Senate GOP leaders press ahead on a health care reform bill: What's in it, what's not, and will voters like it any better? Then, lessons learned from the Republican victory in a Georgia special election on Tuesday.
If a woman wants to obtain hormonal birth control like the pill or the patch, they have to first go to their doctor for a prescription. Now two western states – California and Oregon – have passed laws allowing pharmacists to prescribe birth control. Public health advocates see it as a way to expand access to the pill, and many doctors say it’s safe. But others argue these measures don’t go far enough. They want to see birth control pills offered over the counter and bills have been introduced in congress to do just that. Diane and her guests discuss why some say women don’t need doctors to access contraception.
- Julie Rovner Senior correspondent, Kaiser Health News; author of "Health Care Policy and Politics A-Z"
- Frank Palumbo Executive director of the University of Maryland School of Pharmacy Center on Drugs and Public Policy
- Dr. Nancy Stanwood Associate professor of obstetrics and gynecology, Yale School of Medicine; board chairwoman, Physicians for Reproductive Health
- Dr. Mark DeFrancesco President, American Congress of Obstetricians and Gynecologists
MS. DIANE REHMThanks for joining us. I'm Diane Rehm. California and Oregon are the first two states in the country allowing pharmacists to prescribe hormonal birth control. Here to discuss the new laws, what they mean for access to the pill, Julie Rovner of Kaiser Health News, Frank Palumbo of the University of Maryland School of Pharmacy Center on Drugs and Public Policy. Joining us from the studios of Yale University, Dr. Nancy Stanwood of Physicians for Reproductive Health and by phone from Waterbury, Connecticut, Dr. Mark DeFrancesco of the American Congress of Obstetricians and Gynecologists.
MS. DIANE REHMI want to invite all of you to join us, 800-433-8850. Send us your email to firstname.lastname@example.org. Follow us on Facebook or send us a tweet. And thank you all for being with us.
MS. JULIE ROVNERThank you.
MR. FRANK PALUMBOAnd thank you for having me here.
DR. MARK DEFRANCESCOThank you very much.
DR. NANCY STANWOODThank you. I'm happy to join you.
REHMGood to see you all. Julie Rovner, how do these new laws in California and Oregon change women's access to the pill?
ROVNERWell, the idea is to make it easier. Right now, in the other 48 states and actually still in California and Oregon for at least a couple of more weeks, you have to get a prescription from a -- for birth control from a doctor or someone else with prescription writing authority and then go to the pharmacy and get your pills. This would change that in these two states. It would allow the pharmacist to do a preventive screening. You can't just go up and ask for it. There would be a questionnaire and you would have to answer question to make sure that there are not medical contraindications to the pill, which there are for some women.
ROVNERBut if that was okay, then the pharmacist could go ahead and prescribe birth control pills. It's been done in other countries and it seems to work fairly well.
REHMDr. Stanwood, why do you think this is important?
STANWOODI think it's vitally important for the health of our patients to have access to the care that they need. I think when we consider that the pill was FDA approved 55 years ago, people's lives, women's lives have changed so much in that time and that really medicine and public health need to keep up with the times and think about innovative ways to expand access. And this is an important way to do that.
REHMDr. DeFrancesco, first, talk about how hormonal birth control actually works and how safe you think it is without a doctor's prescription.
DEFRANCESCOYes. Diane, certainly, oral contraceptives, as Dr. Stanwood mentioned, has been around for 55 years so if anything, the test of time has shown that it's a very safe way to achieve contraception. What we've seen over the years, I've been in practice for 32 years in direct care practice and have been writing prescriptions for patients for 32 years and have seen an increasingly decrease in the dosage that the pill contains. So basically, the pills over the years have gotten to be far less hormone in the actual pill itself.
DEFRANCESCOAnd they were safe to begin with, relatively, for just about everybody. They're even safer now because, again, the much lower dose involved. My concern only is that I think these two laws are absolutely a step in the right direction. But ACOG has actually come out in favor of over-the-counter not behind-the-counter, but over-the-counter access for women to decrease unintended pregnancies and to have all kinds of other good effects. And it's very unusual for a physician's group like ACOG to recommend bypassing the prescription process all together for our patients.
DEFRANCESCOBut it's based on, A, the need to increase access to this contraception and, B, to recognize the fact that our patients really can self screen. To put a pharmacist in between -- and this is no reflection on pharmacists, they do a fantastic job. They're wonderful professionals. But we're really replacing the physician with a pharmacist now so there's still a barrier, a relative barrier to the patient that I think is unnecessary and we'll get into more details on that, but again, I think...
REHMYes. We will get into a little more detail on that. But right now, I just went to a CVS the other day and got a flu shot. Now, how similar is that to what we're talking about as far as you're concerned, Frank Palumbo, as the executive director of the University of Maryland School of Pharmacy, when you think about giving something like birth control pills, after the patient responds to questions, how do you feel about interceding, as it were, between the patient and the doctor?
PALUMBOWell, that's a very good question, Diane, and I don't see the pharmacist as interceding the patient and the doctor. I see the pharmacist as being the frontline person, health professional who's able to help patients obtain their oral contraceptives without the need to schedule a physicians visit, to go to a physician, possibly miss their medication because they haven't bothered to do so, they haven't refilled them, unwanted pregnancies and all those sequelae. And I think the pharmacist is in a good position.
PALUMBOAnd you did ask me about the flu shots. I think they point out the increasing responsibilities that pharmacists are taking on in healthcare. Pharmacists, literally, every state now allows pharmacists to provide immunizations. Some state offer the ability to do different immunizations than others. For example, in Maryland, pharmacists can give pneumonia, shingles shots in addition to influenza and in other states, it's a mixed bag. But I think that points out the public recognition of pharmacists as health professionals who can offer services to patients in need and not really bypass the physicians.
PALUMBOI mean, if you look at the Oregon regulations, for example, I may be jumping ahead a little bit, but they provide for the pharmacist to contact the physician when there's an issue with the patient.
REHMWhen there's an issue. But isn't that issue likely to be self-reported by the patient?
PALUMBOIt is likely to be self-reported and the pharmacist will -- I think the only hands-on requirement is that the pharmacist take their blood pressure. The other -- but there is a CDC algorithm that has been adopted upon which these questionnaires that we're talking about is based. And that algorithm will help the pharmacists determine which category the patient might fall in.
REHMAll right. All right. Dr. Stanwood, how do you approach this entire discussion of a patient going to -- directly to a pharmacist, getting not only the flu shot, but also birth control after responding to a few questions?
STANWOODWell, again, I think we really do want to look at innovative ways to break down the barriers that stand between women and the contraceptive care that they need. I think one of those barriers has been access and getting a doctor's appointment and needing a prescription and the science really has shown us that women can safely self screen. If you give women, you know, the checklist of here are the things that if you have them, you shouldn't take standard birth control pills, women, very accurately, self identify and in many ways, in a comparison with women screening themselves and doctors screening women, the women were more conservative.
STANWOODSo that I think the science is pretty clear that women can self screen. I think the other piece is, women really would value this and a survey done of women of reproductive age, more than two-thirds said they would use pharmacy access. And of those interested women, more than two-thirds were not currently using any contraception so that this would really be an innovative way to reach the women who don't have access to effective methods of contraception and really help them get started on contraception and decrease their risk of an unintended pregnancy.
REHMAll right. So if you have a woman who, in Oregon, all women 18 and older can obtain birth control from the pharmacist, Julie, what about those under the age of 18?
ROVNERWell, this is, obviously, going to be a point of contention. This is what I was getting at before is that, you know, whether or not doing this sort of thing, having pharmacists do the screen instead of the doctor, will interfere with efforts to have it available over-the-counter. And it's not a theoretical question. We saw this in spades with Plan B, the emergency contraceptive pill. Again, much the same debate had been found to be safe. Two FDA advisory committees said should be over-the-counter.
ROVNERIt took 13 years and several iterations of regulations. Again, this was called behind-the-counter, which is what we're talking about here, where you have to go and get it from the pharmacist rather than grab it off the shelves and the big argument in that was younger -- was teens and younger women and it got -- it started out, it was only available if you were over 18 and then they changed it to 17 and then they changed it, I think, to 16 before they changed it to 15. Eventually, they took it away.
ROVNERBut it took 13 years to go through all of this back and forth. The other thing that they found is that when you have an age restriction, it means -- it generally means that you have to show ID. There are a lot of women who need birth control who don't have a state-issued ID, even if they're -- I mean, I'm not just talking about people who are not here legally. They're people who simply, if they don't have driver's license, many of them don't have any kind of official state ID or -- and you can't have someone else go and pick it up for you.
REHMAnd speaking of bypassing a doctor, in the case of someone under 18, you may be, indeed, bypassing the parent, which does raise all kinds of...
ROVNERWhich you can already do, actually -- if you go to a Planned Parenthood, teens have privacy regulations about this.
REHMJulie Rovner, she's senior correspondent at Kaiser Health News. She's the author of the book titled "Healthcare Policy and Politics: A Through Z." Short break here. Your calls soon. Stay with us.
REHMAnd welcome back. Here in the studio, as we talk about the availability of birth control devices -- the hormonal sort, the pill and patch and other such devices -- over the counter with the help of a pharmacist. Here in the studio is Frank Palumbo. He's at the University of Maryland School of Pharmacy Center of Drugs and Public Policy. And Julie Rovner, she's at Kaiser Health News. Joining us from the studios at Yale University, Dr. Nancy Stanwood. She's associate professor of OB/GYN at the Yale School of Medicine. She's board chairwoman of Physicians for Reproductive Health. And by phone from Waterbury, Conn., Dr. Mark DeFrancesco, president of the American Congress of Obstetrics and Gynecologists.
REHMA comment from our website, saying, my wife and I lived in Saudi Arabia, before coming to the U.S., for 15 years. We never had a problem to get birth control pills because, simply, they have it as an over-the-counter medication. That takes us to the next step, Julie. There is now a move to make this available over the counter, without even a pharmacist's okay. What do you think?
ROVNERWell, this was recommended, as we already heard, by ACOG in actually in 2012. So there's been this effort. One of the complicating factors of this is that if it were to become over the counter, it wouldn't -- in most cases, be reimbursed by insurance. And birth control -- and this was another issue that came up with Plan B. When Plan B went fully over-the-counter, suddenly $50, and people don't necessarily have that. So then there's now competing bills in Congress, because this was how the -- some of the Republicans were trying to get around the requirement in the Affordable Care Act that birth control be covered. They said, well let's just make it over the counter and that will take the whole employer problem out of the...
ROVNER...church problem. But then you have the cost problem.
ROVNERSo there's that issue.
REHMDr. Stanwood, what is your feeling about simply making it available over the counter?
STANWOODWell, we know that women can safely self-screen and that they can detect their own contraindications to taking the pill. Fortunately, most women who are seeking contraception are young and healthy and don't have any contraindications. The other thing to keep in mind is that when women have expanded access, either behind the counter or over the counter, they don't stop going to see the doctor. There's been this traditional concern that will women no longer get other screening that was packaged and bundled before with going to see your gynecologist every year. And that we really know that when you separate those, when they're no longer connected, that women still access screening, both for Pap smears, for sexually transmitted infections.
STANWOODAnd this harkens back to what happened with the move to make emergency contraception, Plan B, over the counter. There was a concern that women would abandon their Plan A, if they had Plan B, or that they wouldn't get screening. And that that public health change, we've seen, has not brought those fears to bear, that hasn't panned out and that women still are sensible and reasonable. And that having expanded access really is what women need in their really busy and complicated lives. The patients I see, they're raising their kids, they're going to school, they're working their jobs. And to have a more convenient way to access their contraception is really going to be very helpful.
STANWOODWe know that when woman also have more access, that they continue their birth control at better rates and that they have a decreased risk of unintended pregnancy. So the public health upsides are really important to keep in mind.
REHMDr. DeFrancesco, would you or the American Congress of OB/GYN have a concern about making these pills available over the counter, no matter what the age of an individual female?
DEFRANCESCOWell, I think, clearly, as I stated, we have come out already in favor of making them over the counter. I think age brings up other issues. And I think, at some point, you need some kind of confidence that people buying them are not at an extreme of an age that you'd be concerned about. I don't know how to draw that line. But I think that's what needs definition is what the lower limit of that age.
DEFRANCESCOBut, more importantly, to the point that Julie mentioned about the -- one of the unintended consequences of becoming over the counter, we strongly support Senator Barbara Murray's (sic) legislation that would not only make it over the counter but also insist that if you have insurance coverage, your insurance coverage for over-the-counter contraceptives would remain in place without a co-pay, as it was in the ACA. So we do hope that that would be passed. Because, again, that was the intent of the ACA and to cover. So we are in favor of it.
REHMAs the pharmacist on this panel, Frank Palumbo, what is your thinking?
PALUMBOWell, as far as OTC goes, I think there are a number of issues. One of them is that the FDA is not likely, in my opinion, to just wholesale adopt OTC status for oral contraceptives. They are different drugs, different combinations. Each one of them is unique. And I think that FDA, if it wants to move them over the counter, is going to deal with them on a drug-by-drug basis. And I think that will take years for that to happen. The FDA has mechanisms in place to be able to do such things. But it takes a long time to ramp them up, to deal with over-the-counter oral contraceptives.
REHMAnd would pharmacists be in favor of the FDA moving in that direction?
PALUMBOI think what pharmacists might prefer -- it's not that they wouldn't be in favor of it -- what they might prefer is that there be a transition period, where perhaps they would be involved at the level, as we see in California and Oregon. And then, later on, if that proves to be safe, then I think they could be moved to over-the-counter status.
REHMBut, as you've already said, that could take years. And many women are saying, why can't I do this right now? Dr. Stanwood.
STANWOODYeah, I think this brings up the issue of, when we talk about are things safe, what are the risks? It's safe compared to what? I think it's always important to compare that, to bracket it. And birth control pills are safer than other things that are already over the counter right now, such as Tylenol where, if you take too much Tylenol, you can induce liver failure. I think one of the other concerns has been that for women on birth control pills that have both female hormones -- estrogen and progesterone -- there's a slight increase in the risk of a blood clot or something called a deep venous thrombosis. And people worry about that.
STANWOODBut, again, risk compared to what? We know that the risk for women on the pill is less than the risk for women who are pregnant, that being pregnant significantly increases the risk of a blood clot. So when we talk about risk, it's always compared to what? And, again, the overarching public health issue that I and my colleagues at Physicians for Reproductive Health really want to think about is, how can we get women access to have healthy reproductive lives? And that means access to contraception with many fewer barriers.
STANWOODIf we look at the past 55 years of the history of the pill, one of the most significant differences has been financial access, with the change of the Affordable Care Act, having preventative care covering all contraceptive services and prescriptions. And now, this issue of over-the-counter or behind-the-counter access really is looking at logistics. Do you need an appointment? Do you need to get there during business hours when the doctor is open or can you go when a pharmacy has extended hours?
STANWOODThe other issue is also education. The pill is certainly the most common method of contraception but it's not necessarily the most effective. So that making sure that women have access to the education about what are their contraceptive options? What are other things that might work better than the pill, such as things like IUDs or the birth-control arm implant, and really breaking down the barriers that we created in the 20th century. We sort of put women in a box when it comes to contraceptive care. We need to think outside the box. We need to break outside the box and really look at decreasing these barriers that prevent women from having the care that they need to lead healthy and productive lives.
REHMDo you want to add to that, Dr. DeFrancesco?
DEFRANCESCOYes. And just to clarify my initial comment, what I meant to really say was that the -- I don't see the pharmacists as stepping between us and the patient. I have great respect for pharmacists. I got my shingles shot from a pharmacist, in fact, a few months ago, so I trust them to do these kinds of things, no question about it. But the -- I'm seeing the pharmacist, because of these kind of bills, now being -- replacing the physician as a barrier between the patient and the pill. And I agree, no question, the FDA's going to take some time to change these things. But we need to start the momentum in that direction to get them to change. And, you know, the fact that it may take some time to do it shouldn't argue against doing it, in other words.
DEFRANCESCOBecause we're talking about access.
ROVNERThere's also this issue of -- and we've seen this going back a decade now -- about pharmacists who have ideological concerns about prescribing contraceptives, about prescribing them to women, to young women, to teenagers, to unmarried women. And there are, you know, we have seen a whole rash of what are called refusals. So pharmacists basically saying, I don't want to be involved in this. That can be another barrier. We saw that again, when Plan B was available behind the counter. There were pharmacists who simply would not prescribe it.
REHMHere is an email to that very issue. Does this now empower pharmacists in these states the right to deny women's access to the birth control they want? Julie.
ROVNERWell, it does vary by state. There are still -- I believe there's a big fight about federal regulations. I believe the federal regulations are still in place. But, generally, we've seen, you know, some states that actually have laws that allow pharmacists to refuse to -- to dispense, not to prescribe, these drugs. And there are some pharmacies, I know, that advertise that they don't even carry them. So it is -- the question is whether that will be on the increase or whether that will be another barrier to women being able to get these drugs.
REHMAnd, go ahead, Dr. Stanwood.
STANWOODYeah, you know, I wanted to follow up on the issue of age and think about teen reproductive health. Our professional organizations -- be it the American Academy of Pediatrics, the American Congress of Obstetricians and Gynecologist -- we're very clear that teens need to have access to reproductive health care. And that when teens think that their parents are going to find out, that they don't then seek the care that they need and then they have poorer health outcomes. So that this is something that we learned from Plan B going over the counter, that when you have age restrictions, that that puts an extra barrier between the people who very specifically are at the greatest need for access.
STANWOODAnd, as we move in the direction of broadening access to hormonal contraception like the pill or the patch or the ring, I think we need to learn from the policy lessons of the past and look forward to additional state laws that hopefully don't have age restrictions. Because we've learned in the past that that is just not what teens need. They don't need more barriers.
REHMFrank Palumbo, John in Lafayette, Ind., wants to know, what are the HIPAA requirements for pharmacists?
PALUMBOWell, in most states, the privacy requirements for youth taking oral contraceptives are intact, in that a parent cannot go in and request the record of their parent -- of their child who is taking oral contraceptives -- that those records are protected. Whereas a parent might go in and get the records of antibiotics, of other things.
PALUMBOBut if it's a oral contraception or a sexually transmitted disease, states generally will allow for privacy.
ROVNERAnd they're -- and I think I mentioned earlier, there is a long-standing -- I think dating back maybe to the origin, Title X, the Federal Family Planning Program, that requires that teens have privacy from their parent on these issues. There was a huge fight over it in the '80s because Utah passed a law saying the opposite and then was denied its Family Planning money.
REHMBut -- and that law still stands.
ROVNERI believe the law -- in Utah. But, yes...
ROVNER...the general requirement that student -- that teens be -- have privacy in obtaining birth control stands.
REHMAnd you're listening to "The Diane Rehm Show." Here's an email from Teresa, who says, how will -- you mentioned cost, Julie -- she says, how will these ordinances affect low-income women who get their birth control free through Medicaid? These women cannot afford to pay for birth control, especially if they are charged full price. Frank Palumbo.
PALUMBOThat's an excellent question. I think, I would like to point out that Medicaid has the flexibility within each state to pay for over-the-counter medications. So that I think that should not be a barrier. I would imagine that, if these laws pass, if we're ever over the counter, actually, that Medicaid would pay for it in the states. But it would have to be dealt with on a state-by-state basis. Even though Medicaid is a federal program, the states administer Medicaid and the states make most of the rules.
REHMWhat about costs in Oregon and California, which have already passed physician provide -- pharmacist provider?
ROVNERI don't know actually, specifically what they're doing about Medicaid. But then another thing to remember about Medicaid is that they pay much more for Family Planning to the states than they do for other things. It's always been a Medicaid priority to cover Family Planning for Medicaid patients.
PALUMBOAlso, I'd like to point out that if they are pharmacist provided, with a pharmacist's prescription, that pharmacists would be deemed authorized prescribers in those states.
PALUMBOAnd as such, they're -- those prescriptions would be paid for.
REHMHere's an email for Dr. Stanwood. Is there concern about a drop in Pap smear screenings by making birth control dispensed by pharmacists?
STANWOODRight. Well, we know from the science that women don't abandon their other routine health screening. And I think, again, when we look at the box that we've built women into about contraception in the 20th century, when I was a resident, lo these many decades ago, they trained me that I couldn't refill her prescription for birth control until she came in for her annual Pap smear. We held birth control hostage to cancer screening. And that's absurd. They are both very important public health issues. They're both very important issues for my patients' lives. But we don't want to hold one hostage to the other. If you think about the flip side, will we tell women they can't have their Pap smear unless they can prove they've been taking their pill.
STANWOODI think, when you flip it over, you realize that you don't want to have one public health issue held hostage to another and that women really do get access to what they need. I wanted to follow up on one issue that comes to the issue of payment and insurance. In a survey of women who were not currently insured and they were asked about, would you -- and they were also not on any birth control -- if you could go to the pharmacy, would you use it? Half of those women said, yes.
STANWOODAnd when we look at the epidemically, chronically high level of unintended pregnancy in our country -- half of all pregnancies are unexpected and unplanned -- a large proportion of those come from the small number of women who are not using any contraception. So that access like this will really improve women's reproductive health.
REHMDr. Nancy Stanwood of Yale School of Medicine. Short break here. We'll open the phones when we come back. Stay with us.
REHMAnd it's time to open the phone, 800-433-8850. First to Tom, in Pittsburgh, Pa. You're on the air.
TOMHappy holidays, Diane. Diane, I want to ask the guests, who's gonna be -- if it hasn't already been answered -- who's gonna be liable if there are complications, you know, from getting these hormonal birth control pills dispensed by the pharmacist? And secondly, are the doctors afraid that if this does take off country-wide, are they afraid that other medications might end up becoming in the same category, where the pharmacist can just dispense them?
REHMAll right. And Frank Palumbo, who is going to be held liable if something goes wrong?
PALUMBOWell, I -- that's an excellent question. And I would say that if the pharmacist prescribes the medication, that the pharmacist would presumably be liable for any malpractice that's involved in the process of prescribing.
REHMAnd what might that malpractice involve? Would it be not having gone through the prescribed questions or what could that be?
PALUMBOExactly. Something like that. The pharmacist didn't go through the screening questions. The pharmacist didn't evaluate it properly. The pharmacist didn't take the patient's blood pressure. The pharmacist didn't council the patient on how to take the medicine. There are many, many issues that could come forth with regard…
REHMSo it's not only the pharmacist, him or herself, but also the, say CVS, the owner of the drug facility?
PALUMBOYes. Basically, what would happen is the pharmacist would be sued. The corporation, such as CVS -- not that they're a bad guy, but just using them by name, would possibly be sued. But even if they didn't, because the pharmacist is an employee they would undertake the defense. They provide insurance for that pharmacist. But let's look at the pharmacist who isn't employed by CVS. The pharmacist who's the sole provider of a community pharmacy. That pharmacist would carry malpractice insurance, as well, just like physicians do, like lawyers do, like any professional does. And that is…
REHMSo they've got to be careful.
PALUMBOThey've got to be careful. Absolutely.
REHMAll right. And Dr. DeFrancesco, what about his second question, the idea of other medications falling into this category of pharmacist prescribed?
DEFRANCESCOI don't see that as a likely scenario. I think that the reason that we're talking about the benefit of these oral contraceptives going over the counter is because by definition, by our definition certainly, they've achieved the status of proven to be not only effective, but very safe and for the public benefit, there's a lot of reasons to have them out there, that accessible.
DEFRANCESCOI could argue counter for other things, like certain antibiotics for instance, you don't want those over-the-counter willy-nilly because of the fact that, you know, you don't want germs and bacteria to develop immunities to the various -- you don't want to overuse antibiotics. We know that's a bad thing to overuse antibiotics.
REHMBut how new is it? Julie Rovner, Dr. Francesco mentioned he had just had his pneumonia shot or his shingle shot, forgive me. Now we have shingles/pneumonia/flu shots. Are more and more of these kinds of things being asked of pharmacists?
ROVNERWell, I don't think it's a matter of being asked of pharmacists. There is a move in the health system sort of system-wide, to have people -- it's called practice to the top of their licenses. Things that medical professionals have been trained to do, but have traditionally been done by someone higher up the food chain and more expensive. So that the idea is to push some of these things down to, you know, allow doctors to have a better quality of life. They're not being basically, you know, all their time's not being taken up with stuff that other health professionals could be doing, like giving shingles vaccines. And I got my flu shot also at a drug store the last couple of years.
REHMMe, too. Me, too.
ROVNERSo these are -- this is considered a way to both try to stem health inflation and try to more rationalize the health care system.
REHMAll right. Let's go to Jane in Louisville, Ky. You're on the air.
JANEMy question is this, if over-the-counter birth control would bring down the number of abortions, if the panel agrees that this is true, and I think it would happen, by what percentage? And isn't that a very good talking point for having over-the-counter birth control?
ROVNERWell, actually, one of the interesting things that -- and we have indeed seen abortions coming down. Since the Affordable Care Act went into effect and started covering, you know, no upfront-cost birth control, we've seen a lot of women moving to long-acting, reversible contraception. As we were talking about earlier, things like the IUD and the implant. And those are more effective even than the pill.
ROVNERThe barrier had been high upfront costs. Now that the high upfront costs has basically been taken away, you're seeing more women, particularly more young women, taking advantage of those things. And that will also reduce the abortion rate. So it's not entirely clear how much having freer access to birth control pills would reduce the abortion rate, although one would infer that it also probably would. There would be fewer unintended pregnancies.
REHMAll right. To Lauren, here in Washington, D.C. You're on the air.
LAURENHi. When I was in fifth grade I started having hemiplegic migraines. And it really wasn't until years later that I found out that I probably should not be prescribed birth control. I was too young at the time to be told that. And it's not something that's in the mainstream as much as, you know, people who have a history of blood clot, they know that, or people who smoke.
LAURENI think that -- I was just wondering if these do go over the counter, I mean, we're not talking about safety with Tylenol, where you're taking it as actually prescribed on the bottle. You're taking it as prescribed. And you're following the instructions, but there may be people who don't know that they're at risk. So if these do over the counter without having a screening, you know, with bypassing screening and education from a pharmacist, I was just wondering, you know, how the panelists would respond to such a risk.
STANWOODYes. Hi, Lauren. You know, I had mentioned before that in a study that looked at women screening themselves for reasons not to take standard birth control pills versus doctors, that the women were more conservative. And one of the areas that they were very conservative in is when you look at the screening it's do you have terrible migraine headaches. And that women oft times have terrible headaches, but they're not migraines, such as you unfortunately suffer from. So that -- you're right.
STANWOODWomen who have severe migraine headaches should not take standard birth control pills that have estrogen. They can safely take other things. But the screening that we would anticipate would be on over-the-counter birth control pills would have questions that included, do you have terrible headaches. And that women could know, I have a terrible headache. Oh, then I shouldn't take this. I should talk to a doctor or pharmacist about this. So that we already know from one study that women can do that correctly and effectively.
REHMDr. DeFrancesco, do you want to add to that?
DEFRANCESCONo. Just, I would agree. Because I see that in my practice also, when I talk with patients and we talk about the birth control pills, half the time the patient tells me, well, I know I can't take the pill because I have migraines. And so basically this is out there. I think a lot of people are aware of that. And I think clearly whether it's me or the pharmacist asking the patient these questions, or whether it's written on the side of the box that patients picking up over the counter as a clear labeled warning to the patient, our patients are very smart and they know what they're doing.
REHMTo Morgan, in Pensacola, Fla. You're on the air.
MORGANHi there. First of all, I wanted to say that I do support easier access to contraceptives. My question is in regards to kind of the mental health aspect of it. As a person who took hormonal contraceptives fairly early on, I didn't realize for quite a while how they affected me and my mood. And I think this kind of goes with the caller who just called in.
MORGANIf these things were over the counter, how will young women be counseled in regards to their effects on mood and their impact on their mood? If you talk to any young woman or woman, they've all had some horror story of one type of birth control, which, you know, made them depressed or anxious. And so I was just wondering what the panel had to say about that.
STANWOODYeah, I'd think I'd want to reiterate, Morgan, that there's nothing about these laws that say that you can't make an appointment with the doctor. This is all about making ready access for women who are ready to be on contraception and don't have an additional barrier. But you can certainly always call and make an appointment with your doctor to discuss any concerns you have. So this isn't replacing counseling. It's making it easier to access.
DEFRANCESCOYeah, and I would add to that I think, again, part of the clear labeling on the box would say if you do have any experience, any side effects or any concerns about side effects, then contact your physician immediately.
REHMOkay. Here's a question I have because I personally happen to have had a conversation with a physician who, for example, said that her office is no longer offering flu shots because the amount of money involved with the patient load she had made no sense. Do you perhaps eventually see that birth control pills could move to exclusively over-the-counter, without doctor involvement or will there always be that doctor involvement availability? Dr. DeFrancesco?
DEFRANCESCOYeah, I think there's two different things. The flu shot is something that if, like other vaccines, if you're administering those in your office, you are storing an inventory of that. So you're…
DEFRANCESCO…putting out a lot of money upfront to store inventory and then dispense it as needed. That's not the case with the pill. We don't store the pill. We don't buy the pill. So it's a totally different analogy there. So this does not impact the way -- our prescribing habits with the pill.
REHMAll right. To Las Vegas, Nev. Amy, you're on the air.
AMYHi. I was calling in because my 22-year-old daughter, Shoanne (sp?) died from a blood clot and she was taking birth control.
REHMOh, I'm so sorry.
AMYI'm not against having -- thank you. It just happened four months ago. And unexpected. And the thing that really struck me was once that this happened that the lack of education for women on the risks associated with taking birth control. So I'm not against them getting it. I was supporter of my daughter being on birth control. But I really concerned…
REHMMay I ask how old she was, Amy?
AMYShe was 22. And she had been on it for years. And we had very open conversations about being on birth control. She was on the NuvaRing. So we thought it was the least amount of hormones that she could be on.
REHMAnd had she talked with a doctor about it?
AMYNo. And I, you know, we had -- I had never heard of -- I had heard somewhere along the line that, like clots, but I'm really advocating and trying to make changes as far as getting more information and making it mandatory that they discuss the risk and what a clot looks like. Women don't know what it looks like. They hear it, but they don't know what is the, you know, what does it look like when you have a clot.
AMYAnd I'm concerned if they start going to a pharmacist, then we're really lessening the chance of them getting the information they need on the risks of taking birth control. It's a very, very important woman's issue because women of all ages die from this.
REHMIndeed. Again, my condolences. Frank Palumbo, do you want to comment?
PALUMBOCertainly. Again, I'm so sorry about your daughter. I just want you to know that. It's terrible and I can see you're still trying to deal with it. I think that you make a very good point. I will point out, just to your example, that one of the items in the questionnaire relates to clots. Now, it asked if they've ever had one. So it's really hard for a pharmacist to examine a patient to see whether there's a clot. I do admit that. That would be the physician's job. But if the -- perhaps there are other risk factors in that questionnaire that would lead the pharmacist to tell your daughter, for example, to go to their physician.
REHMAnd you're listening to "The Diane Rehm Show." Dr. Stanwood, how would you respond?
STANWOODWell, again, my condolences. It's a terrible thing to lose a child. I think when we look at some of the barriers that are between women and contraception, I mentioned the idea of education. And that, again, it's not an either/or. Either you go and get over-the-counter pills or you get counseling. You can have both.
STANWOODBut this is to be more thoughtful about giving access to birth control, without needing a doctor's visit. But that the education still is there. You can still make an appointment with the doctor. And we also need to think more broadly about health education, reproductive health education that's done in our schools so that people know the warning signs to look for.
REHMAny comment, Julie?
ROVNERI would -- and I'm also very, very sorry for your loss. You know, this is sort of the risk/benefit I think that had been addressed earlier, that, you know, the vast majority of women -- or I don't know the vast -- but many, many, many women can take these pills safely and some can't. And it's just a question of whether the doctor's gonna make that determination, whether it's gonna be a nurse practitioner or a physician assistant who can also have prescribing privileges, whether it's gonna be a pharmacist or whether it's gonna be the woman herself. But there's gonna, you know, there is some -- there are going to be, you know, some adverse consequences no matter who is doing the screening.
REHMAll right. And a final question, Julie. The Supreme Court is going to take up birth control next year. It's about whether religious employers must provide free insurance for birth control. Talk about that and how it might figure in here.
ROVNERIt's not even that. It's really whether or not religious employers have to tell the federal government who their insurer is so that the federal government can then arrange for their workers to have coverage of contraception. Remember, these are largely Catholic entities, colleges and universities and schools and hospitals that don't believe in artificial birth control. So they're saying that it's a violation of their freedom of religion to basically check a box on a form that says we're religious, we don't want to provide this.
ROVNERBut then on the other side of the form to say, and we're gonna tell you who are insurance company is so you can do it. They say that that's facilitating, something that they believe is a sin. So that's -- and this is part of the issue that has gone on around this, you know, where there are religious issue. There are religious barriers also to women either getting insurance, in this case for birth control, or to actually getting it at the pharmacy.
REHMWell, what an interesting and valuable discussion. I want to thank you all so much. Julie Rovner, Frank Palumbo, Dr. Nancy Stanwood, Dr. Mark DeFrancesco, thank you all. I wish you all happy and safe holidays. Merry Christmas.
PALUMBOThank you and same to you.
REHMHappy New Year. Thank you. And thanks, all, for listening. I'm Diane Rehm.
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