In the Obamacare birth-control debate, there's a logical path

Birth control pills over the counter? Hold that thought, add insurance

In case you haven't encountered enough illogic in the American healthcare system, consider this: Once a medication has been determined to be safe and effective enough to be available without a prescription, we assume it should no longer be covered by insurance. That doesn't follow, and contraceptives are an important case in point.

Insurance coverage of non-prescription birth control pills is at the heart of a simmering debate in the midterm elections. As Republicans have faced accusations that their agenda is anti-woman, several GOP candidates have resurrected a proposal made by Louisiana Gov. Bobby Jindal in 2012 to make the pill available to adult women without a prescription. Now candidates such as Rep. Cory Gardner (R-Colo.) are proposing over-the-counter birth control pills as an alternative to the contraceptive coverage guarantee built into Obamacare.

Democrats, largely caught off guard by these proposals, have focused their counterattacks on their opponents' history of anti-contraception and anti-abortion positions. They emphasize the importance of maintaining the contraceptive coverage guarantee in Obamacare. According to the Guttmacher Institute, a reproductive health research organization, that coverage is already having a profound effect by reducing women's out-of-pocket costs for birth control.

Lost in the campaign mudslinging is the fact that this shouldn't be an either/or debate. Although the birth control pill has not yet been approved for over-the-counter sale, most of the medical establishment is in favor of that outcome. The best policy, the one that would help women effectively meet their family planning needs and reduce the high rate of unintended pregnancy in this country, is over-the-counter availability and insurance coverage for birth control pills (along with coverage for all other contraceptives approved by the Food and Drug Administration).

The medical side of this debate is just about settled. Physician groups such as the American College of Obstetricians and Gynecologists and the American Academy of Family Physicians agree that the pill is safe enough to be available without a prescription. There are good studies in hand that show that women can use simple checklists to determine on their own whether the pill is right for them, and that when they can obtain the pill without a prescription, they stay on it longer than if they have to keep getting a prescription renewed.

American women are also eager for an over-the-counter birth control pill. A national survey found that 62% of women support the pill being available without a prescription. Interest was highest among current pill users, but about one-third of women using condoms alone, or those not using any birth control method when they had sex, said they would be likely to start using the pill if an over-the-counter option was available. These data suggest that removing the prescription requirement for the pill would increase the use of effective birth control and help reduce unintended pregnancies, which Guttmacher research puts at 51% of all pregnancies now.

Chief among women's concerns, though, is the fear that an over-the-counter pill will be too expensive. This is a very rational concern. Another kind of contraception, emergency contraception — the so-called morning-after pill — is already available without a prescription. However, unless insurance covers it, emergency contraception sells for $35 to $60 at a pharmacy, keeping it out of reach for many low-income women. Not surprisingly, in the national survey mentioned above, women's interest in regular birth control pills sold over the counter decreased sharply as the cost increased, with few willing to pay more than $30 per month.

Despite what politicians would have you believe, it doesn't have to boil down to a choice between insurance coverage for birth control pills or over-the-counter access. Again, the example of emergency contraception is instructive. A few state Medicaid programs cover emergency contraception without a prescription. In New York and Washington states, for example, a woman can walk into a pharmacy with only her Medicaid card and get the morning-after pill free. This model of insurance coverage without a prescription could be extended to other state Medicaid programs and even to private insurance, which would improve women's access to emergency contraception today and set the stage for a future over-the-counter regular birth control pill to have the biggest possible effect.

The reality is that getting non-prescription birth control pills onto pharmacy shelves is still several years down the road — and the decision won't be made by politicians. Pharmaceutical companies will need to do more research showing that women can use an over-the-counter pill appropriately, and the FDA will have to review those data and make the ultimate determination.

Election season is a bad time to hope for any meaningful dialogue on contraceptives. But in an era of little bipartisan consensus, the apparent agreement among liberals and conservatives about the merits of moving the birth control pill over the counter is cause for excitement. It's an opportunity for constructive policy change, as long as the gains made in one kind of access aren't undercut by losses in another.

That would be illogical.

Daniel Grossman is an obstetrician and gynecologist, a clinical professor at UC San Francisco, and vice president for research at Ibis Reproductive Health, a nonprofit research organization.

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