Legislature(2001 - 2002)
05/11/2002 05:50 PM House FIN
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* first hearing in first committee of referral
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= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
SENATE BILL NO. 364
An Act relating to medical services under the state
Medicaid program.
GWENDOLYN HALL, STAFF, SENATOR PETE KELLY, noted that a
majority of Alaskans agree that it is inappropriate to use
State funds to provide elective abortions. Despite the many
efforts of the Legislature, the State has been unable to
implement the will of the people. All attempts to bring
Alaskan Medicaid funding under federal standards, which
prohibit funding abortions except for rape, incest and life
of the mother, have been thwarted by the Alaska Supreme
Court.
Ms. Hall stated that the Alaska Administrative Code defines
therapeutic abortion as:
"The termination of a pregnancy, certified
by a physician as medically necessary to
prevent the death or disability of the woman,
or to ameliorate a condition harmful to
the woman's physical or psychological health."
"Medically necessary" has proved to be too broad language,
allowing elective abortions to take cover under the umbrella
of protection. She suggested that any form of emotional
discomfort a woman may experience from pregnancy could
warrant a "medically necessary" termination. Ms. Hall noted
that SB 364 would define "medically necessary", restricting
Medicaid funded abortions to those cases that fall under the
Hyde Amendment guidelines.
REPRESENTATIVE FRED DYSON explained that Senator Kelly has
attempted to narrow down the definition of what is medically
necessary for emotional and psychological problems. SB 364
makes a clear provision that the woman must, in order to
maintain emotional and psychological stability, take a
powerful drug, which would not endanger the child, and
currently is allowed. The bill would "tighten" up that
language.
He pointed out that in 1998, when the Legislature tightened
up the language on "medical necessity", the number of State
funded abortions dramatically decreased. That court case
was overturned and it now appears that more abortion cases
are being paid with State dollars.
Representative Dyson advised that all polls in Alaska
indicate that the public is not interested in using public
money to fund abortions.
Representative Davies asked the definition of "medical
necessity" used in the State of Michigan.
Ms. Hall read the list of complications listed in that
report:
· Shock
· Uterine Perforation
· Cervical Laceration
· Hemorrhage
· Allergic Response
· Death
· Infection
· Retained Products
· Other complications
Representative J. Davies pointed out that no psychological
sections had been added.
Ms. Hall acknowledged that was true.
Representative Whitaker asked for clarification that the
bill would not restrict the Supreme Court decision Roe
versus Wade and the woman's right for an abortion. He noted
that the legislation only restricts what the State will pay
for.
Representative Dyson agreed.
DR. COLEEN MURPHY, (TESTIFIED VIA TELECONFERENCE),
PHYSICIAN, ANCHORAGE, testified in opposition to the
proposed bill stating that it is important that Alaska not
compare itself to Michigan. The Alaska State Constitution
has a greater right to privacy than Michigan State one does.
Dr. Murphy stated that previous testimony indicates how lay
people confuse indications for incomplete abortions. There
is a difference between evacuating a uterus for a uterine
preparation and an incomplete product of conception. It is
important to understand those distinctions. At present
time, legislators are attempting to provide what they
determine a "clear" provision of what constitutes "medical
necessity" for termination of a pregnancy.
Dr. Murphy noted that she is a practicing medical doctor,
who currently provides reproductive health services to women
in need. The language of the bill is not clear. She
commented that the bill attempts to meddle in the
relationship between a doctor and their patient, a
relationship which should remain private.
Dr. Murphy explained that when she talks with women about
their pregnancies, she requests an informed consent about
that pregnancy. Each woman signs certain conditions that
are acceptable.
Dr. Murphy provided hypothetical pregnancy situations
questioning if they were considered appropriate for
consideration of "medical necessity". She acknowledged that
she personally could not make that determination for any
woman and that ultimately that must be their choice. It
should be a very private discussion.
Dr. Murphy voiced concern that when a woman is depressed
that they should be medicated during their pregnancy. She
reminded members of the Committee that Andrea Yates
experienced multiple signs of depression throughout her
pregnancy preceding the murder all her children. She warned
members that the patient's doctor should make the ultimate
choice regarding medication.
Dr. Murphy stressed that pregnancies, where the woman wants
a termination, are high-risk pregnancies. Right now the
State Medicaid program costs $450 dollars for a State
termination of pregnancy. If those pregnancies go on to
full term, basically, the State would be paying out $75
dollars for every prenatal visit and $1500 dollars for the
delivery services. She emphasized that if the State wants
to save money, give women what they want and do not judge
them for their choice. She reiterated that women should be
able to decide for themselves.
TAPE HFC 02 - 109, Side B
Representative Croft asked if defects of the fetus would fit
into the definition.
Dr. Murphy advised that some of the highest risk medical
conditions for women are associated with a 50% mortality
rate. She addressed primary pulmonary hypertension
conditions associated with up to a 50% mortality rate. She
pointed out that nothing is 100% guaranteed. Doctors can
access good pictures of what the fetus looks like but the
ultimate outcome cannot be determined until birth.
Dr. Murphy commented that the legislation gives doctors too
much credit about their ability to predict outcomes. She
stressed, ultimately the decision is a private choice
whether a woman wants to continue a pregnancy associated
with long term disabilities. Those costs are usually
shifted from the family to the State.
Dr. Murphy discussed the number of uninsured people that
live in the State of Alaska. Many of those uninsured people
qualify for the State Medicaid Program for their pregnancy
care. She added that she was disturbed that there is a
partial solution for some of the unwanted pregnancies, the
prescription equity bill. She stated that bill should have
been addressed with the legislation before the Committee.
There are women that do not receive contraception options
through their current insurance provider. She noted that
contraception works and prevents unintended pregnancies.
Dr. Murphy mentioned that the rate of termination of
pregnancies in Alaska is lower than most other states.
There are tremendous access issues compared to other states.
The most recent statistic in Alaska is that 16% of
pregnancies result in termination as compared to 34% in all
other states. The epidemic in this State is uninsured women
seeking reproductive health.
Vice-Chair Bunde commented that medicine is more of an art
than it is a science. He claimed there is a "public policy
issue" regarding women that use abortion for birth control.
He questioned how often that occurs.
Dr. Murphy replied that there is national data regarding
that concern with 50% of women using a contraceptive
technique and 50% not using a contraceptive. Despite
efforts to have reliable contraceptive devices, there will
continue to be contraceptive failures. One out of two women
that come in for a termination of pregnancy have used
contraceptives. The other 50% of women, who did not use
contraceptives, have an opportunity to prevent the pregnancy
by using "Emergency Contraception". Most women are very
responsible. She challenged that the Committee provide a
companion bill, which legislates the sexual behavior of men.
Vice-Chair Bunde asked if out of 100 performed abortions,
would 25 of those result from accidents using birth control.
Dr. Murphy spoke to the elective abortion. Invariably every
woman contemplates the risk factors involved with her
pregnancy. There is nothing elective about those risks.
Abortion is not a procedure that most women want to under
go. They would prefer to avoid it.
DR. JOHN MIDDAUGH, (TESTIFIED VIA TELECONFERENCE),
EPIDEMIOLOGY SECTION, DEPARTMENT OF HEALTH AND SOCIAL
SERVICES, spoke in opposition to SB 364.
Dr. Middaugh explained that the legislation has language
problems with regard to the physician and patient
relationship. The absence of a fair understanding and the
meaning of the language, physicians would have great
problems meeting the certification required by the
legislation. The terms "serious, adverse, physical
conditions" could seriously aggravate the physical health.
That language would need to be interpreted to enforce the
statute.
The language also has problems in the areas of psychological
illness that require medication. He pointed out that there
are many serious psychological illnesses that are not
treated by medication. Because of the wording, women who
have a serious mental problem would not be eligible for
funding. Dr. Middaugh proposed to delete "would" and insert
"could" or "might". Rarely, if ever, can physicians make a
prediction to 100% accuracy. By requiring a standard of
"would", implies a certainty that almost could never be met.
Dr. Middaugh pointed out that the bill omits coverage in all
instances in which a pregnant woman bearing an infant with
horrible congenital malformations, even if they are known to
be incompatible with the mother's life.
Dr. Middaugh reiterated that there is no epidemic of
abortions in Alaska. He pointed out that Alaska ranks #33
of all the states for the number of average abortions. The
State's policy does not pay for elective procedures.
In summary, Dr. Middaugh urged that the bill not be passed
and offered to answer questions of the Committee.
Vice-Chair Bunde asked if the statistic for Alaska's rate
was based on per capita or total numbers performed.
Dr. Middaugh replied that the rate was based on the number
of abortions for 1000 women between the ages of 15-44 years.
In 1997, the national rate was 22 women per thousand and in
Alaska that rate was 12 per thousand.
Vice-Chair Bunde inquired the difference in comparison
between Michigan and Alaska.
Dr. Middaugh responded that the numbers quoted for Michigan
were based on Michigan State law that was restrictive and
enabling payment only for saving the life of a woman. He
advised that law has been held unconstitutional. Using
those figures today would be inaccurate.
Representative Hudson asked about Dr. Middaugh's
recommendation on Page 2 replacing "would" with "could" or
"might".
Dr. Middaugh advised that "would" implies that you know that
something is going to happen with 100% certainty; however,
medicine is always about probability. The physicians can
only inform patients of probable outcomes.
Vice-Chair Bunde asked if it would be medically more
accurate to say "would more likely".
Dr. Middaugh recommended using "could" or "might". Using
"would more likely" would eliminate the eligibility of women
who should have a therapeutic and indicative procedure.
Those women would fall outside that category.
Vice-Chair Bunde commented that "could" was far too
permissive and agreed that "would" allows little. He
inquired if there was any middle ground.
Dr. Middaugh pointed out that for three years,
Representative Rokeberg attempted to define "medical
necessity" in the patient's bill of rights and in those
efforts, he was unable to do so. All the efforts lead to
additional problems and basically do not take into account
the unique circumstances and problems that happen in the
practice of medicine. Dr. Middaugh reiterated that there
are not a large number of abortions occurring in Alaska, and
that in fact there is a high bar related to limiting
procedures to those that are medically needed. He noted
that information should only be decided between a physician
and a patient.
WILLIAM CRAIG, ALASKA INDEPENDENT BLIND, SITKA, spoke in
support of the legislation. He commented on various
individuals that have had developmental disabilities that
went on to become important people in society.
HELEN CRAIG, SITKA, commented that sexual abuse and rape
would be reasons for a woman to be able to have an abortion.
She admitted that babies are priceless and the ultimately
the decision should be left to the woman and her higher
power and the doctor. Ms. Craig stated that the decision
comes down to moral choices.
CHIP WAGONER, ALASKA CATHOLIC CONFERENCE, JUNEAU, stated
that there is nothing in the bill that interferes between
the doctor and the patient's relationship. The
communication between the physician and the patient will
continue just as before, and the decisions made between the
doctor and the patient will continue just as before. The
only difference is that if the bill passes, State Medicaid
funds would no longer be used to pay for the abortion
procedure.
Mr. Wagoner continued, the reason that the statute is needed
is because there is no other medical procedure paid for by
Medicaid funds for purely elective reasons. He stressed
that the issue was the payment.
He added that an additional issue is the language of "would"
verses "could". Using "would" modifies the word "aggregate"
and would be dangerous. To change "would" to "could" would
basically gut the bill because everything "could" be an
opportunity. He emphasized that if "would" was not used in
the bill, there would be no reason for the legislation.
There is an additional safeguard in the bill. It was
impossible to write the bill to take into consideration
every circumstances; that is why there are regulations and
that is why the bill authorizes the Department of Health &
Social Services to adopt regulations. He recommended that
the Department should have a review process to determine
medically necessary cases.
Mr. Wagoner spoke to the "uncomplicated" legal abortions,
which were performed that were unnecessary. He addressed
the unwanted pregnancies. Diagnosis codes should be closely
scrutinized. State funds should be used outside of the
State determined necessity and that Medicaid funds should
not be used for those abortions. Mr. Wagoner noted that the
Alaska Catholic Conference strongly supports the bill.
NANCY WELLER, DIVISION OF MEDICAL ASSISTANCE, DEPARTMENT OF
HEALTH AND SOCIAL SERVICES, offered to answer questions of
the Committee regarding the bill. Ms. Weller distributed a
handout: "Complications of Pregnancy, Childbirth, and the
Puerperium". (Copy on File).
She stated that the list of diagnostic codes for abortion
procedures are very specific and do not correlate to those
suggested by previous testimony. The diagnosis codes used,
determine if there are complications to the woman and/or the
baby. Ms. Weller offered to answer questions of the
Committee.
Vice-Chair Bunde asked about the code, which addresses the
psychological problems of the mother.
Ms. Weller replied that the codes do not indicate why the
abortion is performed, but rather indicate what type of
abortion it is such as a spontaneous abortion or
miscarriage.
Representative Croft asked if "complicated" meant that the
medical procedure was complicated by some other thing and
not a justification of why it needed to be done.
Ms. Weller agreed that was correct.
Representative Hudson referenced the court case definition
previously referenced and asked if the language "medically
necessary" was essential.
Ms. Weller explained that the Division was following the
court order under the language that the Court put forth.
She noted that she could not judge from the fiscal note what
physicians might do in reaction to the court order. She did
not know how the current regulations were being interpreted.
SB 364 was HELD in Committee for further consideration.
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