SENATE HEALTH, EDUCATION AND SOCIAL SERVICES COMMITTEE March 11, 1998 9:10 a.m. MEMBERS PRESENT Senator Gary Wilken, Chairman Senator Lyda Green Senator Johnny Ellis Senator Loren Leman, Vice-Chairman MEMBERS ABSENT Senator Jerry Ward COMMITTEE CALENDAR SENATE BILL NO. 291 "An Act relating to living wills, do not resuscitate orders, anatomical gifts, and the care and treatment of persons with serious medical conditions." MOVED CSSB 291(HES) OUT OF COMMITTEE SENATE BILL NO. 260 "An Act requiring that the cost of contraceptives and related health care services be included in health insurance coverage." HEARD AND HELD PREVIOUS SENATE COMMITTEE ACTION SB 291 - No previous committee action. SB 260 - No previous committee action. WITNESS REGISTER Ralph Bennett Legislative Aide to Senator Robin Taylor Alaska State Capitol Juneau, Alaska 99801-1182 POSITION STATEMENT: Testified for sponsor of SB 291 Bridget Carney 2022 McLean Blvd. Eugene, Oregon 97405 POSITION STATEMENT: Supports SB 291 Virginia Peri 545 W 19th Ave. Anchorage, Alaska 99503 POSITION STATEMENT: Supports SB 291 Deborah Randall Davis and Davis 8601 Pioneer Anchorage, Alaska 99504 POSITION STATEMENT: Supports SB 291 Dr. Thomas Buller University of Alaska, Anchorage 3832 Sycamore Loop Anchorage, Alaska 99504 POSITION STATEMENT: Supports SB 291 Richard Williams Older Alaskans Commission 520 West 19th Avenue Anchorage, Alaska 99503 POSITION STATEMENT: Supports SB 291 Fran McNeill Family Care Coordinator, Life Alaska 1205 E International #103 Anchorage, Alaska 99515 POSITION STATEMENT: Supports SB 291 Melba Cooke Alaska Aids Assistance Association 8821 Banjo Circle Anchorage, Alaska 99502 POSITION STATEMENT: Supports SB 291 Joe Ambrose Chief of Staff to Senator Robin Taylor Alaska State Capitol Juneau, Alaska 99801-1182 POSITION STATEMENT: Answered questions about SB 291 Robin Smith 14100 Jarvi Anchorage, Alaska 99515 POSITION STATEMENT: Supports SB 260 Mary Ostback 10231 Lone Tree Anchorage, Alaska 99516 POSITION STATEMENT: Supports SB 260 Connie Page 2211 Penrose Lane Fairbanks, Alaska 99709 POSITION STATEMENT: Supports SB 260 Gordon Evans Health Insurance Association of America 211 4th Street Juneau, Alaska 99801 POSITION STATEMENT: Opposed to SB 260 Mike Lessmeier State Farm Insurance Company Lessmeier & Winters 124 W 5th Juneau, Alaska 99801 POSITION STATEMENT: Opposed to SB 260 Angela Salerno Nasional Assn. of Social Workers 525 Main Street Juneau, Alaska 99801 POSITION STATEMENT: Supports SB 260 Karen Pearson Division of Public Health Department of Health & Social Services P.O. Box 110610 Juneau, Alaska 99811-0610 POSITION STATEMENT: Answered questions about PRAMS Lisa Blacker 536 Paul Street Juneau, Alaska 99801 POSITION STATEMENT: Supports SB 260 Caren Robinson P.O. Box 33702 Juneau, Alaska 99801 POSITION STATEMENT: Supports SB 260 ACTION NARRATIVE TAPE 98-24, SIDE A Number 001 CHAIRMAN WILKEN called the Senate Health, Education and Social Services (HESS) Committee to order at 9:10 a.m. Present were Senators Wilken, Green, and Ellis. CHAIRMAN WILKEN announced SB 246 and SB 252 will be before the committee on Friday, at which time he intends to pass both bills out of committee. He asked anyone interested in either bill to submit suggestions and comments to his office by Thursday. The first order of business before the committee was SB 291. SB 291 - LIV. WILLS/ANATOMICAL GIFTS/PATIENT CARE RALPH BENNETT, legislative aide to Senator Robin Taylor, sponsor of SB 291, read the sponsor statement. SB 291 revises Title 18, Chapter 12, which pertains to rights of the terminally ill. The current statute offers little assurance that an incapacitated person's wishes will be carried out because it states that living wills are operative only if the declarant's condition is determined to be terminal. SB 291 clarifies that an advance directive or living will is given operative effect only if it has been medically determined that the declarant is in a serious medical condition. The bill defines "medically determined" as a determination from two physicians who personally examined the patient, one of whom is the attending physician. The bill defines "serious medical condition" as: a) a terminal condition; b) a permanently unconscious condition; c) a condition in which the administration of life-sustaining procedures would not benefit the patient's medical condition and would cause permanent and severe pain; and d) a progressive illness that will be fatal and is in an advanced stage; the person is consistently and permanently unable to communicate by any means, to swallow food and water safely, to care for the person's self, and to recognize the person's family and other people, and it is very unlikely that the person's condition will substantially improve. SB 291 was modeled after Oregon law. That law was cited in a Journal of the American Medical Association study as respecting the wishes of the patient. Section 7 of SB 291 clarifies that nothing in this chapter is intended to condone, authorize, or approve mercy killing or assisted suicide. Section 8 sets out conditions under which life-sustaining procedures can be withheld when an individual does not have a living will. CHAIRMAN WILKEN noted Mark Johnson of the Department of Health and Social Services (DHSS) and Joe Ambrose of Senator Taylor's staff were available to answer questions. Number 125 BRIDGET CARNEY, Corporate Director of Ethics for PeaceHealth, a Catholic health care system in Alaska, Washington, and Oregon, testified in favor of SB 291 via teleconference. Under Oregon's Self Determination Act, Peacehealth is able to offer to all patients, entering its hospital facilities, the opportunity to complete an advanced directive. When a patient expresses interest, a social worker is available upon request to help complete the documents. This approach has been very successful as far as patient understanding of his/her options in terms of withholding and withdrawing treatment and it forces patients and physicians to communicate about the advance directive options in a thorough manner. It also gives the person with durable power of attorney the ability to withhold and withdraw treatment as needed if the patient is unconscious. Staff clearly explain the difference between an advanced directive and assisted suicide, given that Oregon has such legislation. MS. CARNEY said an advance directive does not substitute for conversation, because one might be kept elsewhere in a clinic file without the knowledge of the attending physician, so the document is not useful. She reiterated she strongly supports this approach and the way it has been adapted in SB 291. Number 174 VIRGINIA PERI made the following comments on her own behalf. Current Alaska law pertaining to living wills is overly broad, speaks only to terminal illness, and needs clarification. She has had five operations in six years but her wishes as a patient, as stated in her Alaska living will, were not honored in Alaska hospitals because she was not terminally ill. She chose to prepare a second living will in Oregon that speaks to serious medical illness which was accepted in Washington State by the University of Washington Medical Center Hospital while she was treated there. In addition, current Alaska law contains no definitions for life- sustaining procedures and nutrition and hydration, and treats all equally. Many persons enter a hospital without a living will and are not aware of their rights as a patient. SB 291 clarifies the law to give greater understanding to those people using a living will. DEBORAH RANDALL, an attorney with the law firm of Davis and Davis, stated she worked with Virginia Peri on this legislation. She and Ms. Peri believe tremendous advancements in the area of advanced directives and health care powers of attorney have occurred over the last few years. Linda Emmanuel, working with the American Medical Association, recently published a 12 page advanced directive that outlines several medical conditions and the medical treatment options a person can choose to have or have not applied. Alaska's statute addresses one condition: a terminal condition, defined as "a progressive incurable or irreversible condition that, without the administration of life-sustaining procedures, will, in the opinion of two physicians, result in death within a relatively short time." She stated under that definition leaves a lot of room for misinterpretation and could result in withholding CPR on a 40 year old who had a heart attack because a heart attack can be considered an irreversible condition. The Oregon statute is much more thorough and has passed the test of time. It allows a patient to tailor his/her wishes to many different situations; i.e., it allows the patient to decide whether he/she wants every life saving measure taken for a terminal condition unless he/she is in a persistent vegetative coma. She suggested combining Alaska's living will statute with the health care power of attorney provision which currently consists of two lines in the general power of attorney law. In addition, she asked that provision be amended to allow an agent to withhold life-sustaining procedures. Ms. Randall stated her support of SB 291 and said it will create a win-win situation for all Alaskans. Number 249 RICHARD WILLIAMS, senior representative of the Older Alaskans Commission, testified via teleconference from Anchorage. MR. WILLIAMS said death does not frighten him, dying does. Recent advancements in the field of medicine allow doctors to draw out the process of dying as long as they wish. SB 291 gives individuals the opportunity to determine how they want to die in certain circumstances. FRAN MCNEILL, Family Care Coordinator for Life Alaska, stated support for SB 291 for the following reasons. SB 291 honors the patient and family by allowing the patient the right of self- determination and preserving the patient's autonomy. It enables the family and patient to look at some of the most pressing and difficult issues surrounding the possibility of death prior to a crisis. It also supports the community and gives people the opportunity to choose whether to donate tissue and organs. SB 291 clarifies some of the complex issues we face resulting from advancements made in the field of health care. TOM BULLER, Ph.D., a member of the Department of Philosophy at the University of Alaska, Anchorage, concurred with remarks made by previous witnesses, and added the following comments. SB 291 has an ethical/moral basis and provides evidence of our respect for self-autonomy, self-determination, and individual well being. Advance directive legislation allows an individual to determine the conditions under which he/she wishes treatment to be discontinued. The bill fosters physician/patient communication and allows for discussion about expectations of the quality of one's life. He agreed with Ms. Carney that SB 291 in no way endorses assisted suicide. It deals with the right to refuse treatment. The Supreme Court stated in two rulings last year that the right to bodily integrity is very different from the issue of assisted suicide. Number 328 MELBA COOKE, a case manager with the ALASKANS AIDS ASSISTANCE ASSOCIATION, stated support for SB 291. At present, her clients must write out everything they wish in regard to life-sustaining procedures; SB 291 speaks to everything her clients would appreciate. She agreed with previous speakers' comments and encouraged committee members to pass this legislation. SENATOR ELLIS pointed out the Legislature passed legislation relating to advanced directives for mental health care by former Senator Reiger two years ago. The Legislature is not plowing new ground in terms of the advanced directive aspect of SB 291, but is reviewing the current living will statute which is unworkable and inadequate. He congratulated the sponsor for putting the bill forward, and said he is glad to be a co-sponsor. Senator Ellis maintained that advanced directives are allowed in the realm of mental health care, therefore the same reasoning should be applied to other areas of health care. SENATOR GREEN questioned whether the new advance directives are complex and will have to be completed in consultation with an attorney. MS. CARNEY answered no, the paperwork does not require a patient to meet with an attorney. The Sacred Heart Hospital has prepared an educational booklet that contains definitions of terms and other detailed information for patients, and the hospital's social workers review the documents with patients. Number 371 MR. AMBROSE indicated the new advance directive is actually less complicated than the medical directive packet compiled by the AMA. The AMA packet gets into areas that most people do not even want to think about. The problem with the current law is that it is so broad, specific instructions are frequently not carried out. The Chase Review reports that a living will should state completely and explicitly those areas of health care about which the individual wants to make decisions. He reminded committee members under state law, any attorney in Alaska must assist a person with a living will on a pro bono basis. He noted committee packets contain a copy of the documents offered to clients. MS. CARNEY indicated PeaceHealth is investigating how to put advanced directives on to a computer system so that patients' wishes are readily available because sometimes records are not accessible in emergency situations. Number 394 SENATOR GREEN asked whether SB 291 mandates that educational materials be provided to the patient. MR. AMBROSE replied it does not. SENATOR ELLIS moved CSSB 291(JUD) out of committee with individual recommendations. There being no objection, the motion carried. The committee took a brief at-ease. SB 260 - INSURANCE COVERAGE FOR CONTRACEPTIVES SENATOR ELLIS, sponsor of SB 260, gave the following synopsis of the measure. SB 260 is known as the Contraceptive Coverage Act. It is intended to broaden the coverage for prescription contraceptives in the State of Alaska through private health insurance plans. Nationwide, most plans exclude such coverage: only one-third of health insurers cover oral contraceptives, the most popular method; 15 percent cover diaphragms; 18 percent cover IUDs; and 24 percent cover hormonal implants. Coverage in Alaska is no better. Those specific birth control methods are the most effective, are more costly, and are obtainable only from a health care provider. Though most insurance plans provide no contraceptive coverage, they routinely cover abortions, sterilization, tubal ligation, infertility, and impotence treatments, all more expensive procedures related to fertility. Increased access to contraceptive services will help families to bring children into healthier homes when the time is right. Senator Ellis noted a slide presentation was prepared to show committee members the economic and social benefits of expanding contraceptive coverage. CHAIRMAN WILKEN introduced MICHELE GEARHART, legislative aide to Senator Ellis, who would be assisting Senator Ellis with the slide presentation. Number 434 SENATOR ELLIS discussed the first slide which contained 1987 statistics on pregnancies by outcome, the most recent statistics available from national sources. The statistics are as follows: 43 percent of all pregnancies were intended pregnancies; 20 percent of all pregnancies were mistimed pregnancies; 8 percent of all pregnancies were unwanted pregnancies; and 29 percent of unwanted or mistimed pregnancies result in abortions. The second slide showed that of the 5.4 million pregnancies that occurred in the last decade, 3.1 million were unintended at the time of conception. Of that 3.1 million, 1.5 million resulted in live births while 1.6 million ended in abortion. Only 2.3 million pregnancies were intended at the time of conception and resulted in live births. SENATOR ELLIS emphasized that intendedness is a big issue for all couples. Statistics show that 57 percent of all pregnancies are unintended. The next slide gave the percentage of women who unintendedly become pregnant according to age, marital status and FPL. The Alaska Pregnancy Risk Assessment Monitoring System (PRAMS) data indicates that of pregnancies among Alaska women, 41 percent were unintended; 90 percent of the women were not using, or improperly using, a birth control method. CHAIRMAN WILKEN asked about the PRAMS program. KAREN PEARSON, Division of Public Health, DHSS, explained PRAMS is a voluntary survey conducted by DHSS, about six months after a birth, to compile information on all live births in Alaska. 14 other states have similar surveys. CHAIRMAN WILKEN asked what percent of surveys are returned. MS. PEARSON answered the responses are broken down by strata but she estimated 60 to 80 percent are returned, depending on the strata. SENATOR ELLIS stated that unintended pregnancy is costly on many levels. The costs to the family include abuse, poverty, and divorce - costs that have a direct impact on the state budget. The social costs include lower paying jobs, higher unemployment, and greater likelihood of welfare receipt. He added the hard core economic costs are pregnancy care costs in the form of ectopic pregnancies, induced abortions, spontaneous abortions, and term pregnancies. SENATOR ELLIS explained the next two slides contain information from a book entitled The Best Intentions. The slides listed the consequences for unplanned babies and the consequences for family formation. SENATOR ELLIS reviewed information about health plans. Despite nearly universal drug coverage, many health plans exclude contraceptives: 97 percent offer prescription drug coverage of other types but 49 percent fail to cover contraceptive methods. Only 15 percent cover all five reversible methods of contraception (IUD, diaphragm, implants, injections, and oral contraceptives). Many policies exclude contraceptives even if they are prescribed for a medical condition other than birth control. The next slide showed the medical costs over five years of using contraceptives versus no method, which leads to wanted and unwanted pregnancies. SENATOR ELLIS stated the average out of pocket cost for oral contraceptives is $25 per month. Adding oral contraceptives to a drug card plan increases employee cost by about $16.20 per year, or $1.35 per month. He added that gender inequity does exist in these health care plans. On average, women pay more and get less for their health insurance coverage. In sharp contrast, most health insurance policies offer full coverage for drugs and devices for men, including prostate treatment, penile implants, testicular or urogenital diseases and medication for male impotence. CHAIRMAN WILKEN thanked Ms. Gearhart for the presentation materials she provided for the committee. Number 506 SENATOR ELLIS summarized by saying society is spending millions of dollars on the consequences of unintended pregnancies. Support for family planning is broad and contraceptive coverage is cost effective. If all families had access to contraception, more children would be wanted, poverty and welfare dependence would be reduced, and the number of abortions would be reduced dramatically. He quoted the former surgeon general of the United States as follows, "The starting point of effective child abuse prevention is pregnancy planning." Senator Ellis noted his appreciation to Tom Atkinson of Representative Croft's staff who helped prepare the materials for the presentation. CONNIE PAGE testified on her own behalf from Fairbanks. She questioned why insurance companies are not already covering all contraceptives. Contraceptives have been regularly excluded by insurers even though they are the most widely used drugs by women aged 18 to 44. Oral contraceptives and hormonal implants are the most effective, yet they are expensive and obtainable only from a health care provider. As the mother of two daughters, she is aware of the statistics on teen pregnancy. The fact is many teens are sexually active at an early age, whether parents want them to be or not. She wondered how low income families face the costs of contraceptives and the hard choices they are forced to make. Research data from the Alaska Division of Public Health show that one-half of the births in Alaska are unplanned. Improving private insurance coverage for contraceptive services, or increasing access to contraception, can reduce barriers to effective family planning. Ms. Page commented that it is ironic that insurance plans cover impotence treatment to assure that men can be sexually active while women are not assured that their pregnancies can be prevented. BETH CARLSON testified from Eagle River on her own behalf in support of SB 260. Women pay 68 percent more in health care expenses during their reproductive years than do men, due in large part to the costs women must pay for reproductive health care, such as gynecological care and contraception. The lack of coverage of these health care costs places a heavy burden on young families struggling with many other expenses. Requiring insurance companies to cover prescription and device contraceptives would not only be economically beneficial to insurance companies but will benefit young women and couples. SB 260 will also benefit Alaska businesses. In a one year time period, 85 percent of women in their childbearing years, who are sexually active but do not use contraception, become pregnant, as opposed to only three to six percent of such women who use oral contraceptives. As any employer knows, a pregnancy, whether planned or unplanned, affects worker productivity. Many women experience morning sickness, have required doctor's visits, sometimes require bed rest, and need time off for the birth itself and maternity leave. The husband's productivity can be affected for various reasons as well. Requiring insurance companies to cover the costs of contraception will almost certainly decrease the number of unintended pregnancies, and will benefit not only those women and couples who are not yet prepared to have a child, but also the businesses that employ them. Requiring insurance companies to cover prescription contraception is also a way to ensure that every child is wanted and loved from the moment of conception. She urged committee members to pass SB 260. SENATOR ELLIS asked anyone who has written testimony to fax it to the committee to be included in committee packets. ROBIN SMITH testified on behalf of herself and her husband, business owners with 11 employees, in strong support of SB 260. In the last couple of years, they have seen a number of both male and female employees deal with unintended pregnancies. Every case has been stressful as well as a financial and time burden. As an employer, she can support employees by providing medical insurance for contraception which she believes to be basic health care for women. In our society, it is a woman's responsibility to prevent unintended pregnancies. While most employment related insurance policies in the United States cover prescription drugs in general, a vast majority do not include equitable coverage for prescriptive contraceptive drugs and devices. Similarly, while both policies cover outpatient medical services in general, they often exclude outpatient contraceptive services. This failure is costly, both to insurance companies who may have to pay for maternity care, as well as families whose lack of physical and financial well-being is threatened by an unintended pregnancy and the lack of access to equitable coverage for contraceptives. TAPE 98-24, SIDE B MS. SMITH continued. Young women entering the workforce frequently start out at minimum wage at a time when they need contraceptives most and can least afford them. As previously stated, women pay 68 percent more in out-of-pocket medical expenses during this time period. Unintended pregnancies can also damage a woman's career. Having the added cost of child care rapidly erodes the purpose of working. If a young woman already has one infant in child care, the cost of a second child could force her to quit her job. Maintaining a well trained dependable staff is vital to operating a profitable business. Encouraging planned pregnancies when young adults can afford a family simply makes sense. MARY OSTBACK testified from the perspective of a contraceptive consumer. Her husband's state insurance policy allows two options regarding contraception: a vasectomy or tubal ligation. When neither option is suitable, women are forced to pay for any of the other options available. This places an unfair burden on women who are already paying much more than men do in health care costs. She believes the state should ensure that women have the support and ability to prevent pregnancies so that they do not have to take advantage of other options. She stated her strong support for SB 260. Number 548 GORDON EVANS, representing the Health Insurance Association of America (HIAA), a national trade association of commercial health insurance companies that provide health insurance for approximately 55 million Americans, testified. He clarified HIAA does not represent Blue Cross, AETNA, or some of the other major insurance companies. HIAA opposes SB 260 for a number of reasons, not the least of which is that the provisions mandate a specific coverage of something that is not considered to be basic health care treatment. The consequence of this mandate would be to increase the costs of health insurance, and reduce the efficiencies of managed care. HIAA favors the preservation of a system that allows the prospective purchaser of health insurance free choice of which risk he or she wishes to cover from the various coverages offered by competing insurance carriers. HIAA also believes the choice of how a policyholder spends what funds are available for health insurance should be free of government decree. It continues to oppose the proliferation of benefits through a government mandate. The services for which coverage would be mandated by SB 260 are generally considered to be elective services. Insurance companies are not in the business to provide free health insurance coverage. Anytime the government mandates specific coverage, that becomes one of the rating factors insurance carriers then use in making underwriting decisions. If the coverage sought by SB 260 is mandated, premium costs will be increased even for those people who have no use for, or do not want, the coverage. Furthermore, if this legislation passes and coverage for contraceptive services is mandated, this mandate would apply only to individual policies, smaller employer group policies, and certain other group policies, those who can least afford a premium increase. The mandate of SB 260 would not affect Alaska's largest employers: state employee coverage, CARRS, BP, ARCO, EXXON, or the Municipality of Anchorage because they are all self-insured and are subject to federal ERISA law which preempts state law. He thought approaching Congress to change ERISA would be more appropriate. He added that most of the companies he represents do not routinely cover abortions, vasectomies, sterilizations, and tubal ligations. SENATOR ELLIS asked whether HIAA opposed the state mandate for mammograms. MR. EVANS replied HIAA opposes any mandate, but it did not go on record last year as opposing mammograms, pap smears, prostate coverage, etc. SENATOR ELLIS asked if HIAA did not because it would be politically unpopular to specify those services. MR. EVANS said he did not know why. He was instructed to oppose all mandates. SENATOR ELLIS pointed out that while the state would not be affected because it is self-insured, it has been the state's practice to comply with legislative mandates for other carriers. MR. EVANS thought the state considered such mandates through its collective bargaining process. Number 494 SENATOR ELLIS asked Mr. Evans if he agreed with the HIAA quote on the slide. MR. EVANS replied he cannot disagree with that statistic. SENATOR ELLIS clarified that HIAA estimated that adding oral contraceptives to a drug card plan would increase employee cost by about $1.35 per month. MR. EVANS commented if that cost was mandated, insurance carriers would have to drop coverage elsewhere. CHAIRMAN WILKEN questioned the disparity between benefits for males in our society versus females. He stated he always assumed oral contraceptives were covered under all insurance plans but found out they are not, even when they are prescribed for purely medical reasons other than birth control. He said he co-sponsored this bill because he cannot understand why oral contraceptives are not covered, especially when they are prescribed for medical reasons. MR. EVANS responded the definition of the word "contraceptives" leaves a bit to be desired. That definition describes contraceptives as an appliance, a drug, or a medicinal for preparation intended for the prevention of conception. That definition could include a box of condoms. He suggested tightening up the definition. CHAIRMAN WILKEN indicated he thought a drug would be covered if it was medically prescribed, according to the definition of health care services. MR. EVANS stated Section 2(a) of SB 260 mandates coverage for contraceptives and related health care services. Medically prescribed services would be covered under related health care services. Contraceptives include appliances, which can cover many things. CHAIRMAN WILKEN said he interprets that section to mean either would have to be prescribed or administered by a doctor, which is his intent. He asked Mr. Evans if he could offer suggestions to clarify that language. SENATOR ELLIS indicated Chairman Wilken's interpretation is his intent as well. He noted that intent was expressed to the drafter who wrote the bill. MR. GORDON suggested including a letter of intent to clarify the issue. Number 439 MIKE LESSMEIER, representing State Farm Insurance (an HIAA member), stated State Farm is opposed to SB 260 because it mandates a benefit which mandates a cost, and that cost is then mandated to everyone whether or not they need the benefit. Mandating benefits also interferes with the functioning of a system that has worked well in the free market system based on competition. If availability of a coverage is a true concern, mandating an offer of that coverage is more desirable so that the people who use it are the ones who pay for it. State Farm does not believe that relating the issue of an unwanted pregnancy to the issue of the availability of insurance is fair. The Legislature cannot legislate personal responsibility. State Farm's concern about mandates does not only relate to this issue; it relates across the board. CHAIRMAN WILKEN asked why State Farm would oppose an increased cost of $1.60 per month now to prevent a problem that could cost thousands. MR. LESSMEIER replied to begin with, he does not think the $1.60 figure is accurate. He commented if that is truly the question, then the state should pay that increase, rather than private individuals who have no need for the service. He repeated his opposition to imposing that cost on everyone. He maintained it is unfair to look at individual issues in isolation because there is a laundry list of services many people believe are necessary and should be covered, counseling being one. He stated the question is, where does one draw the line because if all of them are covered, the product will be unaffordable, which will help no one. He repeated that if availability is the problem, mandating an offer of availability is a better approach. Number 386 SENATOR ELLIS indicated he agreed with Chairman Wilken that the incremental cost of providing this coverage is tiny and that SB 260 will not mandate personal responsibility; it will enable people to exercise personal responsibility. Asking people to bear this small increase in policy costs is not an issue because society is bearing the costs of unintended pregnancies now to a great extent. MR. LESSMEIER repeated it is unfair to equate an unwanted pregnancy to a lack of health insurance coverage for contraceptives. He suggested looking at data from other states with similar legislation to see if it has had any impact on unwanted pregnancies. Number 327 LISA BLACKER, representing herself, made the following comments. Regarding Mr. Lessmeier's opposition to requiring all policyholders to pay for the increased cost of contraceptive coverage, she said she is already paying for things that go toward men's health care coverage in her premium cost. She supports SB 260 for two primary reasons. First, it will reduce the disparity in out-of-pocket health care costs between men and women. Second, and more importantly, it will help reduce the number and consequences of unintended pregnancies. The National Academy of Sciences' Institute of Medicine released a 1995 report stating that 50 percent of all pregnancies in the United States were unintended. The number climbs to 60 percent among poor women; 73 percent among never-married women; and 86 percent among unmarried teens. Such pregnancies impose great burdens on families and societies. The Institute of Medicine also notes that the failure to cover birth control leads to higher costs for the insurer. Abortions, delayed prenatal care, low birth weight, and higher infant mortality rates are the costs associated with unintended pregnancies. Those costs are far higher than the costs of birth control and are reflected in the price we pay for insurance premiums now. SB 260 could play a significant role in increasing access to more safe and effective methods of birth control and reduce the tragic consequences of unintended pregnancies. Number 327 ANGELA SALERNO, representing the National Association of Social Workers (NASW), made the following comments. NASW strongly supports SB 260 as it will help working families access the most effective forms of birth control so they can plan happy, healthy, wanted families. Unintended pregnancy is an issue of basic health care for women and families. A 1996 Institute of Medicine Report found the contraceptive needs of a number of groups in society remain unmet so recommended that new and improved forms of contraception be researched and that the full range of contraceptive products be made accessible to consumers. It further states that, "...third party payers, who bear the cost and reap the benefits of the health status of their covered population, include contraception as covered service. Family planning services and the management of sexual health should be integrated as comprehensive reproductive health services." Ms. Salerno maintained SB 260 will not impact those Alaskans who are wealthy and can purchase any kind of contraception they wish. It will impact Alaska's working families, the people who have taken personal responsibility for themselves. It will help them plan for wanted children. NASW believes prevention is the future of providing health care in this country. Cost containment is an issue; prevention is the number one method of containing cost. This type of measure will also prevent some of the social problems experienced by the entire community because everyone pays for unwanted pregnancies. SB 260 is about working families, prevention, social problems, and unwanted pregnancies. Number 288 CAREN ROBINSON, testifying on her own behalf, related her recent experience working with a group of Close-Up students. The Close-Up group studied SB 260, as well as companion legislation in the House. The group had a mock committee hearing as well as a mock legislative session. The mock committee members passed SB 260 unanimously. In the mock legislative session, SB 260 passed with a vote of 35 to 5. Amendments containing intent language were offered. She concluded by saying the third group of Close-Up students supports SB 260. SENATOR ELLIS commented a Senate version of the letter of intent that originated in the House clarifies that the sponsor does not intend to mandate coverage for abortions or other medicinal preparations that affect a fertilized ovum. Also, some concern has been expressed about teens using SB 260 to access contraceptives without their parents' knowledge. He explained that insurance claims require a parent's signature therefore it is very unlikely that a child could get services without a parent's knowledge. CHAIRMAN WILKEN asked Senator Ellis to read the letter of intent into the record. SENATOR ELLIS read his letter of intent to SB 260 as follows: Contraceptive technology is constantly changing, and even medical experts disagree on how certain methods of contraception work. Thus, the sponsor believes it is unwise for the legislature to dispute specific methods, but that it is very important to clarify the intent of SB 260. This legislation is intended to require insurance providers in Alaska to cover contraceptives and contraceptive services. Contraceptives have the primary purpose of, or special utility for, preventing conception. The sponsor intends that conception be understood as the fertilization of an ovum. The sponsor does not intend to require insurance coverage for any appliance, drug or medicinal preparation (or related health care service) the primary purpose of which is to affect a fertilized ovum. Put more plainly, the sponsor does not intend to mandate coverage for abortions. There being no further testimony on SB 260, CHAIRMAN WILKEN adjourned the Senate HESS meeting at 10:32 a.m.