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Sell Birth Control Over-the-Counter

Megan McArdle is a Bloomberg View columnist. She wrote for the Daily Beast, Newsweek, the Atlantic and the Economist and founded the blog Asymmetrical Information. She is the author of "“The Up Side of Down: Why Failing Well Is the Key to Success.”
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Over-the-counter birth control is an idea whose time has come -- if Democrats will let it.

I am not very patient with the political fights over the Affordable Care Act’s contraception mandate. The number of employers who want to drop out is trivial. Moreover, most of the women who are genuinely going to have trouble paying for birth control are not going to be covered by employer plans; they’re covered by Medicaid, an exchange policy or nothing at all. Generic birth-control pills are a cheap, regular expense used by many millions of people, exactly the sort of thing that insurance is not designed for. All this does is spread the cost around a bit while adding administrative overhead for your policy.

I’m sure that we can find one woman, somewhere, who is determined to work for nuns and also use birth-control pills that she cannot afford without a top-up contribution for her insurer. But you cannot make policy on the basis that someone, somewhere, might possibly be better off. I’m sure that right now in America, among our vibrant array of 300 million individuals, there is some woman who cannot get birth control because her car is too unreliable to drive to the distant pharmacy or the town’s only pharmacist is her jerk ex-boyfriend. But these are matters for expressions of sympathy, not a federal program to buy people better cars or better ex-boyfriends.

Given how few of our nation’s larger employers have strong religious convictions that forbid the purchase of certain forms of birth control, the harm we’re talking about is really, really small. So small that I see a lot of people making expressive rather than practical arguments about “respect” and “fundamental rights.” Forcing other people to express their respect for women by violating their freedom of conscience does not seem to be to be a worthy undertaking -- especially when it is likely to make the fights over Obamacare longer, angrier and more divisive.

But the Democratic base wants it, and in politics, what the base wants, the base must have, at least as long as it mostly angers people who won’t vote for you anyway. It’s nice to see that Republicans are trying to come up with a solution to short-circuit this unholy mess. Unfortunately, their solution won’t work unless the Barack Obama administration allows it. And while they should, they probably won’t.

The Republican idea is to make birth-control pills available over-the-counter rather than a prescription item. This is an excellent idea. It was an excellent idea before Obamacare passed, and it will remain a fine policy even if Obamacare somehow vanishes into dust. Physicians assess the danger of giving you birth control by asking simple questions you can ask yourself: Are you over 35, a smoker or troubled by a family history of early stroke?

Every time I ask gynecologists about this, they argue that it’s necessary so that women will keep coming in for annual pelvic exams. There’s some good news, however: Annual pelvic exams may not be all that necessary. Especially now that we can vaccinate for the most common strains of HPV, the major cause of cervical cancer.

So I’m glad that Republicans are looking to change this policy. But it won’t have the effect that they seem to imagine. The administration can still require employer-sponsored insurance to cover over-the-counter medications that are prescribed by a doctor. And it probably will, because did I mention that the Base Wants It? Obviously, this keeps the conflict very much alive. It also diminishes much of the benefit of making the pills available over-the-counter.

Republicans should still push forward, because this does, at least marginally, improve access for women who have belatedly realized that they’re out of refills. But this battle will go on for as long as the administration wants it to and the courts allow it. That looks to be a good, long time.

  1. Intrauterine devices, which are also at issue, are less cheap. But they are also much less popular. Providing IUDs for a small number of people who want them and can’t afford them is exactly the sort of thing that private charity excels at, unlike, say, mass relief.

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