The Trump administration and conservatives in Congress are driving a health care agenda that, among many negative consequences, threatens affordable birth control access for tens of millions of U.S. women. Their plans include undermining the Affordable Care Act’s (ACA) guaranteed coverage of contraceptive methods and services with no out-of-pocket costs, gutting the Title X national family planning program, and excluding Planned Parenthood from Medicaid and other federal programs.
Going after birth control access is deeply unpopular, which is why conservatives pushing for it routinely fall back on a set of talking points touting alternate ways for people to obtain contraceptive care, namely: to make birth control pills available without a prescription and to help people pay for them through tax-advantaged savings vehicles like Health Savings Accounts (HSAs). However, people should beware these false promises because, as replacements for current programs and policies, they would leave most contraceptive users with fewer options and a bigger hit to their finances.
To be sure, making birth control pills available over the counter (OTC) would improve access for some groups of people by eliminating the barrier of having to see a doctor to get a prescription. This is why the Guttmacher Institute is part of a coalition working toward this goal. But lifting the prescription requirement for birth control pills is utterly inadequate as a replacement for current policies. Here’s why:
- Moving birth control pills OTC will take years: There are only a few versions of the pill where the manufacturers have even declared the intent to apply for OTC status, with the eventual decision likely years away. Even then, because formulations of the pill are not medically interchangeable, OTC status for one formulation of the pill would not benefit the vast majority of people. Far from it: The version most likely to be approved first for OTC status is a progestin-only pill, a type that only a tiny percentage of pill users rely on. Moreover, there are dozens of brands and formulations of birth control pills that would likely need to separately undergo the Food and Drug Administration process to gain OTC status.
- Method choice would be reduced: Even if people had a range of OTC birth control pills to choose from, this would not in any way be a substitute for the ACA’s birth control benefit, which covers the full range of contraceptive methods without out-of-pocket costs. Replacing that coverage with OTC status for some birth control pills would mean an increase in out-of-pocket costs—and possibly an insurmountable one—for anyone using one of the other covered contraceptive methods, including the ring, patch, injectable, IUD, implant or sterilization.
- Lower cost is not a given: Even for birth control pills, the entire premise of conservatives’ argument—that OTC status would automatically make them dramatically cheaper and thereby render insurance coverage unnecessary—is questionable. Emergency contraception has been available OTC for years, but has remained quite expensive. We cannot just assume that OTC birth control pills would be inexpensive, let alone come close to the $0 out-of-pocket cost under the ACA policy. Rather, even for many pill users, making the pill available OTC at the expense of insurance coverage would replace one barrier (ease of access) with another (cost).
- HSAs are not a solution: On the issue of costs, the go-to answer from conservatives is to allow people to put aside tax-free savings for health care expenses via HSAs and flexible spending accounts (FSAs). While this might benefit some better-off people, it would be useless for lower-income people who simply cannot afford to set aside those pre-tax earnings up front. In fact, two-thirds of low-income people say an unexpected $500 medical bill would be unpayable or would place them in debt. And even if they could afford to contribute to an HSA or FSA, those with lower incomes would benefit little from the tax deduction, because they have a low federal income tax rate or owe no federal income taxes at all.
- Age restrictions would be harmful: Another problem is that conservative policymakers say OTC birth control pills should be available only to adult people, even though research suggests that minors can use it safely and effectively. An age restriction would be counterproductive, as adolescents face greater chances of unintended pregnancy and have the most to gain from OTC status. Also, a strictly enforced ID requirement could impact people of all ages, many of whom—in particular, low-income and immigrant people—may not have government-issued photo IDs.
Making birth control pills available OTC could be an important part of broader efforts to bolster access to high-quality, affordable contraceptive care. But it all has to start with protecting and building on the progress we’ve already made. Sen. Patty Murray and Rep. Ayanna Pressley are introducing a bill that would take one step forward, by making it clear that insurers must cover contraceptives even without a prescription. Beyond that, let’s make sure that all contraceptive methods are fully covered by every form of public and private insurance, everyone has health insurance in the first place, publicly supported family planning providers and the programs that underpin their work are protected and, ultimately, everyone can freely use the contraceptive method that works best for them.