Getting the Pill Without a Doctor: The Revolution Begins
Oregon is making hormonal birth control legally available without a doctor's prescription, and California is set to follow suit. This is great policy, and the rest of the country should follow this example.
Before I explain why they should, we should dispense with the policy hopes that easier access to birth control won’t fulfill:
- It won’t end the political fight over the contraception mandate. The administration can still require insurance to cover medicine for which you have a prescription, including birth control prescribed by a pharmacist rather than a doctor. Undoubtedly the administration will require just this. Then if we get a Republican administration, the government will probably stop requiring it, at which point religious conservatives will stop being outraged just as progressives fire up the rhetorical cannons. This battle will probably continue to be fought until the heat death of the sun.
- It won’t end the political fights over abortion, either. Easier access to birth control is a great thing. But there is surprisingly weak evidence that making birth control easier to get substantially reduces abortion rates. Undoubtedly, it will have some effect on the number of unintended pregnancies, and therefore on the number of abortions. But that effect is unlikely to be large enough to make the contentious political debate over abortion simmer down much.
- It won’t save the health-care system any significant amount of money.
Don’t look so crestfallen. There are still very good reasons to make birth control available without a doctor visit, starting with the fact that women like it. As Virginia Postrel has written, requiting women to get a prescription for hormonal birth control means that some of them will end up resorting to other forms of birth control they don’t prefer, because they forgot to get to the doctor before the prescription ran out.
That may not mean a whole lot of extra unintended pregnancies or births. (Used correctly, over-the-counter methods like condoms are pretty effective, especially when a backup like the morning-after pill is available.) But “does it prevent a lot of extra unintended births” is far too narrow a question for policy makers to ask. The Soviet system, in which birth control was unavailable but abortions were extremely common, prevented a lot of unintended births. It was still a lousy system.
Absent a compelling reason that women need to see a doctor, it should be as easy as possible for them to get any form of birth control they might like to have. Obviously, this is not practically feasible in every case. We are not going to see at-home IUD insertions any time soon. But it should include oral contraceptives, some of the most extensively studied medications of all time.
Oregon now requires patients to fill out a short questionnaire and have their blood pressure checked in order to get a prescription from a pharmacist, which seems like a reasonable enough procedure to weed out the small number of women who really shouldn’t take it. Though even that may go too far.
Advocates for keeping doctors involved in dispensing birth control have historically used two arguments. The first is that the drugs have side effects -- which is true, but of course, also true of over-the-counter medications. Now, these side effects can include strokes, which is why hormonal birth control is not recommended for smokers over 35. But a pharmacist is just as capable of asking whether you have a family history of stroke, or are a smoker over the age of 35, as a doctor. For that matter, most women can probably ask these questions of themselves, though they do need to check their blood pressure.
The second argument is that we need to keep doctors involved so that women will keep coming to the gynecologist to get their annual exam and pap smear. This was always unpleasantly paternalistic and sexist -- no one suggested keeping condoms inside the pharmacy so that guys would have to get regular prostate exams -- and the medical justification is weakening. Doctors are rethinking the need for annual pap smears, moving toward less frequent exams with better diagnostic tests.
But even if you think that annual pap smears are a good idea, that doesn’t justify holding women’s access to birth control hostage in order to force them to get one. For starters, this assumes that the risk to their health from failing to get that annual pap is higher than the risk to their health from an unintended pregnancy. It also assumes that women are child-like creatures who can’t be fully trusted to decide what to do about their own health. Oregon is inching away from that thinking, and it’s long past time that other states did the same.
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