An advisory panel at the Food and Drug Administration this month unanimously recommended that a contraceptive pill, Opill, be made available over the counter. The F.D.A. will decide this summer whether to follow this recommendation — if it does, the United States will join over 100 other countries that have already approved oral contraceptives for use without a prescription.
This development, which health experts widely agree could greatly affect public health for a nation in which nearly half of all pregnancies are unintended, comes three decades later than many people once expected.
At a 1992 conference on birth control, an official on the F.D.A.’s fertility and maternal health drugs advisory committee, Philip Corfman, noted that the birth control pill is safer than aspirin, which is available over the counter. The F.D.A. subsequently announced plans to convene a hearing to consider moving oral contraceptives over-the-counter. It was believed that this would greatly expand access to birth control by bypassing doctors, to whom millions of Americans then — as still now — had little access. But, as the historian Heather Munro Prescott has recounted, the hearing was canceled at least partly because of criticism from what might seem a surprising cohort: the nation’s leading feminist patient advocacy organizations.
Dr. Prescott reported that the program director of the National Women’s Health Network at the time, Cindy Pearson, said that a “birth control prescription is the poor woman’s ticket to health care.” Advocates for women’s health were concerned that if birth control were made available over the counter, then insurance might stop paying for it and impose new financial barriers to access.
It was also argued that if birth control prescriptions were removed as an incentive for women to make regular doctors’ appointments and for insurance companies to pay for these appointments, health care exclusion might deepen. And if women were not seeing doctors, then they might be less informed about potential side effects of birth control pills, putting them at possibly elevated risk.
All of these reasonable concerns stemmed from America’s private health care industry, minimally regulated health insurance markets and the absence of adequate community-based preventive services and health education. This left the public overly reliant on professional medical care — despite the fact that there were not nearly enough doctors and nurses to meet the nation’s health needs. Facing those realities, activists sought to do the best they could to protect women’s health under less than ideal conditions, even if that meant normalizing doctors’ paternalistic authority and involvement in aspects of women’s lives that did not in fact require expert medical supervision.
In our current era in which reproductive and transgender rights are under concerted attack by those who see electoral advantages in fomenting moral panics, Americans are reaping the consequences of such compromises made over decades of incremental health care reform. By delaying confrontation with the for-profit medical monopolization of care, a historically conservative medical field has accrued outsize cultural and policy power over Americans’ lives.
It is an open secret that much of the present role of U.S. physicians, of whom we have a substantial shortage, does not in fact need to be performed by medical doctors.
As practicing doctors, my colleagues and I find our clinical workdays shaped by myriad tasks that remain under our purview not for reasons of effective care delivery but because of longstanding lobbying efforts to maximize doctors’ market share and political influence. The American Medical Association, for example, has made opposition to “scope creep” one of its priorities. Under a thin guise of protecting patient safety, this has consisted of aggressive lobbying to prevent nurses, physician assistants, pharmacists and others — such as community health workers and other lay caregivers — from gaining legal or billing authority to provide services that might compete with doctors’ political power and revenue goals. In large part because of the medical field’s control over reimbursement, non-physician and nonprofessional care systems and their workers have been chronically underutilized and underpaid.
Our resulting top-heavy, doctor-centric health care industry is a major driver of the abysmal population-level outcomes of the American health system. U.S. policy has consistently prioritized reactive medical treatment rather than investments in public health systems oriented toward services for prevention, safety and social support. Public health spending now accounts for less than 3 percent of U.S. health spending according to a 2016 projection, even as it has been shown to yield savings ranging from $67 to $88 per each dollar invested.
Doctors and medical institutions have had vested interests in producing this reality: Nearly one-fifth of the nation’s gross domestic product goes toward health care spending. The United States spends almost twice as much on health care, as a percentage of its economy, as other advanced industrialized countries. That spending is set to increase by 58 percent, to $6.8 trillion, by 2030. And for all this, about 28 million Americans remain uninsured and U.S. life expectancy continues to decline while already being far worse than that in most other wealthy countries.
Medicine is an essential public good. But when it allows itself to be made a tool of health capitalism in which profit rather than care orients its scope of practice and power, it grows like a cancer. As the philosopher and social critic Ivan Illich observed, without limits, medicine itself becomes a cause of our disease.
The question of whether the F.D.A. will approve birth control for over-the-counter sale presents a microcosm of the structural perversity of U.S. health care. Moving to over-the-counter oral contraception — which should come without age restriction and without cost to those who want it — is an obviously needed change to improve population-level health and protect the right to bodily self-determination. (Even the A.M.A. endorses the change and has joined patient advocates in calling for full insurance coverage of over-the-counter birth control and no age restrictions on access.) So, too, is ensuring cost-free access to medication abortion without unnecessary mediation by physicians and protecting legal rights to gender-affirming care.
But, alongside reconsidering physicians’ current prescribing power and whether it in fact best serves public health, we also need to stop taking for granted that physicians should be the primary people upon whom we rely for our health. Essential preventive care, such as vaccinations, referrals for screening exams like colonoscopies and mammograms, diabetes education, basic mental health assessments and support, and nutrition and exercise counseling, for example, can all be more effectively provided by community health workers with basic training.
To improve both reproductive health and U.S. health systems writ large, we need to reverse their capture by the health care industry. Restoring the industry to a more circumscribed role by investing in public health systems for community-based care is essential for making it more effective, efficient and trustworthy — not only to benefit patients but also to build a functional health system in which currently disillusioned physicians and nurses can once again believe in the value of our work.
Eric Reinhart (@_Eric_Reinhart) is a political anthropologist, psychoanalyst and physician at Northwestern University.
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