If politics makes strange bedfellows, there may be none stranger than Rep. Alexandria Ocasio-Cortez (D-N.Y.) and Sen. Ted Cruz (R-Tex.). The Internet was abuzz recently over their supposed meeting of the minds about potentially allowing birth control pills to be sold over the counter (OTC).
How deep does this alliance on contraception really run? As it turns out, not very. Behind Ocasio-Cortez and Cruz’s Twitter exchange lies a significant divide in how they — and their respective parties — think about access to birth control, particularly when it comes to affordability.
Women face three main barriers to getting contraception
The difficulties in gaining access to contraception fall into three primary, sometimes intersecting, groups: legal, medical and economic. U.S. history is replete with legal efforts to limit access to birth control. By the mid-1970s, however, the federal courts had struck down all the most stringent legal barriers to obtaining contraception. But formal legal restrictions could always resurface.
Laws banning contraception outright have not been the only obstacles to access. As the exchange between AOC and Cruz highlights, American women must overcome another hurdle when seeking contraception: the need for a prescription. In the United States, like in most of Western Europe and Canada, birth control pills can be obtained only with a prescription. By contrast, oral contraception is available over the counter in much of Central and South America.
Evidence suggests prescription requirements remain a major obstacle for some women in obtaining contraception because they lack insurance or find it challenging to schedule an appointment. Eliminating that requirement would lead to more women using birth control.
As we explain in our book, “The Politics of the Pill,” economics present a final barrier to access. The most common form of birth control — “the pill” — typically requires a prescription and costs up to $600 a year without insurance. Longer-lasting methods, such as an intrauterine device, are more expensive still; costs can run into the thousands. Historically, health insurance has not provided much help for women seeking contraception. In addition to the relatively large percentage of women who have not had health coverage at all, many insurance plans did not pay for birth control until state laws began mandating it in the mid-1990s. The Affordable Care Act built on these laws to require birth control coverage with no co-pay, greatly expanding economic access.
How likely is Congress to allow over-the-counter sale of contraception nationwide?
In general, protecting legal access to birth control is (and has been) incredibly popular with the American public. Recent surveys find that the vast majority of Americans are not bothered by the use of birth control, and more than 90 percent say its use is “morally acceptable.”
There is strong bipartisan support for over-the-counter access. In a 2014 poll, two-thirds of Democrats and Republicans said it should be legal “for adult women to purchase birth control pills or patches over the counter without a doctor’s prescription.” If that’s the case, the potential AOC-Cruz collaboration makes a great deal of strategic sense: A bill allowing OTC birth control pills would be a rare political win-win for Democrats and Republicans alike.
So does that mean we should expect congressional action facilitating OTC birth control pills soon? Probably not.
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Republicans and Democrats see the issues differently
When we dig deeper into how liberals and conservatives think about this issue, there are clear divisions on how to reconcile eliminating the prescription barrier (medical access) with requirements for insurance coverage (economic access). Despite the public’s general support of legalized access to contraceptives, Republican lawmakers typically haven’t prioritized policies addressing the medical and economic obstacles to access. In many cases, they have actively sought to restrict access — including efforts to weaken the requirement for insurance coverage under the Affordable Care Act. Social conservatives, in particular, have supported retaining most of the existing medical and economic obstacles to contraceptive access.
Nevertheless, numerous Republicans, such as Sen. Thom Tillis (N.C.), former White House counselor Ed Gillespie, businessman Mike McFadden, Sen. Cory Gardner (Colo.), former Louisiana governor Bobby Jindal and Sen. Joni Ernst (Iowa), have recently endorsed OTC birth control pills — perhaps motivated by a limited government ideology that sees any deregulation as a victory, or by a strategic desire to blunt recent claims that they are waging a “war on women.”
Cruz is just the latest Republican to embrace this position. However, Republicans who support OTC birth control have not embraced legislation that would maintain insurance coverage mandates for OTC contraception — which Democrats would require.
Democrats also are navigating a tricky terrain on over-the-counter contraception. For years, liberals were vocal champions of eliminating both the medical and economic barriers to access, and before the ACA passed, there was no tension between advocating for over-the-counter contraception and low-cost contraception.
But the ACA’s contraceptive mandate dramatically reduced the economic barriers to access for women with insurance. As a result, some feminists have urged caution about making birth control available over the counter, fearing insurance companies would no longer cover it.
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Democrats such as Sen. Patty Murray (Wash.), Rep. Ayanna Pressley (Mass.) and Ocasio-Cortez argue that economic and medical barriers can be tackled together. Murray’s bill, the Affordability is Access Act, stipulates that if the Food and Drug Administration expands over-the-counter access, insurance coverage remains in place. That insurance coverage mandate means this legislation is unlikely to engender broad Republican support in Congress.
Health-advocacy circles have raised questions about the details, such as whether OTC access might reduce the number of contraception methods available, and whether there would be a minimum age requirement. Some of these concerns are already being tackled at the state level, and some have passed laws allowing pharmacists to prescribe birth control after inexpensive, noninvasive exams.
Regardless of the immediate policy effect, the public attention to calls to “free the pill” suggests a renewed energy for over-the-counter advocacy and perhaps new directions for discussion of access.
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Rachel VanSickle-Ward is a professor of political studies at Pitzer College, where she specializes in public policy and gender and politics, and the co-author of “The Politics of the Pill: Gender, Framing and Policymaking in the Battle over Birth Control” (Oxford University Press, forthcoming).
Kevin Wallsten is a professor of political science at California State University at Long Beach, where he specializes in political behavior and public opinion, and the co-author of “The Politics of the Pill: Gender, Framing and Policymaking in the Battle over Birth Control” (Oxford University Press, forthcoming).