Why Is It Still So Difficult To Access The Morning-After Pill?

Thanks to Affordable Care Act insurance reform, prescribed contraception must be covered by all insurance plans without a co-pay, meaning the majority of Americans now have access to primary forms of birth control — their “plan A” contraception. As nearly everyone who has ever had potentially procreative sex knows, however, the need for back-up is crucial to peace of mind, whether or not it’s needed in practice.

So as we mark this year’s World Contraception Day (an effort spearheaded by a coalition of 16 international non-governmental organizations, governmental organizations, and scientific and medical societies), it’s fitting that we explore just how inaccessible our contraceptive backstops remain.

Fittingly, as it has existed as long as pregnancy itself, abortion is our most well-known remedy to a confirmed unplanned and unwanted pregnancy. It’s only recently been demonized, turned into a political wedge issue designed to make the party that opposes a social safety net in any form appear to be the party of life and morality. Even those of us working to make abortion accessible and fully funded by taking back the morality of abortion, however, recognize the benefit of empowering people to avoid the hassle and hardships of being pregnant when they don’t want to be. First trimester hormones and body changes are no fun when you’re excited about a pregnancy; they can be a nightmare to endure even temporarily while waiting to see your doctor. Enter: emergency contraception, aka “the morning after pill.”

Known widely as “Plan B” thanks to the most prominent brand — Plan B One-Step® — emergency contraception (EC) is designed to be taken within 72 hours of unprotected sex or possible birth control failure. Essentially, it’s a higher dose of a hormone used in many birth control pills called levonorgestrel that prevents the release of an egg from the ovary. Despite the anti-choice contention that it is an “abortifacient,” Plan B and other emergency contraception will not end an existing pregnancy post-fertilization and implantation of the embryo in the uterus.

In 2013, the FDA finally approved Plan B One-Step for over-the-counter sale without age or point-of-sale restrictions like asking for photo identification. And yet (surprise!), significant barriers remain.

Dr. Diane Horvath-Cosper, reproductive health advocacy fellow at Physicians for Reproductive Health, told The Establishment that the $40 average price is a hardship for many — as is having to visit a clinic to obtain a prescription so that insurance will cover the cost.

But while expense is the most obvious and well-known barrier, it’s far from the only one.

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Technically, thanks to the FDA’s decision, Plan B is now supposed to be available without a prescription. But beyond that, the FDA policy language is a bit murky on where EC is to be kept and how exactly it is to be sold; the FDA simply states that “the product is now available without a prescription for use by all women of reproductive potential.”

As a prescribing physician, Horvath-Cosper is advocating for the real spirit of the policy to be implemented. If the intention is to make EC “available” to “all women of reproductive potential,” then all possible barriers should be eliminated.

Unfortunately, a dismal percentage of retail establishments aren’t interpreting the policy that way.

A 2015 study by the American Society for Emergency Contraception (ASEC) found that only two-thirds of stores stock Plan B over the counter. And most of those — 86% — “secure” it in some fashion with lock-boxes (like the ones enclosing razors requiring a sales associate to open upon request) or stock it either behind the register or with the pharmacist.

In a recent piece, Erin Matson, co-founder and co-director of the reproductive justice organization Reproaction, wrote about going on a drugstore run and noticing that prominent Washington, DC-area pharmacy chain Harris Teeter had cards available on the shelf for customers to take to the pharmacist, but that the medication itself was behind the counter. This method of sale is most often used for medications like Sudafed that are available but controlled because they are used to manufacture illicit drugs like methamphetamine. EC doesn’t have a narcotic effect — and frankly, because the cost is considerable, buying it en mass even to have it on hand just in case seems highly unlikely.

So why, Matson wanted to know, was her pharmacy keeping EC behind the counter, creating an unnecessary barrier?

“Harris Teeter operates more than 230 stores in seven states and the District of Columbia,” she wrote in her piece. “Lamar Hardman, director of pharmacy for Harris Teeter, told me that this is part of the chain’s policy where Plan B is concerned. ‘It’s really simple. We just follow the FDA [and] the new guidelines they put together in 2013, and make it accessible to the customers that desire the product, so it’s not much more complicated than that,’ he said via phone after I asked for more information.”

Horvath-Cosper has also seen this shifty inaccessibility firsthand. “Just yesterday I went to a pharmacy that had the EC sitting behind the pharmacy counter,” she says.

pharmacy
An example of advertising that doesn’t mention Plan B, from a prominent southern California pharmacy.

Even in some pharmacies where the pill, the patch, some injections, and the vaginal ring are available over the counter thanks to recent laws in California, Oregon and Washington, emergency contraception isn’t advertised as prominently as the other forms of birth control — if at all. This creates additional stigma, as though only a handful irresponsible or “slutty” people would need the backup.

Indeed, when stores make Plan B so difficult to obtain, it seems quite clearly to be rooted in stigmatization. This can be especially burdensome for young people, who are often particularly uncomfortable having to ask for EC; for those living in small towns with just one or two pharmacists likely to know their parent or guardian, the discomfort is even higher.

There is simply no reason to keep the actual medication out of reach, except in an effort to police people’s behavior or impose discomfort or embarrassment on them.

Not surprisingly, conservative beliefs are at the heart of many of these restrictive decisions. Horvath-Cosper notes that “there are concerns that pharmacists may cite religious or moral concerns to deny access to patients — something that continues to be a problem nationally.”

Indeed, as reported by Rewire News in June, a challenge to a Washington law requiring pharmacies to stock and dispense Plan B or other emergency contraception was taken all the way to the Supreme Court:

“The Stormans family — who own a local grocery store and pharmacy in Olympia, Washington — challenged the rules in 2012, arguing that the rules required them to violate their religious beliefs. Those beliefs, they said, include a conviction that life begins at conception; therefore, emergency contraception acts as an abortifacient, which they also object to providing.”

The Supreme Court refused to take the case, allowing the lower court ruling denying the Stormans’ contention that their rights had been violated to stand.

Horvath-Cosper explained why their claims aren’t just specious on constitutional grounds, but are also medically inaccurate:

“Plan B primarily works by preventing ovulation; no egg released by the ovaries means no pregnancy. It probably also thickens the cervical mucus and slows down the movement of the egg and sperm, making it tougher for the sperm to get to an egg that’s already released. It isn’t an abortion. In fact, progesterone is a hormone that supports an existing pregnancy, so there’s no evidence that Plan B disrupts an existing pregnancy. Ella, another type of EC, is an anti-progestin, but also works to prevent ovulation. There is no evidence that Ella disrupts an existing pregnancy either.”

All of this is deeply troubling for a simple reason: Plan B is a necessary reproductive health-care option.

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When asked who uses Plan B, the response of Horvath-Cosper was enthusiastic and inclusive:

“Anyone at risk for unplanned pregnancy! Younger people have higher fertility, more sex, and tend to use less reliable primary contraception, so they probably use EC more than older people, but I’ve had patients of all age groups ask for it. It’s safe and there are very few contraindications for using it, so it’s appropriate for anyone who thinks they might be at risk for unplanned pregnancy.”

In fact, she recommends everyone having potentially procreative sex know how and where to access emergency contraception, because the faster you take it, the more effective it is.

“I think EC should be readily available for anyone who needs it,” she says. “When I see patients in the clinic for contraception counseling, I always talk about EC no matter what method the person chooses. Even if my patient never ends up needing EC, maybe they’ll tell a friend or a family member who does.”

Horvath-Cosper doesn’t recommend EC to most patients as a primary form of birth control, simply because it’s not as effective as other forms like the pill or the IUD. However, she and others in the medical community see it as an important tool, recommending and prescribing it regularly to their patients.

“Most clinicians and most patients see it as a backup for their primary method of contraception, in case a person forgets a few pills or if their ring falls out and they didn’t realize it,” she explains. “It can also be a great backup for things like condoms, which can sometimes break or fall off during sex. Most people don’t choose it as a primary method of contraception because it’s not as reliable — and it can be more expensive, especially now that the ACA requires insurers to cover contraception with no cost-sharing.”

In some cases, though, Plan B can be “plan A.” And these patients should have the same access to the method that’s best for them, despite being part of a small minority.

“For some people who have difficulty with other forms of contraception, emergency contraception may by their method of choice, though this is rare,” Horvath-Cosper says. “It’s important to note that everyone’s contraceptive needs are different, and that there may be excellent reasons someone would choose a less effective method like withdrawal plus EC backup. The best thing I can do as a clinician is to listen to patients, try to understand their needs, then collaborate to help them identify the method that fits their needs the best.”

Horvath-Cosper also emphasizes that emergency contraception is “extremely safe,” that “there’s no evidence that it increases risky sexual behavior or encourages people to have unprotected sex,” and that many options exist outside Plan B, including Ella and the copper IUD. (She notes, though, that “Ella isn’t yet available OTC and anyone who wants a copper IUD will need to see their healthcare provider to have one placed, so OTC Plan B may still be the most accessible option for someone seeking EC.”)

The bottom line? All options should be readily accessible to people of all genders. Pushing for policies that make this a reality should be a focus for World Contraception Day — and every day.

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Lead image: flickr/Mike Mozart

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