Commentary Contraception

Dear CVS: A Real ‘Health-Care Company’ Guarantees In-Store Access to Birth Control

Erin Matson

If CVS wishes to keep moving in the direction of providing health care, the women who patronize it need to know they can come in to the store for contraceptives and leave that same store with contraceptives in hand.

Update, February 27, 5:15 p.m.: CVS spokesperson Michael DeAngelis responded to this article, noting in an email that “the reason we require employees to inform us in advance if they have a deeply-held religious conviction against selling emergency contraception is so we can ensure that a store is staffed appropriately to provide this product to the customer promptly.”

DeAngelis also said that sending a customer to another pharmacy for emergency contraception “would not be what we consider satisfying a customer promptly.” He added that “serving the customer is our overriding priority and as such would require the sale of the item.”

In previous emails with DeAngelis about CVS policy, he responded affirmatively to the questions “Does CVS still … [r]equire a partner pharmacist to fill a prescription if a pharmacist objects? And if another pharmacist is not on duty, require the pharmacist to contact a nearby pharmacy (CVS or no) to refer the filling of the prescription?” and “…is there [a] policy that [sales associates] don’t have to sell a drug they object to, while being required to refer that sale to another associate or, if necessary, store?”

At least two CVS stores have not followed this policy in the past.

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Imagine this: You had sex and the condom broke. You definitely don’t want to get pregnant. You cannot afford to have a baby. The next morning you walk into your neighborhood pharmacy to get emergency contraception. The pharmacist looks at you and says no, he won’t give it to you, that’s not something he believes in, his buddy here behind the counter doesn’t either, and you’d better go somewhere else.

Astonishingly, this scenario does not violate a corporate-level policy governing more than 7,600 CVS/pharmacy stores in the United States. Despite recent changes from the Food and Drug Administration, certain types of emergency contraception, including but not limited to brands sold as ella and Next Choice, still require a prescription or are behind the pharmacy counter and require proof of age. When the personal beliefs of all available pharmacists on duty conflict with someone’s need for emergency contraception, CVS specifies that the person seeking emergency contraception should go to another store.

Another type of emergency contraception, Plan B One-Step, is supposed to be sold on the shelf for anyone to pick up and bring to the cash register, but the refusal policy at CVS also extends to sales associates who may refuse to sell emergency contraception that would otherwise be available without a prescription, or who may not be effectively trained to know that it can be purchased by young teens. Mike DeAngelis, a CVS spokesperson, told Rewire in an email that the vast majority of its emergency contraception sales are non-prescription and do not require a pharmacist.

This matters. CVS is an influential player in the industry, and arguably the largest: It receives the most prescription revenue of any pharmacy in the United States. That there is no guarantee of in-store access to contraception is an especially curious thing to consider when the chain is making headlines for its plan to stop selling tobacco products in order to hone a focus on providing for health-care needs. But whose health-care needs?

Emergency Contraception and Its Intended Availability: A Primer

Emergency contraceptive pills prevent pregnancy after unprotected sex or contraceptive failure, and are most effective when taken as immediately as possible. There are different rules about how emergency contraception should be dispensed, depending on its variety:

  • Plan B One-Step (progestin-only) is supposed to be available on an open shelf for purchase by people of all ages, no identification required.
  • My Way, Next Choice One Dose, and Levonorgestrel (progestin-only) are supposed to be available according to age:
    • by prescription only for those 16 and younger, and
    • behind the pharmacy counter without a prescription (or on request) for those 17 and up.
  • Ella (ulipristal acetate) is supposed to be available by prescription only, regardless of age.

In this climate, misinformation about the availability of emergency contraception reigns, according to a recent study published in the Journal of Adolescent Health. Researchers representing themselves as women 17 years of age called 940 pharmacies in five major cities and were told 20 percent of the time that they could not get emergency contraception at all. This wasn’t the only completely false information they found: It wasn’t uncommon to hear that a parent or legal guardian must come along, or that a partner or other person couldn’t buy a prescription for them.

Another thing the callers heard? Pharmacy staff sometimes shared personal reasons for refusing to dispense or stock emergency contraception. Which brings us back to the refusal policy held by CVS, a behemoth that empowers its employees to say no and ultimately puts the burden on accessing emergency contraception back to the customer.

A Corporate Policy Allowing Refusals at CVS

CVS has a longstanding policy that pharmacists and sales associates with personal objections to emergency contraceptives or other drugs are not required to dispense or sell them. The policy also offers ostensible protections to customers and patients that go almost but not quite far enough—a difference made critical by the time-sensitive nature of the need for emergency contraception.

Ten years ago, the Minnesota chapter of the National Organization for Women began to picket CVS stores in the Minneapolis/St. Paul metropolitan area because CVS would not guarantee in-store access to contraceptives, including emergency contraceptives. (Disclosure: I was president of the group at that time.) What caught our attention then was a rash of incidents, some local and some national, of pharmacists in a variety of chains refusing to dispense contraception. The first case we saw was that of a woman who was denied a refill of her monthly prescription at a CVS in Fort Worth, Texas. So we wrote CVS, and spokesperson Tracylynn Dubois cleared up the confusion. Here’s what Dubois told us:

We respect the deeply held personal beliefs of our pharmacists if they have an objection to filling a given medication. Our policy is that … [if another pharmacist] … is not on duty, the pharmacist must contact a nearby pharmacy, whether it is another CVS or a competitor, in order to refer the customer there to have the prescription filled.

This policy still stands, as confirmed by a February 10 email to Rewire from company spokesperson Mike DeAngelis.

Notably, CVS employees are supposed to proactively declare their desire to refuse to fill or sell requests for emergency contraception. If CVS is on its own initiative placing responsibility on its employees to share their refusal to dispense a health product, and it requires those employees to refer the sale to another employee, why won’t CVS accept the responsibility to ensure that another pharmacist who isn’t biased against preventive health care for women is scheduled to work at the same time?

A Health-Care Company Not Acting Like One

CVS is getting a lot of attention for its decision to stop selling tobacco, and it is positioning itself as a health-care company. As Larry J. Merlo, president and CEO of CVS Caremark, which operates CVS/pharmacy stores, said in a press release about that decision, “CVS Caremark is playing an expanded role in providing care through our pharmacists and nurse practitioners. The significant action we’re taking today by removing tobacco products from our retail shelves further distinguishes us in how we’re serving our patients, clients and health care providers and better positions us for continued growth in the evolving healthcare marketplace.”

If CVS wishes to keep moving in the direction of providing health care, the women who patronize it need to know they can come in to the store for contraceptives and leave that same store with contraceptives in hand.

Tobacco is a product that we know kills people, and it makes sense for a health company to pull it from its shelves. Contraceptives, on the other hand, are basic medical care for women, and patients of all genders deserve to know these health-care needs will be met by CVS. Nearly two-thirds of women of reproductive age currently use a contraceptive method. It should be noted that the CVS refusal policy extends to all prescriptions, including all contraception, and not just emergency contraception.

From the pharmacy to the religiously affiliated institution providing health insurance, access to contraceptives has come to be framed as two sets of individual liberties, pitted in competition: the right of a woman to access contraceptives, and the right of another individual to act according to his conscience. This frame is troubling when it comes to the provision of medical care, Greg Lipper, senior litigation counsel at Americans United for Separation of Church and State, told Rewire. He suggests that when we’re looking at this issue, we should see the question this way: “Does a pharmacist have a right, due to his or her religious beliefs, to interfere with the rights of third parties—by interfering with the medical care of customers who have made their own, independent decisions to purchase and use contraception?”

For now, CVS continues to answer this question the wrong way.

Not a Reasonable Accommodation

CVS is claiming to be a health-care provider while putting a heavier burden on women to get access to primary care. Facing refusal at one store may mean that a woman has to travel a great distances to find another store, particularly in rural areas and for people with limited transportation options and those with disabilities. This scenario is even more troubling given the time-sensitive nature of emergency contraception, which relies on taking a specific dosage in a limited window of time, generally between 24 and 120 hours after unprotected sex, with an efficacy rate that is higher the sooner it is taken. Further, you just may not have additional “time” to take away from work, family, or other responsibilities on a wild goose chase in search of a legal drug that you have a constitutionally protected right to use.

In a follow-up email, Rewire asked DeAngelis to explain what happens when CVS is the only provider in town, and the question was not answered. However, DeAngelis wrote, “The overriding priority regarding the sale of emergency contraception is that the customer’s needs must be met.” This is a logical priority in need of a commitment, in the form of making sure that at least some pharmacists and sales associates willing to dispense and sell emergency contraception are on duty when the lights turn on.

CVS could, and should, guarantee in-store access to emergency contraception. It is reasonable to expect CVS to take a page from its own playbook and step up as a health-care company—in this case changing its policy to guarantee that emergency contraception and all other forms of contraception will be accessible in every store, regardless of individual employees who object to it. This is not about personal beliefs, this is about health care, and no one has the right to deny anyone else access to care based on ideology. Customers of CVS should start demanding that the chain treat all persons equally, including those in need of contraception, whether in an emergency or not.

An Rewire petition urges CVS to change its policy and guarantee in-store access to emergency contraception.

Roundups Law and Policy

Gavel Drop: Welcome to the New World After ‘Whole Woman’s Health’

Imani Gandy & Jessica Mason Pieklo

With the recent U.S. Supreme Court ruling, change may be afoot—even in some of the reddest red states. But anti-choice laws are still wreaking havoc around the world, like in Northern Ireland where women living under an abortion ban are turning to drones for medication abortion pills.

Welcome to Gavel Drop, our roundup of legal news, headlines, and head-shaking moments in the courts.

The New York Times published a map explaining how the U.S. Supreme Court’s ruling in Whole Woman’s Health v. Hellerstedt could affect abortion nationwide.

The Supreme Court vacated the corruption conviction of “Governor Ultrasound:” Former Virginia Gov. Bob McDonnell, who signed a 2012 bill requiring women get unnecessary transvaginal ultrasounds before abortion.

Ian Millhiser argues in ThinkProgress that Justice Sonia Sotomayor is the true heir to Thurgood Marshall’s legacy.

The legal fight over HB 2 cost Texas taxpayers $1 million. What a waste.

The Washington Post has an article from Amanda Hollis-Brusky and Rachel VanSickle-Ward detailing how Whole Woman’s Health may have altered abortion politics for good.

A federal court delayed implementation of a Florida law that would have slashed Planned Parenthood’s funding, but the law has already done a lot of damage in Palm Beach County.

After the Whole Woman’s Health Supreme Court ruling in favor of science and pregnant people, Planned Parenthood is gearing up to fight abortion restrictions in eight states. And we are here for it.

Drones aren’t just flying death machines: They’re actually helping women in Northern Ireland who need to get their hands on some medication abortion pills.

Abortion fever has gone international: In New Zealand, there are calls to re-examine decades-old abortion laws that don’t address 21st-century needs.

Had Justice Antonin Scalia been alive, explains Emma Green for the Atlantic, there would have been the necessary fourth vote for the Supreme Court to take a case about pharmacists who have religious objections to doing their job when it comes to providing emergency contraception.

Analysis Human Rights

For Undocumented People Seeking Health Care, ‘The Barriers Can Seem Endless’

Tina Vasquez

“The fear that accessing [health] services will get you deported is very real in undocumented communities,” said Alma Leyva, a research coordinator at the UCLA Labor Center’s Dream Resource Center.

While attending UC San Diego (UCSD), Ireri Lora used her school ID at the university’s medical school to access birth control and other services.

Lora, who was undocumented then, told ​Rewire​, “Sometimes you would see border patrol agents walking around or parked in their trucks, but they were always parked directly in front of the main hospital entrance. They would take people straight from the hospital [to a border patrol station], and they wanted us to see them do that.”

This behavior wasn’t unique to the UCSD hospital, Lora said. An acquaintance whose family members worked for border patrol in San Diego had told her that federal agents would drive around the perimeter of hospitals and park outside of them, presumably to intimidate non-citizens.

Every time Lora had to get her birth control prescription filled, she would make sure multiple people in her life knew where she was going so that if trouble arose, they would answer her call immediately.

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California is often referred to as one of the best states for reproductive rights in the country, and for good reason. NARAL Pro-Choice America gives California an A+ on choice-related laws, and the state legislature is actively trying to expand access to care.

There are, however, California residents for whom none of this matters.

The reasons vary, but what is true across the board is that the more your identity is layered by race, gender, sexuality, and immigration status and the further your income falls below the federal poverty line, the less access you will have to sexual and reproductive health-care services—even in California. There are community-based groups working to fill this gap, but resources are in short supply for those fighting to expand access to undocumented people.

Stifled by Fear of Deportation

In August 2015, when Blanca Borrego, an undocumented mother of three, was arrested by sheriff’s deputies at her gynecologist appointment in Atascocita, Texas, some in the media rightly expressed outrage. But undocumented communities knew it wasn’t an isolated incident and that immigrants are detained and deported for seeking care all the time. Borrego was yet another example confirming some of their biggest fears.

“The fear that accessing [health] services will get you deported is very real in undocumented communities and what happened to Blanca [Borrego] isn’t at all unusual, so it’s not an unfounded fear,” said Alma Leyva, a research coordinator at the UCLA Labor Center’s Dream Resource Center, a national source for research, education, and policy on immigration issues. “She was insured and had been in the country for a long time. A lot of people think, ‘If that could happen to her, why couldn’t it happen to me?'” Leyva told Rewire.

Nearly three years ago, the Dream Resource Center sought to document the experiences of immigrant youth and their families in navigating California’s health-care system as part of its 2013 Healthy California Survey Project. From June 2013 to August 2013, a research team comprised of 37 immigrant youth surveyed 550 undocumented and “DACA-mented” young people. What resulted was Undocumented and Uninsured, the first statewide research project by and about immigrant youth on health access.

As the report explains, while Deferred Action for Childhood Arrivals (DACA) recipients under the age of 21 are eligible for Medi-Cal—the state’s free or low-cost health coverage for children and adults with limited income and resources—that doesn’t resolve a primary reason undocumented people and DACA recipients do not seek care: fear.

National policies contribute to high numbers of deportations and increase immigrant communities’ mistrust, such as the Priority Enforcement Program (PEP), which requires that all fingerprints of arrested persons taken by local law enforcement be sent to ICE to check against immigration databases, and Section 287(g) of the Immigration and Nationality Act, which allows DHS to “deputize selected state and local law enforcement officers to perform the functions of federal immigration agents.”

According to the Undocumented and Uninsured:

The police and Immigration and Customs Enforcement (ICE) are not only in immigrant neighborhoods but also in the minds of undocumented people, triggering constant anticipation of harm and hypervigilant behavior. Emerging research indicates that immigrant youth experience feelings of shame, anger, despair, marginalization, and uncertainty stemming from discrimination, anti-immigrant sentiment, xenophobia, fear of deportation, and institutional barriers. Daily economic uncertainties elevate the risk of anxiety, depression, and vulnerability to mental illness for immigrant youth. Emotional traumas manifest in poor physical and mental health, which often goes untreated.

Leyva told Rewire that she has heard stories “where an undocumented youth was asked by a doctor to relay really complicated medical jargon to their mom as she was giving birth. They were so afraid they wouldn’t translate the information properly that it would be dangerous to their mom,” she said.

“There is anxiety around simple check-ups and fear around obtaining resources to get healthier. We’ve come to believe that this is just the price of being undocumented in this country, and that’s not OK. We too deserve the right to not just survive, but to live full, healthy lives. Health care is a right, not a luxury,” Leyva said.

Dire Circumstances in Rural California

Lora became a legal permanent resident in 2015, but while living in San Diego as an undocumented college student she said her “biggest fear” was a scenario like what happened to Borrego in Texas. In 2009, while working on college campuses and connecting with undocumented families, Lora learned that it was a universal fear among undocumented women.

“When I asked the moms [I worked with] if any of them, about 20 in all, had visited any particular clinics, they all shared that they were scared to because they heard border patrol patrolled the area or that vans waited outside to get people who were leaving the clinic, especially if the clinic was one that primarily served the Latino community. Fortunately, none of the mothers I ever worked with had been stopped by border patrol for seeking services, but that environment made them too scared to go to a clinic,” Lora said.

By that time, she and a friend had started a program where they brought different workshops onto campus based on the expressed needs of the community. Overwhelmingly, Lora said, undocumented mothers requested workshops about sexual education and birth control.

Lora worked with local community clinics from the Barrio Logan area of San Diego to do biweekly workshops in Spanish about sexual health. That experience led her to ACCESS, an Oakland-based organization “founded in 1993 by clinic escorts who were moved to action after witnessing the many barriers women were facing—especially young or poor women—to actually obtain an abortion.” ACCESS further explains on its website that the organization combines direct services, community education, and policy advocacy to promote reproductive options and access to quality health care for California women. It is one of the only organizations in California that helps to provide abortion access to undocumented women while also using a reproductive justice framework created by women of color for women of color.

Lora, who is now on ACCESS’ board of directors, began working with the organization as a healthline intern. The healthline, as Lora explained, empowers callers by giving them all of the information they need to advocate for themselves. It was at this time Lora learned of the very specific barriers undocumented women living in rural areas face.

“They always voiced fears about visiting any government agency to get Medi-Cal or a clinic like Planned Parenthood because they thought they’d be deported or profiled for showing a foreign ID,” Lora said.

Vanessa Gonzalez-Plumhoff, Planned Parenthood’s director of Latino outreach and engagement, made it clear that the health-care provider would not put a patient in harm’s way. She told Rewire that Planned Parenthood is serious about addressing the needs of the undocumented community, asserting that Planned Parenthood will provide health care no matter what, regardless of immigration, citizenship, or income status.

The reason why the services provided to undocumented women may differ by location, Gonzalez-Plumhoff said, is because of the legislative, political, and financial climate of a particular area. As reproductive health care continues to be attacked, it limits what services are made available from clinic to clinic.

Unlike most states, California allows low-income women to obtain public funds for abortion and also provides them with co-pay-free family planning services. Abortions are legal up to viability and California’s AB 154, which took effect in January 2014, increased the number of abortion providers in the state. The law authorized nurse practitioners, certified nurse midwives, and physician assistants to perform vacuum aspiration abortion, which previously only doctors were allowed to do.

But, like in most states, there are districts in California where abortion providers are nonexistent. According to the LA Times, UC San Francisco’s Bixby Center for Global Reproductive Health is largely responsible for the passage of AB 154, but just a handful of the clinicians trained under the six-year study are practicing in remote corners of California. Schools like the UC San Francisco School of Nursing are developing new training programs, but at this point, half of California’s 58 counties currently have no readily available provider. And even when new programs roll out in rural communities, they will only benefit women seeking abortions during the first trimester, leaving out a segment of the population at risk of fetal anomalies or later pregnancy complications.

The process of obtaining an abortion as an undocumented woman living in a rural area is complicated. Lora said these women often work in the fields and live in migrant camps, which makes obtaining the passport that some clinics require as a valid form of ID challenging—and that’s mostly because of the lack of transportation, which Lora said is a “huge barrier” for undocumented women seeking such identification.

In addition, these women often have to travel to reach one of the few clinics providing later abortion care in the state.

“A lot of clinics near women in rural areas only offer abortion until the first trimester,” Lora said. “By the time they’re referred to us, they’re often beyond that point, so they have to get transferred to a clinic that’s even farther away. Transportation comes up again and again.”

This is where ACCESS’ “practical support program” comes in. The organization helps callers navigate paying for care, leveraging over $200,000 of coverage per year for medical procedures. Also, with support from its network of volunteers around the state and the organization’s pool of funds, ACCESS provides around $25,000 annually to help with transportation, housing, meals, child care, medical costs, and doula support.

One of the toughest cases Lora ever handled on the Spanish healthline was an undocumented rape survivor who lived in a rural area. Her family didn’t know of the rape or the resulting pregnancy. By the time ACCESS could walk her through all of the steps, she was in her 20th week. Following the multi-week process, which included acquiring an appointment and bus tickets, she then had to come up with a lie to tell her family as to where she was going for two days.

“The information is not accessible and the barriers can seem endless. That’s why it’s especially upsetting to me when ACCESS constantly hears this misconception that people in California—and women of color in particular—purposefully wait until the last minute to get abortions. It’s simply not true. Most of the women I’ve spoken to were very clear that they wanted to terminate their pregnancies early on, but they were forced to wait weeks because of limited access to information, limited access to clinics, and because of transportation barriers and language barriers,” Lora said. “If abortion was as accessible in California as they paint it to be, all women who wanted to terminate their pregnancies would be able to do it in a week.” 

Community Groups Are Working to Replace Fear With Trust 

There is no telling how many women ACCESS has helped, but what is clear is the ripple effect of the progress the group is making. ACCESS alumna La Loba Loca, who identifies herself as a queer, machona, brown South American migrant, formed Autonomous Communities for Reproductive and Abortion Support (ACRAS) three years ago. La Loba Loca’s collective, comprised of mostly queer people of color, provides free and low-cost abortion support to Angelenos. Her personal project, Serpiente Birth & Spectrum Services, supports individuals and families during life transitions through bilingual full-spectrum companionship and doula work. 

La Loba Loca takes a multifaceted approach to her companion work, coupling an academic framework with traditional knowledge gained through personal research and non-Western education, which she calls “abuelita knowledge.”

“I got into birth work because of abortion. To me, there’s no place people can go that will holistically support them getting an abortion,” La Loba Loca said. “I want to normalize abortion as just another aspect of reproductive health and remind people of the ways our grandmothers took care of their health and well-being outside of the medical industrial complex. It’s medicine and knowledge that is generational and that shouldn’t be lost.”

Above all else, ACRAS works to share knowledge and resources within communities. La Loba Loca has tirelessly compiled documents about abortion and reproductive health for the purpose of being used by undocumented people who don’t have easy access to clinics and hospitals. “The idea was also to include people in the collective who have historically been left out of these conversations or who have been denied the same kind of access to reproductive justice as other people,” she said.

La Loba Loca has been a major proponent of queer and trans people of color receiving the proper training to be both birth and abortion companions. The language used around reproductive justice isn’t inclusive, she said, and it can make queer and trans people of color afraid to discuss their bodies and their needs and afraid to access services.

“I’m hearing a lot of queer and trans people try to figure that out, just because accessing abortion as a queer or trans person can be difficult or when you do obtain one, it can be dehumanizing,” she said. “Right now, there are queer and trans people doing reproductive justice work, but it’s very isolating and frustrating to never receive the funding that’s needed to provide education for and about different bodies.”

To La Loba Loca, the answer to the lack of access and the poor treatment that undocumented people and other low-income communities of color often receive at clinics and hospitals is not working to change these systems, but rather using community-based resources to find ways around the structural hurdles. Roxana, an ACRAS member who requested that Rewire not use her last name, said that the road to sexual and reproductive justice has been built on the backs of women of color and the long history of institutions being harmful to communities of color who are already vulnerable is not something that can easily be overcome.

“I think of the Latinas in L.A. who were coerced into sterilization in the 1970s and how that distrust lingers in the community,” Roxana said. “The trauma stays, and it continues to be a barrier that scares people from going to an institution that historically been violent to people who look like them. It’s only harder when you’re undocumented.”

Like Lora, Roxana realized through her work that immigrant communities, Latino communities, and undocumented communities are all in need of sexual and reproductive health information that is in their language and that comes from people they trust.

At an ACRAS workshop around reproductive justice, according to Roxana, the age of attendees ranged from 15 to 65. A woman specifically asked if it was OK that her teenage daughter was there because she wanted her to have the information that she never did. ACRAS workshops bring a LGBTQ lens and the mother and her daughter were eager to learn about reproductive health for different communities and learn about gender and sexual identities that go beyond the binary. Roxana said the interest is there; it’s just a matter of providing it in a way that’s accessible.

“We’re having real conversations about real experiences and for me, as a person who does this work, it’s very political and very personally meaningful. It’s heart work; it comes from the heart,” Roxana said, growing emotional. “I want to go beyond ‘your body, your choice.’ I’m not really into that, especially because for a lot of us, what happens to our bodies isn’t a choice. For me, it’s more like ‘I got your back.’ ACCESS and collectives like ACRAS serve a very important purpose in our communities. We’re creating alternatives to a system that wasn’t meant for us and we’re providing access to people whose existence was never even considered. We have each other’s backs.”

CORRECTION: This piece has been updated to clarify ACCESS’ funding for “practical support.”