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Case Studies 7 TENNESSEE POLITICS SB1677 was filed for introduction in the state Senate on January 14th, 2016, and the corresponding bill HB1823 was filed in the state House three days later. In both chambers the bill was referred to the Health and Welfare Committee. The bill was first up for debate in the Senate Health and Welfare Committee on March 2nd, 2016. The chief sponsor was Senator Steve Dickerson, a Republican physician. Dickerson briefly introduced the bill, and then turned the floor over to Dr. Leonard Brabson, the Tennessee legislative chair of the American College of Obstetricians and Gynecologists. Dr. Brabson strongly argued on behalf of the bill, stating that “we believe that the risks of this are greatly outweighed by the benefits.” He began by making an economic argument, noting the high rate of unintended pregnancies, and the cost to Medicaid of those pregnancies. He said that while the ACOG formally endorses making birth control fully over the counter, making it available via a collaborative practice agreement is a compromise that ACOG found acceptable. He said that “self-screening by women has shown to be very appropriate” in identifying good candidates for oral contraceptives, and that while “we would like for people to have annual screenings, or every other year screenings… the data show that people can take birth control pills without actually having to do that.” Further, countering the perception that oral contraceptives are overly risky, he said that “we have riskier medications available over the counter… even Tylenol can kill you.” Senator Joey Hensley asked Dr. Brabson whether he had proof that this policy would actually reduce unintended pregnancies. Dr. Brabson replied that ACOG prides themselves on basing policy recommendations on the available evidence. While Oregon and California’s changes were too recent to measure effects, he stated that international evidence finds reductions in unintended pregnancies. Sen. Hensley responded by saying he thinks the law should wait until data from Oregon and California are available. Further, he thought that the law was likely not necessary because birth control pills are so readily accessible, and thought that they were too high risk to be available through a pharmacist. Notably, he also worried that oral contraceptives were too complex for women to understand without education from a physician, stating that “some people may just think that they take them one time and that helps,” rather than taking the pill each day. Despite Senator Hensley’s noted concerns, the bill made it out of committee and was passed on the floor of the Senate and House 28-1 and 68-22, respectively. HOW IT WORKS This bill authorizes pharmacists to provide hormonal contraceptives to patients over the counter so long as they adhere to a “valid collaborative pharmacy practice agreement.” The bill empowered the Board of Pharmacy to, along with the Board of Medical Examiners, draft standard procedures for pharmacists to follow. These guidelines primarily consist of a self- screening tool and education for pharmacists and patients. Then, pharmacists must partner with a physician using the collaborative practice agreement. Pharmacists could then treat all women in the community, not just existing patients of the supervising physician.