It's been more than 18 months since California's governor signed a law allowing pharmacists to distribute birth control without a prescription.
Now, legally, women can simply walk into their local pharmacy and pick up contraceptive pills, the patch or the ring -- much like getting a flu shot or buying over-the-counter medication.
But good luck finding a pharmacy that will actually do it.
Calls to eight pharmacies around the Bay Area, including both large corporate locations and smaller independent stores, yielded no pharmacies delivering these services. Most pharmacists said they still needed to undergo the state-mandated training and that their stores were in the process of figuring out what the service would look like.
There's confusion, too. One person told me that the law hadn’t yet passed; another told me prescription-free birth control was only an option in Oregon, where a similar bill went into effect on Jan. 1.
Pharmacy giants Walgreens and Rite Aid both confirmed that they are not yet providing birth control without a prescription.
Jim Graham, a spokesman for Walgreens, which operates 629 pharmacies in California, said the company is “currently assessing” the law’s requirements. "We plan to test the service in a small number of pharmacies," he said.
CVS said it is testing the service at a few select locations in the Los Angeles area to determine customer demand.
It’s hard to pin down exactly how many -- or few -- pharmacies have implemented the new law, because there is no database of pharmacists trained to distribute birth control without a prescription.
Sally Rafie, a professor at the UC San Diego School of Pharmacy, specializes in birth control training and access. She estimates that of the approximately 7,000 pharmacies in California, fewer than 100 are actually distributing non-prescription birth control to customers.
Rafie has been involved in training pharmacists to comply with the new law. Under protocol developed by the state Board of Pharmacy, pharmacists first have to be trained to do a short consultation with the customer and select the appropriate birth control option, as well as identify potential health red flags. Online courses are also available. Students in pharmacy programs in California since the law passed receive this training in their classes.
At the California Pharmacists Association's annual meeting two weeks ago, Rafie says, 150 people took the birth control training workshop. There are 29,000 registered pharmacists in the state.
Big players, like Rite Aid, Walgreens and CVS, have companywide processes that have to be standardized across all the stores, said Lisa Kroon, a professor at UC San Francisco’s school of pharmacy who has been involved in the implementation of the law.
"There's just a lot of hoops that a large corporation has to implement," she said. She speaks from experience. The Walgreens where Kroon oversees pharmacy students on the UCSF campus has yet to implement the law.
Kroon says she is "really pushing" Walgreens to move the process along.
Stumbling blocks include: Who will answer incoming doctors' phone calls while the pharmacist provides the consultation, or where will the consultation happen? Rafie said that in the community pharmacy where she works in San Diego, a private consultation room has to be designed and remodeled.
All of this takes time, but there are other factors in play.
Although the law finally went into effect on April 8, the state spent the previous 18 months developing regulations. Those were finalized earlier this year. Pharmacies had all that time to prepare to hit the ground running last month.
"I think that they're being cautious," said Virginia Herold, head of the state Board of Pharmacy. "They don't know what demand is going to be, and they're a little hesitant to ramp up."
Complying with the law is optional, not mandatory, and there’s no reason for pharmacies to opt in if there isn’t an incentive for them to do so. And right now, there’s actually a financial incentive for them not to.
"They have the authority to furnish birth control, but it didn't come with the requirement that they get paid for these services," said Kroon.
If you go to a gynecologist for a regular appointment or consultation, your insurance pays for the service (in addition to paying for the medication itself). But, right now, most insurance providers won't pay your pharmacist for the consultation. Customers would either have to pay out of their own pocket or the pharmacist has to work for free. In Oregon, the state's Medicaid pays $35 for the service. Kroon says there are efforts toward a similar law in California.
The bill to allow non-prescription birth control was put forward by Sen. Ed Hernandez, D-West Covina, and sponsored by the California Pharmacists Association as part of a larger effort to put more primary care in the hands of pharmacists and other non-physician providers.
"Pharmacists are accessible, and they're underutilized," said Herold.
Concerns have been raised, though, that by allowing women to bypass a visit to their doctor, they're less likely to get screened for cervical cancer or STDs.
Studies of women living near the border of Texas and Mexico found that women who obtained their birth control over the counter in Mexican pharmacies are less likely to go to the doctor for other preventive care, compared to women who got contraception at clinics. But women who had to go to the clinic were also more likely to stop using birth control, in part because of having to schedule a doctor’s visit to get it.
The potential for controversy may be part of what has slowed adoption at some pharmacies. And, certainly, said Rafie, it will require different marketing than flu vaccines or other services offered by pharmacists. Once it's clear that women want the service, though, she, Kroon and Herold all believe that pharmacies will eventually get on board.
"By the end of the year, this will be very commonplace in California," said Herold.
This post has been updated.