Red Tape Podcast, Episode 1 – You’re not as free as you think
Red Tape is the newest R Street podcast about the country’s biggest problems and the surprising ways that governments (and regular people) often get in the way of solving them. It was produced in partnership with Pod People. Listen wherever you find podcasts, including Apple Podcasts and Spotify, and learn more about the podcast here.
Episode description: How free are we really? In the first episode of Red Tape from R Street, hosts Kelli Pierce and Shoshana Weissmann pull back the curtain on some of the ways that the government is getting in the way of your day-to-day freedom. Host Kelli Pierce first speaks with Jill Snider, a retired New York City Police Officer and R Street’s Policy Director for Criminal Justice and Civil Liberties, who talks about the consequences of cash bail and the punishment it inflicts on those unable to pay.
Kelli also speaks with R Street’s Courtney Joslin about pharmacist-prescribed birth control as a way to improve access and reduce barriers to care. They discuss the significant ramifications birth control access can have on the lives and freedom of women across the country.
Episode breakdown:
(0:00:00) – Show and Host introduction with Kelli Pierce and Shoshana Weissmann
(0:04:45) – The Importance of Bail Reform with Jillian Snider
(0:24:05) – Birth Control and Barriers to Healthcare Access with Courtney Joslin
Episode transcript:
*Cold Open*
Kelli Pierce, Host:
Hey, Shosh. You want to hear about the time that I committed a felony?
Shoshana Weissmann, Co-Host:
Which one?
Kelli:
Yes, you do. Yes, you absolutely do.
Shoshana:
Yes, I do.
Kelli:
So a couple of years ago I moved from California to Utah. And I brought in a couple of boxes of wine. And at the time, that was a class B felony.
Shoshana:
Do you know why that’s a felony there?
Kelli:
So Utah has always had pretty strict laws around alcohol, but I suspect that it’s because they have state liquor stores. And they don’t exactly want the competition, right?
Shoshana:
And there’s not a ton of big areas in Utah that are close to state lines.
Kelli:
Yeah. And I think they changed the law because so many people were just breaking it. Right? So, then they reduced it. So it’s not a felony now.
Shoshana:
Yeah.
Kelli:
It’s a misdemeanor. So I was committing a felony, but had I done it today, it would just be a misdemeanor. Just a slap on the hand.
Shoshana:
And it’s crazy to think that something pretty benign, that I would have never thought of, can ruin your life like that.
Kelli:
Yeah. And to be honest with you, I got a speeding ticket also when I came into Utah. If the officer had found probable cause to search my car, I mean he could have arrested me. And I would’ve been screwed out of a job, apartment. I mean all for a crime I didn’t know I committed. And a crime, which is now, just a misdemeanor.
Shoshana:
You got off good. That could have been really bad.
Kelli:
I saw a story one time that we commit so many felonies or misdemeanors in a day. I mean, tons of them. And we have no idea.
Shoshana:
Isn’t it like the five in a day thing? Five felonies a day?
Kelli:
Actually, I think it’s three felonies a day. But who’s counting? And you know what? If you get caught doing that, your freedom can be taken away. Again for something that you had no idea you were doing.
*Theme Music In*
Shoshana:
Well, maybe this is why we named this podcast Red Tape. You know?
Kelli:
Yeah. Because definitely you do not have as much freedom as you think you do.
I’m Kelli Pierce, an award-winning journalist, and now I work on all things digital at R Street.
Shoshana:
I’m Shoshana Weissmann, Kelli’s boss, and I control Kelli and Head Digital Media. And I’m a fellow at R Street.
Kelli:
And this is Red Tape.
You don’t control me too much, Shoshana.
*Theme Music Out*
Shoshana:
So this is our first episode and we’ve both talked about R Street. Of course we know what it is, or at least we should. Because we work here. But for the people who are listening that don’t work here, how would you describe us, Kelli?
Kelli:
Yeah, well, we both work at R Street. And it’s a think tank in DC where we work on finding solutions to problems. Like how to get more clean energy, letting people work, how to quit cigarettes, voting, flood insurance.
Shoshana:
And we’re also the country’s foremost experts on tweeting SpongeBob memes at senators to help explain those solutions. And I love focusing it on the people and why we’re doing the policies, not just regulatory reform. But here’s why this stuff matters, and here’s who it affects. So what’s today’s episode all about and who are you speaking to today?
Kelli:
So today’s episode is all about freedom.
Shoshana:
So it’s about, you’re not as free as you think.
Kelli:
Exactly. Which as my little story at the top shows, had things gone another way, I might not be speaking to you today. I mean, one of the biggest ways we’re losing our freedom is by getting criminal justice reform all wrong. And there’s no better person to talk about why than Jillian Snider. She’s R Street’s Policy Director for Criminal Justice and Civil Liberties. She’s also a college professor and a retired New York City police officer.
Shoshana:
That’s pretty cool.
Kelli:
So we want to focus on cash bail. Why it’s not needed in most cases, and how it’s discriminatory. And something to keep in mind, most folks are not career criminals. But if you’re accused of something and you don’t have enough money to get out of jail, there could be devastating consequences.
Shoshana:
That’s exactly right. Who else are you speaking to at R Street? I feel like it’s a little hard to pair our justice reform with another topic that’s kind of tight like that.
Kelli:
Well, it sounds a little crazy, but freedom isn’t just about jails. Government can put you in a straight jacket in many ways. I’ll also be speaking with Courtney Joslin about why it’s so tough for many people to get birth control from your pharmacy.
Shoshana:
All right. I have some trouble connecting these issues in my head. I’m not sure I trust you on it.
Kelli:
You will. You will by the end of the episode, I swear. All right, here’s Jill Snider. Hey Jill.
Jillian Snider, Guest:
Hey can you guys hear me? Okay.
Kelli:
Yes, I can.
Jillian:
I had to have my husband set up the camera. And all the stuff that came, I was like, “I don’t know how to do any of this stuff.”
Kelli:
Well, no, you don’t have to be on camera. We can leave the camera off.
Jillian:
Thank you.
Kelli:
So, because you’re a former police officer, a retired police officer, I got to ask, what’s the stupidest thing you’ve ever arrested someone for?
Jillian:
One of the dumbest things that I’ve seen is, and we don’t do this anymore, thankfully. But about 15 years ago, we used to have to arrest people who were homeless living in cardboard boxes. And those cardboard boxes would be constructed on city streets, or under overpasses, or in alleyways. And if the individual that we encountered did not want to go to a hospital or a homeless shelter, we actually had to arrest them for a civil infraction in which their cardboard box was obstructing pedestrian traffic.
Kelli:
I have to ask, how would you have resolved that differently?
Jillian:
I think that has to start from within the social service system. It can’t ultimately be law enforcement’s job to monitor the homelessness because homelessness is not a crime. Most of these individuals are just trying to search for housing, or trying to search for jobs. And the last thing they need is encountering a law enforcement officer who’s going to criminalize their bad situation.
Kelli:
And that’s certainly a problem across the country. But it also plays into, there’s this misconception that cops are constantly, always looking to arrest someone for the most minor of infractions. But that doesn’t seem to be your experience with the NYPD.
Jillian:
No. And I think we would find this across the country. I do go out working in capacity with R Street. Also at John Jay College. I have a lot of engagement with law enforcement officers all over the nation. Both in metropolitan areas, and even your small rural sheriff’s agencies. And the large majority of officers really want to focus their efforts on eliminating the surge in violent crime we’ve been seeing over the last two years. They want to focus their scarce resources, because as you know, we’re seeing a mass exodus in retention. We’re having issues recruiting new officers. So we really have to use what we have to combat the bad crime. The crime that’s causing people to fear for their safety. Homicides, felony assaults, robberies, rapes, all of those numbers we’ve seen trickle upward in the last two, two and a half years. And although officers don’t want to engage in the lower level crimes, if it’s still on the books as illegal in their jurisdiction and in their state, their hands are somewhat tied.
Kelli:
Let’s talk more about that criminal justice reform angle. Because police officers, obviously, they’re not opposed to partnering with social service agencies. And like you said, having them address those issues. But criminal justice reform is one of those areas that, if we get it wrong, really curbs the freedom of both the person behind bars and the public at large it seems. And one of the biggest topics around criminal justice reform is bail reform right now. And we want to talk about sort of the right way and wrong way to do that. So in your opinion, when should we use cash bail and maybe when should we not use it?
Jillian:
So cash bail, in and of itself, is overall ineffective. Cash bail is criminalizing and punishing someone for their inability to pay. And we know right now that 60% of individuals who are remaining incarcerated in pretrial, which means they’re in local jails, pending adjudication of their case or disposition of what’s going to ultimately happen. They’re in just because they can’t pay cash bail. I have seen on several occasions working in New York City, obviously we house our offenders in Rikers Island. And I’ve seen people that, unfortunately, couldn’t afford something as small as $250 cash bail. And they were arrested for a low-level non-violent misdemeanor such as criminal possession of a controlled substance in the seventh degree. That’s a class A misdemeanor. It’s non-violent in nature. Generally, the person who’s accused of that crime suffers from a substance abuse issue. And that person could simply sit on Rikers. Luckily that’s not going on today.
This was something I did see a lot over the course of my career. So we have remedied it somewhat. But they would sit there for three, four months just because they couldn’t come up with $250. And guess what? The maximum under the law that that person would’ve gone to jail for, would’ve been one year. And in most times they would’ve gotten out in half that time. So they’re serving pretrial more time than they could have potentially served if convicted. My husband is a New York City police officer. He’s a detective. He investigates mostly violent crime, homicides, shootings, stabbings. And he’s been in situations where someone accused of a serious violent in nature crime, like a stabbing that led to the ultimate death of an individual. He’s seen that person, because they had the financial resources, they were able to get out on cash bail. And to me, that’s someone that probably did not deserve to get out onto the street, because they pose a serious risk to public safety.
But that’s just the way the system works right now. And we know that it’s not correct. It can’t just be based on a cash system. Cash, it doesn’t mean anything. Because you could front the cash, doesn’t mean you won’t go out and re-offend. The original premise for bail was to make sure that someone returned to court. So I have also at instances seen individuals, who were accused of very low level charges, who were released on their own recognizance. But they had 40 warrants for failure to appear in times past. So I think that should be a consideration as well. If you are not responsible enough to ensure you’re going to return to court, which is the reason that the judge let you out to begin with. Because you promised the court you’d return. Someone who’s failed to appear on 45 different occasions, to me they don’t seem very reliable and they’re coming back to court.
We really need to gauge the violence of the offender, the risk that they pose to society. And those are the cases that I think you were referring to earlier, where we have seen individuals who were out on either low cash bail or released on their own recognizance for violent crimes. Who subsequently went out there and committed even worse acts. So that’s what instills this fear. And that’s what also causes people to be hesitant when contemplating bail reform measures.
Kelli:
And I have to ask you, we talked about the craziest thing that you had to arrest somebody for. What’s the craziest thing you’ve seen someone forced to stay in jail for because they couldn’t come up with the bail money?
Jillian:
Most people that are arrested in New York City for any controlled substance possession, meaning they’re just your average user who suffers from addiction. They usually have very small quantity narcotics on them. But I have seen individuals with these types of charges against them. They’re impoverished, they suffer from mental health or substance abuse issues. They don’t sometimes have the ability to even contribute to their own defense. They don’t always understand the charges against them. And they could sit and languish on Rikers Island for months at a time. And, as of last year, they started doing away with that.
New York City took it to another level in that the district attorney did kind of create this list of what people would go to jail for versus what they would not go to jail for. So he did actively try and eliminate a huge population of people just sitting on Rikers, because they couldn’t pay. But I’d say that’s probably one of the charges that I’ve seen. And unfortunately, the reason behind that is because a lot of the individuals who are arrested for low-level substance abuse have so many arrests under their belt. And again, I contribute that to their substance abuse issues.
Kelli:
So obviously we’ve talked a lot about New York, but are there other states, localities? What’s the situation across the country when it comes to arresting people for just misdemeanors?
Jillian:
So states across the country vary in terms of prosecution of low-level misdemeanors. They vary a lot in terms of when they prosecute people for theft-related cases. We know that theft overall, petty larceny, grand larceny, in nature is a non-violent offense. But in small rural jurisdictions, particularly around the Midwest, you could get arrested for stealing something worth $10. You can go to your local drugstore and try and grab some toothpaste or mouthwash, or a toothbrush or deodorant. Something that you need, but you don’t have the money to pay for it. And you steal it. And unfortunately, the law enforcement officers there are still locking people up for that.
Kelli:
Now, we’re not condoning stealing. However, this cash bail system of allowing people to just sort of sit in jail for a year for a petty crime, that’s also a burden on the taxpayer.
Jillian:
Yes, it costs a lot of money to incarcerate someone. When we have people sitting in pretrial holding in their jails, the tax dollar pays not only for their shelter, their housing, their food, any resources that they may get. It also pays for the time of the officers working there. More importantly, and a lot of people fail to realize this, when an individual is held in custody, that person is now a medical burden of the city or state in which they’re being held. So I had a situation once, and it was a long time ago, but we had apprehended a suspect. He was alleged to have done something. It wasn’t super serious. It was something that he probably could have gotten released on his own recognizance. He had only one or two prior arrests.
But he was ordered in on bail, and he wound up getting a significant tooth infection while he was in. And ultimately he had to get every tooth extracted and he got brand new teeth. And he got it on the government’s dollar. He hadn’t even yet been convicted of a crime, he was still sitting in pretrial holding with, I don’t even know how much dental were cost these days. But tax dollars are what paid for all of this individual’s medical coverage. And again, he was still in the accused stage. He was sitting in pretrial detention. He had not been convicted. He had not pled guilty. But the government bears the burden of paying for this.
Kelli:
We’ve talked a lot about the downside of cash bail for certain crimes. Let’s talk about the benefits of getting rid of it for some offenses. Like how is getting rid of cash bail a better use of police time?
Jillian:
Well, cash bail is really up to the prosecutor’s office. It’s not necessarily up to law enforcement. So law enforcement’s job pretty much ends when we drop off a suspect or an inmate at that point, an alleged offender at central booking. Or at a local jail facility. And then it’s up to the prosecutor’s office, which again, that varies considerably state to state, jurisdiction and jurisdiction. Some states, like your larger metropolitan cities that are trying to reduce their incarcerated populations within their local jails. They are going to be more inclined to support no cash bail and extend the charges in which are eligible for release on their own recognizance. Again, not trying to always bring it back to New York, but that is the example that almost everyone in opposition to bail reform these days, that’s who they will point at and say, “This is not how to do it”.
Again, I don’t think we’ve had it in place long enough to say, “This is the complete wrong way.” But there’s a lot of things to be desired in the way it was implemented and other states around the country. The presumption again is to release a defendant, making sure that that defendant has a likelihood of returning to court. And that they are not posing a risk to the public. That should be the determining factor on whether or not someone has bail set on them or not. And I think what most people can agree upon is cash bail is very disparate in the way it’s given. Poor people who commit low-level offenses will linger in jail, whereas rich defendants who, maybe did something that’s felonious in nature, but they have the means to pay, they could be out on the street.
Kelli:
Does getting rid of cash bail actually make regular people safer? Because the thinking in the public at large, I think is, if we get rid of cash bail, there’s just going to be all these criminals on our streets. But criminal justice reform advocates say, “You know what? Giving people a little more freedom actually is better for public safety.”
Jillian:
This might be my nerd Criminological Theory’s professorness talking, but I teach this class at John Jay College. I teach why people commit offenses, and what contributes to further offense and recidivism. And interaction with the criminal justice system is one of the main ways in which we’re contributing to increased recidivism. So take for example, the war on drugs. And this is something that R Street has worked on substantially in the last year. We are of the mindset that the war on drugs was ineffective, it was costly. We spent billions and billions of dollars locking up people for small amounts of narcotics, particularly marijuana. That was the big focus of the 1970s, right? Everyone has to go to jail, everyone has to go to prison for marijuana. That did not deter crime. At all. Instead, we saw surges in the 80s of crime, and that was nationwide.
We saw violent crime rates increasing. We saw drug use increasing. And we saw market instability. We saw unemployment rates increase. But more importantly, the 1980s is what we look at from a criminology and a historical standpoint as, “Oh my God, what did we do?” And that was all pre-cursed on the war on drugs. And locking all of these individuals up did nothing beneficial, except fill prisons and give the government excuses to build more of them and hire more cops. But recidivism rates are really contributing now. And what we’re seeing is, when we do put someone through the system, whether it be they committed a crime and were convicted by a jury of their peers, or they pled guilty of their own accord or volition, we’re not giving them any opportunities when they come out to contribute to society. To be a regular person who wants to get a job, who wants to get an apartment, who wants to have a family, who wants to just be productive. We’re not giving them that now.
So bail, yes, the consideration of bail is really, really important. And I think right now, because bail is something that is considered before a person is found guilty. So you have to examine it through a lens of civil liberties. Are we encroaching or infringing upon someone’s rights by automatically just locking them up? They have not been found guilty, they have not pled guilty. We’re still trying to weigh the facts, and weigh the evidence, and make the determination of guilt or innocence. But yet they can be incarcerated for months and months because they can’t pay.
Kelli:
Wow. I got to ask my last question. What’s the roadmap on bail reform? Because I imagine while there are commonalities, every city and state has its own needs.
Jillian:
I always believe that crime should be handled at the local level. And obviously bail reform, it can’t always be held at a local level because ultimately state legislators are who are going to pass or not pass these new implementations. But we do see judges still having their discretionary power to consider, “Okay, does this person pose a flight risk? Do we think based on their criminal history or record that they will return to court? Do we think that letting them out is a threat to public safety? Or will it risk or endanger the lives of others?” Those are all things that people are starting to realize needs to be determined. It should not be, “Does this person have the ability to pay money?” Because that is not what we should be gauging our perception of public safety on. Does this person have money or not? And what we’ve found, and again, preliminary because we just started this research this year. Is, most people are like, “We don’t believe that it is fair or just to be locking people up just because they can’t afford to pay.”
We think that it should be based on, does this person pose a risk to society? Do we think this person is going to return to court and face their charges and maybe be held accountable if they’re found guilty? So I think that’s what we’re going to start seeing. More people are receptive to changing. We have known bail to be disparate in terms of the way it’s used racially and economically. Those that are of the black and brown community, those that are impoverished communities, they are most likely to be making up that 60% of individuals who are still in jail simply because they can’t pay bail. So more people are recognizing that, appreciating that, trying to urge changes to be made. But we want to make sure that we’re never threatening public safety in any of our reform measures.
Shoshana:
So Kelli, I think what stood out most to me is just that I didn’t really think about this this way before. But Jill was talking about how sometimes people are detained pretrial, when they’re assumed to be innocent. Before they’ve been convicted, everything like that. So they’re innocent until proven guilty. They’re detained longer pretrial than they would be if they were convicted.
Kelli:
I mean, just think about it. If you were accused of a crime and a judge said that you had to stay in jail because you couldn’t make the bail money. Whatever crime, think about it just in your mind.
Shoshana:
Yeah.
Kelli:
And you were innocent. You were going to be sitting there longer than your sentence would’ve been if you were guilty of that crime. That is so against the presumption of innocence.
Shoshana:
Oh, yeah. No, it totally violates that principle. So what stuff are we doing at R Street to help stop that?
Kelli:
Well, we’ve been going across the country convincing legislators to really rethink bail, of course. But also think about citing people for minor crimes rather than arresting them, which is something that’s pretty popular with police. Or have people who are convicted of crimes maybe do community service. Or put a time limit on how long they can be held in jails or prisons. And these are things that listeners can advocate for in their own communities as well.
*Theme Music In*
Shoshana:
So what’s up after Jill?
Kelli:
We’ve been talking about how the cash bail system can take away your freedom. So naturally we got to talk about birth control next.
Shoshana:
Oh yeah, yeah. Supernatural segue. But before we do that, let’s take a break. Red Tape from R street will be right back.
*Theme Music Out*
*Mid Roll*
*Music Sting In*
Welcome back to Red Tape. So Kelli, remind me why we’re talking about birth control in an episode that’s about freedom.
Kelli:
Shosh, they’re more connected than you think. In both the cash bail system and in birth control policy, in both cases, millions of Americans have less freedom in their daily lives because of bad laws and red tape.
Shoshana:
Oh, that’s cute. Getting the name of the podcast in there.
Kelli:
You know I’m good. But seriously, it’s a money issue too, which is important. Freedom in these areas means people get to choose their own path. They can travel, start businesses, find new jobs because we’ve given them the tools to decide and government gets out of the way.
Shoshana:
So whose Courtney Joslin and what does she do? Because I definitely have not worked with her for the past five years.
Kelli:
For those who don’t know, Courtney’s R Street’s resident fellow and Senior Manager for Competition Policy. But basically she studies why we should expand access to telehealth, and let pharmacists prescribe birth control. And there’s a lot of topics we get into and what Courtney’s about to tell us will probably surprise you. I mean, I thought I knew everything about birth control. But I had no idea why it’s so important for everyone to let women go to the pharmacy counter and get it. So here’s my conversation with Courtney Joslin.
So Courtney, you’ve obviously studied birth control, but before you came to R Street, what was sort of your experience with birth control growing up? Was that something that you talked about with your parents? Did you see your friends using it?
Courtney Joslin, Guest:
So I think I have a similar experience with birth control as a adolescent and teen, and young adults growing up in the South. Which was, it was a little bit taboo to talk about, not necessarily to use it. But we weren’t really given the tools necessary to understand contraceptive methods. How they worked, how effective each of the methods were. And also we weren’t tuned into what their use is, because it goes beyond just contraception. So I think we weren’t really fully exposed to how that could sort of play into our healthcare as young adults. And it was always interesting to me growing up like that. And then getting into, as we get older, sort of as society changes and birth control turns out to be one of the most morally acceptable products used for Americans in survey data time and time again.
And so it’s just become so part of our culture now, largely, that I’m glad it’s gone that way. But I have a feeling that my experience, and for a lot of people in states that are a little more restrictive on things to do with women’s healthcare, they probably also feel like they’re not getting the most accurate information on what contraception’s used for. How to use it properly. And sort of how that can help them.
Kelli:
I Think one thing that’s really important when we’re talking about birth control is like you said, it’s not just used to prevent pregnancy. So listen up fellas, and some ladies too. There are many reasons that women take birth control. And can you talk about some of those reasons?
Courtney:
Sure. So the birth control pill, I think is the most commonly known form of birth control. Most people are familiar with it. Many, many women have taken it. And about 14% of pill users use it primarily for a non-contraceptive reason. And for women who still use it as a contraceptive method, they have a secondary reason. So over half of users have a secondary reason. And these can be things from regulating your cycles, for menstrual pain and cramps, controlling symptoms from some really painful diseases like endometriosis is another one. And also acne regulation is another reason that, especially, young adults tend to use hormonal birth control.
Kelli:
Absolutely. And I remember when I went to my OB-GYN, she recommended birth control because there’s cancer prevention there. My general practitioner said the same thing. Now I’m not currently on it, but that was something they recommended to me because of that benefit. And so I think it’s really important to stress that. And it’s also important to stress that a lot of women use it, right?
Courtney:
Oh, yes. It is very widespread. If we’re talking about birth control in general. So any contraceptive method, virtually every woman of reproductive age has used some form of it in her life. When we’re talking about hormonal birth control. So that’s the pill, birth control patch, there’s a vaginal ring. And then there’s also an injection or sort of the more commonly known methods. As well as an intrauterine device or IUD. About 25% of women of reproductive age use hormonal birth control.
Kelli:
It’s also, I feel like, having that access to birth control is just good for women. Not only medically, but also for their freedom and economic mobility.
Courtney:
Yeah. So this is an interesting one that I think gets overlooked quite a bit. There is a wide array of research looking at the relationship between contraception, contraceptive access, and the effects that it has on a number of individual and societal outcomes. So some of the, I think, primary relationships that have really stood out to me in the academic research is that, contraceptive access is associated with things like lower divorce rates. It’s associated with higher family incomes. Women have higher educational attainment when they have access to contraception. There’s also a tendency for those who prevent pregnancy early on, are less likely to rely on government assistance in the future. Which is another really important one. There are also fewer high-risk pregnancies when contraception is available. So there are a lot of factors at play when you talk about contraceptive access and what that actually means for people, is that it goes far beyond just your ability to plan your family.
I think part of it is the fact that because it’s become so ingrained in daily life for women over time, it wasn’t super long ago that it wasn’t that accessible. I mean, the pill first was approved for use in the US in 1960. And so I think even generations that are still here today, remember a time when they didn’t have access to it. And seeing probably the difference in terms of family units and societal outcomes with contraception. We’ve become kind of accustomed to the benefits of it, because we’ve had it in our generation for quite some time. And so I think there’s a tendency to be very practical about it. To say, “We rely on this.”
A lot of women rely on this for planning for their families, their education, their careers, and their families as well. If you have young kids, you’re probably very keen on being able to plan for the rest of your family. And so it’s just become something that, I won’t say we take for granted, but it’s something that’s becomes such a net positive for us that I think everyone, regardless of political stripe, sort of sees that value. Because they know somebody who’s been on it at some point.
Kelli:
Yeah. And it’s definitely because we’re able to talk about things like that. Whereas back in the 60s, we didn’t talk about anything, right? But now we’re able to talk about it. However, there’s still some fault lines around birth control, and I’m wondering where those fault lines are really drawn. Is it just kind of employers versus employees? Or is there a government angle here trying to tip the scales in one direction or the other?
Courtney:
So, I think for people who have been interested in policy for at least some time, it’s hard to forget the employer and employee fights that happened during the Affordable Care Act when it came to contraception. And the mandate that it would be zero cost to a patient and that insurance would have to cover the full cost. So that was certainly, I think, a huge battle in DC that many people probably remember. But now, since that fight sort of died down, it’s less about what employers and employees fight over. And more about what’s come out of the medical community in the last 10 years looking at hormonal birth control and saying, “Hey, we actually might not need these prescription barriers that we have.” So currently to get a method of birth control, like the pill, you do have to get a prescription in the US. And this does kind of fly in the face of about a hundred countries in the world that do not require a prescription.
But you still require that. And the medical community has sort of come around to saying, “There’s a lot of research here and a lot of clinical data looking at the safety, the efficacy, women’s ability to self-screen, to where we might not need that.” And so now it’s become more looking at, what barriers is government putting up that aren’t necessarily related to insurance coverage? This is more about, what do you need to get a birth control regimen? Do you have to go to a doctor? Do you have to go regularly? What are the steps that we absolutely have to take? And what does the medical community consider to be safe and effective? And they’ve come back and kind of said, “We don’t need this guys, for a lot of these methods. Like for birth control pills, we might not need a doctor’s prescription.”
And so that’s kind of where the emergence in birth control access has come in the last few years. Has been looking more at how can we improve access to birth control by simply getting government out of the way. We’re not asking them to fund anything. We’re not asking them to create some new program. We’re saying, “These regulations you have in place might be out of date.”
Kelli:
One of the things that has come up as a solution for all the issues over birth control, is to make it available from a pharmacist, just like you said. And this is sometimes called over-the-counter birth control, but that’s not exactly accurate. So what are we talking about when we talk about more access to birth control? And how does that work?
Courtney:
Yeah, so I’m glad you pointed that out. So you may have seen state and local news over the past few years saying, “Iowa is considering over-the-counter birth control.” And that’s not exactly what’s happening. So to kind of walk through the differences here. You have pharmacist-prescribed birth control, which is something that about half of all states are now doing. Which essentially says, “We can’t make birth control over-the-counter, only the FDA and the federal government can do that. So what can we do in the meantime to lower the barriers?” And one of those has been, “Well, why don’t we let pharmacists give the same consultation that physicians do for birth control, just for birth control. And allow them to prescribe it directly to a patient in a pharmacy.” When R Street started this program, looking at how pharmacists prescribe birth control might be this deregulatory initiative.
Back in 2018, there were only a handful of states that had done this. And since then, it’s kind of taken off as a successful model for improving access. So over-the-counter birth control is something that only the FDA can do. They have to approve a drug manufacturer application for a birth control pill. And they say this is safe for over-the-counter status. And then it becomes over the counter. So states cannot do that, but they can change their regulations on who can prescribe birth control.
Kelli:
Oh, okay. So you would still be going to a pharmacist, you would still be getting a consultation from that pharmacist. They would be checking records to make sure that you don’t have any contraindications or anything like that. You can ask questions. So it’s sort of like a doctor’s visit, but just through a pharmacist?
Courtney:
Exactly. So in the states that allow this, pharmacists that want to prescribe birth control have to take a contraception-specific continuing education course. So they are trained specifically in contraception and prescribing it. And then what essentially happens is you walk into a pharmacy, if your state allows this. And you say, “Hey, I’d like a birth control consultation from a pharmacist, do you have someone on staff who does that?” If they do, they can provide a consultation. They do the same thing that’s required in a doctor’s office for birth control. Which is they do a blood pressure check. And then they ask you a set of questions that determines if you have any, what’s called, contraindications. So essentially, do you have any conditions that mean it’s not safe for you to take hormonal birth control?
And if you meet those standards and the list, I’ve looked through it myself, it’s pretty straightforward in terms of how to determine whether or not it’s safe. And then if it’s safe, the pharmacist can give you a prescription. If it’s not, they refer you back to a primary care provider. So in that case, no harm, no foul. The safety standards are still there. And it’s just sort of lowering the barriers for patients to get birth control.
Kelli:
Okay. So there is several benefits to me to getting your birth control from a pharmacist. But let’s start with the medical ones, one of which is you’re taking the load off of overburdened doctors.
Courtney:
Oh, absolutely. This is sort of a secondary effect I think that we’ve seen in allowing pharmacists to prescribe. Is, that most people are probably aware, but if not, there’s a primary care shortage in the US. And it’s only projected to get worse. And essentially what that means is that for the current population in the US, we do not have enough primary care doctors to go around. And I mean, we’ve seen the headlines since Covid, right? There’s physician burnout, there’s nurse burnout, they’re overworked. They have too many patients that they have to see. And most people, me included, have probably experienced calling a doctor to just be like, “Hey, I should probably get a checkup.” And they’re like, “Okay, well, our next appointment is in four months.” So offloading some of these lower level routine activities like prescribing birth control to a pharmacist, it takes that load off of the doctor. But then it also makes it a one-stop shop for a patient.
If they’re already headed to the pharmacy, then that makes it a lot easier to also get their birth control prescribed there. Not to mention that pharmacies are very widespread in the country. So we’ve done some research looking at rural areas in the US and looking at the distribution of pharmacies. And most communities have a pharmacy, if not multiple. That’s not the case for doctor’s offices. And so allowing that medical touchpoint in a pharmacy is going to increase access for those who don’t live in communities with easy access to doctors.
Kelli:
So a benefit of having the freedom to go to a pharmacist is actually getting the things that you want. And when you’re going to a pharmacist, if you think about your own pharmacist, they’re able to do more than just dispense medicine, right?
Courtney:
Absolutely. So if you think about it, pharmacists are literally medication experts. They understand the side effects and also things like the contraindications for taking certain medications. One thing that we’ve heard anecdotally that I’ve found really interesting is that, so consider somebody who has a primary care doctor. But then they might have a specialist or two. Let’s say they’ve had some health issues in the past, they have a specialist or two. Everybody who’s been to a doctor has had to fill out the form that says, “List the current medications you’re on”. How many people have probably forgotten one or two that they didn’t list, and gave that form to their doctor? And then the doctor’s going through and they may prescribe you something else. You’re picking up your other prescriptions at the pharmacy. We’ve heard anecdotally that pharmacists have said, “I’ve had patients come in with a new prescription and they’re picking it up while also getting prescription refills.”
And the pharmacist has had to say, “Are you taking these together?” And the patient would say, “Yeah.” And they’d say, “You absolutely should not be taking these together.” And then they call the primary care doctor, get a better plan put together. So pharmacists can also kind of catch these things because they are often seeing patients more than patients are seeing doctors. I mean, if you think about a perfectly healthy person going to the doctor once a year for a checkup, but maybe you have a couple of prescriptions. You’re probably seeing a pharmacist more often than once a year because you’re getting refills. And so they’re just an extra checkpoint with a highly trained medical professional, who’s able to help you walk through some of this.
Another thing that I have found really interesting in this is that, if you are better able to get to a pharmacist for birth control, and let’s say you’re prescribed a method and you decide that method doesn’t work for you. Maybe the side effects are too much. Would you rather wait another three months before you can get into a primary care doctor to switch that method? Or would you rather go to your pharmacy the next day and say, “Hey, this doesn’t work. I need something else.” So the ability to sort of choose what method works for you based on trial and error, is enhanced if you’re allowing pharmacists to also prescribe.
Kelli:
That is so important. And there’s not just the medical benefit, but there’s also sort of a benefit to government at large. Right? So how does state, local, even national governments, benefit from pharmacist-dispensed birth control?
Courtney:
So for pharmacist-prescribed birth control specifically, I’ll walk through an example. So Oregon was the first state to implement pharmacist-prescribed birth control. And they ran a retrospective look at what changes happened to the Medicaid population after they started allowing pharmacists to prescribe. So in the two years of allowing pharmacists to prescribe birth control, at first they found that there was an increase in birth control prescriptions written. And many of those were attributed to pharmacists. There was also a reduction in unintended pregnancies, a reduction in abortions. And it saved the state about $2 million in publicly funded healthcare costs. And that’s a pretty small number. Again, that was the first bit of implementation. It was the first state to do it. But if you look back at sort of the last big study that looked at what the state governments and federal governments spend on pregnancy-related healthcare cost. In 2010, which again is the latest data sort of looking at this nationally, state and federal governments spent a total of $21 billion on unintended pregnancy costs.
So if you look at how those unintended pregnancies could have been potentially avoided with better contraceptive access, you would’ve saved states and the federal government quite a bit of money that could have been diverted into something else. So there’s a huge cost savings component to this, particularly for public health insurance programs. But then you’re also seeing things like I mentioned earlier, which is it’s been shown that if you can avoid pregnancy, especially when you’re younger, you are less likely to rely on government assistance going forward. And so this is an individual effect that turns into a societal effect that states, and their bottom line should care about. I can’t think of a single state that has not had some sort of budget fight in the past few years, particularly as it relates to healthcare. So again, if you get them out of the way and allow pharmacists to prescribe, you might see a little bit of cost savings on the side.
Kelli:
And some things that people don’t always understand is that with pregnancy, there can be complications and there can be complications post-birth. And I’m someone who loves kids, I have a kid. But there is that side effect that people don’t always talk about, that pregnancy is not always smooth sailing. So that’s where that family planning aspect comes in. And greater access can help women not only be free, but also reduce the burden on the taxpayer.
Courtney:
Yeah, absolutely. The idea is not to enhance access so that people will have fewer children. The idea is that, so that they are better able to plan for their families when they feel ready. And space them out the way they want them to. Babies are a good thing, and the more that we can help women achieve a holistic sort of approach to feeling like they’ve reached milestones in their life beyond their family, that’s a good thing. What aspect of allowing people to choose for themselves doesn’t apply here? I don’t think Milton Friedman’s book Free to Choose was about birth control, but maybe there should be some sort of appendix that we add on now.
Kelli:
Absolutely. And that was so perfectly said, Courtney, about women’s choices and planning. And it just sort of encapsulates everything that we need to talk about, except for we got to talk about that culture war. And I’ll use one example. I used to work for a company owned by a church. And they did not pay for most birth control. And some of my coworkers would just have horrible stories about the negative health effects of reduced birth control access. Medically, I mean. But I also have to admit there were some who did not need birth control for let’s say strictly medical reasons. And wanted their employer to violate their principles and pay for it. I feel like getting birth control from a pharmacist solves any problems like these.
Courtney:
So potentially it could. Depending on the state, most states require insurance to cover pharmacist-prescribed birth control just because it does lower the cost. Otherwise, the pharmacist would have to charge fees for a consultation. But if we’re talking about purely over-the-counter birth control, which again, only the federal side of government can do. And which we advocate for very strongly here at R Street. If you’re building a market for over-the-counter birth control alternatives. So if the pill was available over-the-counter, that’s no longer necessarily going to be a fight with an employer. It’s not to say that employers wouldn’t be required to cover it in some cases, but if I have bad allergies because ’tis the season, I’m going to the pharmacy and picking it up over-the-counter. I’m not going to a doctor to get it prescribed and I’m paying for it out of pocket because it might cost me $10 to get allergy medicine. Versus going to a doctor where it might be free, but it’s not nearly as convenient.
And so if we’re building out a free market for hormonal birth control that is available on the shelves, then you’re going to see some of those fights kind of die down. Because there is no longer a fight over who is going to pay for this. Instead, it is government getting out of the way of birth control availability, which then should drive the cost down. We’ve also done a study recently looking at the potential cost implications of an over-the-counter birth control pill. And so if you build out that market, you will likely see prices fall to a point that consumers are more than happy to pay. Which is not currently the case. So it kind of seems like a no-brainer when you look at how we could get the government out of the way without increasing costs, potentially reducing costs to state budgets. And then also making it easier on women and their families.
Kelli:
So what is the blueprint going forward, in your opinion, so everyone wins.
Courtney:
So I think there are two steps going forward. The first is the states that do not allow pharmacists to prescribe birth control should start. They will probably see results similar to Oregon, which is going to be fewer unintended pregnancies, more birth control prescriptions and fewer costs to the state as a result. And then on top of that, we really need to get Congress moving on urging the FDA to make hormonal birth control available over-the-counter.
As I mentioned briefly earlier, about a hundred countries across the world do not have prescription requirements. We are in the slight minority on the prescription stuff. And so if the FDA were to facilitate building out an over-the-counter market for birth control, we’d see lower costs for birth control, more consumers would be able to get their hands on it without insurance. Because that is the other piece. There are those who are uninsured, that insurance coverage does nothing for. And so we’d just see lower costs, better access. And probably a reduction in the fights over it, because there wouldn’t be a government has to prop this up. It’s more getting birth control out of the hands of government essentially.
Shoshana:
Kelli, I really like this one. I feel like the interview got to a lot of different sides of the issue. Because it is a broader issue than people think at first.
Kelli:
Yeah, that was one of the things that just blew my mind, right? Is who exactly is consuming birth control? And then why? And I think it’s really important, especially for us as women. But also for people who have women in their lives that a lot of women need this medication. Not just to prevent pregnancies, but to control a range of conditions that make your life so much better. And not being able to get it on the pharmacy counter or have a pharmacist prescribe it, is really an impediment for everyone.
Shoshana:
Oh, yeah. Definitely.
*Theme Music In*
Kelli:
And when we talk about freedom, part of that is telling our stories. And letting people know that freedom is really the answer to a lot of our problems. But we can’t solve that unless we speak up and tell those stories. Well, Shosh, that’s it. We did it. First episode’s wrapped.
Shoshana:
Finally.
Kelli:
Hey, there’s seven more to go. So keep your energy up.
Shoshana:
But isn’t that what the next episode’s about?
Kelli:
It’s about clean energy actually. And it’s why we don’t have it, and what we can do to get it. Because it seems like everybody wants it, but we don’t have as much of it as we actually should. And we’ll be talking with R Street’s Phil Rosetti and Josiah Neeley. And what they have to say is so out of the box. You don’t think about it when you think about clean energy, but it’s absolutely vital we get that stuff right. Or we won’t have what everyone wants.
Shoshana:
Yeah, I’m excited to hear it. Especially Josiah get spicy. But thank you Kelli for doing this with me.
Kelli:
Thanks so much Shosh. Thanks for hanging with me. Red Tape is produced by R Street in partnership with Pod People.
Shoshana:
To learn more about the work we’re doing at R Street, follow us on LinkedIn and on Twitter. And our Twitter is @RSI.
Kelli:
And for more resources and information on the topics we explore today, you can check out rstreet.org.
Shoshana:
Also, if you’ve enjoyed listening to today’s episode, the best thing you can do is share Red Tape with a friend or an enemy.
Kelli:
And if you’re an overachiever, please leave a glowing review and rate us on Apple Podcast, Spotify, or wherever you listen to podcasts. It really does help us introduce the show to new listeners.
Shoshana:
I’m Shoshana Weissmann.
Kelli:
I’m Kelli Pierce.
Shoshana:
Thanks for listening.
*Theme Music Out*
*Audio Logo*