In September, with less than three months to go before the 2014 midterm elections, some Republican candidates adopted a surprising policy position: Birth control should be sold over the counter.
Cory Gardner was one of them. In a television ad for his U.S. Senate campaign in Colorado, he declared that the pill should be available “ ’round the clock, without a prescription.”
At least five high-profile GOP candidates — including Thom Tillis of North Carolina — announced their support for over-the-counter birth control. (Gardner and Tillis did not respond to repeated requests for comment for this story.) On the campaign trail, they insisted that because economic forces would drive down the price, an over-the-counter solution would provide women with better access than the Affordable Care Act’s contraception coverage, which requires employers to provide insurance that covers female contraception without a co-pay. In Gardner’s case, the platform may have drawn more women into his camp. Mark Udall, Gardner’s Democratic opponent, won 56 percent of the women’s vote in 2008 but only attracted 52 percent of female voters in this year’s race. Gardner’s performance among women (44 percent), meanwhile, was 3 points higher than the 2008 Republican Senate candidate’s.
It was a familiar argument — the market could do better than the government — applied to a new issue. It also gave the GOP a compelling narrative: Democrats were more interested in protecting Obamacare than in improving women’s health, while Republicans had found a no-nonsense way to make birth control cheaper and easier to get. Why force women to go to a doctor for a prescription when they could walk into a pharmacy and buy the pill?
Except there’s one big problem: There’s no evidence that over-the-counter birth control would be any cheaper.
Donald Downing, a clinical professor at the University of Washington’s School of Pharmacy, has been researching over-the-counter contraceptives for nearly two decades. Right now, he said, it may be inconvenient for women to go to their doctors for birth control prescriptions, but thanks to the ACA, they pay nothing for the pill itself. Buying birth control over the counter would certainly require less effort, but without a mechanism to force insurance companies to cover it, women would end up paying more.
Downing said there is a way to maximize both convenience and price — by allowing pharmacists to prescribe birth control in the store. But that’s not what Republicans say they favor. “I don’t think this is a genuine effort to give women more options,” Downing said. “I have been arguing that birth control should go over the counter for years. But what the Republicans are proposing just isn’t a cheaper or better solution.”
It’s impossible to know for sure what would happen if female contraceptives like the pill, the patch, or the NuvaRing appeared on pharmacy shelves tomorrow. But we can draw some lessons from emergency contraception, the most common version of which is called “Plan B.” The drug had been available with a prescription for seven years by the time it was approved for over-the-counter sales in 2006. The impact was nearly immediate. A study conducted by the Guttmacher Institute in 2011 analyzed government data from 2006 to 2008 and found that the number of women who had used emergency contraception had more than doubled since 2002. More than two-thirds of those women had obtained it without a prescription.
But Kelly Cleland, a research specialist at Princeton University’s Office of Population Research, said price has been a barrier from the beginning. “When women started buying Plan B in pharmacies, they were paying out of pocket instead of using their insurance,” she said.
Figuring out just how much emergency contraception cost before it went over the counter is difficult to do, but according to one estimate, women on Medicaid could buy prescribed Plan B for around $12 a pack, and the generic version for $5. Factoring in the cost of a doctor’s visit — according to this estimate, around $20 — prescription-only emergency contraception would set women back between $25 and $32.
Today, Plan B retails for around $50 a pack; the generic version, which went on sale in 2013, is only slightly less expensive, at an average of $41. Most pharmacies stock only one version of the branded pill and one generic, while more than one-third don’t stock generics at all — further reducing the possibility of competition.
Cleland, who monitors emergency contraception prices in pharmacies, said these costs have remained static. “When the generics were about to go onto the shelves I thought there might be a price war that would push the cost down,” she said. “But that really hasn’t happened, and I don’t see a sign that it will.”
It’s tempting to use emergency contraception as a proxy for what would happen if the pill went over the counter. But there are some obvious differences. For example, people tend not to buy emergency contraception in advance (whereas birth control is purchased on a regular schedule). But there are also significant similarities. It’s expensive for pharmaceutical companies to get a drug approved for over-the-counter use, so unless companies were convinced that there was significant demand, only a few kinds of birth control would be available without a prescription. Meanwhile, Cleland said, some form of urgency might remain. One of the most compelling arguments for over-the-counter access is to provide options for women who suddenly lose their insurance, or leave their birth control pack at home when they go on vacation. Those women, too, lack the luxury of time or price comparison.
Joshua Cohen, a health economist at Tufts University, said that Republicans aren’t wrong when they say market forces could bring down the price of over-the-counter drugs. But, he added, it won’t be cheaper than buying it with a prescription. “Any improvement in access is likely to be merely a convenience issue,” he told me in an email, “as [women] would pay more out-of-pocket for the OTC contraceptive than they would for the prescription product.” Convenience, in other words, comes with a cost.
It’s a price some women might be willing to pay, although there are limits. A survey of women at risk of unintended pregnancy conducted in 2011 found that while nearly 40 percent of respondents said they would buy birth control pills over the counter, they also said they wouldn’t pay more, on average, than $20. Another study conducted by two economists, Emily Gray Collins and Brad Hershbein, showed that a woman’s willingness to pay for more expensive forms of birth control also varies, unsurprisingly, depending on her financial situation.1
All of this is why Democrats say over-the-counter birth control would create a price barrier, especially for low-income women. These women remain one of the groups who stand to benefit most from non-prescription birth control — particularly in states that chose not to expand their Medicaid programs. (None of the five GOP candidates I found who endorsed over-the-counter birth control supports Medicaid expansion.) For women with insurance, any cost is more than they’re paying now, thanks to the ACA’s contraception mandate. Because the ACA allows insurers to require a prescription for preventative drugs like birth control, it seems unlikely that many women with insurance would be reimbursed for their over-the-counter purchases. That would force them to choose between convenience and affordability.
From Downing’s perspective, there’s a third way that neither party is willing to take up: allowing pharmacists to prescribe birth control to customers. It’s an approach that he’s studied in Washington, one of the handful of states where pharmacists are legally allowed to prescribe drugs for customers.
From 2003 to 2005, Downing and his team conducted a community-based intervention study with a group of more than 200 women who were prescribed hormonal contraceptives by their pharmacists. Qualitative interviews conducted during and after the study revealed that both the women and the pharmacists were happy with the experience. And it seemed sustainable — after 12 months, more than 70 percent of women reported that they were still using hormonal contraceptives. In other words, pharmacist-prescribed birth control is the best of both worlds: It’s convenient (pharmacists are available in the evening and on weekends, without an appointment) and, because women would still get a prescription for the birth control, insurance companies would have to cover it.
“In some ways it’s better than over-the-counter access because the pharmacist knows about all these different formulations and can help a woman pick the one that’s best for her,” Downing said. “It solves the access issue and the cost issue.”
Of course, Downing’s idea relies on the continued existence of the Affordable Care Act’s contraception mandate — something to which most Republicans remain opposed. It’s also a question for state legislatures, rather than senators like Gardner; states, rather than the federal government, determine what pharmacists can and cannot do. And even if Gardner and the other newly elected GOP candidates who supported over-the-counter birth control decided to make it a priority, the decision isn’t really in their hands — pharmaceutical companies are the ones who decide whether to apply for over-the-counter status, a choice motivated by whether they think a non-prescription form of a drug will make more money.
To Downing, though, the fact that candidates are even talking about over-the-counter birth control is encouraging. Twenty years ago, when he and others were lobbying to put emergency contraception on pharmacy shelves, their effort was seen as a joke. But he said Republicans are kidding themselves if they think over-the-counter birth control access could replace the Affordable Care Act’s contraception coverage.
“It’s just not a suggestion that’s based in reality,” he said. “Without the no-co-pay guarantee, this would make women pay a lot more for convenience. It just seems like politics to me.”