A 2013 law passed in California allows girls and women to access birth control at pharmacies, without first receiving a doctor’s prescription. And when the legislation was passed, some public health advocates argued that removing barriers to access would help reduce the rate of unintended pregnancy and encourage active family planning in underserved communities.

Pharmacy-Prescribed Birth Control Stumbles In California

But four years on, women in California have seen little change, according to a new study from the University of California at Berkeley. Published in the Journal of the American Medical Association, a paper led by Dr. Anu Manchikanti Gomez says that only 11% of eligible pharmacies in California currently offer pharmacist-prescribed birth control.

Pharmacist-Prescribed Birth Control Infographic

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To find that number, Gomez and her team posed as patients, calling 1,008 out of the State’s 5,291 community-based pharmacies. Only 1 in 10 of the pharmacies said it was offering birth control with a pharmacist’s prescription, without any substantial difference between rural and urban locations. “I think everyone kind of thought it would probably be higher than 10%,” Virginia Herold, executive officer at the California State Board of Pharmacy, told the Los Angeles Times.

The market just hasn’t responded to the law’s incentives as early supporters had hoped. In crafting the legislation, California lawmakers tried to encourage pharmacies to offer pharmacist-prescribed contraceptives, rather than force them to. No pharmacy is required to participate in the new program. Or perhaps the study was simply premature. Around 1 in 3 of the pharmacies that weren’t currently offering birth control said they had plans to do so in the future. And despite being passed in 2013, California’s law only went into effect last year.

Can Pharmacists Adequately Protect Patient Safety?

Patient safety is another concern. Before offering any contraceptive, pharmacists have to be trained, both to assess a patient’s health risks and provide effective counseling on contraceptive options. But the training required by law is only one hour long. Is that enough to make the best decisions for patients?

Some experts are worried. “A pharmacist cannot replace a physician,” says Deepjot Singh, MD, who heads the OB/GYN department at Torrance Memorial Medical Center. Speaking to the LA Times in April 2016, Singh said about half of her patients have to switch birth control methods within the first year, largely due to side effects. About 73% of physicians, according to recent poll, agreed with Singh’s judgment that pharmacists shouldn’t be able to prescribe contraceptives.

Financial Investment Leaves Pharmacies Cold

The real problem, however, is likely economic. While insurers in California are required to cover the cost of birth control under the Affordable Care Act, they don’t have to pay for the cost of training pharmacists or counseling patients on their options. So offering pharmacist-prescribed contraceptives might be too expensive for pharmacies to consider in the first place.

It can also be expensive for patients, since pharmacies are allowed to charge for the service. At Vons, a chain of supermarkets in Southern California, it costs $45 to consult with a pharmacist and receive a birth control prescription.In 2016, California’s legislature passed another law that forces Medi-Cal, the State’s health insurance program for low-income customers, to cover the contraceptive fees charged by pharmacists. Some health insurance experts, the LA Times reports, hope that private insurance companies will follow suit.

Walgreens, CVS Begin Pilot Programs

Other pharmacy chains are still trying to gauge consumer demand for the program. Walgreens and CVS are both rolling out limited pilot programs in major markets, like Los Angeles, to see whether or not their customers are interested. Increased visibility may help. As Soumya Karlamangla writes in the LA Times, “pharmacists don’t want to invest in providing the service if women don’t want it, but women aren’t aware it’s an option and aren’t asking for it because pharmacies aren’t offering it.”

And therein lies the rub, since there’s really no incentive for pharmacies to participate beyond increasing their sales. Without informed customers clamoring to make those sales, pharmacies might consider the program more trouble than it’s worth.

Four States Allow Pharmacist-Prescribed Contraceptives

California is now the fifth State to authorize community-based pharmacies to prescribe some form of birth control without a doctor’s prescription. Oregon, Colorado and New Mexico have similar programs, ScienceDaily reports. Select pharmacists in Washington State have been allowed to prescribe the “morning after” pill for several decades.

California’s law is far broader that previous State efforts. While Colorado and Oregon have only extended birth control access to women over the age of 18, California hasn’t instituted any age limit. And the State’s legislation also offers a wider range of contraceptive options. In California, pharmacists can prescribe birth control pills and patches, along with NuvaRing and even hormonal injections. Colorado and Oregon only cover pills and patches. No State program covers Essure, the contraceptive implant now banned or withdrawn in every country but the United States.