On December 01, 2023, The Century Foundation (TCF)’s Health Equity and Reform team responded to a Request for Information (RFI) from the Centers for Medicare and Medicaid Services (CMS) regarding insurance coverage of over-the-counter (OTC) preventive services. In particular, we wanted to provide expert guidance on contraceptive access and breastfeeding supplies. By issuing this RFI, CMS hopes to learn more about the potential challenges and benefits to providing coverage at no cost for recommended OTC preventive products. Nearly every stakeholder group, from patients to care providers and pharmacists, have an interest in the issue.

TCF is committed to ensuring equitable access to health care, and our team finds it encouraging to see the Biden administration’s efforts to implement regulations that further this goal. The worsening U.S. maternal health crisis—which is disproportionately harming women and birthing people of color—and the expansion of contraceptive deserts—or counties where the number of health centers offering the full range of methods is not enough to meet the needs of the county’s number of women eligible for publicly funded contraception—raise a number of concerns about health equity. Ensuring that over-the-counter medications and supplies are affordable and widely available will make a significant impact on fighting back against these crises. Below are the key themes and takeaways from the guidance we offered to CMS about expanding insurance access to OTC preventive products.

1. Removing cost-sharing advances health equity.

People with low incomes, people of color, young people, and people with disabilities are disproportionately likely to face barriers to accessing prescription contraceptive methods. Prior to the Affordable Care Act, cost-sharing, even when set as low as $6, obstructed women from obtaining needed contraception, as evidenced by the nearly 5 percent uptick in filled birth control prescriptions after the implementation of the contraceptive mandate. TCF recommends ensuring that OTC contraceptive methods be fully covered by insurance with no out-of-pocket costs for consumers. There are multiple ways that plans and issuers can ensure that beneficiaries have access to OTC preventive products without cost sharing and without a prescription. In particular, the approach taken to require health plans to cover COVID-19 diagnostic tests can serve as a model.

2. Removing procedural and economic barriers reduces provider bias.

Provider bias—specifically racial bias—in family planning, counseling, and provision can impact the contraceptive methods recommended by providers. Low-income, Black, and Latina women are more likely to be advised by providers to take up permanent or long-acting contraceptive methods. TCF recommends OTC contraception and OTC lactation supplies be fully covered by insurance. By removing economic barriers to over-the-counter products, individuals will have the option to receive medication or services without risk of provider bias.

3. Removing cost-sharing from preventive products benefits both patients and health plan providers.

Greater access to contraception also provides noncontraceptive benefits—which could in turn have substantial cost savings for health plans. For example, coverage of breastfeeding supplies OTC may support uptake and duration of breastfeeding, which has both long- and short-term health benefits for both infants and lactating individuals, including reduced chronic disease risk.

4. Expanding the availability of OTC preventive products with no cost-sharing improves economic outcomes for women.

A wide body of research identifies a causal relationship between contraceptive access and economic outcomes for women, including educational attainment and labor force participation. If OTC contraception is made available and with full insurance coverage, the potential increase in contraception use—because of the removal of these barriers to access—may contribute to improved social and economic outcomes for contraceptive users.

5. Providing OTC preventive products without cost-sharing improves patient quality of life.

Expanding access to affordable contraception improves health outcomes and quality of life by allowing individuals to have more agency and autonomy over their reproductive lives. Research also demonstrates a higher quality of life among women using contraception compared to those not using any method.