the right to control their own bodies.