Americans are living in strange times, when even access to our most basic reproductive health care feels up in the air. While many Republicans are railing against Obamacare (and the birth control mandate that came with it), a small group of them have offered new legislation that would help make the birth control pill available over the counter. The bill, called the Allowing Greater Access To Safe and Effective Contraception Act, would fast-track applications for FDA approval of over-the-counter birth control pills. It would also allow you to pay for that birth control with a healthcare savings account or flex spending. Sounds like a good idea right? Well, as it goes in politics, it depends. Before we can truly grapple with whether this new plan is good, we have to address the elephant in the room: Obamacare was great for people who need birth control. Under that plan, the uninsured rate among women dropped by 44%, and insurers were required to cover in full all 18 types of FDA-approved birth control, from the pill to the IUD. This was a boon for many women — especially poor ones — who went from either going without birth control or paying hefty monthly co-pays for their pills, rings, patches, etc. to having that cost rolled up into the cost of their health insurance. In other words: A lot of women who needed it got it for no extra cost, and those who still had to pay something shared the cost with their health insurance company. This was controversial. Conservatives, including Trump’s nominee to head the Department of Health and Human Services Rep. Tom Price (R.-GA), claimed the mandate encroached on religious freedom because it required people to pay into a system that paid for birth control, a touchy subject for Catholics and other people of faith. Rep. Price is also the guy who once claimed that there’s not one woman in the country who couldn’t afford it. (Wrong.) The fact that Trump picked him to run HHS doesn’t bode well for birth control being covered by insurance. Which brings us back to over-the-counter birth control pills. On its own, it’s a great idea. How can you argue that running into your pharmacy to pick up a pack of pills without a prescription wouldn’t ease access? Certainly it would for many people. The problem, however, is cost. “Over-the-counter is more convenient,” says Stuart O. Schweitzer, PhD, a professor of health policy and management at the UCLA Fielding School of Public Health. “But it’s more expensive to consumers than a prescribed drug that’s covered by insurance.” A 2013 study from the journal Contraception found that 62% of women surveyed think over-the-counter access to the pill is a good idea, and the most they would be willing to pay for it is about $20 per month. “It has the potential to be really beneficial,” says Raquel Dardik, MD, an ob-gyn and clinical associate professor at NYU Langone Medical. “If the price point were correct, and women could reasonably access it, it would reduce costs for the healthcare system overall.” The problem is, we don’t know what the pharmaceutical companies will charge. Plan B, the emergency contraceptive pill that went over-the-counter in 2011, sells for around $50. That is the only example we have of a similar drug on the shelf. Depending on the pill, the out of pocket cost right now can range from $20 to $100 per pill pack, explains Sally Rafie, PharmD. Of course, birth control choices aren’t just driven by costs — but also by side effects and other health concerns, such as acne, polycystic ovary syndrome, endometriosis, and more. In other words, many women are on the pill for reasons beyond preventing pregnancy, and you often have to try a few before you find one you like using. That’s why there are more than 100 pills on the market, which brings us to the next problem.
“Over-the-counter is more convenient. But it’s more expensive to consumers than a prescribed drug that’s covered by insurance.”
Stuart O. Schweitzer, PhD
The current Republican bill doesn’t really do much. Congress doesn’t actually have the power to make a drug available over-the-counter. That’s the (notoriously slow) FDA’s job, and the FDA only grants approval to companies that bring them applications to review for specific drugs, Dr. Schweitzer says. So if you look at the actual bill and translate it into English, it boils down to: Hey big pharma, if you could please take your corporate money and invest it in getting FDA approval for an over-the-counter birth control pill, we’ll try our best to speed up the process of approval so you can make your money back faster. There is one company already working on getting approved for over the counter birth control, says Britt Wahlin, vice president for development and public affairs at the non-profit Ibis Reproductive Health. A French company called HRA Pharma (in partnership with a working group at Ibis) announced in December 2016 that it plans to submit an FDA application for a birth control pill that will be available over-the-counter. This is exciting because it’s the first time a pharmaceutical company has hopped on board that we know of, but the application could still take years, Wahlin says. It is also unlikely that HRA's application will be impacted by the bill in congress because HRA was already planning on submitting it, regardless. Also, the bill includes a requirement that the pills submitted for fast-tracking only be available to women 18 and older. Theirs, like all birth control, will not have an age requirement. Then there is the additional problem that the bill only applies to the pill, which is not the only form of birth control people use. Plenty have found that the vaginal ring, patch, or IUD fit their needs better, and studies show that needs for contraception change over time. “Absolutely this doesn’t eliminate the fact that there’s a number of contraceptive methods that require a physician and insurance coverage,” Dr. Dardik cautions. For example, an IUD will always require a doctor’s appointment, and can cost around $900 without insurance coverage. As a policy brief from the Guttmacher Institute puts it, OTC access for the pill is great, but it’s “insufficient as a stand-alone strategy.”
Oral contraceptives are among the most studied, safest drugs in existence.
So, let’s be real: These are dark times. No matter what, people with uteruses are going to get a bad deal with this new administration in comparison to what we had before. But if there is one helpful aspect of the new bill, it is that it would also change the law so that women could use Flexible Spending Accounts or Health Savings Accounts to pay for over-the-counter birth control pills. This would soften the blow of paying out-of-pocket for those who can afford to put money in those accounts, because the money would be taken out of paychecks pre-tax. Dr. Schweitzer also predicts that once one pill goes over-the-counter, generics would sprout up, giving consumers more choices and driving the price way down. (But it could take three or more years for that to happen if, say, the first drug to get FDA approval for the OTC access is patented.) The American Congress of Obstetricians and Gynecologists as well as the American College of Medicine have supported moving the pill over the counter for years. Oral contraceptives are among the most studied, safest drugs in existence. Ibis’ working group is trying to make sure that if and when a pill does get approved for over-the-counter sale, the price will be right: “Keeping an OTC pill affordable is essential to keeping it accessible, and Ibis and our coalition partners will continue to work for an option that is affordable at the register,” Wahlin says. But if the Republican congress really wants to wow us, they need to share their plan for keeping birth control of all kinds covered by insurance on top of this incremental approach. (The sponsors of the current bill, as well as multiple Republican Senators and Representatives, did not respond to multiple requests for comment from Refinery29.) Overwhelmingly, the evidence shows that investing in birth control is in the public’s interest. Aside from being a health and social issue, unintended pregnancy is expensive for taxpayers: According to the Guttmacher Institute, 68% of 1.5 million unplanned births in 2010 were paid for by public insurance programs. In total, taxpayers spent $21 billion due to unintended pregnancy. Even the Republican-leaning Brookings Institute agrees that investing in birth control is smart policy, and could possibly halve these expenditures. Here’s hoping the new Republican administration will keep these things in mind.