02/28/2017 03:00 PM House HEALTH & SOCIAL SERVICES

          HB 25-INSURANCE COVERAGE FOR CONTRACEPTIVES                                                                       
                                                                                                                                
3:05:35                                                                                                                         
                                                                                                                                
CHAIR SPOHNHOLZ announced  that the first order  of business would                                                              
be HOUSE BILL NO.  25, "An Act relating to insurance  coverage for                                                              
contraceptives   and  related   services;   relating  to   medical                                                              
assistance coverage  for contraceptives and related  services; and                                                              
providing for an effective date."                                                                                               
                                                                                                                                
3:05:44 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  MATT CLAMAN, Alaska  State Legislature,  explained                                                              
that  Alaskan women  living and  working  in rural  areas, in  the                                                              
tourism  industry, in  the military,  and on  the North Slope  did                                                              
not  always have  ready  access to  women's  health services,  and                                                              
faced  additional   barriers  for   obtaining  access   to  family                                                              
planning  options.    He  stated that  women  who  currently  used                                                              
hormonal contraceptives  had to return  to a pharmacy  everyone to                                                              
three  months to  refill their  prescriptions.   He reported  that                                                              
proposed HB  25 required  health insurers  to offer consumers  the                                                              
option to  receive a  12-month supply  of hormonal  contraception.                                                              
He declared  that the women in  his family supported  the proposed                                                              
bill as  improved access to  contraceptives meant  huge reductions                                                              
in unintended pregnancies.   He added that  unintended pregnancies                                                              
had  a  profound  effect  on the  overall  well-being  of  Alaskan                                                              
families, as  it was  associated with  adverse maternal  and child                                                              
health  outcomes.     Along   with  health  concerns,   unintended                                                              
pregnancy was  a dramatic cost  driver to public  health programs.                                                              
He pointed out  that it was often time consuming  and inconvenient                                                              
to obtain  a prescription  for contraceptives  every one  to three                                                              
months.    He   offered  his  belief  that,  with   the  financial                                                              
challenges in  the state, there  should be discussion for  ways to                                                              
reduce costs  in both the short  and long term.  He  declared that                                                              
proposed HB  25 offered  these cost reductions,  and that  it made                                                              
sense for Alaska women and families.                                                                                            
                                                                                                                                
3:07:34 PM                                                                                                                    
                                                                                                                                
LIZZIE  KUBITZ, Staff,  Representative Matt  Claman, Alaska  State                                                              
Legislature,  stated  that proposed  HB  25 mandated  that  health                                                              
care  insurers   provide  coverage   for  a  12-month   supply  of                                                              
contraceptives.       She    pointed    out   that    prescriptive                                                              
contraceptives      included       self-administered      hormonal                                                              
contraceptives   which  did   not  require   insertion  or   other                                                              
administration   by   a   medical    professional,   namely   oral                                                              
contraceptives,  noting that this  was discussed  in Section  1 of                                                              
the  proposed  bill.    She moved  on  to  discuss  the  Sectional                                                              
Analysis of  the bill  [included in members'  packets].   She said                                                              
that Section 1  also included a religious exemption  and defined a                                                              
health care  insurer as  including a  self-insured employer,  such                                                              
as the  State of Alaska.   She  moved on to  discuss Section  2 of                                                              
the proposed  bill, which  directed the  Department of  Health and                                                              
Social Services  to pay  for the  12-month supply of  prescription                                                              
contraceptives  for  eligible recipients  of  medical  assistance.                                                              
She  relayed that  Section 3  of  the proposed  bill required  the                                                              
Department of Health  and Social Services to amend  and submit for                                                              
federal  approval a  state plan  for  medical assistance  coverage                                                              
consistent  with  Section  2.     She  explained  that  Section  4                                                              
provided a  conditional effect of Section  2 and Sections  5 and 6                                                              
pertained to the effective dates.                                                                                               
                                                                                                                                
MS.  KUBITZ stated  that  one major  premise  behind the  proposed                                                              
bill was  that when women had  greater access and  availability to                                                              
contraceptives, there  was a reduction of  unintended pregnancies.                                                              
This resulted  in a direct  cost savings  to the state,  which was                                                              
reflected  in  the fiscal  notes  from  Department of  Health  and                                                              
Social  Services  [included in  members'  packets].   She  relayed                                                              
that  one 2010  study  in Alaska  [included  in members'  packets]                                                              
found  that  48   percent  of  all  pregnancies   in  Alaska  were                                                              
unintended.   She added  that an estimated  94.3 percent  of these                                                              
unintended pregnancies  were publicly  funded.  She  reported that                                                              
Alaska spent  $113.7 million on  unintended pregnancies,  of which                                                              
$70.8 million  was paid  for by the  federal government  and $42.9                                                              
million was paid  for by the state.  She pointed  to an additional                                                              
study [included  in members' packets]  which studied  84,000 women                                                              
in California  given 1  month, 3  month, or  12 month supplies  of                                                              
oral contraceptives.   The  researchers of  this study  observed a                                                              
30  percent reduction  in  the odds  of  conceiving an  unintended                                                              
pregnancy  for those  women  given  the 12  month  supply of  oral                                                              
contraceptives.   This  study also  reported  that the  California                                                              
family  planning program  paid  $99 more  annually  for women  who                                                              
received  three cycles  and $44  more for women  who received  one                                                              
cycle  than for  women  who received  a  year-long  supply all  at                                                              
once.  She stated  that this cost "was mostly due  to the costs of                                                              
associated  visits and  the higher  use of  pregnancy tests  among                                                              
women  who received  fewer cycles."   She relayed  that women  who                                                              
received three  cycles were  almost twice as  likely as  women who                                                              
received  the  12  month  supply  to  visit  a  clinic  to  get  a                                                              
pregnancy test.   She noted that the proposed bill  did not change                                                              
who  was eligible  for  coverage, or  the  types of  prescriptions                                                              
covered.    The  bill  merely  allowed   women  already  receiving                                                              
coverage for  prescription contraceptives  to receive, if  they so                                                              
choose, a 12  month prescription.  She addressed  concerns brought                                                              
forward  by   the  Alaska   National  Federation  of   Independent                                                              
Business  (NFIB) and  by America's  Health  Insurance Plan  (AHIP)                                                              
[included  in  members'  packets].    As  NFIB  had  concerns  for                                                              
whether  the  proposed  bill  would  include  the  state  employee                                                              
health  care  plan, a  definition  of  health care  insurer  which                                                              
included  self-insured employers,  such  as the  State of  Alaska,                                                              
had  been included  in the  proposed bill.   She  relayed that  an                                                              
additional  concern voiced  by NFIB  was  for the  cost burden  of                                                              
supplying a  12 month supply  of contraception  at one time.   She                                                              
pointed to  multiple studies  which had  found that  contraceptive                                                              
coverage  did   not  raise  insurance   premiums,  and   that  the                                                              
employers  providing coverage  could  save money  by avoiding  the                                                              
costs  associated with  unintended  pregnancy.   She relayed  that                                                              
the  average  commercial  insurer  payment for  all  maternal  and                                                              
newborn care ranged  from $18,000 to $28,000, whereas  the average                                                              
hormonal birth  control cost  ranged from $100  to $600  per year.                                                              
She  stated that  prevention  of  one unintended  pregnancy  could                                                              
save an  insurer at least  $17,000, enough  savings to pay  for 29                                                              
additional years  of contraception.   She moved on to  discuss the                                                              
concerns   from  AHIP   [included  in   members'  packets]   which                                                              
concluded  that  the  12-month   supply  of  contraceptives  could                                                              
compromise  patient  safety  as  a  result  of  decreased  patient                                                              
visits  to the  prescribing physician.   She  pointed to  research                                                              
which  showed that  birth control  pills  were safe  and could  be                                                              
safely  prescribed based  on  a careful  review  of the  patient's                                                              
medical history and  blood pressure measurement.   For most women,                                                              
no  further   examinations  were   necessary  after   the  initial                                                              
prescription,  unless the  patient asked  for a  follow up  during                                                              
the recommended yearly  examination.  She stated  that the Centers                                                              
for  Disease Control  and Prevention  (CDC) and  the World  Health                                                              
Organization   (WHO)  had   presented  a   study  in  2013   which                                                              
recommended dispensing  a yearly  supply of contraception  with an                                                              
advisement to  return at any time  for discussion of  side effects                                                              
or  other problems,  or  to  change the  method.    The study  had                                                              
declared  that  no routine  follow-up  was  required.   She  added                                                              
that,  although  AHIP  had  concerns  for  the  efficacy  of  oral                                                              
contraceptives  due to  improper storage  for a  12 month  supply,                                                              
CDC had  declared that  oral contraceptives  had  a shelf  life of                                                              
three  to five  years,  dependent  on the  manufacturer,  although                                                              
temperature  and moisture  could diminish  this time  frame.   CDC                                                              
stated that most  women who opted for a 12-month  supply, and were                                                              
regular  users  of  hormonal  contraception,  would  know  how  to                                                              
properly  store  the  medication.    She  addressed  concerns  for                                                              
waste, fraud, and  abuse, and pointed out that  research had found                                                              
that the average  waste of a 12-month supply was  for one cycle of                                                              
prescription  contraceptives,   and  this  was   insignificant  in                                                              
comparison  to the  other  cost savings  for  fewer clinician  and                                                              
pharmacy  visits,   and  the   associated  costs  for   pregnancy.                                                              
Regarding fraud  and abuse, although there were  existing criminal                                                              
statutes  for  sale  of  hormonal  contraceptives,  this  was  not                                                              
anticipated   as  women   would   have  greater   access  to   the                                                              
contraceptives.   She  concluded by  stating that  proposed HB  25                                                              
would offer "huge  advantages for Alaskan women,  from eliminating                                                              
the  inconvenience  of refilling  the  prescription  every one  to                                                              
three months  at a  time, to  the real  inability of some  Alaskan                                                              
women to  make it to the clinic,  hospital, or pharmacy  to refill                                                              
that  prescription at  all."   She  pointed  out that  fisherwomen                                                              
sometimes  spend  three  to  four  months out  on  a  boat,  women                                                              
attending college  often have busy schedules balancing  school and                                                              
a job, and  women in Rural Alaska  often had trouble making  it to                                                              
a clinic or hospital  due to a lack of transportation  and limited                                                              
operating  hours.    She  declared  the HB  25  ensured  that  all                                                              
Alaskan  women  had the  freedom  to  make decisions  about  their                                                              
futures.                                                                                                                        
                                                                                                                                
3:16:28 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  JOHNSTON  shared  that  a three  month  supply  of                                                              
birth  control pills  for her  daughter was  $800.   She asked  if                                                              
there was a discount for a 12 month supply.                                                                                     
                                                                                                                                
MS. KUBITZ  replied  that her research  had shown  a cost  savings                                                              
for buying in bulk.                                                                                                             
                                                                                                                                
REPRESENTATIVE JOHNSTON suggested more research for this.                                                                       
                                                                                                                                
3:17:40 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE EDGMON pointed to the zero fiscal note.                                                                          
                                                                                                                                
MS.  KUBITZ  replied  that  there   were  two  zero  fiscal  notes                                                              
[included  in members'  packets]  provided  by the  Department  of                                                              
Health and  Social Services [OMB  Component 242 and  OMB Component                                                              
2007].   She relayed  that one fiscal  note projected  anticipated                                                              
costs due  to implementation of  the proposed bill and  the second                                                              
fiscal note detailed the cost savings.                                                                                          
                                                                                                                                
3:18:35 PM                                                                                                                    
                                                                                                                                
MARGARET BRODIE,  Director, Director's Office, Division  of Health                                                              
Care  Services,   Department  of   Health  and  Social   Services,                                                              
addressed  the Department  of Health  and  Social Services  (DHSS)                                                              
fiscal note  labeled OMB Component  2007, and explained  that this                                                              
fiscal note analyzed  7,940 female Medicaid recipients  using oral                                                              
contraceptives.   She estimated that 10 percent,  794 women, would                                                              
require duplication  of services  because  the medication  was not                                                              
effective, it was  lost or stolen, or was not  stored properly and                                                              
could lose its efficacy.   She based the replacement  value at $45                                                              
per month  which was  the national  average drug acquisition  cost                                                              
and  the cost  that the  state used  for its  determination.   She                                                              
shared that DHSS  assumed that 75 percent of the  women planned to                                                              
use oral  contraceptives longer than  12 months, and that,  as the                                                              
CDC  cited  a standard  failure  rate  of  9 percent,  this  would                                                              
result  in 540  unintended  pregnancies.   She  reported that  the                                                              
failure  rate would  decrease  about 30  percent  with a  12-month                                                              
supply of contraceptives,  thereby lowering the failure  rate to 7                                                              
percent.   She pointed out  that about 120 unintended  pregnancies                                                              
could  be  avoided  by using  the  12-month  contraception.    She                                                              
stated  that  the estimated  savings  was  based on  the  Medicaid                                                              
data,  which  reported  that  5.28   births  of  the  120  avoided                                                              
pregnancies  would   have  been   complicated  births,   with  the                                                              
remainder  of births  being non-complicated.    She reported  that                                                              
the  cost factor  for a  complicated birth  was $110,000,  whereas                                                              
the cost  factor for  a non-complicated  birth  was $8,000.   This                                                              
would result  in a  benefit cost savings  to the Medicaid  program                                                              
estimated   to  be  $1,498,000,   of  which   $562,000  would   be                                                              
attributed  to the Medicaid  expansion population.   She  reported                                                              
an annual  projected savings of  $1,355,600.  She added  that this                                                              
was  a conservative  estimate, as  some  complicated births  could                                                              
cost hundreds of thousands of dollars.                                                                                          
                                                                                                                                
MS. BRODIE  addressed the second  fiscal note, OMB  Component 242.                                                              
She offered  her belief  that this fiscal  note could  be removed,                                                              
as there  was no  state or  federal statute  that declared  a need                                                              
for the department to go back and collect from the recipients.                                                                  
                                                                                                                                
3:24:41 PM                                                                                                                    
                                                                                                                                
CHAIR SPOHNHOLZ  expressed  her agreement  with saving the  "money                                                              
in this  particular area."  She  suggested that the  savings would                                                              
be  $1.2  -  $1.3  million  annually  in  overall  Medicaid  costs                                                              
related to contraception and unintended pregnancies.                                                                            
                                                                                                                                
MS. BRODIE expressed her agreement.                                                                                             
                                                                                                                                
3:25:03 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  SULLIVAN-LEONARD asked  whether the proposed  bill                                                              
would allow the  state workers' health insurance  program to offer                                                              
this benefit.                                                                                                                   
                                                                                                                                
REPRESENTATIVE  CLAMAN, in  response, relayed  that the intent  of                                                              
the  proposed bill  was for  this benefit  to be  included in  the                                                              
state workers' health insurance plan.                                                                                           
                                                                                                                                
REPRESENTATIVE   SULLIVAN-LEONARD  asked   if  there   were  other                                                              
medications that  could be  prescribed on a  yearly basis,  or was                                                              
this the first proposal for a year-long prescription.                                                                           
                                                                                                                                
MS.  KUBITZ asked  if Representative  Sullivan-Leonard was  asking                                                              
specifically about  contraceptives.  She  stated that she  was not                                                              
aware  of  any  other medications  that  could  have  a  year-long                                                              
prescription, as  often many of these medications  were controlled                                                              
substances.                                                                                                                     
                                                                                                                                
REPRESENTATIVE  SULLIVAN-LEONARD asked  if any other  prescription                                                              
drugs could  be included in this  format, pointing out  that a 90-                                                              
day prescription  was because  a physician  wanted to  oversee the                                                              
interaction of the drug for the patient.                                                                                        
                                                                                                                                
REPRESENTATIVE  CLAMAN said  that  his office  had not  researched                                                              
this  specific question.    He  recollected that  certain  mail-in                                                              
drug  programs  allowed  for  longer  prescriptions,  although  it                                                              
depended on the medication.                                                                                                     
                                                                                                                                
CHAIR SPOHNHOLZ  offered her belief  that some other  medications,                                                              
including some  hormonal medications,  were available on  a yearly                                                              
prescription.                                                                                                                   
                                                                                                                                
REPRESENTATIVE CLAMAN replied that he would look into this.                                                                     
                                                                                                                                
3:28:53 PM                                                                                                                    
                                                                                                                                
CHAIR SPOHNHOLZ said that HB 25 would be held over.