Why Aren't Birth Control Pills Sold Over the Counter? They Should Be

This article first appeared on the Cato Institute site.

An argument will soon erupt over the fate of the Affordable Care Act's mandate that requires health insurance to cover oral contraceptives at no direct out of pocket cost to the patient.

This mandate was never explicitly listed in the ACA as one of the "essential health benefits." Its inclusion was made at the discretion of the HHS Secretary. According to press reports, the Trump Administration is about to relax the requirement.

The arguments made in favor of loosening the mandate mostly revolve around the employers' right to freedom of conscience. Meanwhile, some advocacy groups fear this will mean many women won't be able to obtain affordable oral contraceptives.

As I recently wrote in Morning Consult, it can help temper the concerns of all parties to the argument if the Food and Drug Administration (FDA) followed the recommendation that the American Congress of Obstetricians and Gynecologists (ACOG) has been making for decades, and reclassify oral contraceptives from prescription to over the counter (OTC).

Birth control pills are already available over the counter in 102 countries.

But health insurance plans usually only cover prescription drugs. Making birth control pills available OTC means that women can purchase them directly, like they purchase aspirin, ibuprofen, antihistamines and antacids.

In my Morning Consult piece, I point out that the average cash price of prescription birth control pills runs from $20 to $50 per month but can range as low as $9 per month.

Various community health centers across the US, as well as Planned Parenthood, offer free oral contraceptives for those unable to afford them. If birth control pills are made available over the counter prices are likely to drop. That's because oral contraceptives will be liberated from the third-party spending trap.

Felicitas Rohrer holds a box of the birth control pills in Willstaett, near Offenburg, southwestern Germany on December 1, 2015. FREDERICK FLORIN/AFP/Getty

As is the case with doctor, hospital, and lab bills, the presence of a third-party payer results in higher prices for prescription drugs than would otherwise be the case if a pharmacy was dealing directly with the patient, not the third-party middleman.

That's because the third party severs the link between the consumer and the producer of goods and services that allows market forces to work. Doctors, hospitals, labs, and pharmacies negotiate with a deeper-pocketed third party, not the consumer, to arrive at a price.

For example, in a March 2017 Consumer Reports interview, University of Minnesota Professor of Pharmacoeconomics Stephen Schondelmeyer stated:

Retail chains such as CVS and Rite Aid aren't concerned about consumers who pay out of pocket…What does concern them is how much third parties, such as insurance companies, will pay, usually either a negotiated reimbursement fee or the list price —whichever is lower.

So retailers intentionally set the list price very high so that there's no chance it could undercut what they get paid by insurers.

And here is Douglas Jennings, PharmD, writing in the June 2016 Pharmacy Times:

Cash prices started to dip below co-pays a decade ago, when several stores started offering dozens of generic drugs for as little as $4 per prescription. But, as co-pays increase and high-deductible insurance plans become more common, patients may be overpaying for their prescriptions when using insurance.

When the FDA reclassifies a prescription drug to over the counter it extracts it from the third-party spending trap. As consumers play their part, market forces often bring prices down and new competitors frequently enter the market.

Moving to OTC also adds further savings—like the saving of time taken away from work or other activities to sit in a doctor's waiting room for a prescription; and the saving of money from not having to pay for the office visit. It also means an improvement in privacy and comfort, as many women prefer to purchase this kind of product discreetly and avoid unwanted discussion or counseling, even if offered by a health care provider.

Privacy appears to be a major issue for women purchasing emergency oral contraception, which has been available over the counter since 2006. There is even convincing evidence that reclassifying prescription birth control pills to over the counter increases their continuous use by women.

Some health care practitioners are leery of making oral contraceptives OTC, citing safety concerns. ACOG's Committee on Gynecologic Practice believes any safety concerns are not great enough to deter reclassification of oral contraceptives to OTC. I further explore that matter here.

Reclassifying birth control pills to over the counter can save women money in the long run. It also adds convenience, choice, and privacy. Medical science supports the move. The only remaining obstacles are political.

Jeffrey A. Singer is a general surgeon in private practice in metropolitan Phoenix, AZ.