David R. Henderson  

Progress on OTC Contraceptives

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In February 2012, I posted a proposal that the federal government allow contraceptives to be sold over the counter. I wrote:

Nevertheless, there is a way that the federal government now cuts access to contraceptives in a way that substantially raises the cost. Were the government to get rid of the regulation that does this, women's access to contraceptives would rise and the cost would fall.

What is the regulation? It's the one that requires contraceptive pills to be prescription drugs. If, instead, drug companies were allowed to sell contraceptives over the counter, access would rise and cost would fall.


In December 2012, I posted about other commentators who agreed with my proposal.

Recently, polling data showed that a supermajority of Americans now agree with this proposal. Emily Elkins writes:

The latest Reason-Rupe poll finds 70 percent of Americans favor legalizing over-the-counter birth control pills and patches without a doctor's prescription, 26 percent oppose such a proposal, and 4 percent don't know enough to say. There has been a slight uptick in support for OTC birth control, rising from 66 percent in May of 2013. Moreover, Reason-Rupe finds that women across income groups highly support legalizing OTC birth control at about the same rates.

I asked back in December 2012:
Could this be a case such as the ones Wayne A. Leighton and Edward J. Lopez talk about in their new book, Madmen, Intellectuals, and Academic Scribblers, in which the moment is ripe for change?

I think it is.


Comments and Sharing






COMMENTS (25 to date)
Ken from Ohio writes:

Prof Henderson makes it sound as though the decision for a medicine to make the transition from prescription to over the counter is a political question based on poling data.

It is not.

There is a process by which a medicine qualifies for over the counter status.

Many medicines have made this transition - Ibuprofen, Naprosyn, Pepcid, Zantac, Prilosec, topical cortisone, topical Lotrisone...the list is very long.

But I don't think the decision to become over the counter was based upon public opinion poling data.

Instead the decision was based upon, safety, effectiveness, side effect profiles, dosing (a one size fits all dosing system).

So does oral contraception fit the medical criteria to become over the counter? Maybe. Probably.

And if it does become over the counter - likely the price will drop (as it has for other OTC medicines).

But the decision to proceed is not based upon popular opinion.

MikeP writes:

...and 4 percent don't know enough to say.

I seriously question any poll that came up with such a small number here.

My guesses would be that 6 percent know enough to say that all drugs should be OTC, that 4 percent know enough to say that all drugs except those with genuine public health concerns, such as last line antibiotics, should be OTC (my position), that 25 percent know enough to say that contraceptives meet current standards for making drugs OTC (probably Ken from Ohio's position), and that 4 percent realize that they don't know enough to say. That leaves 61 percent who don't know they don't know enough to say, yet who said anyway.

If Emily Ekins meant to write "and 4 percent think they don't know enough to say", then ignore this comment.

JLV writes:

Don't get super excited - one survey with N=1000 is pretty weak evidence (note also that the sample may skew left relative to the electorate - 42% say they'll vote for a Democrat in November compared to 33% Republican, which goes against the current consensus among poll aggregators.

Glenn writes:

70% agree now. Once politicians and the media explain that - while this change will indeed lower the gross cost of the contraceptive - net costs apparent to consumers will RISE absent the mandatory ACA coverage/exemption/subsidy, support will collapse.

This polls well now because it is a periphery issue and peoples gut reaction is, "sure, why not?". They simply haven't been told why not yet (for better or worse).

Charley Hooper writes:

@Ken from Ohio,

Like it or not, the FDA is, at its core, a political organization that's susceptible to public opinion.

True, there's a process for taking a medicine from Rx to OTC status, but the FDA's weighing of risks and benefits for patients is heavily influenced by the FDA's assessment of its own risks and benefits, which are ultimately a function of politics and public opinion.

Or, the politicians simply tell the FDA what to do. Consider the OTC status for Plan B, an emergency contraceptive. Why is it OTC when regular birth control pills aren't?

MikeP writes:

Why is it OTC when regular birth control pills aren't?

Because it's for acute use rather than chronic use. As such, it is less likely to cause long term sequelae. Plan B is also needed immediately, while regular birth control pills aren't effective immediately, so in the latter case there is more time to get a prescription.

I agree with you that the FDA's decisions must be politically palatable. But this particular distinction is easy.

NZ writes:

Progress towards what?

Question for anyone who isn't an alpha male pickup artist: what long-term benefits do you expect from our society further lowering the costs of responsibility-free (typically extramarital) sex?

What about long-term costs?

Ken from Ohio writes:

For sure the FDA is a political institution. And with that status comes a certain overlay of public choice, rent seeking, and overt political influence. And this is true for all political institutions.

But at its core, the FDA is a medical decision maker and must follow its established policies and procedures. Popular public opinion polls, all else being equal, is (I believe) low on the priority list.

After all, given that the FDA 's primary motivation may be its own preservation( public choice), it does not want to make a mistake that initially seemed popular but turned out to be medically dangerous.

ColoComment writes:

Birth control pills have been used by the public since the early 60s. One would think that ~50 years of use would have produced sufficient evidence of safety, efficacy, and contraindications to speed FDA approval for OTC sale and labeling.

One would also think that, with their long history of relatively safe use, BC pills would likely be approved for OTC sales 'way before Viagra or Cialis, but nooooooo.

http://www.usatoday.com/story/money/business/2014/05/28/cialis-over-the-counter/9681243/

mobile writes:

Apropos: https://www.youtube.com/watch?v=9IhgwCB14To

Mark V Anderson writes:

NZ -- More pleasure less pain? That seems sufficient to me. Sex is a good thing because it's fun, and unwanted pregnancy is a bad thing ( I assume you agree with the latter).

ThomasH writes:

This is a no brainer that takes Liberals' efforts to prevent Conservatives from preventing women to have access to contraceptives one logical step further. It should be complimented with proposals to let school nurses and other paramedics provide IUDs and implants. Likewise withdrawing from employers the "right" to dictate what the coverage of the health insurance purchased with employees' wages.

NZ writes:

@Mark V Anderson:

Does "sex is fun" really fit your definition of a long-term benefit?

Even ignoring long-term vs. short term, do you imagine that when the cost of sex is lowered there are no external or unintended consequences?

Do you imagine that cheaper, more readily available contraception has no impact on people's sexual habits, marriage habits, or childbearing habits? On venereal disease? Illegitimacy rates?

If a man and a woman want to have sex because it's fun but they don't want a pregnancy, so one of them easily purchases (and, perhaps, correctly uses) contraception and so they screw without otherwise committing to each other, will all the relevant externalities obediently stay within the boundaries of that "transaction"? Is that how you think reality works?

I swear, these questions aren't meant to be rhetorical, but I'm genuinely baffled how you'd answer yes to any of them. But answer "Yes" is what you need to do if you want to defend making contraceptives easier to access and still claim to care about the quality of the society you live in.

john hare writes:

NZ,

Your questions don't exactly fit a yes/no format.

Yes fun is a benefit.

Yes there will be long term societal changes caused by the unexpected consequences. It is not clear which direction these consequences will be. Harm in marriage practices and venereal disease may well be far less damaging than the unwanted pregnancies that drive decisions for the rest of the participants lives.

I care deeply about the society I live in, and more so about the choices available to the people in it. Restricting choices to force people into a certain groove has serious consequences as well.

RPLong writes:

I'm always genuinely surprised at how many people are in favor of state-controlled access to medicine. To me, OTC contraceptives are a no-brainer. OTC insulin and epinephrine are also no-brainers. I can understand the arguments against OTC vicodin and stuff, but for the most part, I don't understand why people are so scared of giving people unrestricted access to prescription medications.

It's true that some people will take medications incorrectly, but the vast majority of people will consult their needs with their doctors and then purchase the correct dose from the pharmacist, as directed by the physician, without having to get the state involved. I'm certain of this.

How can I be so sure? Because there are many countries in the world in which this is exactly how medications are dispensed.

Andrew_FL writes:

NZ, I don't think government regulation of birth control is the last bulwark against a responsibility free culture. We are already pretty much there, unfortunately.

If it's a choice between you and I paying for someone who wants to behave in a manner we disapprove of, or merely allowing people to behave in a manner we disapprove of I would think we would both choose the latter, yes? I'm generally in favor of letting people behave in manners I disapprove of if they don't harm some third party, of course. You might not be?

I mean the fact that said people are not having children as a result of their activities kind of negates the argument that there is a third party they are harming (how does birth control increase the illegitimacy rate?). Increased venereal disease is not an "externality" at all. If you know you have it and lie about it to your partner it's more like aggravated battery. If you don't know, it's more like a very serious car accident.

NZ writes:

@John Hare:

Yes fun is a benefit.

You were careful to omit the phrase "long-term" there.

Yes there will be long term societal changes caused by the unexpected consequences. It is not clear which direction these consequences will be.

What is unclear about it? We have some 60 years (two generations!) of experience on which to draw since widespread adoption of the pill.

Harm in marriage practices and venereal disease may well be far less damaging than the unwanted pregnancies that drive decisions for the rest of the participants lives.

But then again they well may not. After all, a child who is brought to term and raised by both parents, even if that child was initially unwanted, is typically loved and cared for in the end. I hope I don't have to go into stats about the long-term outcomes of kids raised by two parents vs. kids raised by only one, or stats about long-term outcomes for people who have (more) kids. (Didn't one of the EconLog guys write a book about that?)

I care deeply about the society I live in, and more so about the choices available to the people in it.

The problem is when people's choices, in aggregate, end up ruining the society. But then again, that's okay for you because as you said, you care more about the choices than the society.

I don't. My ability to make choices is meaningless outside of the society in which I'm making them, because society is what enables me to make most of my choices in the first place.

I'm not afraid of nudging people into grooves. Grooves are normal and healthy for people, because most people naturally fall into grooves based on their general characteristics anyway. It is erroneous to think that without such nudging people would just randomly scatter.

I'm not saying we should put barbed wire around those grooves, but, to shift the analogy somewhat, if you see natural trails developing through the woods, it's not a bad idea to consider clearing and paving the trails--it doesn't mean cut down and pave the whole forest though, just for the sake of a few weirdos who like to go off-road.

Jay writes:

@Thomash

Withdrawing what employer's "right"? They're the ones paying the vast majority of the cost not the employee's wages, the employee is welcome to take their wages and pay for their own plan but don't let me stop you from making an unrelated talking point.

NZ writes:

@Andrew_FL:

I don't think government regulation of birth control is the last bulwark against a responsibility free culture. We are already pretty much there, unfortunately.

That's a good example of the "Ship's already sinking, might as well cut some more holes in the hull" argument. You know, you can also grab a bucket or try plugging a breach.

I'm generally in favor of letting people behave in manners I disapprove of if they don't harm some third party, of course. You might not be?

What we disagree on is what the third party is and how they are related to the primary parties. (Or you may just not have thought about it much.) In the real world, the outcomes of transactions, whether I approve of them are not, rarely obediently limit themselves to the parties immediately involved.

For example, just because birth control is more readily available does not mean that couples simply control when their sex leads to children and when it does not, and that nothing else in society is touched. Instead, increased availability of birth control changes people's attitudes about sex, which in turn changes the way people go about anything that has even the least bit to do with sex. Then there is a ripple effect out to tangent areas as well, on and on.

In the end it isn't about what you or I approve of, it's about what leads to the best long-term outcomes for the society as a whole. If you care more about the trees than the forest, you'll soon have neither.

joe c writes:

While I certainly believe contraceptives should be less regulated, I'm struggling with potential adverse effects of it being OTC. My SO needs a very specific type of BC to avoid nasty side effects, which a doctor knew about and was able to prescribe. Other friends of the female persuasion have other similar stories. I don't necessarily know if allowing people to freely choose their BC is a good thing. Certainly, it should be cheaper and completely covered by any insurance, but is making BC OTC for people to test on out themselves the answer?

I don't exactly have a comprehensive understanding of the public health issues re: contraception so I don't know exactly what the adverse effects would be. This is just speculation. Nearly every woman I've known though needed a very specific type of BC for their own particular hormonal makeup; maybe I just happened to encounter that more than the general population. There is really no reason to have to constantly renew prescriptions each month though once you know what works, unless another medication at the time fundamentally alters your hormonal balance.

Andrew_FL writes:

@NZ-

Instead, increased availability of birth control changes people's attitudes about sex, which in turn changes the way people go about anything that has even the least bit to do with sex. Then there is a ripple effect out to tangent areas as well, on and on.

This is precisely the part of your argument I find unpersuasive. First, that people could become more casual in their attitudes about sex, second, that more people using birth control means more people having sex and not using it, as well. The first point seems implausible, the second seems like a non sequitur.

john hare writes:

NZ,

You seem to believe your choice is superior to that of the people involved. I don't.

Mark V Anderson writes:

john hare's last comment is the most persuasive one. People have the right to do what they want with their lives.

I believe there should be no prescription medicine, because everyone has the right to make up their own minds, and nothing is stopping them from asking for advice from their doctors or pharmacist. Maybe I could be persuaded that anti-biotics should be regulated, because there is an externality there. Except that the current regulation hasn't done any good.

This is mostly a logical approach and not an empirical one. But looking around real life it is real clear how wasteful the whole prescription process is. How often do folks go to their doctor just to get a prescription that both the doctor and patient know is necessary? Think about the excess time and billings this generates. I suspect a large portion of our current medical spending, and even more when counting patient lost productivity.

And now for the more fun part. One time sex is a short term benefit. A lifetime of sex is a long term benefit. I am 58, so it's long-term for me. OF course I don't cotton to the traditional rules that it is good for one to be committed before having sex, or that sex with more than one person is bad. So yes, the extra sex arising from more contraception is definitely a long term benefit.

Jaime L. Manzano writes:

Making contraceptives available over the counter has merit, albeit it does facilitate sexual promiscuity, and subordinates procreation within a marriage as preferable. The removal of government as the setter of moral standards is even more attractive and supportable. That function ought to rest with common social practices and religious institutions. In the medical field, that would mean terminating the power of government over individual choice in accessing drugs, even those that are habit forming, at least for adults. Abuse is likely, as is probable with contraceptive medications. On the other hand, consumers would begin to learn when and what to take, the cost of policing illegal trafficking of drugs would largely be eliminated, and the costs for medications would likely drop, at least insofar as the requirement of paying a physician for access to them.

NZ writes:

@Andrew_FL:

Why treat this as theoretical?

It is almost certain that instances of sexual intercourse in which birth control is used are more common today than in the past, both absolutely and as a percentage of all instances of sexual intercourse.

However, if this takes place within the context of attitudes towards sex becoming more casual (and I think it's plainly obvious this has happened) then there will also be an increase in instances of people having sex without birth control, and also of people having sex while using birth control incorrectly or lying about using it.

The illegitimacy rate is the best way to gauge whether this has happened. How's that rate looking these days?

@john hare:

When did I express my personal choice? I only said that lowering the cost of extramarital sex by making contraception more readily available was bad for society in the long term.

But why feign ignorance about the quality of various choices? If you waited to have unprotected sex until you were married to your female sexual partner and gainfully employed full-time, how could you claim not to know whether this series of choices was better than that of a guy who knocked up three girls by the time he graduated high school and then got arrested for selling drugs?

@Mark V Anderson:

You wrongly presume that what people do with their lives has no discernible impact upon the lives of others or upon the quality of society as a whole. In fact, the thing a person does that never ends up impacting anyone else, especially when that thing is aggregated among the others who also do it, is the rarest thing of all.

@Jaime L. Manzano:

What happens when common social practices and religious institutions fail to perform that function, or worse, come heavily under the influence of the most libertine factions of the government and media?

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