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HARTFORD – A Republican proposal giving pharmacists the ability to provide birth control without a doctor’s prescription prompted a number of concerns from Democratic and Republican senators during a hearing on Monday. Similar laws have been passed in more than 20 states and have the approval of the American College of Obstetricians and Gynecologists.
State Sen. Ryan Fazio, R-Greenwich, one of the legislators introducing the bill, said that being able to obtain contraceptives from a pharmacist would help women who can’t get an appointment with a doctor or who have trouble finding a physician who will accept Medicaid. Fazio cited a study in the Journal of American Medical Association that found that the majority of women who obtained contraceptives directly from pharmacies in other states tended to be young, poor and lacked insurance.
“In the real world it is not always easy, affordable or desirable to get an appointment with a physician. Giving women a choice to either use their physicians or pharmacist to get a prescription will improve outcomes for many who find it easier or better to avail themselves of the latter option,” said Fazio.
But several state legislators — including State Sen. Saud Anwar, D-South Windsor and State Sen. Jeff Gordon, R-Woodstock – both medical doctors — said that hormonal contraceptives can pose health risks and expressed concern about what would happen if they were prescribed without consultation with a physician.
“I’m not opposed outright, per se to the bill,” said Gordon. “I just want to understand the logistics as it comes to actual patient care.”
Anwar, a pulmonologist who chairs the Public Health Committee, said that contraceptives can have serious side effects for people with certain preexisting health conditions. He asked during the hearing whether this legislation would force pharmacists to carry additional malpractice insurance as a result.
“When I see oral contraceptives going wrong, they cause deep vein thrombosis and pulmonary emboli, and sometimes you find a young person dead,” said Anwar.
A month ago, Anwar expressed support for a proposal from the Senate Democratic leaders that included increased access to hormonal implants and IUDs, as well as allowing over-the-counter contraceptive care provided by a pharmacist.
Reached by phone on Tuesday, Anwar told CT Examiner that he agrees that there needs to be greater access to contraceptives for women, but that he wants to make sure that having pharmacists provide the contraceptives does not become a band-aid solution that allows the state to avoid addressing what he sees as the underlying problem — access to healthcare in general.
“Everybody uses the excuse that we don’t have enough physicians in the state. Rather than figuring out a way to fix the number of physicians, we find shortcuts and bypasses … based on immediate needs,” said Anwar. “Access to health control or birth control is part of the symptom of not getting access to healthcare.”
Anwar said that there also needed to be a system in place so that doctors were made aware when a pharmacist prescribes the medication.
“If Jane is going to get oral contraceptives, how will Jane’s primary care physician know about it? How is the pharmacy going to communicate with them?” said Anwar. “Are we going to create a disjointed healthcare system where everybody’s getting treatments in different places and there’s no central place for coordination of that?”
The bill also drew opposition from the Connecticut Chapter of the American College of Physicians.
“Increasing access to a drug is not the same thing as increasing access to high quality health care,” Ben Cherry, a doctor at the Yale School of Medicine and co-chair of the chapter’s health and public policy committee, told legislators. “The argument about access, while well-meaning, would not have the intended effect of increasing patients’ ability of getting good counseling and good healthcare information from their physicians, which allows them to really have more autonomy.”
Cherry said that the increasing use of oral contraceptive pills that was occuring in states that have allowed pharmacists to prescribe these drugs could also reflect decreasing use of other contraceptives, like IUDs, which pose less risk of blood clots.
“They can have an IUD placed in the office, removed in the office, it gives them control over their reproductive health, it gives them autonomy, and they are making a decision that is more effective, and safer,” he said.
State Sen. Heather Somers, R-Groton, who introduced the bill with Fazio, emphasized that the bill was not meant to stand in for seeing a doctor.
“This is not in any way shape or form to replace a primary care physician or to replace a gynecologist. This is an added measure of access for a product that has been on the market for 61 years and is found to be very safe and very effective,” said Somers.
Somers said she believed there was an “unnecessary fear” around this proposal. She noted that pharmacists are trained, they are able to electronically share information with primary care physicians and they are able to perform risk assessments. She also pointed out that this was something that was already approved in other countries.
“If you go to France, or Germany, you can just buy your birth control pills over the counter,” said Somers.
State Rep. Tracy Marra, R-Darien, a pharmacist, also spoke in support of the bill, but said that pharmacists should be able to opt in to the service rather than be required to provide birth control without a doctor’s prescription.
“I do believe that with proper training, pharmacists can take on this responsibility,” said Marra.
Nathan Tinker, CEO of the Connecticut Pharmacists Association, told the Public Health committee that there are already protocols available for pharmacists who offer birth control, including a screening tool similar to a pre-immunization questionnaire. He said that when patients report a condition that could make it risky for them to take contraceptives — like high blood pressure — the pharmacist would refer them instead to a doctor.
In his written testimony, Tinker cited a study done in California showing that about three-quarters of women who obtained contraceptives directly from pharmacists did so “because it would be faster than waiting for a doctor’s appointment,” and that one-quarter didn’t have a regular doctor.
Anwar said that he was concerned that having pharmacists take the time to prescribe contraceptives could exacerbate the already long wait times at pharmacies. But Tinker said he didn’t see that as a reason that they shouldn’t prescribe contraceptives — particularly since a patient could have to wait months to see a doctor.
“The idea that just because pharmacies are busy places is a reason to restrict access seems illogical to me,” said Tinker.
According to Tinker, 24 states and the District of Columbia have already passed legislation allowing pharmacists to provide hormonal birth control directly.
Gretchen Raffa, vice president of public policy, advocacy, and organizing at Planned Parenthood Votes Connecticut said that Planned Parenthood supported both selling emergency contraceptives in vending machines – another bill being considered in the legislature — and allowing pharmacists to prescribe contraceptives.
“Allowing pharmacists to prescribe hormonal birth control will provide more options for people seeking contraceptive care. This would be an intermediate step to increase access to contraception; however, over-the-counter access to hormonal contraception should be the ultimate goal,” said Raffa.
The federal Food and Drug Administration has not yet approved hormonal contraceptives for over-the-counter purchases — as of now, a person has to have a prescription or consult with a pharmacist before buying the pills.
Raffa told the legislators that while it would be ideal for people to see their primary care physicians, the healthcare shortages in the state meant that this wasn’t realistic.
“Ideally we want everyone to be able to access contraception, and the most important thing is that people have timely access to contraceptive care,” she said.
Age limits and small pharmacies
Other representatives asked about whether the bill set a minimum age for obtaining the contraceptives. Currently, the bill does not have an age limit, but Fazio said he would be open to that conversation, and that he could see both sides of the argument.
State Rep. Michelle Cook, D-Torrington, said she feared the legislation could disadvantage smaller pharmacies. Cook said the small, independent pharmacists in her region were not thrilled with the idea of offering contraceptives directly.
“They are overloaded … and they feel that this is just one more thing that will put them in a situation where they will be held responsible — and God forbid something goes wrong – extremely liable,” said Cook.
Fazio said he had spoken to independent pharmacies in the southwestern area of the state, and that they seemed supportive of the legislation.
Cook said she was worried that if a small pharmacy decided it did not want to provide contraceptives, it would increase the risk of being pushed out of the market by the large chain pharmacies. She also said she believed contraceptives should be taken only after speaking with a doctor.
“It is not as simple as ‘press a button and this is the medication that I want to take for reproductive protections,’” said Cook.
Anwar said he hoped to have a bill drafted this session that would include what he saw as the necessary safeguards, including protecting people who are at risk for negative reactions, making sure that pharmacists and doctors are communicating and including provisions to connect people who seek out oral contraceptives at a pharmacy with the healthcare system.
“We start to ask the broader question — why is it that all the physicians are leaving? Why is it that the healthcare system, women’s health is being lost? Why is it that OBGYNs are saying that the cost of staying in the state of Connecticut is more, and therefore we are moving our future to other parts of the country,” Anwar said.
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This story has been updated with a quote from State Sen. Jeff Gordon