People in North Carolina no longer need a doctor’s prescription to get hormonal birth control. Under a new law passed last year that went into effect February 1, contraceptive pills and patches can be bought at local drugstores and community pharmacies — after a brief consultation with a pharmacist. 

But who that empowers — and who that leaves behind — remains to be seen.

North Carolina is now one of more than a dozen states to make contraception available over the counter, according to Elizabeth Nash, a state policy expert with the Guttmacher Institute. 

“There’s real potential in these bills, but the issue is in the details,” Nash said. “Who does this apply to? What methods does this apply to? Does insurance cover it? Are pharmacists getting the proper training? Do people know this is even an option?”

But the answers to her questions vary from state to state, with different implications for who can access and afford birth control. Nash said that the push for over-the-counter contraception medication had been growing for years and that the pandemic helped accelerate some efforts.

“Last year we saw laws from politically diverse states, from Delaware to Arizona to North Carolina. I think people are recognizing that pharmacies prescribing contraceptives is a real positive.”

The North Carolina bill’s primary sponsors did not respond to requests for comment before publication. When the bill overwhelmingly passed in August 2021, members of the Republican-led legislature said those living in rural areas and health care deserts would benefit the most. While access to doctors can be uneven in less densely populated areas, the majority of Americans live within five miles of a pharmacy, enabling a swift and comprehensive distribution of care. The pandemic only reinforced the effectiveness of a pharmacy-centered distribution model after the governor gave pharmacists the authority to administer COVID-19 vaccines. 

Other lawmakers spoke about the measure in the context of the fight over abortion access, pointing to contraception access as one preventive solution.  

State Sen. Jim Burgin, a Republican, told local news outlets he was in favor of the legislation: “Can we just all agree that an abortion is a bad outcome for everybody? What can we do to prevent people from ever having to make that decision? And so the best way to do that is to prevent an unplanned pregnancy.” 

Gail Murphy-Geiss, a sociology professor at Colorado College, said views like Burgin’s could be an indicator of policies to come elsewhere. “I know we’re seeing states talk about how they want to manage reproductive health in light of what may be coming,” Murphy-Geiss said, referring to the Supreme Court’s upcoming ruling on a challenge to Roe v. Wade, the landmark ruling that protected the right to an abortion. “There are some redder states, some bluer states and some purple states, like North Carolina. … It’s been proven that when people have access to birth control, there are lower abortion rates. This can be a space where we all agree.” 

While many reproductive justice advocates and experts applaud the move, some are concerned that birth control will remain unaffordable for those who need it most, particularly the young, the poor and the uninsured. 

More than 65 percent of women between the ages of 15 and 49 used a method of contraception, according to a 2019 survey conducted by the Centers for Disease Control and Prevention. Since the passage of the Affordable Care Act in 2010, insurance companies have been required to cover the cost of birth control. Insured women went from paying a 94 percent share to just 11 percent on average. But for those without insurance, the cost is often unaffordable, with annual out-of-pocket costs reaching up to $600. 

Carrie Baker, a women and gender studies professor at Smith College, said of the 17 states that have enacted similar laws, some include age restrictions, and only nine have explicit provisions requiring insurance companies to pay for over-the-counter birth control, regardless of whether the patient is covered.

“If insurance companies don’t cover the cost, low-income women — disproportionately women of color — will not benefit from the law,” Baker said. “Most women can’t afford $600 a year. The law almost becomes meaningless, except symbolically. It looks like it’s helping, but it’s not.” 

Elspeth Wilson, a government professor at Franklin and Marshall College, said these state policies will absolutely expand the reproductive choices of wealthier people but not those struggling to make ends meet. This has been the case for decades, she argued. 

“There’s always been this divide in our law that allows what I call a marketplace of reproduction,” said Wilson, who is currently writing a book on how policy that expands choices for some women often contracts opportunities for others. “From the Comstock Act in the 1870s, which prohibited the dissemination of birth control through the mail or across state lines, to the eugenics movement in the early 1900s — poor women have been ignored and left behind.” 

Some experts called into question the new law’s impact on equity and reproductive justice for a younger generation. 

Lori Brown, a sociology professor at Meredith College in Raleigh, N.C., said all women have a right to birth control and should not have to pay for it under any circumstances. As a North Carolina resident, Brown was excited to hear about the new law. However, when she read the legislation text and realized people might have to pay up to $50 a month for the pill when they could have gotten it for free through other means, she grew angry. 

“I teach at a women’s college, and when birth control was added to the ACA, students were stunned,” Brown said. “Many were paying $30 to $50 a month, but now we have a new generation of college women who’ve never not had this covered. … Poor and uninformed women might be tricked into paying for something they shouldn’t have to pay for. That’s not empowerment.”

Brown also said she was wary of a process that removed a doctor’s visit. 

“A lot of the women I work with wouldn’t take care of themselves and wouldn’t go to a doctor unless they needed birth control,” Brown said. “I love my pharmacist, but he’s not going into a back room with me or checking my weight and blood pressure.”

Murphy-Geiss said the United States could benefit from leaning more on pharmacists as medical professionals and not just drug dispensers. In France, for example, people tend to go to their pharmacists as a first stop and without an appointment to relay symptoms and receive treatment recommendations. And more than 100 countries around the world currently provide oral contraception without a prescription.

“In the U.S., it can be days or weeks before you can see a doctor,” Murphy-Geiss said. “I would hope there would be better access to birth control.” 

Access is only as good as knowledge. Nash, who lives in Washington, D.C., said she lives in an area where pharmacists can already prescribe birth control, but there is not enough effort to educate people or raise awareness — which is a major barrier to access. When visiting local drugstores, she said: “I don’t see any signs that this service is available. I’m ‘in the know,’ but I’m not sure if other people know.”