A roadmap for making over-the-counter birth control affordable

The Food and Drug Administration recently approved Opill, the first over-the-counter access birth control pill, in a monumental and long overdue win for reproductive and public health care. This FDA ruling will significantly expand access to high-quality contraception for folks across the country. However, true access will require affordability, too.

I had the honor of serving on the team in the Obama White House that tackled the challenge of making health insurance affordable to all under the Affordable Care Act. I had a front-row seat to see how women in Congress — led by Speaker Nancy Pelosi, Sen. Patty Murray, and especially former Sen. Barbara Mikulski — fought for coverage of women’s preventive services like mammograms, cervical cancer screenings, prenatal care, and, yes, contraception. When President Obama signed the ACA into law on March 23, 2010, reproductive health took a giant step forward with its commonsense yet revolutionary approach. But today, we are still working to turn that the promise into reality.

For the first time in our nation, the Affordable Care Act provided a mechanism for millions of people to receive contraception at no cost from their insurance company. This was a very popular advancement when it occurred 13 years ago and has resulted in more than tens of millions of people being eligible for no-cost contraception.

With abortion now illegal in many parts of the country, even more Americans agree that birth control should be free. A huge bipartisan majority of voters want policymakers to do more to make birth control accessible. The public mandate for affordable — including no-cost — contraception remains strong.

Now that we are just months away from the birth control pill being sold on store shelves without a prescription, there is new urgency to make sure that over-the-counter contraceptives are free or affordable for all. Obtaining the pill OTC is an important option for people who face barriers to getting a prescription because they are uninsured, but also for those for whom seeing a provider is an obstacle because they don’t have good access to care, live in rural areas, would have to arrange for time off work or child care, or any number of reasons.

Over-the-counter affordability includes four elements: rules regarding contraceptive insurance coverage under the ACA, adjustments to government-run insurance, a low retail price, and accommodation for those without insurance who cannot afford to pay out of pocket.

The fix for private insurance plans is straightforward: The ACA did not limit coverage of preventive services (like birth control) to those that require a prescription, but that’s exactly how it’s been applied. As a result, insurance companies have been allowed to deny coverage for OTC forms of contraception. Further, many federally funded programs must adhere to the ACA, and this lack of clarity generates widespread confusion. Advocates have been asking administration after administration to fix this.

Forty million women of reproductive age receive their health care from a government program, including Medicare, Medicaid, Military Health System, Indian Health Services, Veterans Affairs, or Children’s Health Insurance Program.

While the regulations for each are different, in general, the federal government can take three steps.

First, where possible under current law, it can require coverage with no copays for over-the-counter contraceptives, including condoms and emergency contraception. Second, if a specific requirement is not possible, the government can send written clarifications on how programs and plans are permitted to cover over-the-counter contraceptives and explore proactive actions such as issuing a federal standing order for over-the-counter contraceptives. And third, it can provide technical assistance for implementation. It is important for plans and programs to understand their obligations, and for consumers to know their rights.

To ensure seamless coverage for people with insurance, we must immediately modify the pharmacy-based claims process for covering prescription products and make the reimbursement process as easy as possible. While some over-the-counter medication and devices are already covered by insurance, the consumer experience desperately needs improvement. Remember when the government wanted to make it possible for more Americans to get at-home Covid tests? The process was chaotic, but where it worked well was at the pharmacy counter. Similarly, the pharmacy tools that enable us to pick up prescription medication without paying out of pocket can be turned on to allow over-the-counter medications to be charged to your health insurance.

When people buy contraception off the shelf because the pharmacy is closed or the retailer doesn’t have a pharmacy (like a convenience store), there must be an easy and fast way to obtain reimbursements for this timely medication. And because reimbursement is far from ideal, we must work toward a process in which consumers don’t need to pay out of pocket when they purchase birth control from cashiers who aren’t connected to pharmacy systems. This might include an EBT or debit card issued by the insurance plan, similar to health savings account and also how SNAP benefits are provided. Notably, these solutions to seamless access could be leveraged for the growing market of OTC products that could be covered by insurance, like Covid tests and Narcan and others.

Of course, to make access to OTC contraception equitable, we must find ways to make it accessible to the 30 million Americans who don’t have health insurance. First and foremost, there must be a low on-the-shelf price. Studies show that on average, adults are willing to pay $15 per month and teens $10 per month. It’s unclear right now how Opill will be priced.

And the federal government administration must find ways to use its power to get OTC contraception to those for whom the retail price is prohibitive. There are many mechanisms to do this, including using federally funded clinics as distribution centers or establishing a new program for uninsured or underinsured people. Community health centers could provide OTC contraception at no cost, and an expansion of the proposed Individual Contraceptive Arrangement could include anyone without comprehensive contraceptive coverage.

A near future in which contraception products are on store shelves and free from access barriers, discrimination, or inflated prices is possible.

The FDA’s approval of over-the-counter access to one of the most reliable and popular forms of contraception is a monumental breakthrough in the continuous uphill battle for substantive reproductive health care. And the government has a responsibility to ensure that not just access to but also affordability of reproductive health resources is fully cemented for all folks, irrespective of race or gender or economic status, as affordability is truly key to fully realizing the health and equity potential of the FDA ruling itself.

The ACA enabled millions of women to get access to free, reliable contraception. The country is ready for the next step toward equity: no cost over-the-counter contraception.

Dana Singiser is a partner at Keefe Singiser Partners in Washington, D.C., and a co-founder of the nonprofit Contraceptive Access Initiative. She served on the Obama administration team that helped pass the Affordable Care Act and led Planned Parenthood’s policy team when emergency contraception was approved.