Legislature(2017 - 2018)CAPITOL 106
04/17/2018 03:00 PM HEALTH & SOCIAL SERVICES
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SB 198-UAA LONG-ACTING CONTRACEPTION STUDY 3:04:25 PM CHAIR SPOHNHOLZ announced that the first order of business would be SENATE BILL NO. 198, "An Act relating to a study of the effectiveness and cost of providing long-acting reversible contraception to women with substance abuse disorders." 3:05:12 PM SENATOR PETE KELLY, Alaska State Legislature, shared some background of his reasons for bringing the bill forward and paraphrased the Sponsor Statement [included in members' packets] [original punctuation provided], which read as follows: The rising rate of maternal opioid use has resulted in a drastic increase in children born with Neonatal Abstinence Syndrome (NAS). In Alaska, the incidence of children born with NAS has increased over 500% from 2004 to 2015. 1 In addition to the ongoing opioid crisis, Alaska continues to report one of the highest rates of fetal alcohol spectrum disorders (FASD) in the nation. The true rate of FASD in the state is likely to be significantly higher according to recent national prevalence studies. Through SB 198, the UAA Center for Alcohol and Addiction Studies will evaluate the feasibility and effectiveness of providing Long Acting Reversible Contraception (LARC) to women involved in services such as Alaska Regional Hospital's Neonatal Abstinence Evaluation Support Treatment (NEST) program. The population of women served by the NEST program represent one of the highest risk groups in Alaska for unintended pregnancy and prenatal drug/alcohol exposure. The public health consequences of NAS and FASD addressed by this program highlight the critical importance of providing effective long-term contraception options to women struggling with alcohol and drug addiction challenges. SB 198 is an important step in eradicating FASD and NAS in Alaska. This study will provide critical data on LARC as an effective tool in reducing the rates of FASD and NAS. Furthermore, the anticipated outcomes can inform future state spending related to LARC as a public health strategy and its utility for reducing pressure on state programs and budgets. Approximately 50% of infants with Neonatal Abstinence Syndrome treated at Alaska Regional Hospital's NEST program were immediately placed into the care of the Office of Children's Services. 1 In Alaska, the Department of Health and Social Services has estimated the average cost of treating an infant with NAS is $88,869, which is predominantly paid by Medicaid.2 According to the Alaska Department of Health and Social Services, each child born with FASD in Alaska will cost the State of Alaska between $860,000 and $4.2 million dollars from birth to age 18. SB 198 is a foundational step towards turning the tide on these staggering statistics. 3:13:17 PM HEATHER CARPENTER, Staff, Senator Pete Kelly, Alaska State Legislature, paraphrased from the Sectional Analysis, [Included in members' packets] which read: Section 1: (A)Directs the University of Alaska Anchorage Center for Alcohol and Addiction Studies to conduct a study to evaluate the effectiveness of providing long-acting reversible contraception (LARC) to women with substance abuse disorders who are at high risk for unintended pregnancies that may result in prenatal drug or alcohol exposure. The study shall be done in collaboration with hospitals and health care providers in Alaska who treat women with substance abuse disorders and: (1) Establish an advisory council to assist with designing and implementing the study, (2) Evaluate best practices for treating women and children when there is a high risk of neonatal abstinence syndrome (NAS) or fetal alcohol spectrum disorders (FASD), (3) Facilitate a network for sharing of best practices, (4) Identify women and children to participate in the study on a voluntary basis, (5) Provide LARC to participants who are at a high risk for unintended pregnancies that may result in prenatal drug or alcohol exposure, (6) Evaluate the cost and effectiveness of providing LARC to reduce the occurrence of NAS and FASD, (7) Develop a cohort of women and children who can be evaluated in later studies regarding NAS and FASD, (8) Provide a data driven framework to establish a comprehensive strategy for using LARC to reduce NAS and FASD in Alaska. (B) Directs the University to complete two interim reports by June 30 of 2019 and 2020 and a final report by June 30, 2021. (C) Provides definitions for "fetal alcohol spectrum disorder," "long-acting reversible contraception," and "neonatal abstinence syndrome." Section 2: Repeals Section 1 on June 30, 2021, which coincides with the date of the final report on the project 3:17:06 PM SENATOR KELLY, in response to Representative Zulkosky, explained that the NEST program was the Neonatal Abstinence Evaluation Support & Treatment program to treat women with substance abuse problems at Alaska Regional Hospital. He said that this was an example of the kind of program that would be partnered with in the proposed research program under SB 198. REPRESENTATIVE ZULKOSKY reflected on the research regarding the efficacy of long-acting reversible contraception and asked what medical question remained that was necessary to cover in the proposed bill. SENATOR KELLY offered his belief that the depth of information derived from the pregnancy test dispensers revealed a question as to what was effective and for what populations. 3:19:39 PM MS. CARPENTER explained that this was applied health research, that the long-acting reversible contraception (LARC) would be provided and data would be gathered. She stated that it was important to have a smaller test group. She explained that the NEST program was doing a good job providing intense services, pointing out that it cost $88,869 for treatment of an infant with NAS (Neonatal Abstinence Syndrome). She noted that the fiscal note would help fund provision of the LARC. REPRESENTATIVE ZULKOSKY stated that the Department of Health and Social Services had reported more than 3400 Medicaid claims for coverage of LARCs and asked what were the barriers that Ms. Carpenter referred. 3:23:08 PM MS. CARPENTER offered her belief that, although 80 percent of women stopped drinking when they found out they were pregnant, the LARC study would impact "this very vulnerable population who have alcohol and addiction." She shared that there were about 120 new cases of FASD (fetal alcohol spectrum disorder) diagnosed and that the NEST program was serving a lot of this high-risk population. She reported that, for women with an FASD or NAS baby, there was a high likelihood for having another baby with FASD or NAS. This would offer a woman an option right after birth to have LARC or some other contraception. SENATOR KELLY offered that this population may never attempt to get those contraceptive services, which may separate them from the general Medicaid population. 3:24:01 PM REPRESENTATIVE KITO noted that he did not see a request from the University research department for this study. SENATOR KELLY replied, "yes." In response to Representative Kito, he said that it may not be in the material, his office had been asked to move forward with this. 3:24:22 PM REPRESENTATIVE KITO asked where that was stated in the material, as there did not appear to be a formal request. SENATOR KELLY said that he would obtain a request. 3:24:28 PM REPRESENTATIVE KITO shared that none of the members of the legislature were research scientists and that, as this proposed study appeared to be a political policy direction not based on any scientific knowledge, this caused him "grave concern." He declared that when the legislature requested money to generate a data set, that data set was not objective. He referenced an earlier statement that 20 percent of women did not quit drinking [when pregnant] and that this study would target those women. He asked whether this 20 percent of women were all in the NEST program. 3:25:53 PM SENATOR KELLY expressed his agreement that, as the members of the legislature were not scientists, the UAA Center for Alcohol and Addiction Studies had requested to conduct the program. He added that the idea for the study was to get to a more representative smaller population. He stated that this was just a research program, not a program for statewide distribution of contraceptives. 3:26:21 PM REPRESENTATIVE KITO offered his belief that the original statement had been for this data to be used to inform future policy. He expressed his concern that, as this question was not scientifically posed, the information would not be universally useful. SENATOR KELLY reiterated that this was the reason to have the Center for Alcohol and Addiction Studies run the program. 3:27:01 PM REPRESENTATIVE JOHNSTON suggested that this study was for how we can best provide a birth control service that would be helpful to the community and how to eradicate FAS. She mused that it was more of a pilot process for how to create an effective program for the State of Alaska. SENATOR KELLY added that it was also for "studying this particular population." 3:28:04 PM REPRESENTATIVE TARR expressed her concern that this set up a situation that separated a woman from her addiction by focusing on control of her ability to reproduce. She offered her belief that, although this may be a temporary way to relieve a situation for as long as she has the LARC and would not become pregnant, the underlying problem was the addiction. She declared that it was necessary to "view the woman as a whole person, pregnant or not pregnant, with addiction or not having addiction." She asked how the other needs would be met "through participation in this potential research program." She declared that it was necessary for a woman to get comprehensive information to choose the method that was right for her. It should not be an assumption entering this study that the LARC was the best method. She pointed out that there were adverse health and cultural issues to be addressed, and she suggested that, if a woman did choose to participate and had some adverse effects, there should be the ability for follow up health care and counseling. SENATOR KELLY expressed his agreement that the addiction and the reproduction should not be separated. 3:31:30 PM MS. CARPENTER directed attention to the fiscal note, which included payment for a case manager position to ensure that all the women would receive assistance and critical services such as addiction treatment and access to housing. She offered her belief that it was a benefit to do the research this way, as there was a high bar to work through the university. 3:32:44 PM REPRESENTATIVE ZULKOSKY asked about the fiscal note, which indicated that, although the funding would cover the personnel costs for the investigators and the case management, and the associated medical costs for providing the contraceptive, there was no indication for the cost of removal if there were an adverse reaction to the LARC. MS. CARPENTER explained that this was one of the pieces that would be addressed by the University while setting up the program. 3:34:05 PM CHAIR SPOHNHOLZ opened invited testimony on SB 198. 3:34:17 PM AMANDA SLAUNWHITE, Associate Professor, Center for Alcohol and Addiction Studies, College of Health, University of Alaska Anchorage, stated her support for the proposed bill. She declared that "this critical project will partner the university with a network of hospitals and health care providers lead by the NEST program at Alaska Regional to evaluate increased access to substance abuse treatment and effective contraception to women in need, including mothers with opioid use disorder." She said that women with substance abuse disorders reported an unintended pregnancy rate of nearly 90 percent, and that significant barriers existed for access to substance abuse treatment and effective long lasting reversible contraceptives. She added that most mothers addicted to opioids when leaving hospitals would not have access to substance abuse treatment services or effective family planning services. She reported that, as almost 70 percent of mothers with one child exposed to drugs or alcohol in utero will have another, it was very important to figure out a way to solve these challenges for unintended pregnancies and access to substance abuse treatment. She stated that the ethical oversight offered by the institutional review board would protect all the human subject research at UAA to ensure that the research fulfilled the federal regulations and requirements and operated in an ethical and non-coercive manner. She added that the staff were highly experienced in conducting applied health research projects with vulnerable populations. She offered an example of the Vivitrol evaluation project being completed in conjunction with the Department of Corrections. She noted that UAA offered assurance to the Department of Health and Social Services that they would meet all the requirements outlined in federal regulations, which ensured that projects conducted by researchers met the highest ethical standards, including that risk was minimized, the protocols were not coercive, and informed consent was obtained. She declared that participation was always voluntary and that participants could withdraw at anytime for any reason. She declared that the program fully anticipated that the proposed bill would result in improved health outcomes to mothers and infants, and significantly reduce the cost and social impact associated with unintended pregnancy and prenatal drug and alcohol exposure. 3:38:41 PM REPRESENTATIVE KITO asked about her doctorate. DR. SLAUNWHITE said that her PhD was in Health Geography, with background as a research scientist. 3:39:10 PM REPRESENTATIVE KITO asked who would provide the medical oversight for the participants. DR. SLAUNWHITE said that an advisory board would be guiding the development of the protocols for the research. 3:39:32 PM REPRESENTATIVE KITO pointed out that these were invasive medical procedures on people and reiterated his question for the medical responsibility to the patients. DR. SLAUNWHITE explained that they would work in partnership with the NEST program at Alaska Regional Hospital. 3:40:10 PM REPRESENTATIVE KITO asked for verification that the medical director and the doctors would be providing medical oversight for these participants. DR. SLAUNWHITE expressed her agreement, noting that the participants would be patients of Alaska Regional Hospital. 3:40:27 PM REPRESENTATIVE KITO asked about any relationships with other hospitals for this study. DR. SLAUNWHITE opined that the advisory group would approach interested hospitals about participation. She shared that she had on-going relationships with numerous other hospitals. 3:41:11 PM REPRESENTATIVE KITO asked for a request to this study since he did not see it in members' packets. DR. SLAUNWHITE explained that they had been working to get funding in place to conduct the work. She listed some of the applications submitted but pointed to the urgency for getting the work underway due to the opioid epidemic. She stated that a large portion of the study would focus on women currently struggling with opioid use disorder and would collect data on the mothers and children to track them through adolescence and adulthood. 3:42:34 PM REPRESENTATIVE KITO offered his agreement that prevention of an unwanted pregnancy during alcohol or drug use would result in better outcomes for the child and asked what was the question seeking a resolution. He mused that the only need was to provide for the appropriate contraception to individuals with alcohol or drug problems and that it was not necessary to study whether a contraceptive would decrease incidences of FAS or NAS. DR. SLAUNWHITE replied that it was necessary to find the way to do that. She shared that, as many women were detached from health care providers and would not seek pre-natal care, the question was how to reach these women to offer addiction treatment and family planning resources. 3:44:44 PM REPRESENTATIVE KITO suggested that, as family planning, counseling, and contraceptive use would be beneficial, why was there a focus on the LARCs. DR. SLAUNWHITE explained that past research had indicated that women with substance abuse issues did not have a high adherence to traditional forms of birth control. She added that LARCs were often chosen because of the ease. 3:45:50 PM REPRESENTATIVE KITO offered his belief that this should be a decision between the patient and a medical professional, and not directed by a study. DR. SLAUNWHITE pointed out that the women had full choice for birth control including LARC. 3:46:10 PM REPRESENTATIVE KITO asked if the proposed bill included more than a LARC, as that was not stated in the bill, and if so, then the proposed bill needed to be corrected. CHAIR SPOHNHOLZ suggested that there were more questions about the protocol and the entry point for women participating in the study. 3:46:37 PM REPRESENTATIVE JOHNSTON asked if the advisory council would be part of the initial development of the study, how it would interact with the academic committee, and what would be its makeup. DR. SLAUNWHITE replied that the advisory council would be fully integrated into the academic research component of the project. She said that she would fully expect that the advisory council would provide input and guidance on all aspects of the research project. She opined that the council would be made up of stakeholders from throughout the state including family planning, women's health services, pediatricians, and the Office of Children's Services. 3:48:04 PM REPRESENTATIVE TARR posed that Dr. Slaunwhite had offered a much broader description of the project than what was included in the proposed bill. She questioned whether the National Institute of Health would support the proposed bill. She opined that the research question should be for the most effective intervention for women at high risk for substance use disorders that could result in pregnancies with the offspring having FAS. She declared that the research project should not be entered with any kind of inherent bias as it would negate the value of the study. She offered her belief that this also made the choices a bit coercive as the study was geared toward the use of LARCs. She reiterated that the proposed bill and the study as described by Dr. Slaunwhite were different. DR. SLAUNWHITE said that the bill did describe the development of a cohort related to the broadening that had been referenced. REPRESENTATIVE TARR said that research from Alaska Regional Hospital, the largest urban center in the state, should not be applied statewide as it was not relevant, especially to questions for access. She noted that there was not any indication where the other collaborations would be. She declared that $500,000 was not enough money to do this study properly because one adverse reaction with one woman which required hospitalization could "eat up thousands and thousands of dollars in short order." She added that there was not any follow up care addressed in the proposed bill. DR. SLAUNWHITE said that Alaska Regional Hospital was the only unit in Alaska that was specifically designed to treat neo-natal abstinence syndrome. She said that data had shown that 82 percent of infants born with in-utero opioid exposure were from the Anchorage area. She declared that it was desired to have collaborators from throughout the state to have the rural-urban diversity. 3:52:34 PM REPRESENTATIVE ZULKOSKY asked for elaboration about the research question, offering her belief that it "treads really closely to some historic issues around forced sterilization for certain subsets of the population." DR. SLAUNWHITE reported that women would have the choice for the type of birth control, if any, that they would prefer to receive. She explained that the focus was on LARC because of the scientific foundation that LARC were very effective for women with substance abuse disorders in reducing rates of unintended pregnancy. She added that women who receive the LARC would be the intervention group, and women who decide to either not receive any birth control or receive a different form of birth control would be the comparison group. 3:55:20 PM REPRESENTATIVE ZULKOSKY asked if the research dollars would cover women using a type of birth control other than LARC. She asked how the research would address access to contraceptive counseling training for health care providers, and whether there were experts in family planning and contraceptive counseling included in the design and implementation plans for the proposed study. DR. SLAUNWHITE replied that they would like to have family planning experts "heavily involved in this project" and engaged in the conversations for the research protocol. She suggested that coverage for the removal and medical care could be covered by Medicaid. She offered an example for a similar situation to the aforementioned vivitrol program. She added that the substance abuse treatment services and case management would be provided to women in the NEST program at Alaska Regional Hospital, as the health insurance status of the participants could be determined. She stated that a broader discussion for the options to women without health insurance would be a conversation with the advisory group in order to determine participation in the study. 3:57:58 PM REPRESENTATIVE ZULKOSKY questioned the necessity of the expense for a $0.5 million study when it was already known that Alaska women eligible for Medicaid had access to LARCs if they so desired. She suggested that the money be used to provide a process or comprehensive care, instead of "looking at the need for efficacy in a particular group of women." DR. SLAUNWHITE said that it was known that this group of women was not accessing these services and that it was necessary to learn more for how to reach these women and how to provide care, treatment, and services after delivery of a drug or alcohol exposed infant. 3:59:41 PM CHAIR SPOHNHOLZ reflected on the question of contraception to address Fetal Alcohol Syndrome (FAS) and neo-natal abstinence syndrome (NAS) and asked if the study was about the care coordination as much as about delivery of contraception. DR. SLAUNWHITE acknowledged that, although it was known that contraception, especially LARCs, was successful, it was the coordination for delivery and the services that was the core of the intervention. She said that these were not currently being provided in maternity services. 4:00:40 PM CHAIR SPOHNHOLZ asked if this was "a care delivery model that is being framed as a study." DR. SLAUNWHITE expressed her agreement and said that the Alaska Regional Hospital NEST program was selected as the first pilot site because it was a unique program using an evidence based, anti-stigma, family-oriented approach toward the birth of an infant exposed to opiates and other drugs. She declared the desire to build on this existing model as it was known to be effective for reducing the need for medication during withdrawal and for increasing mother-baby bonding. She said that these services would get the mother into addiction treatment and provide family planning resources. 4:02:07 PM CHAIR SPOHNHOLZ asked if there were partnerships with any other hospitals. DR. SLAUNWHITE replied that there were partnerships and collaborations with researchers and medical staff at many other institutions throughout Alaska. She noted that conversations with facilities in Fairbanks for their program changes had indicated this as "a really great second site, if they're interested because they are starting to use some of the approaches used by the NEST unit." 4:03:01 PM CHAIR SPOHNHOLZ asked how the program would specifically identify the patients and the type of care available as part of this process. DR. SLAUNWHITE explained that the protocols would be developed with the advisory council, as this discussion was just beginning. She said that a woman who had disclosed a substance exposed pregnancy could potentially be approached by medical or research staff for participation in the study and she would be briefed on her rights as a participant. She would be given a lengthy consent form and then a care coordinator and social worker would be provided to collect information. 4:05:03 PM CHAIR SPOHNHOLZ asked if contraceptive care was paid for by the study from the point of consent to participate. DR. SLAUNWHITE replied that there would be an evaluation to determine whether the participant had health insurance coverage. If not, there was an amount in the budget to cover the cost of birth control. 4:06:00 PM CHAIR SPOHNHOLZ asked if contraception would be provided, regardless of the type or her ability to pay. DR. SLAUNWHITE replied that was her understanding. 4:06:20 PM CHAIR SPOHNHOLZ asked whether, if a woman opted for a type of contraception other than LARC, that care would be paid by the study. DR. SLAUNWHITE offered her belief that this would be a small number of participants as her research indicated that many women had health insurance coverage. 4:07:10 PM CHAIR SPOHNHOLZ expressed her concern that there was not a coercive motivation to use one form of contraception over another form, especially for a woman who did not have health insurance. DR. SLAUNWHITE said that a woman would be free to choose and that any form of birth control included in the study would be offered, as determined by the advisory group. She expressed her understanding for the ethical concerns for "even an appearance of coercion." 4:08:43 PM CHAIR SPOHNHOLZ reflected on the Institutional Review Board (IRB) process and asked for more detail about the review of a human subject research project. DR. SLAUNWHITE explained that it would include a full application to the board for the way participants would be recruited, who was eligible to participate in the study, all sites where the research would be conducted, all instruments used to gather data, any medical records, and any other data or processes used to gather the data. She said that the University of Alaska Anchorage (UAA) IRB would review the packet. After the review, there would be a meeting with faculty, community members, and the chair of the IRB with an opportunity for questions about the protocol. She shared her experience that this was a very rigorous process that could last for several months, with revisions of protocol and surveys after advice from the group. 4:11:20 PM CHAIR SPOHNHOLZ asked who served on the IRB. DR. SLAUNWHITE replied that there were two community members, often representative from specific groups, as well as research professors for feedback on protocols and instruments. 4:11:53 PM CHAIR SPOHNHOLZ asked if any necessary follow up care for women without health insurance would be covered by the study. DR. SLAUNWHITE offered her belief that there would be follow up care while at Alaska Regional Hospital, and that part of the service "would be to obtain some form of health insurance especially because as part of this project we want to provide case management and a direct pathway into substance abuse treatment for these women." She noted that, as these women would be going into treatment, there would be an associated cost, payment of which would be determined through the advisory board and the protocol development. She reported that, with a link to addiction treatment, there would be a requirement to have health insurance, most likely to be Medicaid. 4:13:40 PM CHAIR SPOHNHOLZ asked who the principal investigator was for this research project. DR. SLAUNWHITE said that she was the principal investigator. 4:13:50 PM REPRESENTATIVE KITO asked if there were any medical doctors on the IRB. DR. SLAUNWHITE replied that the chair of the IRB was a clinical psychologist, and although there were not any medical doctors on the IRB, there were temporary IRB members added, as needed. She expressed her hope that, through the advisory council, there would be a group of experts including pediatricians, OB GYNs, and representatives from family planning and women's health sectors. 4:15:21 PM REPRESENTATIVE TARR expressed her concern for coercion, opining that the process "sounds horrible." She shared that, as a woman with a substance disorder, most likely with a difficult pregnancy, and having health impacts after delivery unrelated to substance use disorder, she would not be fully "of my right mind" because of the throes of addiction. She would need a significant period of time for detoxification to have full capacity for decision making. If she was a vulnerable women, she had probably not had positive experiences with government or police and now, post-delivery, there would be someone with lengthy paperwork telling her to read and to sign something she may not comprehend. She declared that in this scenario, a woman would not have real choice, and that this was a problematic process. She directed attention to page 2, lines 14 - 19, of the proposed bill, and pointed out that there was no mention of care coordination or the correct interventions for the woman to access health care, addiction treatment, and birth control. She declared that what Dr. Slaunwhite had described and what the proposed bill said were not the same. She reiterated that this was not a situation whereby a woman had full choice over these decisions. 4:18:39 PM DR. SLAUNWHITE replied that if a woman was incapacitated or going through significant detoxification and unable to comprehend or fully understand the project, they would not be accepted for participation. She declared that people with addiction issues consented to be involved in research projects all the time. She said that they could fully understand what was being asked and what were the risks and benefits associated with the project. She pointed out that they did not have any interest in participation by someone who did not want to be involved. She reiterated that it was fully voluntary, and the person was free to withdraw from the study at any time. She relayed that they would do everything to ensure that the information and the consent forms were communicated at a low reading level, to ensure understanding and that there would not be any coercion for anything. She acknowledged that she may have communicated the research somewhat differently that the proposed bill, although the proposed bill did articulate the research questions that she had described for evaluating the costs for providing LARC and its effectiveness for reducing the occurrence of FAS and NAS, as well as the cohort development to facilitate the long-term study of the development of infants born with substance exposure. 4:22:05 PM REPRESENTATIVE TARR declared that the idea of choice was impacted by physical condition. She suggested that the individual have an advocate whose purpose was to monitor the needs of a vulnerable individual with no motivation for participation in the program. She offered her belief that this should be more accurately described in the language of the bill. She opined that there was a difference between the Vivitrol intervention and the control of a woman's right to make reproductive choices. She reminded that there was a terrible history for segmenting different women and trying to control the ability to reproduce. She reiterated that she had strong concerns as this was a significant medical intervention. 4:24:16 PM REPRESENTATIVE ZULKOSKY, pointing to an earlier statement that participation in the study would be fully voluntary and that participants could withdraw at any time for any reason, asked whether it was a penalty to not have removal or follow up costs for care be covered by the study. She noted that, as the study in its current form did not cover these costs, this could be a coercive way for participation. She declared a need for "greater wrap around services for care coordination or greater resources for substance abuse treatment, not necessarily access to birth control." She suggested that there was a segment of women, and possibly children, viewed as a cost risk to the state, and instead, the state should be dealing with the holistic needs of an individual. DR. SLAUNWHITE expressed her understanding and offered her belief that approval for the project would necessitate a protocol to ensure that women would be able to have the LARC device removed, should they wish, with no penalty. She added that there should also be a protocol to give women a clear choice for the type of birth control available, and that there would not be any penalty for discontinued use. 4:27:37 PM JEFFREY JESSEE, Dean, College of Health, University of Alaska Anchorage, shared that he had previously been CEO of the Alaska Mental Health Trust Authority for 22 years. He noted that, as a lot of the material had already been covered, it was important to keep a few points in mind. He said that all hospitals were required by law to report to the Office of Children's Services (OCS) any positive drug screen on any mother or child. He pointed out how traumatic it was to both the mother and the child, as often the child was removed from the mother. He stated that much of this applied research was for how to take the next step and do better than this process. He said that, as currently there was not comprehensive counseling and referral services, many of these mothers ended up back in the community, still addicted, with data indicating a high probability for having another affected child. He reiterated that this was not a study of the effectiveness of birth control, if it was used reliably, and he stated that the LARC was one form of birth control which was easiest for women who wanted to remain on birth control with no interference from an addiction or chaotic personal life. He acknowledged that, although the best solution would be for the women to become sober and have housing and a better life experience, there was not the technology to help everyone who was addicted to get sober. He said that some addictions were so pervasive and ingrained in an individual's life that it was not known how to get them sober. He pointed out that one reason for the Housing First concept for people with chronic alcoholism was to provide effective treatment and support, instead of being prisoners of their addiction, waiting for the next terrible thing to happen. He declared that this proposal was the next step for these women who had been repeatedly traumatized and would be referred to the Office of Children's Services at the end of their pregnancy. He declared that the points by the committee were excellent, that there should not be a coercive element to the program and that the IRB would work with researchers to ensure this was considered. He added that, for full data of the research, not everyone should choose LARC, which would allow for a control group to test for the most effective strategy to help these women gain control over at least part of their future. He declared that it was absolutely essential to have "the highest quality medical care that we can possibly give them." He noted, however, that hospitals were limited in the ability to follow through with effective case management to access critical services such as treatment and safe housing. He added that many women were concerned with accepting services from a hospital which had just referred them to the OCS. He opined that this applied research project would offer more objective assistance to these mothers than total reliance on the hospitals for these services. He reiterated that the purpose of the University [of Alaska] was to assist legislators in "getting the best bang for your dollars and the best outcome for the public policy outcomes that you want to see." He declared that it was necessary to "look at how to best approach these women; how to best present an option; how to best help them follow through with at least housing, if not treatment; and help them to move forward in their lives in a more positive way... " He declared that there was a commitment to respect the rights of the women, and, as the women were offered a full range of options, this would provide answers to the many questions asked by the legislature for how to move forward and reduce the incidences for these affected children. He added that healthy living would lead toward a more fulfilling life for these women. 4:38:04 PM REPRESENTATIVE ZULKOSKY lauded the great mental health work and advocacy performed by Mr. Jessee. She acknowledged that they had shared goals for the reduction of pre-natal exposure to drugs and alcohol for Alaska children, as well as resolution to the conundrum around the provision of care and services to a population of women that may not otherwise seek this care. She directed attention to the proposed bill which explicitly stated that the intention of the study was to provide long acting reversible contraception to participants who were at risk for unintended pregnancies that may result in pre-natal drug or alcohol exposure. She added that another intent of the proposed bill was to provide a data driven framework to establish a comprehensive strategy for using long active reversible contraception to reduce fetal alcohol spectrum disorders (FASD) and neo-natal abstinence syndrome (NAS) in Alaska. She expressed her concern for social justice and racial equity as there had not been any discussion for the issues of demographics for women in Alaska who may fall into this population. She declared that she did not see any difference from forced sterilization on women who could not advocate for themselves. MR. JESSEE reported that forced sterilization was "a very dark part of our past in this country" which had been conducted as the perceived solution for many reasons, including developmental disabilities and mental illness. He added that this was not a system of support but a means of control, specifically of the reproductive rights. He reported that there were even court orders supporting these practices. He stated that this proposed bill was not about these practices but was about working with women who were currently not able to get sober and were at a much higher risk for unintended pregnancy. He shared his surprise that 50 percent of all pregnancies were unintended and noted that the percentage of unintended pregnancies was much higher, over 80 percent, for this group of addicted women. He declared that it was not helping these women to bring them to a hospital, deliver the babies, refer them to OCS, provide minimal support, and then send them back into the community. He acknowledged that these women could not be forced to use any birth control, to seek treatment, or to stay in safe housing. He referenced the Housing First model and reported that this was a valuable service which gave addicted people a belief that something positive was happening and they had some control over their life. He reported that many people at Housing First reduced their drinking, while "some even get sober," and that most all have improvements to their health condition. He stated that the opportunity to control reproductive health with the choice of birth control was the exact opposite of forced sterilization. He declared that the proposed bill would be a benefit to the individuals and the community and would offer a better understanding for how to work with these women to achieve the desired outcomes. 4:45:41 PM REPRESENTATIVE ZULKOSKY opined that it was important to acknowledge the history for full choice of reproductive rights, regardless of an individual's station in life. She shared her struggle of coming from a rural area as an Alaska Native woman with the background for challenges to the Alaska Native community. She stated that there were many similarities for ostracizing a subsect of the community for the advancement of an institution and declared that it was "deeply disturbing." DEAN JESSEE expressed his agreement for the trauma experienced by the women and their children and declared that not enough was being done to avoid further trauma. He said there was not "a magic wand" to help these women become sober, pointing out that they did not have control over their addiction or the trauma it included. He emphasized that it was necessary to take the next step in order "to value these women and believe that there's a better future for them." 4:50:18 PM ART DELAUNE, Legislative Chair, Governor's Council on Disabilities and Special Education, stated that the Council supported the proposed bill and agreed with the concept for the option to LARC for women who are known to have substance abuse disorders. He shared a personal anecdote for his two sons with FASD and with his background as a parent navigator for the Fairbanks FASD diagnostic team. He stated that FASD was 100 percent preventable and that women needed access to resources, information, support, and care or treatment. He said that the research from the proposed bill had the potential to identify barriers and examine the long-term cost and savings to Alaska. 4:54:09 PM REPRESENTATIVE TARR added that it was necessary for a holistic approach. MR. DELAUNE expressed his agreement. CHAIR SPOHNHOLZ shared the difficulties for understanding FASD and its effects. 4:56:38 PM TREVOR STORRS, Executive Director, Alaska Children's Trust, shared that ongoing research had shown that social determinants could be a predictor to the level of risk for a child experiencing child abuse and neglect. By identifying these social determinants that influence this level of risk, it was possible to move further "upstream" to prevent this child abuse and neglect. He stated that the proposed bill was an example for achievement of this goal. He pointed out that Alaska had been able to identify key social determinants which included unplanned and unwanted pregnancies. He shared that 49 percent of pregnancies were unintended, and that, for women age 19 and younger, more than 4 out of 5 pregnancies were unintended, while under the age of 15, 98 percent of the pregnancies were not planned. He reported that unplanned or closely spaced births were associated with adverse maternal and child health outcomes, which included depression, smoking, alcohol consumption, poor mental health, increased risk of physical violence during pregnancy, reduction of the likelihood for breast feeding, and lower mother-child relationship quality. For the children, the result included greater infant mortality, likelihood to be less physically and mentally healthy, less likely for success in school, and more likely to live in poverty, need public assistance, and have delinquent and criminal behavior. He reported that 90 percent of women stopped drinking once aware of their pregnancy, which meant that the highest risk for exposure of the fetus to alcohol was between conception and realization of pregnancy. He pointed out that all of these adversities resulted in greater economic and social impacts on the state, and to reduce unplanned and unwanted pregnancies, it was necessary to ensure better access to the most effective contraceptive methods. He referenced an article which stated that experts suggested that programs which improved family planning would be the best strategy for prevention of child maltreatment and would reduce FAS and pre-natal drug exposure. 5:00:34 PM CHAIR SPOHNHOLZ announced that SB 198 would be held over.