As Election Day nears in the US and talks around reproductive health care heat up, the Biden-Harris administration is announcing its plans for a rule that would increase access to birth control. This rule would require all insurance companies to cover all over-the-counter birth control at no extra cost, without the need for a prescription. Specifically, it applies to products like condoms and emergency contraception (also known as "Plan B") that don't necessarily require a doctor's visit but aren't covered by the Affordable Care Act.
The new rule, which isn't in effect yet, would prevent people from having to go to their doctor to get a prescription for reimbursement over something that doesn't medically require one.
It would also require plans to cover more variety in birth control methods that require a doctor's appointment, such as IUDs and most birth control pills on the market.
Birth control is covered for most people in some way under the ACA, which expanded to contraception in 2012, but existing loopholes mean some people may not get their preferred medication or will run into hiccups and extra costs if they need or want to switch for whatever reason. Also, while over-the-counter methods don't require a prescription and are theoretically easier to access, insurance companies may end up requiring a doctor's appointment or prescription anyway if people wish to be reimbursed. This could be especially true for newer birth control methods or devices, which reflect changing consumer demand but may also be more experimental in health insurers' eyes.
Isn't birth control already covered by insurance?
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The existing ACA has a specific requirement for birth control, requiring insurers to cover it as prescribed by a health care provider.
According to information from GoodRx, a popular medication discount site, about 15% of people had no out-of-pocket cost for their birth control pills prior to 2012, when the ACA's birth control rule went into effect. This is compared to about 77% of people paying zero out-of-pocket costs for the same birth control in 2024.
While most people should have some type of birth control coverage, insurers may not cover all types or brands of birth control, and people may be switched to a brand they don't like or have to settle for a different method. Under the proposed plan the Biden administration just announced, this loophole may be partly filled by requiring insurance companies to provide people with a "broader array of contraceptive drugs," which means people should have more choices in intrauterine devices or birth control pills. This is notable because IUDs and more permanent forms of birth control are considered the most effective at preventing pregnancy.
But the latest proposed rule takes aim mostly at "over-the-counter" birth control, which is intended to make the types you can pick up at a grocery store or drugstore free without doctor sign-off.
While coverage for it has varied, and how much someone will pay depends on the product or type of care, preventing pregnancy can largely be considered preventive medicine by insurers because, put simply, it's less expensive in the health care system than covering pregnancy and birth. One 2022 report from the Kaiser Family Foundation and Peterson Center on Health Care found that the average cost of pregnancy, birth and postpartum care was $18,865, and the average out-of-pocket payment was $2,854 for women enrolled in large group plans. A JAMA Network Open article from 2020 found that eliminating cost-sharing for contraception may decrease income-related differences in unintended birth rates, meaning people with lower income may have fewer unplanned pregnancies.
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What birth control would be free under the proposed rule?
OTC birth control includes the kinds you don't need a prescription for (such as the vast majority of hormonal birth control pills, which require a prescription) or those that don't require a medical procedure to get (like IUDs or the arm implant, which people go into a doctor's office or clinic to receive).
While it isn't in effect yet so we can't say for sure, this means the expanded birth control coverage should apply to products like condoms, sponges and spermicides, as well as newer hormone-free birth control devices, including the Natural Cycles app, which is the only app with FDA authorization to market itself as birth control, and Phexxi, which is a gel people administer like spermicide, but it contains different ingredients. Over-the-counter birth control also applies to Opill, the only hormonal birth control pill you can get in the US without a prescription, and most (not all) emergency contraceptive pills.
While these products don't have a prescription barrier, they may end up requiring a doctor's visit anyway if you want to get reimbursed, as health insurance companies may require sign-off from a doctor in order for a patient to get their money back. Making new, more specific requirements of insurance companies may make this process less burdensome.
The proposed rule comes after the FDA approved the very first over-the-counter birth control pill called Opill. However, the fact that Opill made it to over-the-counter, prescription-free status reflects a key difference between it and the type of birth control pill most people take. Basically, Opill is a progestin-only pill (or "mini-pill") that works primarily by thickening the cervical mucus to block sperm and thin the uterine lining. In contrast, the more popular "combination" birth control pill works fundamentally by stopping ovulation, keeping your eggs from leaving your ovaries.
Because estrogen-containing medications raise the risk of blood clots and similar health risks slightly, they require a prescription from a doctor. However, combination birth control pills are also considered more effective than progestin-only "mini" pills like Opill since it's extra crucial you take these at the same time every day in order for them to work.
Are there any types of birth control that cause abortion or end a pregnancy?
Put simply, no. Following the overturn of Roe v. Wade, which ended the constitutional right to an abortion and led to the restriction of pregnancy-related procedures and medical care in many US states, misinformation around emergency contraceptive pills like Plan B started to swirl. But emergency contraception won't end a pregnancy if one has already started developing in the uterus. That is because the large dose of synthetic progesterone in a Plan B pill (levonorgestrel) works by stopping or delaying ovulation in that given menstrual cycle; ovulation is necessary for fertilization and pregnancy to occur. Morning-after pills appear to not be effective if taken during or after ovulation.
If someone's concern is preventing the ability of a fertilized egg to implant successfully into the wall of the uterus, the only method of emergency contraception that appears to potentially work this way is if someone were to get an IUD placed within five days of having unprotected sex. (You can't get an IUD if you're already pregnant. It's also important to note that when used typically as birth control, all IUDs generally work by turning the reproductive tract into a temporarily hostile environment for sperm to live, seemingly preventing fertilization in most cases.)
The new rule proposed expanding access to over-the-counter contraception also wouldn't apply to emergency contraceptive pills that contain ulipristal acetate, such as Ella, since that requires a prescription. Morning-after pills that contain levonorgestrel are available at drugstores without a prescription and at online stores.