Nearly five years ago, the nation’s leading group of obstetricians and gynecologists issued a policy statement saying the time had come for oral contraception to be available without a prescription.

We wrote about it and everything.

In the intervening years, some states have changed their laws. California authorized pharmacists to distribute most types of hormonal birth control. Oregon passed a similar law covering both pills and patches.

But neither law changed the status of birth control pills from prescription to over-the-counter. Only the Food and Drug Administration can do that. And in Oregon’s case, the law does not apply to people of all ages. People under 18 are still required to get their first contraceptive prescription from a doctor.

But researchers say there is no evidence that adolescents are at greater risk from birth control pills than adult women.

A review of oral contraceptive research presents the most comprehensive evidence yet that, as the authors state, “There is no scientific rationale for limiting access to a future over-the-counter oral contraceptive product by age.”

“There is a growing body of evidence that the safety risks are low and benefits are large,” says Krishna Upadhya, an assistant professor of pediatrics at the Johns Hopkins University School of Medicine and the lead author of the review, which was published this week in the Journal of Adolescent Health.

In fact, she says, some of the potential negative side effects of oral contraception are less likely in younger people. For example, birth control pills that contain both estrogen and progestin come with an increased risk of a type of blood clot called a venous thromboembolism, but that risk is lower in teenagers than in older women.

As a result, the pill is “potentially safer the younger you are,” says Upadhya.

The review also found no evidence that increased access to birth control would lead teenagers to have more sex or engage in riskier sex, a concern voiced by some critics of oral contraception access.

Teen pregnancy rates are way down in the U.S., and teenagers are using contraceptives more often. Between 2007 and 2013, the number of 15 to 19-year-olds giving birth dropped 36 percent. The abortion rate has also fallen.

“These pills are safe and effective and we should reduce barriers to using them. And teens should benefit just as adult women do,” Upadhya says.

One reason more girls and women are using birth control is that the Affordable Care Act requires insurers to fully cover prescribed contraception. That includes the pill, implanted hormonal birth control and intrauterine devices.

So what would happen if oral contraception no longer required a prescription? The Affordable Care Act does not require insurance companies to cover over-the-counter birth control like condoms, sponges and spermicide. If hormonal birth control was available over the counter, it too would fall outside the law’s coverage mandate.

Sen. Patty Murray, D-Wash., introduced a bill in 2015 that would automatically amend the language of the ACA to require insurance companies to pay for any contraceptive approved for over-the-counter sale by the FDA. Sen. Kelly Ayotte, R-N.H., introduced a separate bill that proposed giving priority to any request from a birth control manufacturer asking the FDA to consider over-the-counter status for its drug, as long as it only applied to women over 18. Neither bill has made it out of committee.

The current Republican proposal to repeal part of the ACA would not affect mandatory coverage for prescription contraceptives, as we have reported.

The American College of Obstetricians and Gynecologists has issued multiple statements in the past year stressing that, while the group still supports making oral contraception available without a prescription to teens as well as adults, such a change is not enough on its own for making birth control available to everyone who needs it.

“Over-the-counter contraception is not an acceptable substitute for the ACA contraceptive coverage mandate,” the group wrote in a statement issued in February.

Of course, there is currently no version of the pill has been approved by the FDA for use without a prescription.

An FDA spokesperson said the agency “generally cannot confirm or deny the existence of a pending product application,” so it is difficult to know whether any birth control manufacturers have requested that that their products be considered for over-the-counter status.

If a manufacturer did apply, the FDA would consider many of the same things Upadhya and her team looked at, including safety and efficacy data and potential age restrictions.

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When Democrats held a majority of the seats in the U.S. House of Representatives, and Rep. Nancy Pelosi was the House speaker, she helped pass the Affordable Care Act, also known as Obamacare.

Now, after more than six years in the minority party, she is watching House Republicans move to repeal and replace parts of the law.

She says that although Democrats don’t have the votes to stop the GOP legislation alone, they can still show their opposition to it.

“In my office I have a painting of Abraham Lincoln, who said, ‘Public sentiment is everything,’ ” Pelosi told NPR’s Robert Siegel. “Regardless of the number of Democrats in the House, the number of people who are affected, 24 million [people] who would lose their care, I’m depending on public opinion. … The fact is the more we point out the shortcomings of the legislation, the fewer votes [Republicans] will have.”

The interview below has been edited for length and clarity.

Interview Highlights

On the shortcomings of the Affordable Care Act

Let’s go back to where we were before the Affordable Care Act, because that was a time where [some people] wouldn’t even be able to have any insurance. So what was the purpose of the Affordable Care Act? [It was] threefold. One, to lower cost. Two, to improve benefits. And three, to expand access for millions more people. And it’s done all three. …

Look, there hasn’t been a bill ever passed of this magnitude, whether it was Social Security, Medicare, Medicaid, voting rights, civil rights bill, that was not revisited. Some of the improvements we [could] have [had] in the Affordable Care Act were there, but the Republicans prevented them from happening. So you can be a self-fulfilling prophecy and say, “I’m gonna make sure this doesn’t work now. Now see, it didn’t work.”

On whether the Democrats could work with President Trump or House Speaker Paul Ryan on health care legislation

We have a responsibility to the American people to find as much common ground as we can. There has to be sincerity, though. … I don’t think he has the faintest idea — the president — about the health care thing.

[But Rep. Paul] Ryan … is [a] philosophical, right-wing, anti-government [person], and so an act of mercy for him is to reduce the government’s role. So we’re talking about two different things. They’re debating whether it’s “Trumpcare” or “Ryancare,” but neither of them wants it identified with themselves because it’s such a failure in the public mind.

On Trump’s knowledge of health care

The more the president might learn about [health care], then he might see where there’s a path [to working with Democrats], because to tell you the truth, the Affordable Care Act is a private sector initiative. It contains many Republican ideas.

Understand this about Republicans, and then you’ll understand part of what our challenge is here: They always are gearing whatever they do to benefit the high end. This is the biggest transfer of wealth in the history of our country, in terms of hundreds of billions of dollars going into the pockets of the top 1 percent of the people in our country, at the expense of the good health of our middle class and those who aspire to the middle class.

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The proposed American Health Care Act targets the health provider Planned Parenthood with a set of proposed limits on Medicaid payments to the organization.

Monday, the nonpartisan Congressional Budget Office confirmed the magnitude of those limits. The Republican plan would block $178 million in Medicaid reimbursements to Planned Parenthood in 2017.

“The vast majority of our patients are on some kind of federal program,” Cecile Richards, president of Planned Parenthood, told NPR’s Ari Shapiro on Tuesday.

In all, she said, about 1.6 million patients receive health care from the organization each year through federal programs such as Medicaid, totaling upwards of $400 million in annual federal reimbursements.

“Planned Parenthood operates just like every other health care provider in this country that provides abortion services. We get reimbursed for preventive care,” she explained.

“I guess if you want to reduce unintended pregnancy and the need for abortion, the last thing you should do is try to deny women the access to family planning,” Richards said.

Tom Glessner, the president of the National Institute of Family and Life Advocates, which lobbies against abortion, is optimistic about the projected savings for the federal government.

“On the positive side, taxpayers benefit from this provision,” he told NPR.
“Taxpayers would spend $156 million less, over a decade, by defunding Planned Parenthood, even if women used more Medicaid dollars during their pregnancies.”

Glessner was referring to the increase in births the CBO projects if Medicaid patients are cut off from Planned Parenthood. The costs associated with about 45 percent of all births in the U.S. are paid for by the Medicaid program.

“In the one-year period in which federal funds for Planned Parenthood would be prohibited under the legislation, the number of births in the Medicaid program would increase by several thousand, increasing direct spending for Medicaid by $21 million in 2017,” the CBO report notes.

The Republican plan technically cuts off funding to Planned Parenthood for only one year. If the organization stops providing abortions, it will be eligible for Medicaid reimbursements again. But Richards said there is no chance that will happen.

“We provide full reproductive health care for people in this country,” she said. “And even though abortions may make up a small portion of what we do, women and families and young people come to Planned Parenthood because they count on us to be on their side, and to provide them with health care they need.”

Federal spending on abortions is already illegal, except in the case of pregnancies that are the result of rape or incest or that threaten the life of the mother, as NPR has reported.

Republican lawmakers and some clinicians have said that if Planned Parenthood closes clinics, other health providers would try to take on those patients. But community health clinics say they are already overburdened.

The Republican plan currently calls for tens of billions of dollars for states to spend as they see fit, including on preventive care for women.

“How will the states use that money? They have great flexibility,” Douglas Holtz-Eakin, former director of the Congressional Budget Office and current president of the conservative think tank American Action Forum, told Ari on Tuesday.

“They can give it to insurers as reinsurance for expensive patients; they can give it directly to individuals to cover out-of-pocket costs; they can create a variety of other programs like high-risk pools for expensive patients.”

But Richards argued that spending would need to address a supply problem in rural or poor communities.

“The public health community has been abundantly clear that they cannot absorb the 2.5 million patients that Planned Parenthood sees each year,” she said. “And particularly for women who have found a lump in their breast or need birth control immediately, and maybe a community health center can see them in a month or two months, that’s not good enough.”

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