RENF engaged a broad range of health care stakeholders, including OB-GYNs, family physicians, pediatricians, certified nurse midwives, nurse practitioners, and clinic and practice managers in both clinical and administrative roles. We spoke with ACOG leaders in all three states. One of the most striking findings was how limited providers' knowledge of specific state-level policies was, including extended supply enacted many years ago. This was true even among providers who are actively engaged and participate in state-based advocacy work. Providers who were aware of extended supply had largely stopped attempting to prescribe it due to the high rate of insurance denials, finding it easier and less burdensome to prescribe a three-month supply with refills than to fight a system that routinely denied the prescribed amount. 

Follow-up discussions highlighted the ways in which our initial discussions prompted providers to ask colleagues about policies and, in many cases, change their own prescribing practices. Early Learning Collaborative engagement sought feedback specifically from reproductive health providers such as OB-GYNs and sexual and reproductive health clinics, but RENF also expanded our reach to include family medicine, pediatrics, and college health, acknowledging the many settings in which contraceptive care is delivered in practice. These specialty areas offered particularly interesting insights. Pediatricians, for instance, are often the ones initiating contraceptive care for young people and hold a unique opportunity to educate and counsel them. One pediatrician we spoke with was enthusiastic about incorporating advance provision of emergency contraception into routine contraceptive care visits. 

Providers report being overworked, contending with high patient volume alongside the ongoing demands of tracking a rapidly shifting health care landscape. While they explained that Electronic Medical Records (EMR) dictate much of the office visit flow, providers were genuinely interested in the idea of using EMR as a tool to encourage changes in prescribing behavior. The volume of information reaching them is itself a challenge: too many emails, too much technical and legal language, and too little clear guidance about what a given policy actually requires in practice. 

Finally, providers knew and understood very little about how pharmacies operate and what authority pharmacists had to adjust prescriptions. A clear theme emerged about how siloed community pharmacy practice is within the larger health care field.

RENF engaged a wide range of pharmacist stakeholders, including practicing community and health system pharmacists, pharmacist educators, independent pharmacy owners, and regional chain managers. We also spoke with regulators of pharmacy practice, including Connecticut's Department of Consumer Protection Drug Control Division, and representatives of Boards of Pharmacy, as well as pharmacist associations at the state and national level. As with providers, knowledge of extended supply was noticeably low, though generally, pharmacists understood their prescriptive authority even if they were not actively offering hormonal contraceptives. Notably, RENF engaged with more than one Massachusetts pharmacist who did not know about the statewide standing order for emergency contraception. Other pharmacists noted a shift towards fielding more questions about birth control causing infertility, a common misinformation talking point from social media influencers. There is more information about pharmacist knowledge of policies in the Field Scan in Appendix C. 

The differences in pharmacist association capacity across states were notable: Connecticut's pharmacist association operates with dedicated staff and funding, which translates into stronger advocacy capacity, more robust continuing education offerings, and deeper member engagement. In Massachusetts and New Hampshire, the picture is different with mostly all-volunteer associations. Advocacy work without sufficient infrastructure moves slowly as volunteer leaders who are also practicing pharmacists carry a significant burden.

All of the pharmacists RENF engaged identified lack of reimbursement as the single largest impediment to offering hormonal contraception, noting that without a viable payment pathway, expanding clinical services is simply not sustainable. Compounding this challenge, pharmacists raised serious concerns about short staffing and the wave of pharmacy closures sweeping across the region, which together are straining an already overburdened system. They shared that oftentimes they field patients' frustrations about anything that may have gone wrong, including mistakes and insurance denials, between their provider writing the prescription and coming to pick it up. Many pharmacists commented on their willingness and excitement to practice at the top of their licence, but named the structural and financial conditions needed to support that expanded role. 

Running through all of our conversations were themes about a broader shift underway in pharmacy practice itself. Accelerated by the expansion of vaccine administration and testing in community pharmacies during the COVID-19 pandemic, the profession has been moving toward an expanded scope of practice. This includes additional services such as test to treat, smoking cessation, and, for the purposes of this project, hormonal contraception. These new services require pharmacists to use clinical skills in addition to dispensing medication. This reflects a larger shift away from the "bright line" model of care, wherein statute and regulation set clear, binary rules that apply uniformly regardless of individual patient circumstances and instead toward a "standard of care" model that accounts for patient-specific factors, clinical context, and professional judgment. Given that pharmacists now hold a doctorate, a PharmD, with significant clinical training, many pharmacists we spoke with are excited for these shifts but still express concerns about reimbursement and staffing shortages.

Key Partner: Dr. Aimee Dawson, PharmD, CDCES
Dr. Aimee Dawson, PharmD, CDCES, is an Associate Professor and Vice Chair of the Department of Pharmacy Practice at Massachusetts College of Pharmacy and Health Sciences Worcester and practices at Holyoke Health Center in Holyoke, MA. Dr. Dawson has been a longtime partner in promoting contraceptive access in the Massachusetts pharmacy landscape and played a critical role in making RENF’s Learning Collaborative a success. She was a pioneer in offering contraceptive prescriptions in Massachusetts, bringing the service to the pharmacy at Holyoke Health Center, starting in 20XX, and has served on the ACCESS Working Group, hosted by RENF and UpStream, to promote awareness of the 2017 ACCESS law since 2020. Dr. Dawson’s contributions to RENF’s Learning Collaborative have been invaluable. She has not only facilitated connections in the pharmacy industry, but more importantly, has helped us navigate and decode the specialized world of pharmacy practice. Alongside Dr. Dawson, RENF engaged pharmacy students in conversation about the intersection of policy and pharmacy in the reproductive health space.

A key challenge encountered throughout RENF’s Learning Collaborative was the distinction between self- and fully-insured plans, the ability for states to only govern fully-insured plans, and the difficulty individuals encounter understanding what type of plan they are enrolled in. Private healthcare insurance is delivered through for-profit or not-for-profit corporate  insurance companies and funded through premiums paid by individuals, employers, or both. Most people with private insurance are enrolled through their employer, though plans can also be purchased individually through a state’s health care exchange or the ACA Marketplace. For those with employer-sponsored insurance, the plan can either be fully-insured or self-insured. In a fully-insured plan, the employer pays a fixed premium to an insurance company, which takes on the financial risk and manages all claims. These plans are regulated by the state government, meaning that state-mandated benefits, including an extended supply of contraceptives, are only required to be covered by fully-insured plans. KFF estimates that in 2024, 59.4% of Connecticut’s population, 45.5% of Massachusetts’ population, and 63.3% of New Hampshire’s population are insured through self-insured plans, meaning contraception is not required to be covered. 

Separate from this challenging distinction, conversations with health insurance associations and payors reflected the broader instability currently gripping the health care landscape. Amid escalating costs and intensifying competing demands, payors are effectively navigating a convergence of simultaneous pressures and crises; consequently, initiatives such as expanding reimbursement for pharmacist-provided contraceptive services or advancing policies that support extended supply have, for the moment, receded from immediate strategic priority. That said, payors demonstrated a clear openness to continued dialogue, driven in part by a credible and compelling cost-containment rationale. Generally, pharmacists are reimbursed at rates more closely aligned with nurse practitioners than physicians, suggesting that an expanded role for pharmacists in contraceptive care may offer a meaningful opportunity for cost savings without compromising access or quality. At the same time, payors also acknowledged an ongoing challenge in striking the appropriate balance between transparency and usability; specifically, how to convey information that is often legally mandated in a manner that is both accessible and digestible for members. RENF remains deeply grateful for our continued partnership with payors and looks forward to ongoing collaboration as we work collectively to advance a more efficient, accessible, and patient-centered health care system. 

RENF engaged elected officials and state employees across a range of agencies in our region, including Departments of Health and Human Services, state Medicaid programs, Connecticut's Drug Control Division, and the Massachusetts Division of Insurance. These conversations offered an opportunity for RENF to share the focus of our Learning Collaborative efforts, offer insights into the implementation challenges uncovered by Learning Collaborative stakeholders, and allowed for substantive and constructive discussion about the challenges of the current system. A particularly encouraging moment emerged in discussion with a member of the New Hampshire Board of Pharmacy, who expressed genuine enthusiasm for our work and welcomed RENF’s attention to contraceptive access policies in the Granite State. These interactions signify meaningful goodwill at the government level, even where structural and bureaucratic barriers hinder immediate change.

A persistent and cross-cutting barrier that surfaced in all conversations is the distinction between self-insured and fully-insured plans. Access to many state-level mandated benefits depends on this distinction, and it is poorly understood by providers, pharmacists, and consumers alike. State agencies, including Departments of Insurance, have an opportunity to do more to explain this distinction and its practical implications for patients. We were encouraged to see a new acknowledgment amongst officials of the significance of this confusion and the way in which it hinders the ability for state-mandated benefits to be fully utilized.  

At the national level and outside of our New England region, RENF engaged with key subject matter experts and organizations including the National Health Law Program, the American Public Health Association, the National Women's Law Center, and academic partners in California and North Carolina. These organizations have published extensive resources related to pharmacist-prescribing of hormonal contraceptives, including roadmaps, toolkits, and policy analyses. 

The difficulty posed by lack of information sharing systems, particularly between advocates in different states, emerged as a common theme in discussion with subject matter experts. With no single, trusted central repository for this implementation work, this gap in information sharing has significantly shaped how the field operates, and many state-level advocates lack the capacity to tailor national information to their own advocacy or implementation needs. Consequently, the ability for RENF to have this dedicated capacity to spend on focused implementation efforts in our three states and put together our roadmap offered a significant opportunity to bridge this information sharing gap. National leaders were excited to learn that RENF was focused on these implementation questions, suggesting an appetite for deeper partnership between national and state-level efforts.

Conversations with advocates in Maine, Maryland, and North Carolina echoed that funding and sustained collaboration are critical factors for implementation success. These advocates also named a lack of bandwidth to stay informed about ongoing advocacy efforts even in neighboring or peer states, further reinforcing the utility of RENF’s dedicated attention to building a regional network to share learnings and strategies across states.

RENF also engaged with national subject matter experts who brought deep technical knowledge and genuine enthusiasm for state and local implementation work. These discussions similarly reinforced that RENF’s positioning as a trusted regional partner with local knowledge and relationships, and our focus on the practical realities of implementation fills a gap that national-level work alone cannot address. 

Key Partner: American Society for Emergency Contraception
RENF worked closely with Claudia Trevor-Wright, JD, MA, MCHES, who is the Director of Higher Education and Special Projects at the American Society for Emergency Contraception (ASEC). Claudia provided expertise on emergency contraception access as well as insights into higher education health services as RENF explored how to expand outreach and work with special populations around contraceptive access. ASEC focuses on expanding access to emergency contraception through expert guidance and technical assistance to movement partners on clinical and access issues, hosting the only dedicated annual meeting in the U.S. focused on emergency contraception for health care providers, community activists, pharmaceutical partners, and researchers, and conducting a nationwide study of real-world emergency contraception access. Claudia leads Emergency Contraception for Every Campus (EC4EC), a nationwide campaign to support student activists expanding access to emergency contraception vending machines on college campuses, which served as an inspiration for RENF’s exploration of advancing emergency contraception access (see Appendix J). 

Claudia’s participation in the Learning Collaborative illuminated persistent stigma and barriers surrounding emergency contraception, widespread lack of consumer knowledge regarding the two types of emergency contraception, and the ongoing challenges surrounding consistent pharmacy stocking of these medications. Lack of consumer knowledge regarding emergency contraception variations was echoed in the listening sessions held with Health Care For All in Massachusetts (see Appendix D). In New Hampshire specifically, when asked about emergency contraception availability and point-of-sale insurance coverage, the resounding response was a confident assertion that because over-the-counter emergency contraception is available throughout the state, no further implementation or advocacy efforts to improve access are necessary. 

Key Partner: Birth Control Pharmacist
Dr. Sally Rafie, PharmD, and her team at The Birth Control Pharmacist were key partners in our work, bringing deep policy and technical expertise that significantly strengthened our ability to engage pharmacists and pharmacy representatives in RENF’s Learning Collaborative. Dr. Rafie is widely regarded as the national expert in contraceptive access in pharmacy settings, with nearly 20 years of experience at the forefront of policy advocacy, research, public awareness, technical support, and implementation strategy. Her team is currently leading state-level work across the country, developing best practices for adopting policies that work for both pharmacists and patients. 

Dr. Rafie was impressed by RENF’s ability to convene such a broad range of partners for collaboration, emphasizing that having an organization with established relationships and a presence on the ground in New Hampshire is essential to translating national policy into real change at the state and local level. The Birth Control Pharmacist already offers training programs for pharmacists in Massachusetts and Connecticut, and as a direct result of our collaboration, is poised to launch a comparable training in New Hampshire in partnership with both state pharmacist associations as soon as implementation of the state's program is complete. Dr. Rafie is the lead author of an important paper published this January in the journal Contraception, "Recommendations for Policies Enabling Pharmacist-Prescribed Contraceptive Services," which offers a timely and authoritative overview with significant guidance to support our recommended course of action. Notably, the paper highlights New Hampshire as a state where technical challenges in implementation, combined with a lack of momentum and resources at the state Board of Pharmacy, have stalled a contraceptive access program that the legislature authorized in 2019. 

Dr. Rafie and the Birth Control Pharmacist team attempted over multiple  to assist the Board by updating required counseling materials but encountered significant difficulty making progress through that process, underscoring the very implementation barriers RENF set out to identify and address.