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.