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Case Studies 4 HOW IT WORKS On the patient end, the bill simply permits women to obtain birth control pills directly through their pharmacy after consultation with a pharmacist, without a prescription written by a doctor. The bill has no age minimum, and the medication should still be covered under insurance. Since only the federal Food and Drug Administration can determine which medication can be bought over-the-counter, rather than making contraceptives truly over-the-counter, the law simply expands the scope of what a pharmacist can do as a health care provider (Karlamangla, 2016). Specifically, SB-493 allows pharmacists to dispense the aforementioned types of birth control following a questionnaire, blood pressure test, and consultation. CONCERNS Although SB-493 has been signed into law, it has faced many difficulties with implementation, largely due to lack of take-up by pharmacists. In May of 2016, several weeks after the law had gone into effect, NPR reporter Kelly O’Mara found that both large national pharmacy chains and local pharmacies in the San Francisco area were not offering access to birth control as permitted in SB-493 (O’Mara, 2016). Since pharmacist participation is not mandatory, O’Mara found that most pharmacists were still waiting to complete state-mandated training or to evaluate the logistics of the law. One major concern was payment; the law did not indicate how or whether pharmacist consultations would be reimbursed, particularly as they are not covered by insurance in CA (although Medicaid covers them in Oregon). The law also did not address the logistical issue of where consultations would take place. Instead, pharmacists themselves have to determine where to conduct consultations. Further, some pharmacists interviewed were either entirely unaware of the law or misunderstood the timing or implications of the policy. O’Mara consulted Sally Rafie, a pharmacist and medication safety specialist for the University of California-San Diego Health System, who estimated that four weeks after the law went into effect, fewer than 100 of the nearly 7,000 pharmacies in California were distributing birth control through pharmacist consultation (O’Mara, 2016). For states looking to implement a policy similar to SB-493, recognizing California’s successes and difficulties is crucial. The policy had support and input from relevant groups across the state, both in advocacy and academia. However, the implementation process has struggled immensely. The policy was optional for pharmacists. It left many pharmacies confused, and many pharmacies were unwilling to participate after performing their own cost-benefit analyses. SB- 493 failed to address the logistical concerns and pharmacists’ self-interest in changing their business’ offerings associated with expanding scope of practice in the medical field. The bill’s goal, to increase access, hinges entirely on the actual implementation and adoption of the policy, a crucial step that did not go according to plan. Moving forward, states must anticipate these potential barriers to successful implementation.