On May 9, 1960, the U.S. Food and Drug Administration first approved the birth control pill. And yet, despite contraception being safe and effective, many people still struggle to access prescription birth control. In 2019, Ibis Reproductive Health started the Free the Pill Day annual campaign to draw attention to this fact.
Birth control use is overwhelmingly common: in 2018, 65 percent of U.S. women of reproductive age were using a contraceptive method, and 99 percent of women use at least one method during their lifetime. The full range of contraceptive methods must be made accessible and affordable, and this includes allowing for over-the-counter (OTC) provision of oral contraceptives.
At a time when abortion access faces its greatest risks in decades, it is critical that contraceptive access is expanded to allow every person to make decisions about their reproductive lives, free from interference.
Last week’s leak of a draft opinion in the U.S. Supreme Court Case Dobbs v. Jackson Women’s Health Organization has only made the need to free the pill more clear. Though not a final opinion, the Court is poised to completely overturn the fifty-year precedent of Roe v. Wade, which could lead to the elimination of abortion access in over half of states. Contraception is not a substitute for abortion care; rather, it is part of the full spectrum of reproductive health care that is necessary for individuals to achieve bodily autonomy. At a time when abortion access faces its greatest risks in decades, it is critical that contraceptive access is expanded to allow every person to make decisions about their reproductive lives, free from interference. This Free the Pill Day was an especially important one for examining how to make equitable access to birth control a reality.
An Issue of Access and Equity
Ensuring access to a full range of contraceptive choice is critical for people to be able to exercise their reproductive rights. That right to reproductive autonomy has long been limited and denied, and continues to be violated to this day—particularly so for people of color, women with low incomes, disabled women, and members of immigrant communities. This legacy of reproductive control includes the coercion of these communities into using long-acting reversible contraception (LARC), such as subdermal implants and intrauterine devices, or undergoing sterilization, often against their will or without their knowledge. Even today, there is evidence of bias in contraceptive care: a randomized trial found that providers were more likely to recommend long-acting methods to Black, Latinx, and low-income white patients. This highlights the need for contraceptive counseling and care to be patient-centered, particularly when dealing with LARC methods.
The communities which have been harmed the most by reproductive coercion are also the communities least able to access contraception today.
The communities which have been harmed the most by reproductive coercion are also the communities least able to access contraception today. Black women have a higher unmet need for contraception than white women, and women who are Medicaid enrollees, underinsured, or uninsured have a disproportionately high level of unmet need compared to women with private insurance. Notably, the COVID-19 pandemic has created even greater financial and logistical barriers to accessing sexual and reproductive health care.
Medicaid, the nation’s largest payer of family planning services, the birth control requirement within the Affordable Care Act (ACA), and Title X, the only federally funded family planning program, play major roles in affordability and access of contraception, and in ensuring that access is equitable. Family planning is a mandatory benefit within Medicaid, and Medicaid expansion is associated with an increase in access. But because of the Medicaid coverage gap, in which low-income individuals in states that chose not to expand Medicaid—which are concentrated in the South and whose populations are disproportionately Black and Hispanic—are denied affordable health coverage, equitable contraceptive access is still a challenge. The ACA requires coverage of birth control (without cost-sharing) as well as any services related to the birth control method, such as counseling, insertion, removal, or management of side effects. Thanks to this requirement, as of 2020, 64.3 million women were able to have insurance coverage that included contraception without cost-sharing. Title X served 1.5 million individuals in 2020 alone—though this number is a sharp decline from previous years due to lack of adequate funding and changes in care-seeking behavior during the pandemic. People of color, low-income individuals, and those who are underinsured or uninsured are disproportionately represented as Title X patients.
Not only can access to contraception depend on economic factors: access to contraception itself improved economic outcomes for women. Both the availability of the first birth control pill and the creation of Title X resulted in economic gains for women. These effects included improved educational attainment, greater workforce participation, and a reduced likelihood of living in poverty—both for women who gained access to contraception and for future generations.
Freeing the Pill: Over-the-Counter, Pharmacist Provision, and Telehealth Access
Even with increased access facilitated by Medicaid and Title X, many people in the United States face barriers to obtaining contraception. One-third of adult women in the country have reported facing barriers to receiving a prescription, including difficulty obtaining an appointment or reaching a clinic. These obstacles were most commonly reported among groups that already struggle to access health care, including uninsured and Spanish-speaking patients. Making oral contraceptives available over-the-counter (OTC) would simplify the process and facilitate access to contraception.
What’s more, there is evidence that contraceptive users are interested in accessing birth control pills over-the-counter: nearly 40 percent of adults reported likely use of over-the-counter contraception, with that proportion even higher if covered by insurance. If oral contraceptive pills were available without a prescription, it would also substantially decrease (potentially up to 25 percent) the number of unintended pregnancies, particularly if out-of-pocket costs were low. So there is demonstrated demand for over-the-counter access, as well as evidence that this access would better allow individuals to control their reproductive lives. What about safety? Research demonstrates that the method poses relatively little risk.
Oral contraception is one of the most well-studied medications available, in addition to being one of the most widely used. In over 100 countries, oral contraception is available without a prescription, and a recent systematic review found that OTC access was generally associated with high continuation rates and low rates of side effects. And it has been demonstrated that patients can self-screen for contraindications—meaning conditions that make taking a medication potentially risky—with similar accuracy to health care providers. In particular, progestin-only pills have few contraindications—and progestin-only emergency contraception is already available over-the-counter—so may be the first candidate for an OTC oral contraceptive option.
Still, both clinics and brick-and-mortar pharmacies are not accessible to every person in need of contraception. As demonstrated by its increased use during the pandemic, telehealth provides an opportunity to make health care—including medication—readily available to patients. This access is particularly important for individuals who may not live within reasonable distance to a pharmacy, lack reliable transportation, have work or care schedules that prohibit travel, or have disabilities that make travel difficult. In addition to traditional telehealth models through formal health care providers, there are a number of online platforms which facilitate access specifically to hormonal birth control without requiring a physical visit to a provider. As with all forms of telehealth, it is necessary to close the digital divide: universal access to broadband must be achieved in order for equitable access to telehealth services.
A clear through-line is the need for contraception to be affordable, regardless of the method in which it is dispensed.
A clear through-line is the need for contraception to be affordable, regardless of the method in which it is dispensed. All pathways to expand access—over-the-counter, directly through pharmacies, and via telehealth—must provide affordable contraception that is covered by insurance.
Truly freeing the pill requires ensuring that access is expanded equitably—and there are a number of available policy levers to do so.
- The FDA should act quickly and follow the science in its review of applications for over-the-counter birth control pills
- States (which have not done so already) should pass contraceptive equity legislation to ensure that all contraceptive methods are truly available without cost-sharing—without requiring a prescription.
- The Affordability Is Access Act—introduced in the 116th Congress by Representative Ayanna Pressley and Senator Patty Murray—would not only expand access to over-the-counter contraception, but would also ensure its insurance coverage without out-of-pocket costs.
- In order for contraception to be truly accessible to those who need it most, Title X must be funded at a sufficient level to rebuild its network, and states that have not expanded Medicaid must do so immediately.
Access to affordable contraception has always been crucial to reproductive freedom, and the likely overturning of Roe in the coming weeks only intensifies the need for accessible reproductive health services. As we reflect on this year’s Free the Pill Day, it is necessary to equitably and creatively expand contraceptive access—through over-the-counter access and more—by advancing federal policy and strengthening public insurance and family planning programs.