Over-the-counter birth control will soon hit pharmacies. But that doesn't mean it will be accessible

This week brought a bright light to an otherwise darkening landscape in reproductive autonomy in the United States. For the first time in U.S. history, an oral contraceptive pill called Opill will be available to purchase over-the-counter. This means in less than two weeks, people will be able to go to their local pharmacies and buy an oral contraceptive without having to obtain a prescription from their doctor, or purchase it online.

“This is a landmark event for us in the United States,” Dr. Alison Edelman, professor and OB/GYN at Oregon Health & Science University, told Salon. “In general I’m really happy about that.”

Dozens of countries have had such options for decades. Indeed, the U.S. has been quite behind in this arena. In a global review of over-the-counter access to oral contraceptives, researchers found that oral contraceptives were informally available without a prescription in 38 percent of 147 countries surveyed, and legally without a prescription in 42 percent of countries surveyed. But Edelman, and other OB/GYNs Salon spoke with, anticipate a “bumpy” roll-out — and have some concerns around accessibility and access to care for some people.

As Salon previously reported, over-the-counter availability is expected to improve accessibility to birth control. That’s why in July 2023, when the U.S. Food and Drug Administration (FDA) approved it to be sold over-the-counter, many doctors called the move “monumental.” It was also a victory for organizations like the American College of Obstetricians and Gynecologists (ACOG) and "Free the Pill" advocates who have long advocated for and supported over-the-counter birth control for decades.

At the time, some were skeptical about how accessible it would become — primarily due to much it would cost. On Monday, the manufacturer also announced a recommended retail price of $19.99 for a one-month supply, $49.99 for a three-month supply and $89.99 for a six-month supply. However, retailers can set their own prices, which may vary across stores and locations. 

Edelman said there were many people who were hoping the pill would be free or under $5, as many other countries have contraceptive methods that are free and subsidized.

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“But I think given how we develop drugs and how drugs are brought to market, these companies spend millions of dollars having to bring a product to market,” Edelman said. “To expect them without subsidy to not have a higher price point, so they can recoup some costs, is a little unrealistic and impractical.”

Dr. Anne-Marie Amies Oelschlager, a pediatric gynecologist and chair for the clinical consensus gynecology committee for ACOG, told Salon she expects the cost to be prohibitive to some people. And then for others, it will make more sense to get Opill over-the-counter than to pay out-of-pocket. 

“It’s still less costly than taking time off of work and having to drive or take public transportation to go to a doctor's office. The cost of just going to the doctor is going to be substantially higher,” Amies Oelschlager said. “I think people are going to do a head-to-head cost comparison with going to the physician to get a prescription for contraception versus just walking into the local pharmacy.”

According to a survey conducted by the Kaiser Family Foundation (KFF), only one-third of women between the ages of 18 and 49 — who said they would likely use over-the-counter oral contraception — would be willing to pay $20 a month for it.

While the barrier of a prescription has been removed, cost still could be an issue especially since health insurance isn’t required to cover non-prescription contraceptives. As it stands, seven states require state-regulated private health insurance plans to cover at least some methods of over-the-counter contraception and seven states use state funds to offer the same coverage for Medicaid enrollees. Currently, there is a coalition of Democratic governors and reproductive health advocacy groups pushing the Biden administration to expand the Affordable Care Act’s prescription contraception requirement to cover over-the-counter contraception without a prescription.

Edelman said one way to think about the price is that it’s comparable to other options on the market that are less effective. For example, condoms range in price between $6 and $35. 

Dr. Jen Ashton, a  board certified OB/GYN and Chief Medical Correspondent for Good Morning America, told Salon another way to look at the cost is “an unintended pregnancy is much more expensive.” 

“Whether it’s inexpensive, affordable or expensive is not for anyone to say but the woman purchasing the product,” she emphasized. “What might be affordable to one person could be expensive to someone else.” 

Ashton added that she is concerned about accessibility to follow-up care, in case someone doesn’t take the birth control pill correctly or has side effects. 

Opill, which has the generic name norgestrel, was first FDA-approved in 1973 as a progestin-only medication, referring to the class of drugs it falls under. Compared to combination oestrogen-progestin pills, norgestrel carries fewer risks, such as blood clots. It works by thinning the lining of the uterus, which can prevent sperm from reaching an egg by thickening mucus in the cervix — but it’s not 100 percent effective. According to the FDA, perfect-use effectiveness rate can be as high as 98 percent. But that requires that a woman is taking the pill every day. Ashton said by removing the barrier of seeing a doctor, that could become a missed opportunity for proper counseling. 

“What if you miss a period? What if you have irregular bleeding?” Ashton posited. “When you remove that kind of counseling, that kind of follow-up, that kind of relationship, which already is in critical condition in this country, I think that you may be solving one problem and causing another.”

That being said, all experts agreed that this is improving accessibility in general. A study published in The Journal of Health Politics, Policy and Law in 2021 found that low-income people and people of color are more likely to live in contraception deserts. By being able to order Opill online or go to a pharmacy without a prescription will certainly be helpful. But it won’t immediately improve the crisis of reproductive health and autonomy in the United States. As experts have said before, Opill is not a replacement for access to abortion.

“It’s important for a lot of women,” Ashton said. “But it's not going to miraculously repaint the whole landscape; it’s unfortunately way more complicated than that.”