If you live in the United States, you can't obtain birth control pills without a prescription from a doctor. This federal requirement means that the roughly 10.6 million American women on oral contraception must accept regular, invasive, and unnecessary medical care as part of preventing pregnancy.
When the pill first came to the U.S. in 1960, such prescription-only status made some sense. Medical professionals were uncertain how many women would react physiologically. And hormone levels in the first commercially available brand were incredibly high—10,000 micrograms progestin and 50–150 micrograms estrogen, compared to 50–150 micrograms progestin and 20–50 micrograms estrogen on average recently.
But in the nearly 60 years since then, pill formulations have become at least as benign as your average drugstore-aisle offering. Decades of research favors the idea that over-the-counter (OTC) oral contraceptives are safe. They're sold without a prescription in nations across the world, and high-dose emergency contraception has been sold over-the-counter in the U.S. for years. Safety isn't the issue.
Nor is there an obvious political impediment. Republicans believe (at least sporadically) in individual rights and deregulation, and a number of GOP lawmakers have recently supported ending the prescription requirement. Democrats often wax on about a woman's right to take control of her reproductive destiny, and in the past many have pushed for freeing the pill, too. So legalizing OTC contraception should represent common policy ground.
Yet the prescription requirement remains on the books. Why?
For years, blame could be cast on the traditional villains of progressive politics: social conservatives who opposed the pill, the Bible thumpers in the Republican Party who pandered to them, and drug companies with no incentive to do anything that might puncture their profits.
But recently, thanks to Obamacare, Democrats have become the primary impediment to freeing up rules around the sale of contraception. In 2019, it's liberals, not conservatives, who are holding the pill hostage for political gain.
The Case for OTC Contraception
America's paternalistic gatekeeping to contraceptive access is not supported by medical evidence, influential health care groups, or popular opinion.
To put America's prescription rule in context, consider how uncommon it is internationally. Out of 147 countries, the U.S. is among just 45 where a prescription is necessary to obtain birth control pills, according to a study from Daniel Grossman of Ibis Reproductive Health. Polling consistently shows that women favor over-the-counter access. A 2017 survey by the Kaiser Health Foundation found three quarters of women of reproductive age supported "making oral contraceptives available over the counter if the FDA said it was safe and effective."
That support may be especially high among women who previously had an unintended pregnancy or abortion, suggesting that OTC pills could be quite effective in reducing unintended pregnancies.
A 2014 survey from UCSF's Bixby Center focused on members of that group, finding that all but 19 percent were in favor of making birth control pills prescription-free. Only 42 percent said they planned to go on the pill soon, but 61 percent said they would if they could get it over the counter. And around a third of women "who planned to use no contraceptive following their abortion said they would use an over-the-counter pill, as did 38% who planned to use condoms afterward," note the study authors in Perspectives on Sexual and Reproductive Health.
Studies also show that women and teens can effectively self-screen for contraindications to hormonal birth control, that they're prone to err on the side of caution concerning any gray areas, and that doctors aren't always reliable prescribers anyway. Birth control "recommendations of family medicine physicians were found to be inconsistent with CDC guidelines 23% of the time for oral contraceptives (OCs) and 40% of the time for intrauterine devices (IUDs)," according to one study from 2003–06.
Yet under the current status quo, obtaining birth control generally requires a specialized doctor's visit and fee plus a separate trip to the pharmacy, as well as a spate of unrelated tests, since doctors have long made cervical cancer testing and other invasive vaginal examinations a condition of getting contraception. Women must return to the doctor every year or two to maintain the prescription and, in many cases, are barred from obtaining more than a three-month supply of pills at a time.
As a result, a significant number of U.S. women report difficulties in obtaining prescription birth control. A 2016 study found that among U.S. women who had tried to get or refill a prescription, nearly one-third ran into trouble. (Ten years earlier, only one-fourth of women had trouble, according to a 2006 study published in the journal Contraception.) Uninsured women, Spanish-speaking women, and women with less than a high-school education were the most likely to report issues.
"Difficulties included cost barriers or lack of insurance (14%), challenges obtaining an appointment or getting to a clinic (13%), the clinician requiring a clinic visit, exam, or Pap smear (13%), not having a regular doctor/clinic (10%), difficulty accessing a pharmacy (4%), and other reasons (4%)," notes Ibis Reproductive Health.
Affordability presented an obstacle to medical care for about one-quarter of women in the 2017 Kaiser survey. But it was far from the only barrier, with roughly similar percentages citing a lack of time in general or inability to get time off work, and 14 percent citing unreliable transportation or issues with child care.
As these surveys make clear, insurance coverage alone—even coverage that makes pills themselves "free"—is an insufficient condition for expanding birth control access. That's why women's rights advocates have long supported lifting restrictions on access to contraception—a notion that conservatives traditionally opposed.
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