In Oregon, a new law took effect on January 1, 2016, allowing women 18 years or older to obtain hormonal contraception directly from pharmacies, without having to visit a physician or other prescribing clinician (eg, nurse practitioner, physician assistant, midwife).1 California will follow Oregon later in 2016, having already passed similar legislation.2 Colorado, Washington, and New Mexico are considering similar bills as well.2 These new laws decrease some access barriers to contraception, thereby potentially reducing the number of unplanned pregnancies and abortions. Yet the American College of Obstetricians and Gynecologists (ACOG) and others contend that the new law does not go far enough, leaving an unnecessary barrier between women and contraceptive access.2 In this Viewpoint, we evaluate the new legislation, the views of supporters and opponents, and the potential implications for contraceptive access in the United States, which still has a substantially high rate of unintended pregnancies (49%3 vs 41% worldwide4).
Allan H. Goroll, MD1
OREGON’S NEW LAW
Today in Oregon, women have fewer barriers to accessing some forms of birth control, but some notable restrictions remain in place. Oregon women can obtain only 2 types of hormonal contraception, oral contraceptive pills and hormonal patches, from their pharmacists.1 For other forms of birth control, such as intrauterine devices (IUDs) or contraceptive implants, women must still seek a prescription from a clinician.1 In addition, hormonal contraception is not available as an over-the-counter drug, like aspirin; a pharmacist’s prescription is still needed.
To obtain this prescription, women must first answer a written health questionnaire. If a potential health concern is identified, the pharmacist advises the woman to seek a prescription from her clinician. Only pharmacists who complete a required Oregon training protocol can issue prescriptions to patients directly. Under Oregon’s new law, patients younger than 18 years must still seek their first contraceptive prescriptions from their clinicians.1 California’s law, although similar to Oregon’s, does not place age restrictions on obtaining birth control from the pharmacy and allows pharmacists to prescribe an additional form of self-administered hormonal contraception, the vaginal ring.2
The Republican-sponsored Oregon law garnered bipartisan support when introduced in the summer of 2015. Republicans, sometimes viewed as resistant to aspects of contraceptive health, have been a driving force behind the Oregon law.2 One Republican state representative said, “I feel strongly that this is what’s best for women’s health in the 21st century, and I also feel it will have repercussions for decreasing poverty because one of the key things for women in poverty is unintended pregnancy.”2 The Oregon law represents an example of bipartisan cooperation in ensuring access to evidence-based preventive women’s health care. Nevertheless, federal efforts on women’s health have remained highly partisan and politicized. In the immediate term, state-level efforts may hold the greatest hope for progress on reducing unintended pregnancy.2
Most clinicians agree that the barriers between women and contraception should be minimal.5 Roughly half of the 4 million annual births in the United States result from unintended pregnancy.3 Other unintended pregnancies end in abortion. In 2012, the Centers for Disease Control and Prevention reported nearly 700 000 legal abortions performed in the United States.3 Clinicians and researchers expect that increased access to effective contraceptive methods could reduce the number of unintended births, as well as the number of abortions per year.5 The Oregon law requires insurers to cover the cost of a 12-month supply of contraceptives at once.1 This could help women with family planning, as women who receive a 12-month supply of contraceptives have lower rates of unintended pregnancies and abortions, compared with women who receive a supply for just 1 to 3 months.5 Hormonal contraception methods may also have numerous positive side effects for women, such as lighter and less painful menstrual periods, reduced risks for ovarian and fallopian tube cancer, and pain relief for endometriosis.5
Studies have shown that it is safe for women to obtain hormonal contraception without a clinician’s prescription,4 and obtaining it without a prescription is not expected to discourage women from continuing regular preventive care examinations.5 The new laws will likely decrease the overall number of visits to a clinician for women each year and thereby decrease related medical costs associated with those visits, without anticipated adverse effects on health.
Costs also may decrease more broadly. There are decreases in health care, workforce, and social services expenditures when contraceptive use is expanded via reducing structural barriers to access.6 For example, when Colorado made long-acting reversible contraceptives (LARCs) free and accessible to teens, the state estimated that it saved $5.85 in short-term Medicaid costs for every dollar spent on the birth control program.6 In addition, pharmacists are highly trained clinical professionals, and shifting some responsibility of care allows both pharmacists and clinicians to work to their scope of practice, more logically distributing efforts and conserving costs.
Further, there are potential equity benefits. It is possible that by lowering barriers to self-administered contraceptive methods, which African American and Latina women are more likely to use and may prefer to use over methods that are clinician-controlled,7 these laws may help mitigate persistent racial disparities in unintended pregnancy.
CRITICS RAISE CONCERNS
Despite these likely benefits, the laws are not without their critics. Planned Parenthood and ACOG have expressed concerns that the new laws do not go far enough to improve contraceptive access for US women. They argue that the effectiveness of contraceptive methods must also be considered, as well as women’s preferences for methods. ACOG has recently expressed concerns that allowing pharmacist-prescribed birth control pills may shift contraceptive use away from highly effective LARCs, such as implants and IUDs, out of convenience.5 Further, there is concern that the passage of these laws may reduce attention to initiatives to make oral contraception available over the counter and discourage manufacturers from applying for Food and Drug Administration approval of over-the-counter methods of birth control.2 In addition, the age requirement of the Oregon law, as well as identification requirements, may discourage vulnerable women from seeking contraceptive care. In short, some reproductive rights advocates and policy groups characterize the new laws as a “quick fix” for reproductive rights.
The new laws’ requirement of a prescription by a pharmacist replaces one barrier to women’s access to contraceptive health services with another. While the United States, Canada, and most European countries require prescriptions for hormonal birth control, some other countries (eg, Portugal, Russian Federation, South Korea) provide hormonal contraception without a prescription.8 In a worldwide survey, the United States was one of 45 countries requiring a prescription, whereas women in 106 other countries could obtain oral contraceptive pills over the counter.8 Importantly, international comparative studies on availability of contraceptives have determined that more restrictive policies do not confer health advantages to women.8
The new birth control laws in Oregon and California decrease barriers to contraceptive access and may reduce costs and unintended pregnancies. However, instead of providing over-the-counter, easily accessible birth control for women, the new laws shift the burden of prescribing onto the pharmacy. Even though this approach provides an excellent way to economize health care costs and free up physicians and resources, it stops short of fully alleviating the burden of prescription on women who seek to access contraceptives. In a country with a substantial rate of unintended pregnancy, evidence supports policy efforts that go further in removing barriers and restrictions on contraceptive access.