Prescription Birth Control is Not Extortion
Now that the Obama administration has promised to make hormonal contraceptives available without a co-pay under health reform, libertarian Virginia Postrel is suddenly very eager to make birth control available over-the-counter.
Postrel argues that birth control pills should be available over the counter like condoms, to anyone, even students at Jesuit universities (a reference to Sandra Fluke, the Georgetown law student attacked by Rush Limbaugh for suggesting her university health insurance should cover the Pill).
Making birth control pills available OTC would seem to reclassify them as a consumer product--like condoms--as opposed to a prescription drug that needs to be monitored as part of a woman's health care. The medical risks, Postrel asserts, are low.
Dr. Russell Saunders, a New England pediatrician specializing in adolescent medicine who prescribes birth control to some of his patients, explains what's medically wrong with Postrel's suggestion:
The medical risks for most women are quite low. But for certain women, the risks are actually quite a bit higher. Women who have a certain kind of migraine headache are at increased risk of stroke if they take most forms of oral contraceptive pill (OCP), particularly if they smoke. The same applies to women with high blood pressure, which is almost always undetectable without a medical exam. Certain kinds of clotting disorders can make OCPs very dangerous, and while taking a detailed family history may not detect everyone with these disorders, it’s a lot better than not asking at all. The list of risk factors is not as short as Postrel implies. Who will do that screening and counseling about this risk if OCPs are available without a prescription?
Postrel's reasoning is circular. You can't point to the safety statistics on birth control by prescription and use them to prove that birth control is therefore safe enough to be available over the counter. Birth control pills have great safety stats because doctors screen out patients with contraindications.
She really goes off deep end in her summation:
Aside from safety, the biggest argument for keeping birth- control pills prescription-only is, to put it bluntly, extortion. The current arrangement forces women to go to the doctor at least once a year, usually submitting to a pelvic exam, if they want this extremely reliable form of contraception. That demand may suit doctors’ paternalist instincts and financial interests, but it doesn’t serve patients’ needs. As the 1993 article’s authors noted, the exam requirement “assumes that it would be worse for a woman’s health to miss out on routine care than it would be to miss out on taking oral contraceptives.”
Most doctors will happily write refills for a whole year's supply of birth control pills at once. If it's too much of a hassle to go to the doctor once a year, it's probably too much of a hassle to remember to buy the pill at regular intervals and take it every day.
Postrel suggests that women are just as good as doctors at finding their own contradindications with a checklist. But if a woman isn't seeing a doctor at least once a year, she's probably not up-to-date on her own risk factors. Most people don't chart their own blood pressure, for example.
One key difference between birth control pills and OTC drugs is that the other drugs are designed for short-term use. Unlike Tylenol or Plan B (which has been extensively tested to prove it is safe to dispense over-the-counter), birth control pills are typically used continuously for months or even years. Any long-term medication requires a certain amount of medical oversight.
There's also a lot more science and clinical art behind choosing a birth control pill than Postrel seems to realize. Pills aren't like condoms. You don't just pick up a box and see if you like them. Doctors take various factors into account when recommending a pill, such as the ratio of estrogen to progestin in combination pills. The ideal choice may depend on the women's famly and medical history and her overall reproductive health--like whether she suffers from endometriosis, polycystic ovary syndrome, difficult periods, and so on. Finding the right pill is often a process of trial and error, even with medical oversight. Expecting women to muddle their way through, picking pills at random, is a much bigger barrier than requiring a prescription. This individualized attention is basic health care that every woman should be entitled to.
The only good argument for relaxing the prescription requirement is that some women can't afford the a doctor's visit and live in areas that are underserved by free clinics. You could argue that the benefits to these women outweigh the risks of making birth control available to everyone over-the-counter.
However, that argument will lose its force once the Affordable Care Act is fully implemented. If everyone is insured, and insurance covers birth control pills with no co-pay, the barriers to using birth control will be minimal.
Postrel and other proponents of OTC birth control like to imply that the Pill will become cheaper if it's available without a prescription. That's not necessarily the case. Plan B is available OTC, but it still costs $50 a pop. Check out the prices on Nicorette, Xenical, and other OTC "lifestyle" drugs. They tend to be pretty expensive. After all, the pharmaceutical companies set the price, and they're not above making us pay a premium for convenience.
Incidentally, the birth control mandate is very smart politics for the Obama administration. In addition to promoting women's health, and saving everyone money on unwanted pregnancies, the mandate gives young, healthy women (and their male partners) a tangible stake in health reform. These are the so-called "young invincibles" who wonder why they should have to buy insurance to subsidize old people's blood pressure meds. Once they get accustomed to insurer-provided birth control, they will be loathe to give up this benefit. That's one more reason why conservatives and libertarians hate the mandate.