In April 2016, California implemented legislation that allows pharmacists to prescribe birth control—an exciting step forward in making contraception more accessible and convenient. But one year later, only 11 percent of pharmacies actually offered the service.
To carry out the project, researchers secured a list of every California pharmacy from the state Board of Pharmacies. They removed mail-order pharmacies, hospital-based pharmacies, and other specialized centers so every location was accessible to the community.
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The researchers posed as patients and called a representative sample of more than 1,000 pharmacies between February and April 2017. They asked if the drugstore could prescribe birth control, which options were available, and how much they cost. Just 112 locations (or 11 percent) offered prescriptions for contraception, according to the study published in JAMA Internal Medicine in December.
The policy is still new, so availability will likely increase with time, experts say. But assessing California’s law and analyzing the barriers that pharmacies face is important, so that states introducing similar legislation can create strong and effective policies.
“California is seen as a leader in progressive policies for women’s health. We have this great policy that allows pharmacists to prescribe contraception, but it doesn’t actually look to be available at this point,” says Anu Manchikanti Gómez, assistant professor at the School of Social Welfare at the University of California, Berkeley and director of Berkeley’s Sexual Health and Reproductive Equity (SHARE) program. “We want to figure out why and see if there are ways we can address those challenges.”
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Three key barriers prevent pharmacies and their staff from providing the service, Gomez says. First, the law requires pharmacies to incorporate new infrastructure into their business. The law doesn’t make birth control available over the counter; women need to consult with a pharmacist about their medical history and different options like they would with a doctor. This means pharmacists have to be trained, locations need a full staff, and a private consult room, and the company becomes more vulnerable to lawsuits.
The second challenge is that the public may not be aware of the new option, so low patient demand could discourage pharmacies from making the change. Women may also be hesitant since they have to pay a fee of about $45—which brings us to the third hurdle.
California’s law does not mandate that insurance companies reimburse pharmacies for the service of prescribing birth control. Patient fees may cover part of the cost but not the larger infrastructure changes like staffing and liability.
“The insurance piece is huge,” says Sally Rafie, an assistant clinical professor at the Skaggs School of Pharmacy and Pharmaceutical Sciences at the University of California, San Diego, who was not involved with the study. “Giving someone the prescriptive authority is inadequate. We also have to make sure that there’s reimbursement. As other states are considering this, that would be a really important piece to try and bundle together.”
California is working to address the financial side now. The governor signed a second bill that will require the state’s Medicaid program to reimburse pharmacies for the service by July 2021. Still, that would only apply to people with Medi-Cal insurance, not those with health coverage through their employer.
Despite the early challenges, California has still made significant progress, Rafie says. Eleven percent of pharmacies seems low, but since the state has more than 7,000 pharmacies, it has introduced hundreds of new locations for women to access care. Pharmacies also need time to carry out the change. At least one large retail chain has plans to roll out the service, and others will hopefully follow suit, Rafie says.
A handful of other states allow pharmacists to prescribe birth control, including Oregon, Colorado, and New Mexico, and others are working toward the same policy. “We’re going to see this become an option in more and more states,” says Maria Rodriguez, an assistant professor of obstetrics and gynecology at Oregon Health & Science University School of Medicine. “We hear about new states being interested in this legislation and Oregon’s experience all the time.”
Pharmacists will never completely replace doctors in prescribing contraception, but they’re another valuable option, especially for women in rural areas or women looking for a more convenient alternative.
“Reproductive health is fundamental to both a woman’s well-being as well as her rights, and it’s important that we safeguard it and promote access to contraception and abortion services in a whole range of settings,” Rodriguez says. “I think pharmacist prescription of contraception is one key policy arena where we can work to improve access for women.”
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