Rachel Ralph works long hours at an accounting firm in Oakland, Calif., and coordinates much of her life via the apps on her phone.
So when she first heard several months ago that she could order her usual brand of birth control pills via an app and have them delivered to her doorstep in a day or two, it seemed perfect. She was working 12-hour days.
"Food was delivered; dinner was often delivered," Ralph says. "Anything I could get sent to my house with little effort — the better."
Ralph ordered a three-month supply of pills via the app of a San Francisco-based company called NURX. It's one of several digital ventures, including Maven and Lemonaid Health, that now provide several types of hormonal contraception without requiring a live visit to a doctor or other health care provider.
Women using these services in cities say they like the speed and no-hassle privacy they get by making a purchase through the app. And in some rural areas where women's health clinics are few and far between, being able to buy prescription contraceptives online — starting at around $15 for a month's supply — can be not only much more private, but much more affordable and less time-consuming than driving an hour or more to the closest clinic, or paying for a doctor's appointment.
NURX is now available in 18 states. It's popular in Texas, where many women live in what some health policy analysts call "contraception deserts" — places that lack easy access to women's health services.
The company's process is pretty simple. After users log in to the NURX app, they fill out a questionnaire.
"They tell us about their medical history," says Jessica Horowitz, a nurse practitioner with NURX who consults with patients via online chats. "They give us a blood-pressure check."
A clinician like Horowitz then reviews the answers and, based on that, makes a suggestion about what type of hormonal contraception might be best for that individual; a pill, a ring or a patch are available, as well as emergency contraception. If the patient has a question about the product she's considering, she can send an instant message or call to chat with a provider.
"It doesn't matter what time of day it is," Horowitz says. "Someone responds."
Then NURX sends a prescription to a pharmacy and the drugs are mailed out via priority mail, or faster for emergency contraception. The cost of a month's supply of prescription birth control is often free to patients, if they have health insurance, Horowitz says, and otherwise starts at $15 out-of-pocket for a month's supply, depending on the brand.
For Claire Hammons, who lives and works in Llano, Texas, about 90 minutes outside Austin, the low cost of the pills was as important as the convenience.
Hammons loves many aspects of life in her small town. "There is a population of 3,000 people," she says. "But we have a lot going on. We are a huge art town. We have the Llano River. We are surrounded by state parks."
Still, living there has its drawbacks, she says. There's no women's health clinic nearby, and getting prescription contraceptives isn't easy, especially without health insurance. And for Hammons, the main medicine she needs is birth control pills.
"I've been taking birth control since I was 16 because of endometriosis," she explains.
If she can't get the pills, Hammons is in a lot of pain every month. A while back, after losing her health plan, Hammons had a particularly hard time getting a prescription. Her out-of-pocket cost for a doctor's visit in Llano would have been $140.
"I really did not have — literally — have the money to go to the doctor. Period," she says.
Hammons says she also couldn't afford to pay out of pocket to pick up the pills every month at a pharmacy.
Then, about six months ago, she went online and found NURX. The cost-savings, she says, was "really amazing and ... saved me a lot."
Texas has become a big market for the app. Dr. Brook Randal, an emergency medicine physician in Austin who works as a provider for NURX, says her patients come from different backgrounds and use the app for different reasons.
"A lot of them are low-income women who may not have a low-cost clinic available to them in the communities where they live," she says. "And so we provide an important service for those women."
In 2013, the state passed an abortion bill that led half of all Texas clinics that performed abortions to close — clinics that often also provided birth control and other medical services to low-income women.
"Many of those women will tell us that they would have had to drive a really long distance in order to get to a clinic where they can get birth control economically," Randal says.
And their access to birth control got even worse when Texas lawmakers cut funding for the state's family planning program, says Stacey Pogue, a health policy analyst with the Center for Public Policy Priorities in Austin. The cuts came at a time when the state's population was growing and more women were seeking services, Pogue notes.
"The ability of our safety net system to meet those needs and deliver health care — to actually get health care to women who are looking for contraceptives and well-woman exams — that has certainly been diminished," she says.
Apps like NURX that give women access to at least some types of contraceptives are definitely helpful, she says. But they aren't a comprehensive solution.
Some of the most effective types of birth control — IUDs and implants — aren't available through the apps, Pogue notes, because they require a visit to a health provider. And apps will never substitute for the missing medical clinics — places where, beyond contraception, women could also get life-saving services, such as pap smears, breast exams and cervical cancer screenings.
Texas is one of two states (Indiana is the other) where minors can't buy prescription birth control through NURX because of laws restricting minors' access to contraception.
DAVID GREENE, HOST:
You know, there seems to be a smartphone app for everything. You need a taxi, you use a ride-sharing app. You want food, you have delivery apps that are a dime a dozen. Well, now access to birth control is a few clicks away. Online services allow patients to avoid waiting rooms, pharmacies, even political controversy. But is it safe to skip the doctor? We have two reports now - one from California, which is providing the service, and another from Texas, where women are using it. First, Lesley McClurg from member station KQED in San Francisco.
(SOUNDBITE OF FOOTSTEPS)
LESLEY MCCLURG, BYLINE: It's nearly 8 o'clock at night. Rachel Ralph trudges up the stairs to her apartment.
(SOUNDBITE OF LOCK OPENING)
RACHEL RALPH: I'm very happy it's the end of the day.
MCCLURG: She works long, erratic hours at an accounting firm in Oakland, just across the bay from San Francisco. The floor of her artsy apartment is covered in mail. She picks up a package.
RALPH: It's just basic birth control pills. I've been on the same kind forever.
MCCLURG: She ordered a three-month supply of pills from an app called Nurx. It's one of several digital ventures, like Maven and Lemonaid, that provide contraception. Ralph heard about the service about six months ago when she was regularly working 12-hour days. She coordinated as much of her life as possible through apps.
RALPH: Food was delivered. Dinner was often delivered. Anything I could get sent to my house with little effort, the better.
MCCLURG: Millennial women like Ralph were some of the first users of Nurx. Hans Gangeskar is one of the founders of the San Francisco startup. He wanted to make it easier for women to access birth control.
HANS GANGESKAR: There's no offering for people who need something quickly from the healthcare system and then sort of just want to go on with their life.
(SOUNDBITE OF MUSIC)
MCCLURG: Lounge music plays in the background at Nurx headquarters, an upscale brick loft. Most of the company's employees are 20-somethings dressed in skinny jeans and T-shirts. Many consider themselves activists trying to prevent unplanned pregnancies.
GANGESKAR: We naively thought that if you go to a doctor, even if it's in a really red state and in a really small town, and you, like, suffer through the judgment and the questions, that you would walk out with a prescription to birth control. And the fact that that's not true really surprised us.
MCCLURG: That's why patient interactions take place almost exclusively in online chats. Jessica Horwitz is a nurse practitioner for the company who consults with patients.
JESSICA HORWITZ: Maybe they don't feel comfortable saying to their doctor in front of them, you know that birth control I was on before, like, killed my sex drive.
MCCLURG: The whole process is pretty simple. After users log into the app, they fill out a medical questionnaire.
HORWITZ: They tell us about their medical history. They give us a blood pressure check.
MCCLURG: Then a clinician, like Horwitz, reviews the answers and makes a suggestion for a pill, a ring or a patch. The morning-after pill is also available. If the patient has a question about the product, they can send a chat.
HORWITZ: And it doesn't matter what time of day it is, someone responds.
MCCLURG: Then a prescription is sent to a pharmacy, and the drugs are mailed out. Jennifer Conti is a gynecologist at Stanford University. She says that process is safe, but something is lost in virtual medical care.
JENNIFER CONTI: The downside with making it too simplistic is that a lot of times in real life, there's follow-up questions.
MCCLURG: Conti says face-to-face interactions allow for more nuanced care, which she says is especially necessary for patients with medical complications.
CONTI: That's the situation in which you want to be seeing an actual gynecologist and talk in person about what might be the right method for you.
MCCLURG: But seeing a gynecologist is difficult for some women. Nurx sells contraception in 18 states. And some of their customers live in areas with no easy access to women's health services. For them, a smartphone is another way to prevent pregnancy. For NPR News, I'm Lesley McClurg in San Francisco.
ASHLEY LOPEZ, BYLINE: And I'm Ashley Lopez in Texas, where many women live in these so-called contraception deserts. Claire Hammons is one of them. She lives in a small community in Central Texas about an hour and a half outside of Austin. It's called Llano.
CLAIRE HAMMONS: It's a very small town. There's a population of 3,000 people. But we have a lot going on. We're a huge art town. We have the Llano River. We're surrounded by state parks.
LOPEZ: Living in a small town like Llano has its drawbacks. There's only one doctor, and there are no clinics nearby. For Hammons, this means getting health care isn't easy. And Hammons says what she needs the most is birth control pills.
HAMMONS: I've been taking birth control since I was 16 because of endometriosis.
LOPEZ: Without birth control pills, Hammons is in a lot of pain every month. And a while ago, she had a particularly hard time getting a prescription. That's because she lost her health insurance.
HAMMONS: I really did not have - literally have the money to go to the doctors, period. And the local doctor - the only doctor, you know - is $140 to get in.
LOPEZ: She would also have to pay out of pocket to pick up the pills every month at a pharmacy. And Hammons says she just couldn't afford it. But about six months ago, Hammons went online and found out about Nurx. The app offers birth control pills at a price she can afford, and she doesn't have to pay to see the doctor. Hammons says finding Nurx has been...
HAMMONS: Really amazing, and awesome and saved me a lot.
LOPEZ: Texas has become a big user base for the app. Dr. Brook Randal is a physician based in Austin working for Nurx. She says patients come from different backgrounds and use the app for different reasons.
BROOK RANDAL: A lot of them are low-income women who may not have a low-cost clinic available to them in the communities where they live.
LOPEZ: In 2013, Texas passed an abortion bill that led half the states' clinics, which performed abortions, to close. Clinics that often also provided birth control and other medical services.
RANDAL: And so many of those women will tell us that they would've had to drive a really long distance in order to get to a clinic where they could get birth control economically. And so we provide an important service for those women.
LOPEZ: Advocates say the state has long struggled to serve low-income women seeking contraception. And access also got worse when Texas lawmakers cut funding for the state's family planning program. Stacey Pogue with the Center for Public Policy Priorities in Austin says the cuts came at a time the state's population was growing and more women were seeking services.
STACEY POGUE: The ability of our safety net system to meet those needs and deliver health care, to actually get health care to women who are looking for contraceptives and well-woman exams - that has certainly been diminished.
LOPEZ: Pogue says it's a good thing women are finding ways to get birth control pills through technology. But she says this app doesn't give women access to more effective birth control, like IUDs and implants. It also is not a substitute for clinics that provide lifesaving services like pap smears, breast exams and cervical cancer screenings. For NPR News, I'm Ashley Lopez in Austin.
[POST-BROADCAST CORRECTION: In the audio of this story, as in a previous Web version, we incorrectly suggest that Llano, Texas, has only one doctor. In fact, there are about a dozen physicians there, and most of them provide primary care.]
(SOUNDBITE OF THE MICROPHONES SONG, “I WANT WIND TO BLOW”) Transcript provided by NPR, Copyright NPR.