HB 58-CONTRACEPTIVES COVERAGE:INSURE;MED ASSIST  4:20:54 PM CO-CHAIR ZULKOSKY announced that the next order of business would be HOUSE BILL NO. 58, "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." 4:21:08 PM The committee took an at-ease from 4:21 p.m. to 4:26 p.m. 4:26:21 PM REPRESENTATIVE MATT CLAMAN, Alaska State Legislature, answered questions during the hearing of HB 58, as prime sponsor. He reminded the committee that HB 58 would make contraception more readily available for individuals who choose to use it, but it does not require anyone to use contraception. He said the bill would make it easier in particular for individuals who oftentimes have difficulty getting long-term prescriptions. 4:27:07 PM CO-CHAIR ZULKOSKY asked Renee Gayhart to speak to the change in the fiscal note from a cost-savings fiscal note to a zero fiscal note. 4:27:24 PM RENEE GAYHART, Director, Division of Health Care Services, Department of Health and Social Services, stated that the Division of Healthcare Services is looking at a neutral fiscal note and a zero fiscal note for 2021. She expressed that the division supports the policy and shared her understanding that the program could absorb any potential costs with the change and the disbursement to 12 months. She added that the cost would be absorbed in the existing appropriation, and similar to other healthcare market utilization trends. The zero fiscal note, she said, means that the cost avoidance of previous fiscal notes is not a guarantee. She reiterated that the division supports the policy, and explained that it would be looking retrospectively at claims to consider what the savings were in areas such as labor and delivery and prenatal care. She offered clarification that the division is looking at cost of implementation, and would retrospectively be looking at savings. 4:28:55 PM REPRESENTATIVE MCCARTY asked Ms. Gayhart whether there are changes that are necessary for regulation in the fiscal note. MS. GAYHART responded that there would be regulations in amendment changes, but the division does not see a change in the fiscal note with implantation of the policy changes. 4:30:00 PM REPRESENTATIVE FIELDS moved to adopt Amendment 1 to HB 58, labeled 32-LS0259\A.1, Marx, 4/16/21, which read as follows: Page 1, following line 10: Insert a new subparagraph to read: "(B) emergency contraception, including over-the-counter emergency contraception, approved by the United States Food and Drug Administration; the insurer may not require a prescription for coverage of over-the-counter emergency contraception under this subparagraph;" Reletter the following subparagraphs accordingly. Page 6, line 23: Delete "and" Page 6, following line 23: Insert a new paragraph to read: "(2) emergency contraception, including over-the-counter emergency contraception, approved by the United States Food and Drug Administration; the department may not require a prescription for coverage of over-the-counter emergency contraception under this paragraph; and" Renumber the following paragraph accordingly. CO-CHAIR ZULKOSKY objected for discussion purposes. REPRESENTATIVE FIELDS explained that, during the House Health and Social Services Standing Committee on April 15, 2021, he learned that there are circumstances under which emergency contraception, or the "morning-after pill," would not be covered by insurance if it were to be purchased over the counter, but it would be covered if an individual were able to obtain a doctor's prescription. He opined that it is unreasonable that an individual with insurance would not be able to receive insurance coverage for a covered product simply because there are circumstances that prevent them from getting in contact with a doctor. He explained that Amendment 1 addresses this inequity, and that it would allow emergency contraception to be covered by insurance regardless of the presence of a doctor's note. 4:31:05 PM REPRESENTATIVE KURKA expressed his concern about the use of the term "emergency contraception." He shared his understanding that it does not simply refer to contraception, but also to "abortabations." He opined that one of the purposes of the morning-after pill is to prevent implantation of an "already created human embryo," which he understands to be ending a human life. He said he opposes this perceived consequence. 4:31:51 PM REPRESENTATIVE MCCARTY asked for clarification on whether there is a window of opportunity for a physician to prescribe emergency contraception otherwise it is not effective. REPRESENTATIVE FIELDS responded yes, that is his understanding as well. REPRESENTATIVE MCCARTY asked if he understands correctly that an individual might seek out emergency contraception in instances of rape or domestic violence. REPRESENTATIVE FIELDS responded yes, and expressed that those instances are good reasons as to why insurance should cover emergency contraception. 4:33:28 PM REPRESENTATIVE CLAMAN noted that Dr. Tina Tomsen is available for questions, and she may be able to offer a medical perspective on the suggestions made by Representative Kurka. 4:33:44 PM TINA TOMSEN, MD, shared that she retired at the end of 2020 after practicing medicine in obstetrics and gynecology for 34 years. She said that there is an older form of emergency contraception called Plan B, which is approved for over-the- counter administration and is available for purchase. If a doctor were to write a prescription for a patient for Plan B and that patient were to take it to a pharmacy, she explained, that pharmacy would direct the patient to purchase Plan B over the counter. She said that the patient would not need to get Plan B from the pharmacists. However, there is a newer form of emergency contraception that works over a longer period of time and has a higher effectiveness rate, she said, and that form does require a prescription, and a patient would have to get it filled at a pharmacy. An example of a situation that might arise, she continued, is that a patient might need emergency contraception on a Friday night and there might be something that makes the patient's physician unavailable, such as a long weekend, which might necessitate that the patient purchase Plan B out of pocket rather than the newer form of emergency contraception with a prescription. She ensured the committee that both forms of emergency contraception are effective, and not considered by the American College of Obstetricians and Gynecologists (ACOG), based on science, to be abortibations. 4:35:39 PM REPRESENTATIVE SPOHNHOLZ expressed her support for the proposed amendment. She shared her understanding that Amendment 1 would correct an oversight that didn't get remedied as new medications became available. She expressed support for efforts to increase access to better medication, and divulged that, as someone who has personally used emergency contraception, she views it as a "common sense" measure. 4:36:20 PM REPRESENTATIVE KURKA asked Dr. Tomsen whether the emergency contraception she described that requires a prescription prevents implantation once the embryo is formed. DR. TOMSEN answered that she is not a physiologist and that is not her area of expertise, but shared her understanding that the position of ACOG is that none of the hormonal contraception available, including emergency contraception, qualifies as abortibations. She said that contraception makes implantation more difficult, but also interrupts the quality of ovulation. CO-CHAIR ZULKOSKY removed her objection to the motion to adopt Amendment 1. 4:37:33 PM REPRESENTATIVE KURKA objected. 4:37:35 PM REPRESENTATIVE FIELDS stated that he looks to the will of committee members as to whether the committee would like to adopt Amendment 1 or if it would prefer that he withdraw it. He said that he understands that there are some tradeoffs and is interested in the opinions of committee members. 4:37:54 PM The committee took an at-ease from 4:37 p.m. to 4:38 p.m. 4:38:14 PM A roll call vote was taken. Representatives Spohnholz, Fields, McCarty, Zulkosky, and Snyder voted in favor of Amendment 1 to HB 58. Representatives Prax and Kurka voted against it. Therefore, Amendment 1 was adopted by a vote of 5-2. 4:39:03 PM REPRESENTATIVE KURKA moved to adopt Amendment 2 to HB 58, labeled 32-LS0259\A.2, Marx, 4/17/21, which read as follows: Page 3, line 5: Delete "a religious" Insert "an" Page 3, line 7: Delete "religious" in both places. Page 3, lines 8 - 9: Delete "and is an organization that meets the criteria set out in 26 U.S.C. 6033(a)(3)(A)(i) or (iii) (Internal Revenue Code of 1986), as amended" Insert "on religious grounds" REPRESENTATIVE FIELDS objected. REPRESENTATIVE SPOHNHOLZ objected. REPRESENTATIVE KURKA explained that proposed Amendment 2 spoke to a perceived error in constitutional provisions. He shared his understanding that the bill limits the religious exception for non-profit organizations that identify as religious, and not for religious people that are business owners. He cited Supreme Court case Burwell v. Hobby Lobby Stores, Inc., and stated that the court's ruling in favor of Hobby Lobby showed that the "conscious rights of Americans" is not limited to non-profits, but also includes individual business owners. He opined that HB 58 would violate Supreme Court precedent, and that proposed Amendment 2 would protect the conscious rights of individuals. 4:40:13 PM REPRESENTATIVE SPOHNHOLZ spoke to her objection by noting that her understanding of the proposed amendment would essentially "gut" the bill, which intends to expand the insurance coverage for contraception. She expressed that expert testimony has indicated that providing contraception reduces unintended pregnancy, which, in Alaska and nationwide, makes up 50 percent of all pregnancies. She continued by stating that it has been shown that reducing unintended pregnancy reduces child abuse and neglect, as well as the need for abortions. She said the underlying bill should remain intact, and therefore she will continue to oppose proposed Amendment 2. REPRESENTATIVE FIELDS asked whether Director Lori Wing-Heier could speak to the bill language, and whether it might cause problems with respect to insurance exemptions to religious organizations. 4:41:35 PM LORI WING-HEIER, Director, Division of Insurance, Department of Commerce, Community & Economic Development (DCCED), said that Representative Kurka is not wrong to bring up Amendment 2. She shared that DCCED did some research and found that the administration of former U.S. President Donald Trump had a rule that allowed employers to decide to not provide contraceptive care. This was upheld in July of 2020 by the Supreme Court, she said, which means that employers can decide to not provide contraception in policy. The policies in Alaska today all write for the Affordable Care Act (ACA) and do provide contraceptive care. If an employer were to ask an insurance company to not provide contraception within a policy, then the division working with the insurer would be required to allow that. However, if the employer did not bring this objection to providing contraception to an insurer, the plan would automatically include it. REPRESENTATIVE FIELDS asked Ms. Wing-Heier, if HB 58 were to pass and an employer were to approach the division [to remove contraceptive care from the employer's insurance policy], whether that would insure compliance with case law and the previous administrative decision. MS. WING-HEIER answered yes, the employer would have to ask the division to allow for a plan without contraceptive care. 4:43:35 PM REPRESENTATIVE MCCARTY asked Ms. Wing-Heier whether there is "discrimination" in other policies in which a company or provider can determine the items that are covered under a policy. MS. WING-HEIER answered that, under the ACA which a benchmark that health plans must meet, there are 10 essential health benefits. Mandates were then added to these health benefits by the states, such as mammograms in the state of Alaska, she explained. The benchmarks of the essential health benefits allow for contraception, she said, but the issue is that employers can now decide to not provide contraceptive care. She reiterated that this is something the division has to allow, even though the ACA has defined contraception as one of the 10 essential health benefits. REPRESENTATIVE MCCARTY shared his understanding that, as a health care professional, if a patient were to come in to his place of work with a limited policy due to the patient's employer's allowances, it would be important to clarify the specifics of the plan because another patient could come in with a plan that does not have the same restrictions. He said that he experiences that type of discrimination with insurance companies often in his practice. He asked for clarification on whether his understanding is correct. MS. WING-HEIER responded that she would not determine it as discrimination, but there definitely would be a difference in plans. She noted that these differences exist in plans now with differing deductibles and co-pays. Whether the plan provides for contraception would just be another element to check when verifying insurance information, she said. REPRESENTATIVE MCCARTY asked for clarification on whether this would be out of the ordinary, as it seems to exist already based on her comments. MS. WING-HEIER answered yes. 4:45:57 PM REPRESENTATIVE PRAX asked Ms. Wing-Heier whether the insurance company would then have to offer a completely separate plan for those who may object to contraceptive coverage, or whether that would be dealt with on an individual level. MS. WING-HEIER answered that it would be dependent on each employer. For example, if one employer determined that it wants to provide contraceptive care and another employer does not, these two plans would be different. REPRESENTATIVE PRAX asked for clarification on whether the plans would necessarily be pre-approved by the division. MS. WING-HEIER responded yes, the division will approve all plans, including those that do not include contraceptive care. She explained that determination is part of what the division does on a regular basis, which involves determining whether filings are compliant with state law and offer consumer protections 4:47:19 PM REPRESENTATIVE FIELDS commented that, if the committee were to reject proposed Amendment 2, it seems to him that the division already has an effective plan for complying with federal law, and for that reason he said he doesn't see the need for the amendment. 4:47:47 PM REPRESENTATIVE KURKA asked Ms. Wing-Heir for clarification that, currently, there isn't an option for an employer to "check a box" to determine the inclusion of contraceptive care, but it instead defaults to being included in a policy. He asked whether an employer would have to request an exemption that is not listed. MS. WING-HEIER responded that there is no question on the application that asks whether employers would like to cover contraceptive care. REPRESENTATIVE KURKA commented that he still sees the importance in the proposed amendment. He shared his understanding that the oath to uphold the constitution goes beyond the Supreme Court decision. He said that he has been surprised to hear insistence that whatever the Supreme Court says is law. 4:49:14 PM A roll call vote was taken. Representatives McCarty, Prax, and Kurka voted in favor of Amendment 2 to HB 58. Representatives Spohnholz, Fields, Zulkosky, and Snyder voted against it. Therefore, Amendment 2 failed to be adopted by a vote of 3-4. 4:49:58 PM CO-CHAIR SNYDER moved to report HB 58, as amended, out of committee with individual recommendations and the accompanying fiscal notes. REPRESENTATIVE KURKA objected. 4:50:38 PM A roll call vote was taken. Representatives Fields, McCarty, Prax, Spohnholz, Zulkosky, and Snyder voted in favor of moving HB 58, as amended, out of committee with individual recommendations and the accompanying fiscal notes. Representative Kurka voted against it. Therefore, CSHB 58(HSS) was reported out of the House Health and Social Services Standing Committee by a vote of 6-1.