Saturday, February 24, 2007

Tennessee Pregnant Women Support Act

Warning: lengthy post follows.

A bill has been introduced in Tennessee entitled the "Pregnant Women Support Act" [SB2161, HB2146] The bill is essentially a state version of the Pregnant Women Support Act introduced in the federal legislature last year and currently winding its way through committees and such. The national bill was introduced by another Tennessean, Representative Lincoln Davis. The national bill began as an effort to reduce abortion, and the state bill will likely be touted in the same terms.

As Sean Brainsted points out, it's difficult for advocates of reproductive rights to find much in this bill to be strictly against, and it's certainly a more reasonable approach to abortion than Stacey Campfield's monstrosity. However, criticism of the bill is likely to address what it does not include. As has been pointed out with regards to the national bill (posts 1 and 2), this bill does nothing to actually reduce unwanted pregnancy in the first place. Some of the language provides for informing women about how to prevent future pregnancies, which is great, but a bill attempting to reduce abortions might at least pay lip service to well-woman care (when reproductive health education can occur), comprehensive sex education, and access to contraceptives.

The bill in full:
AN ACT to amend Tennessee Code Annotated, Title 49; Title 56; Title 63; Title 68 and Title 71, and to enact the “Tennessee Pregnant Women Support Act”.
SECTION 1. Tennessee Code Annotated, Title 68, is amended by inserting Sections 2 through 6 below as a new chapter thereto to be designated as Chapter 59.

SECTION 2. This act shall be known and may be cited as, the “Tennessee Pregnant Women Support Act”.

SECTION 3. The department of health is authorized to and shall apply for any available federal grant providing for the collection of data regarding the number of abortions performed in this state, the characteristics of those seeking abortions, the reasons why women choose abortion, or any other information applicable to supporting pregnant women in this state who may be seeking an abortion.

While the number of abortions performed in the state is already collected by the Department of Health, this portion encourages the Department to seek funds to research why women have abortions. It seems reasonable to collect this type of data in order to plan any future prevention programs. This section specifically corresponds to the section of the national bill that would have the Institute of Medicine conduct a study on why women have abortions, to release a report by 1/2010.

SECTION 4. The department of health shall develop a comprehensive informational pamphlet for distribution upon request to Tennessee licensed physicians. Every licensed physician in this state shall provide such pamphlet to any woman to whom the physician provides an abortion or provides information concerning a possible abortion. The pamphlet shall contain: a list of public and private health care services available to women during pregnancy and after the birth of a child, whether the women wish to keep their children or place them for adoption; public and private adoption resources available in the state, including but not limited to the surrender of an infant without criminal liability pursuant to § 68-11-255; and public and private services available, pursuant to Title X of the federal Public Health Service Act, to assist women in preventing future pregnancies. The pamphlet shall contain the name, address and telephone number of public and private organizations, health care facilities, or other persons providing these services; provided, that the commissioner of health may promulgate such rules in the commissioner’s discretion as are necessary for any public or private organization, health care facility, or other person to qualify for inclusion in the pamphlet. The department shall make the pamphlet available to physicians by no later than January 1, 2008.

This is a slightly problematic section. I am supportive of women having all possible information on all of their possible options in times of crisis, such as an unplanned pregnancy. The section provides for informational pamphlets on non-abortion-related services to women who ask their healthcare providers about abortion. It might be more appropriate if the pamphlets contained information on all related services and options, including abortion. It might be argued that the pamphlet simply provides an alternative to the information the physician is providing, but physicians frequently provide patients with pamphlets on conditions they have just discussed in the office. If all information were presented, the pamphlet would simply be an information resource for the woman as she weighs her options. As-is, it is specifically positioned to counter the option of abortion, and becomes a persuasive tool rather than a strictly informational one.

Additionally, the Department would provide pamphlets on request, rather than automatically distributing them to the licensed physicians and nurses who are registered with the State. However, the section also requires provision of a pamphlet to any woman asking about a possible abortion. Therefore, if time a woman visited her family physician and received an unexpected pregnancy result, that physician would technically need to have the pamphlets on hand in order to legally have a conversation with the patient about abortion. I hope that logistical concerns such as these will not, in real practice, get between a woman and her physician talking about her health.

SECTION 5. The department of health shall develop a toll-free telephone hotline for pregnant women or other interested parties to obtain information about: public and private health care services available to women during pregnancy and after the birth of a child, whether the women wish to keep their children or place them for adoption; public and private adoption
resources available in the state, including but not limited to the surrender of an infant without criminal liability pursuant to § 68-11-255; and public and private services available, pursuant to Title X of the federal Public Health Service Act, to assist women in preventing future pregnancies. The department shall operate the toll-free telephone hotline no fewer than eight (8) hours per day for no fewer than five (5) days per week, during normal business hours, and shall publicize the hotline through the use of media which may include radio, television, newspaper, billboard or other advertisements. The commissioner of health may promulgate such rules, in the commissioner’s discretion, as are necessary for any public or private organization, health care facility, or other person to qualify for inclusion in the information distributed pursuant to the hotline. The department shall make the hotline available by no later than January 1, 2008.

I'm a librarian, I'm all for the dissemination of information, so a hotline suits me just fine. Numerous voluntary health organizations run hotlines to provide information for consumers on their health information needs. I'd like to see a website with directory accompany the hotline - even if it couldn't be accessed by all w omen, it would be accessible to healthcare providers, librarians, and others who may serve in a role that exposes them to health and community service information requests.

(a) There is hereby created in the general fund an account to be known as the "Tennessee pregnant women support fund", hereinafter known as "the fund", as a special nonreverting fund. Funds appropriated from the Tennessee pregnant women support fund shall be administered by the department of health to support women and families who are facing unplanned pregnancy.
(b) The department is authorized to solicit gifts, donations, bequests and grants on behalf of the fund from any source and to deposit all moneys received in the fund. The commissioner shall submit to the governor an annual report of all gifts, donations, grants and bequests accepted; the names of the donors; and the respective amounts contributed by each donor.
(c) All moneys received from any source pursuant to subsection (b) shall be credited to the fund. Interest earned on moneys in the fund shall remain in the fund and be credited to it. Any moneys remaining in the fund, including interest thereon, at the end of each fiscal year shall not revert to the general fund but shall remain in the fund. Moneys in the fund shall be used solely for the purposes of carrying out the activities enumerated below:

The question I still have after reading this section is how much money will be allocated to the program from the State budget, and where that money will come from. I don't see anything in this proposal that says, "The State will provide X dollars to establish the fund and support the activities required by this legislation." It does allow the Department of Health to solicit grants and donations to support the programs, but doesn't seem to provide for how to administer the law if there is not enough grant/gift money to carry out the directives.

(1) Purchasing or upgrading ultrasound equipment for the benefit of any public health program or private health provider in this state;

The emphasis on ultrasound equipment is interesting. Healthcare providers who see pregnant women (and women of reproductive age in general) need equipment other than ultrasound machines on a daily basis. Ultrasound equipment is expensive, and if this section benefits legitimate, unbiased clinics who provide services to women, that is a good thing. However, ultrasound machines are also a point of controversy in the reproductive rights movement, as so-called "crisis pregnancy centers" like to add ultrasound services, believing that they can help coerce women into rejecting abortion as an option. See my previous post on "Option Ultrasound," just such an initiative by anti-choice Focus on the Family. Not every woman will want to have an abortion, but to try to convince women to "choose life" based on emotional manipulation is unseemly. The warm-and-fuzzy a woman gets from viewing an ultrasound is in no way going to make the emotional, physical, and financial resources needed for childbearing magically appear. This provision corresponds to a section in the national bill that would allow grants to be made for the purchase of ultrasound equipment.

(2) Creating a separate program within the department to address domestic violence, dating violence, sexual assault and stalking screening against pregnant women and new mothers;

This is important and worthwhile if well-executed, because the statistics on women abused during pregnancy are staggering. Part 2 corresponds to the national bill section providing for states to "obtain funding for a separate program for domsetic violence, dating violence, sexual assault, and stalking screening and treatments for pregnant women and new mothers. This would include training health professionals to identify and respond to patients experiencing abuse, and ensuring that services are provided in a "linguistically and culturally relevant manner." $4,000,000 would be authorized for appropriation for each of the fiscal years 2007-2011."" Note that the national bill does something the State bill does not, which is to specifically address the training of providers, a monetary value, and linguistic and cultural appropriateness.

(3) Conducting the campaign outlined in this chapter to increase public awareness of public and private resources available to pregnant women in this state;

Again, regarding Part 3, information is a good thing. This is directly taken from the national bill.

(4) Providing support services for students of institutions of higher education in this state who are pregnant;

(5) Providing funds to allow early childhood education programs to work with pregnant or parenting teens to complete high school and provide job training education; or

Part 4 also corresponds with measures in the national bill, which included disbursement of grants (not to exceed $25K) to public higher education institutions to assist pregnant students who intent to carry their pregnancies to term through on-campus facilities. More specific information is needed in the state bill to address what type of support will be offered and how it will be funded. Part 5 also replicates the national bill. Supporting women's pursuit of primary and higher education is a good goal, as it wasn't so long ago that pregnant women were automatically expelled from schools.

(6) Providing education on the health needs of infants to teenage or first time mothers through free home visits by registered nurses.

Part 6 is a laudable objective, and there are already agencies in Tennessee providing this kind of service, who I hope would benefit from funding under this section. This provision appears in the national bill, although the national bill also provided for breastfeeding education through WIC.

(d) The department shall establish an application process and related procedures for community health centers, migrant health centers, homeless health centers, public-housing centers, or any other public or private entity seeking grants from the fund. A grant may be made only if an application for the grant is submitted to the department in such manner as specified by the department pursuant to rule.

This is just administrative, so just needs to be done well. The process needs to be done in a way that is not so burdensome to the already stretched resources of public agencies and healthcare providers that it becomes a barrier to funding and implementing services.

SECTION 7. Tennessee Code Annotated, Title 56, Chapter 7, Part 23, is amended by adding the following language as a new, appropriately designated section:
(a) Notwithstanding any other provision of law to the contrary, any individual, franchise, blanket, or group health insurance policy, medical service plan contract, hospital service corporation contract, hospital and medical service corporation contract,
fraternal benefit society, health maintenance organization, preferred provider organization, or managed care organization which provides hospital, surgical, or medical expense insurance shall not deny coverage under any such policy, contract, or plan for obstetrical services to a pregnant woman insured on the basis that the pregnancy was a pre-existing condition if such plan otherwise provides coverage for obstetrical services for insureds who become pregnant after enrollment in such policy, contract or plan.
(b) The provisions of this section are applicable to all health benefit policies, programs, or contracts which are offered by commercial insurance companies, nonprofit insurance companies, health maintenance organizations, preferred provider organizations, and managed care organizations, and which are entered into, delivered, issued for delivery, amended, or renewed after January 1, 2008.
(c) Reimbursement for obstetrical services for insureds who are pregnant at the time of their enrollment shall be determined according to the same formula by which charges are developed for obstetrical services for other insureds. Such coverage shall have durational limits, dollar limits, deductibles, copayments, and coinsurance factors that are no less favorable than for other types of obstetrical services generally.
(d) Nothing in this section shall be construed to prohibit any insurer from providing medical benefits greater than or more favorable to the insured than the benefits established pursuant to this section.
(e) The provisions of this section shall not apply to short term travel policies, short term nonrenewable policies of not more than six (6) months’ duration, accident only policies, limited or specific disease policies, contracts designed for issuance to
persons eligible for coverage under Title XVIII of the Social Security Act, known as Medicare, or any other similar coverage under state or governmental plans, including the TennCare and Medicaid programs.

I'm not seeing a corresponding portion in the national legislation, but I seem to recall another federal bill that addressed this topic (I'm unsure of the status). It would essentially prevent insurors from denying care to pregnant women, which is a good thing.

SECTION 8. Tennessee Code Annotated, Title 68, Chapter 5, Part 5, is amended by inserting the following as a new, appropriately designated section thereto: Any person who offers or provides to a pregnant woman a testing or screening service to detect genetic disorders in that woman’s fetus shall inform the woman in a medically and statistically accurate manner of the likelihood that a positive result of such test or screen might be a false positive. For a person who is a licensed physician or osteopathic physician in this state, a violation of this section may be considered a violation of the practice act governing that person pursuant to title 63, chapter 6 or title 63, chapter 9, respectively. In addition, a violation of this section may be considered a violation of the licensure requirements governing any facility licensed by the department pursuant to this title where the testing or screening service was provided.

This is similar to but more limited than the national bill, which would also provide for peer-support programs, a phone hotline and website for patients, a registry of families willing to adopt newborns with genetic disorders, a clearinghouse of information on these conditions, and education programs for healthcare providers. Information on the false positive rates of these tests, as is information on false negatives, which should seemingly also be included.

SECTION 9. Tennessee Code Annotated, Section 68-11-255, is amended by deleting subsection (a)(1) thereof and by substituting instead the following: (1) “Facility” means any hospital as defined by § 68-11-201, birthing center as defined by § 68-11-201, community health clinic, outpatient “walk-in” clinic, local department of health clinic, local office of the department of human services, or local fire department or police station.

SECTION 10. The commissioner of health is authorized to promulgate rules and regulations to effectuate the purposes of this act. All such rules and regulations shall be promulgated in accordance with the provisions of Tennessee Code Annotated, Title 4, Chapter 5.

SECTION 11. This act shall take effect July 1, 2007, the public welfare requiring it.

As stated in my previous post on the national legislation, I do think this bill does some very worthwhile things, and at least partially addresses the old argument that if you want to reduce abortions, you have to make it easier for women to have children and support them after birth. On the other hand, the folks involved with tthe national bill have proposed it as a means to reduce abortion, and I don't see a single thing in it about comprehensive sex education (big surprise) or contraceptives. There is nothing in here that addresses preventing pregnancy in the first place, except when a woman has already experienced an unplanned pregnancy. Also, I think it's good if more women are referred to appropriate community agencies, but I don't see a specific increase in funding for existing providers. If they suddenly become swamped with women, will they be able to afford it, and will women receive good service? I also don't see much that truly makes it easier for women to afford to have a baby, because there isn't a lot of substantial funding increase for prenatal care, the actual birth, or all the expenses that come with children (especially after the first year covered by the home visits, which are educational rather than medical). Finally, this legislation could be read as an attempt to push women into carrying a pregnancy to term and giving up the child for adoption, while it does not in any way address the psychological consequences or provide post-surrender counseling for these women. It will be interesting to see how this plays out.


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