PolicyLab

Editor’s Note: This post is part of an effort to use research and expertise to help other researchers, policymakers, program developers, and institutions understand the downstream effects of limiting youth access to comprehensive reproductive health care. For more, read posts on the importance of high-quality, comprehensive digital health information about reproductive health options, why access to comprehensive reproductive health care is an adolescent issue, and ensuring access to contraception, and view a recording of our virtual conversation on centering youth voices in supporting access to comprehensive sexual and reproductive health services.

In 2022, I was a part of a coalition that led the American Medical Association to declare that access to contraception and abortion is a human right. The overturning of Roe v. Wade and the constitutionally protected right to abortion in June 2022 sent shockwaves through the country. And for health care providers such as myself focused on caring for adolescents, it prompted the reevaluation of the opportunities for adolescent contraception access. With the legal landscape around reproductive health care still in flux, it's vital to explore new avenues for providing young people with affordable and accessible contraceptive options. 

As Dr. Sarah Green recently outlined in her PolicyLab blog post, contraception restrictions disproportionately affect adolescents. When the Federal Drug Administration (FDA) announced in July of this year that they approved the first over-the-counter (OTC) birth control pill, Opill (norgestrel), many reproductive rights advocates lauded this decision, including the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics. 

However, both organizations noted that Opill alone would not solve the critical issue of access to contraception, particularly for adolescents. In this piece, I will discuss the science behind Opill as well as the potential opportunities and challenges that it will present for contraception access to adolescents when it hits the shelves in early 2024. 

The Safety, Evidence & Efficacy Behind Opill

In general, youth are fairly nuanced about the decisions they make surrounding contraception. A systematic review published in 2018 found that youth carefully weighed the benefits and drawbacks of different methods but were ultimately more likely than adults to be influenced by social context. Additionally, youth valued privacy, autonomy and confidentiality with regards to accessing care, method choice, use and discontinuation.

Oral contraception methods, including Opill, are highly effective at preventing pregnancy and are very safe and well-tolerated with minor side effects. With "typical use," meaning use associated with imperfect adherence, the rate of unintended pregnancy is less than 10%. With progestin-only pills, of which Opill is one, it is necessary to take the medication at the same time every day for full efficacy. Typically, I’ve seen that my patients who choose oral contraceptive methods are diligent and take ownership over adhering to this regimen to maximize effectiveness. In my experience, patients who may want to take the burden of remembering to take the medication off their plate will choose an alternate contraception method such as long-acting reversible contraceptives.

The Opportunity of Opill for Increasing Adolescent Access to Contraception

According to research, the largest barriers to adolescent contraception use and adherence are confidentiality, cost and access. Opill holds the potential to enhance adolescent contraception access significantly through several avenues:

• Streamlined Process: Opill eliminates the need for a medical provider visit and prescription, reducing barriers to access.

• Increased Privacy: Without the need for a prescription, adolescents can access contraception with greater privacy. This can be particularly important for those who may be uncomfortable or unsafe discussing their reproductive health with others, including their caregivers.

• Convenience: Opill's availability in stores and online offers convenience that suits the digital age. Young people can order Opill online or pick it up at a local store, aligning with their preferences and needs.

More fundamentally, by removing the need for a provider's prescription, OTC birth control will increase patients' bodily autonomy and ownership over the decisions surrounding their reproductive health care. I see this as a win for reproductive justice, but one that we’ll only harness if we also act on policies that support access to Opill.

Policies Needed to Support Adolescent Access to Opill

While Opill offers exciting prospects, it also has limitations that must be addressed. The Kaiser Family Foundation's 2022 Women's Health Survey found that 11% of women would not be willing or able to pay anything for an OTC oral contraceptive, and 39% would pay $1-$10 monthly. Only 16% said they would pay more than $20 a month. Recently published research found that teens ages 15-17 would only pay $10.

While the Affordable Care Act (ACA) requires coverage of contraception with no out-of-pocket costs for most patients, this only applies to prescription contraception and does NOT cover OTC medications. Therefore, in order for some patients to afford Opill, they may still need a prescription, negating many of the benefits of the OTC option.

Earlier this year, President Biden issued an executive order directing federal resources to address the issue of insurance coverage of OTC contraception. Currently, there is no federal guidance on this issue. Thus, insurers handle it differently, presenting a diverse and confusing landscape for patients, medical providers and pharmacists. 

Even within Medicaid, which together with the Children’s Health Insurance Program (CHIP) insures about half of children and adolescents in the U.S., coverage of OTC medications varies by state, with very few state Medicaid plans covering OTC medications. Of plans that do, if the patient doesn't have a prescription, then the state will not receive matching federal Medicaid dollars. Standardization, including federal guidance on reimbursement for OTC medications, would provide much-needed clarity and increase access.

One solution could be dropping the prescription requirement included in current federal guidance for coverage of contraception under the ACA. The U.S. Departments of the Treasury, Labor, and Health and Human Services have put out a request for information to comment on a proposed rule to do just that. Comments close on December 4, 2023, and can be submitted here.

Opill's introduction can be a significant step toward improving adolescent contraception access amid the changing landscape of reproductive health care. By addressing its limitations with sound policy solutions, we can help ensure that Opill fulfills its potential.