The Certificate of Need program, administered by the Department of Health and Social Services (DHSS), monitors the development of health care facilities, and was established to prevent excessive, unnecessary, or duplicative development of such structures. In addition to providing governmental oversight of the construction of high-cost medical facilities, the Certificate of Need program also allows for public scrutiny of the proposed projects. Certificate of Need guidelines state that any proposed facility, proposed increase to the number of beds in an existing facility, or addition to the categories of health care services provided, requires a Certificate of Need if the expenditures will be more than $1 million. The only exemptions from Certificate of Need requirements are the costs of relocating an ambulatory health care facility. Even then, the exemption only exists when neither bed capacity nor the number of categories of health care services provided are greater than they were before.

State Certificate of Need guidelines were last amended in 2005. The legislation, HB 511, addressed the standards of review for nursing homes, nursing home beds, and Residential Psychiatric Treatment Facilities (RPTF). Many of the changes were a direct result of seeking to include these facilities in the legislative language that dealt with other health care facilities.

Certificate of Need Legislation, 1999-2007

This is not to say; however, that Certificate of Need legislation wasn't brought up before these changes. On the contrary, there has always been at least one Certificate of Need bill introduced during each legislative session since the 21^st Legislature (1999-2000). The bills themselves have ranged from increasing the expenditure limits, to discarding Certificate of Need completely in urban areas, to putting a full moratorium on all Certificate of Need projects until the program's guidelines could be re-evaluated. Some measures have advanced further than others, including being passed into law, but all illustrate a constant interest in the program itself.

21^st Legislature (1999-2000)

There were three proposed Certificate of Need bills during the 21^st Legislature (1999-2000), only one of which was passed into law. HB 187 Certificates of Need for Health Facility has been in effect since June 5, 1999. It addressed several statutory issues relating to the application for, and the review of, Certificates of Need. Prior to the passage of HB 187, facilities required a Certificate of Need to remove a category of health service currently provided by the facility. HB 187 eliminated this requirement. It also set a standard for review of applications for Certificates of Need relating to nursing homes and nursing home beds, and defined the term "nursing home bed." The definitions of nursing homes and nursing home beds play a role in future legislation, making HB 187 an indication of the eventual direction Certificate of Need legislation would take.

The other bills from the 21^st session were SB 59 and SB 195. SB 59 was a cost saving measure designed to avoid potential future costs to the state from construction of new nursing home beds. SB 195 addressed facility compliance with health and safety laws.

22^nd Legislature (2001-2002)

The 22^nd Legislature (2001-2002) did not produce new Certificate of Need legislation, although several bills were proposed. HB 407 Certificate of Need contained an interesting dilemma: a disparity between the proposed legislation and the accompanying fiscal analysis, and even a disparity among the fiscal notes themselves. HB 407 proposed a massive policy change to the entire Certificate of Need program, seeking to do away with Certificate of Need requirements except in the cases of skilled nursing facilities and residential psychiatric treatment facilities (RPTFs) in urban areas, defined in the bill text as areas of 55,000 people or more. This meant a full exemption from Certificates of Need for Anchorage, Fairbanks, and the Mat-Su region--the most urbanized areas of the state--and also the areas with significant health care services already available.

The two fiscal notes prepared by DHSS for this bill seemed to contradict the spirit of the proposed legislation. Where the bill text supported the notion of freedom from governmental oversight into the construction of health care facilities (evidenced by the complete removal of Certificate of Need requirements for urban areas), these two fiscal notes focused on how much money unrestrained construction of such facilities might cost Medicaid each year. According to the notes, such construction would have cost the state $30 to $50 million each year in new Medicaid costs. The notes also stated in several places that they (DHSS) didn't have adequate data to use to make cost projections that might have resulted from passage of HB 407, and that it was impossible to predict how much increased Medicaid and Medicare costs due to unrestrained construction could have cost the state. A second, more intriguing, issue arises from the fiscal notes themselves. Three notes accompany the bill, and among them two very different interpretations of the fiscal implications of the legislation are presented.

While two fiscal notes are hesitant to expound on the virtues of HB 407 and actually caution against the expected cost increases that would result from the bill, a third fiscal note takes a decidedly more supportive stance on the bill, stating outright that the legislation would have no fiscal impact on Medicaid Services or DHSS Administrative Services. The fiscal notes in question were prepared by two different groups--the more cautious notes were prepared by DHSS, and the more supportive note was prepared by the House Health, Education, and Social Services Committee. The differences in opinion about the potential expenses that would result from this bill are marked. One of the primary sponsors of HB 407, Representative Dyson, was also the then-chair of the House HESS committee, and Representative Dyson personally signed off on the supportive fiscal note.

HB 485 and SB 256 were also proposed during the 22^nd Legislature. HB 485 Certificate of Need/Mental Health sought to establish a temporary moratorium on the issuance of Certificates of Need for acute psychiatric care beds and to establish a working group to study and issue a report about psychiatric care services. SB 256 Certificate of Need Program sought to establish a working group to examine the program in its entirety and to establish a temporary moratorium on the issuance of certain types of psychiatric beds for children and youths. Both bills specifically addressed issues related to RPTFs, continuing a trend in Certificate of Need legislation that focuses in part or in whole on psychiatric care facilities.

23^rd Legislature

The 23^rd Legislature (2003-2004) saw only one piece of Certificate of Need legislation, but the bill, HB 511, was passed into law. HB 511 Certificate of Need Program continued the trend of explicitly addressing psychiatric care facilities. Once again, the fiscal notes prepared by DHSS indicated that no concrete data exists to predict future needs; in this case, future needs for psychiatric facilities or beds, although the findings in the notes do support the actions proposed in the bill.

HB 511 created the first increase to the Certificate of Need expenditure cap since 1983. The $1 million threshold was left intact, but the bill established a $50,000 annual increase each year through 2014. The bill amended several sections of the existing Certificate of Need law to include residential psychiatric treatment centers and nursing homes. The need for new review standards for these particular facilities was established, and the facilities are included in the existing language governing other aspects of Certificate of Need.

One of the primary goals of the legislation was to make RPTFs subject to the requirements of the Certificate of Need law. Once again, no data existed at the time to adequately calculate the costs of developing additional RPTF capacity, despite the state's interest in doing so. Youth RPTF services are used as an example in the fiscal notes. The development of additional RPTF capacity would counter the high cost of sending children for out-of-state residential psychiatric care. The total number of youth served by RPTFs increased 222% between 1998 and 2002, and the total amount spent on youth RPTF services rose from $5 million in 1998 to $32.2 million in 2002. The "ripple effect" is also mentioned by the fiscal analysis, noting that developing capacity to serve children and youths in RPTFs would benefit the Alaskan economy by creating more jobs and ensuring that Alaskan dollars are spent in Alaska. The final fiscal analysis of the bill indicates that the costs of developing more in-state facilities for residential psychiatric treatment will balance out against the costs of sending children for out-of-state care.

24^th and 25^th Legislatures

The 24^th legislature (2005-2006) saw only one Certificate of Need bill introduced, and it is identical to one that was referred to the House HESS committee during the first session of the current, 25^th, legislature. HB 4 Medical Facility Certificate of Need, sponsored by Representative Lynn, would drastically reduce the scope of the current law. It proposes to apply Certificates of Need only to health care facilities that are nursing homes or RPTFs, or that are located in a borough with 25,000 people or less. The legislation seems aimed at streamlining the review process, although no fiscal analysis of the bill is available as of this writing. It is impossible to know what impact HB 4 would have on Alaska until DHSS fully analyzes the bill. Senator Huggins introduced an identical bill, SB 65 Medical Facility Certificate of Need, during the first session, which also never made it further than a referral to the Senate HESS committee.

Certificate of Need legislation has been a constant topic of debate for the last several years, resulting in significant changes to the existing laws. While more bills remain in committee than pass into law, the interest in, and discussion about, Certificate of Need does not seem to be abating. With the upcoming House HESS committee hearings, this controversy is not likely to disappear any time soon.

Rep. Sharon Cissna is co-chair of the Legislative Health Caucus, and a member of the House Health, Education, and Social Services Committee. In this wide-ranging interview, Rep. Cissna discusses the work of the Legislative Health Caucus, proposed legislation she will be submitting in 2008, and her view of the role of state government in health care reform. Rep. Cissna can be reached by email at Rep.Sharon.Cissna@legis.state.ak.us, and by telephone at 907-269-0190 or 800-922-3875 (toll free). This interview has been edited for length and clarity.

AHPR: You are the co-chair, along with Senator Donny Olson, of the Legislative Health Caucus. What is the history of that most interesting caucus and what are its accomplishments?

Representative Cissna: Well, the concept of the Health Caucus was not mine; it was given to me by a small group of health professionals. Well, I think education more, but there were some applied health care workers, as I recall. It was a suggestion that we needed a health caucus.

It was the House and Senate Democrats that were the source of the Health Caucus and who voted to pass the authorship of a health caucus. It was not easy but we did it and Senator Olson agreed to be the co-chair and he's perfect because he's in rural Alaska. He has a medical background. He's a doctor and he's had a lot of different experiences so he's been a wonderful partner in working on that.

We started in 2004, and we did seven forums in 2004. We were doing them every few weeks during part of the session, and we did that again in 2005. Then in 2006 someone challenged us on, "What exactly are you doing and what are your goals?" We began to really look at where we were heading and what subjects we were taking on, and realized that we could be doing far more reaching out to a broader group if we would do it on a monthly basis, give ourselves more time in-between each one, and also have it in the interims here in Anchorage and try to get more people into the caucuses and have a longer time so that we could get some really rich discussion going. And that actually has happened.

So that was 2006 and right now...in the interim, we'll have six and we've gotten through two so far. So we've had July and August. This year we've had a theme, and actually it sort of followed some of the theme from last summer, which was looking more and more at the workforce. It started with a discussion of health economics, which was great.

AHPR: When you say "the workforce", are you talking about shortages in providers?

Representative Cissna: Both sides, so in other words, workforce health, and health workforce. During this session, in 2007, we started with looking at the top rung, medical doctors and dentists and the Ph.D.s, and then we went down to the mid-level, then down to the complementary, and then traditional. They [DHSS researchers] actually hadn't announced anything when we did this in May but they came out with the first glance at what their findings [Alaska State Planning Grant Research on the Uninsured] had unveiled, which was this oddity about Alaska and its very transient workforce. Much of this is not even documented in data. It's this kind of floating mass of people that were hanging outside of view but are obviously out there in those communities really impacting. At least that is what I'm seeing when I go to communities myself.

I must admit the second part of the year, during this next five months and it's really strong during the next four months, is my own epiphany, I guess you could say, with having begun to look at it entirely different. I know that we've got people in the Legislature that are working now on insurance. I know how important that is, but I now really believe that far more important is the fact that since--and I've heard different numbers and both of them have been gotten in different ways--but somewhere between 50 and 70% of your health is dependent upon decisions you make, behavior you control.

In this four months we're looking at tools to stay healthy. That is the biggest responsibility of government because government's role is to fit in where the market will not, to do what no other part of society will do.

We get huge amounts of money that come from the big foundations that go to our rural communities to help in health care and this and that and the other thing, but I've had a real problem since I started in really trying to figure out what's the right answer because this state doesn't do a really good, systematic job of keeping track of what's happening. Going back and working on a master's (and then dropping out) was very helpful to me because I did take the Economics and Public Policy class and a lot of performance-based budgeting, so know that we're not doing it, that we do not have performance-based budgeting, we're not keeping track of things and we do not do our budgeting tied to any kind of outcomes, any kind of programs that we have here now. We might as well be taking darts and just hitting at the wall and hoping that we get something that might make a difference.

In my mind, you could pass every bill you want to, you could spend every dime you want to, but until you know the outcome of that expenditure, that isn't real thoughtful policy. You could maybe call it policy but it doesn't have feet, it doesn't actually meet what we have to have in order to change outcomes, especially the outcomes that we're finding now with obesity and children. I'm horrified by that. That's where I am now. And I'm going to put as much energy as I can conceivably put into helping kids start moving, start learning how to eat and helping their parents to do it. That's a lot of what's framing what I'm doing now.

AHPR: I'm curious about one thing; my background is also sociology and public health. And the sociologist in me wants to say that I hear this issue all the time, the whole issue of "personal responsibility," but I really have to say that I don't think I've often heard anybody talk about the other side of that at the same time. In other words, why is it that people overeat, and eat junk food and so forth? Well, because it's available and because there's an industry worth hundreds of billions of dollars to make you think that way and to make you a consumer of that stuff and to place it where you'll buy it. Coming from sociology, I'm very well aware of those training techniques and I don't hear the equal discussion about controlling industry or controlling advertising, I only hear all the blame placed on the individual.

Representative Cissna: Right. That is because we're Americans, and because America very early on bought into an expanding idea [that] the market knows what's right, and what's good for the market is good for you. If you go back to Adam Smith and you look at the whole concept of the market and that whole philosophy he was developing, he looked at government and was expecting government to pick up the pieces that the market wouldn't. That in fact, government was the one that regulated, they did build the rules and when the market wouldn't cover something like the utilities, like in maybe health care...but we're not looking at it this way in this country.

Health education is one of the most important pieces that we've got that the state needs to do but we keep pulling back on money to that. You go to economics classes and they talk about one of the real essentials for the market system to work well, [it must be] based on information. We have a dearth of information for the public on how their dollar, [is spent] on health care.

The insurance company does it, or whoever is handling the Medicaid, or your union. Other people are really purchasing that health care that comes to you, that actually directly affects you. You don't make that final choice, you don't decide which doctors to go to based on who's giving the best [care]. The market system is not working the way it needs to work. I know that sounds like a more conservative view, but I think it's part of the problem, and we're not looking at this. If we're going to have the market system work in our country and we've bought into it, then let's look at it in a way that fits what it really is, and that means that we need to be informed, we need to know what it is we're really getting. So you can say people aren't taking responsibility for themselves, but it's a cultural issue and culturally, we've decided people are too dumb or they're not a part of the bigger picture so they shouldn't make the decision. I think, personally, my own concern is that the state is for what industry won't do. It's for what the market won't do, and education needs to come from the state and we need to put a big bunch of bucks on that one.

AHPR: And that's because it's not being done in the private sector.

Representative Cissna: Yes, nobody could or would do it.

AHPR: This is a good segue to my next question, which is: looking into the coming years, what do you believe the Legislative Health Caucus will contribute to the formation of health policy in Alaska?

Representative Cissna: What we've tried to do in the Health Caucus, is to look at the major issues around Alaska in health--it's an amazingly broad subject. Health has huge numbers of pieces to it and we've tried to bring in people from around the state, and that's what is always the amazing thing to me, is how much talent there is out there. And actually, health is one of those topics that almost everybody has some expertise in because even though they may not make the decision on how their dollar is spent, they sure as heck know what the outcome was and they know their family members and what some of the real problems are.

Not that we pull in the average person from the street, we usually pull in expertise of some kind on each of the issues that we approach. But we've had this wonderful grouping because we usually never have less than four or five people and we've made it up to ten people that we've heard from on any given subject, from around the state. So it's been a real rich gathering of the information and it's all available online.

What I would hope is that we've been getting more and more legislators and their staff interested over time. We've had a huge number of hits and downloading of our material, and the record has been really pretty surprising how much information's going out there to people who want it.

I'm hoping that we either win or that Alaskans begin to understand that health is political, that it is something that their representatives, that they choose, can change. I don't personally want to do a lot of personal legislation myself. I have a few things I care about enormously, the prevention and health education thing is a huge interest to me, and trying to make sure that people around Alaska actually have a voice in state government. I don't think they do now, so that's another piece of legislation actually I'm working on.

AHPR: Again, this is a really good segue, because you just began to address my next question, and that is: During the last Legislative session, you were the prime sponsor or cosponsor of nineteen bills and resolutions. Which two or three of these were the most important to you and why?

Representative Cissna: Number one, the giant one, the one that I could see having made more difference than any other piece of legislation, I think that could go through was the Health Compact. We did get that through the Legislature because Senator Davis, as a leader in the Senate, was able to get it through, whereas on the House side it sat in my committee for a year and we couldn't get anything going on that.

The Health Compact was merely asking the Legislature and the Governor to invite Alaskans to celebrate their own personal health and to begin to really try to work on improving their own health and helping other people do the same. Through the example of the Legislature and the Governor, to spread that as a social change, and not as the way we normally do by spending lots of money, because we do have to make a social change here and we're not going to change what's happening through a piece of legislation. It won't happen.

It would be great to change the insurance picture and cover people who are uninsured. However, that doesn't change what choices you personally make. It's education but it's also a social approval of your importance to the governor and the legislature. The choices you make are something that's actually a gift to Alaska because the only way we're going to lower our prices and actually make health more abundant is to share what's good about what we've got with other people and grow our way out of it as a people. And that bill would have done it.

We did pass it. The Governor's still sitting on it and I've written to her, I've called the office, I've tried to see if she wouldn't make that announcement to the people in this state because I think that would make a big difference and I think that could, with a popular governor, do a lot. And it's nowhere right now. That's a huge disappointment to me.

AHPR: But if the Governor doesn't sign it, doesn't it become legislation anyway?

Representative Cissna: It's a resolution and she doesn't have to sign it, so it's the invitation and the promotion of it that really count. The cost of the press releases are not a big cost to this state. It's essentially free, and I think that it's the kind of thing that most TV stations and most radio stations would like the idea of making money off of, because I think you could. You know, I've been in the game. You use things like that to sort of generate business. Then people start realizing just how much fun that could be and it starts actually working on the social part, and we are a people that really need to have the social strength too.

That sharing and giving and taking is one of the things that strengthens communities. Doing more of that would be a really healthy thing--really healthy. And it would be as healthy as the actual things like moving more and learning some new exercises and new activities that made you happier and healthier.

AHPR: What do you anticipate will be the big health issues in the 2008 Legislative session?

Representative Cissna: I think probably, the biggest ones for a long time will be where we spend our money, and that's kind of one of the things that I've been really upset about because of course, we've had the FBI, and the court systems and all of that at our heels because there's a culture here in this Legislature. That culture is one that's driven by the fact that multinationals have a huge [interest] in what the state spends its time on.

In the Legislature time is in short supply. You've only got so many hours in the day. We spend our hours on oil and gas. We spend our time on the big money, and in health care we spend our money on what makes the most money. That's what we do. We pay for chronic care--cost plus--and we keep going down on prevention, keep going down on health education, and down on money means also down on time.

It's the workers of the state that work in those fields, in prevention. I know how horrible they feel, and that's the catch in the Legislature. I know state government's got that problem, but the Legislature does itself as well. We don't spend time talking about the really tough issues--Medicaid's one.

We actually have had a [Legislative Health] Caucus on Medicaid. I think that's really important. I think people really need to understand it, and we need to understand, and it is complex, but we need to understand it well. We need to spend time on that but we will not. If we're going to spend time on trying to figure out how we get around the problem, usually what we do is figure out different banking techniques and things like that. But we don't look at health care. We don't actually look at the health of people and the outcomes of different choices in how you spend your money. I never heard that discussion, ever. That's the one we need to make. We need to spend lots of time on health because it has not been paid attention to for a very long time and we're getting in bigger and bigger trouble because of it.

AHPR: So that sounds like your answer to the question, to two questions: What do you anticipate will be the big health issues in 2008 and what do you think they should be?

Representative Cissna: I'd love to spend huge amounts of money on education. I'm a realist, you know. I probably would never have gotten where I am without that. You have to be able to figure out what you're going to drop because it just isn't going to happen. I'm idealistic but then I can't be too idealistic.

The catch is that we don't have the kind of numbers and the kinds of tracking that we need to have in place in order to do what I personally think we need to do. I think what we need to do is have some real good knowledge of the programs we've done and which ones have been most successful, which ones have had the highest cost-benefit ratio on actually good outcomes, then put some money into those things. Early childhood stuff is extraordinarily important because if you start a child out well and help their parents to keep it going, then you just get a better return than you will if you wait until they're teens or adults or in middle age or at the end of life, and then expect a big return because you're not going to have it.

AHPR: Do you think there will be legislation in the coming year that will promote those goals or values?

Representative Cissna: I've got a little piece in there and I think it would give a chance for that, perhaps, and that's a citizens' task force that would pull from across the state. I think that legislators need to find out what's happening because I think one of the reasons legislators don't really address a lot of the problems we have is because they don't know they exist.

A lot times what I find in my own door knocking in my own community, that a lot of the problems I know exist, in the casual conversations you have with people at the door, don't come up. But because I've been, for instance, looking at the uninsured issue for so long, when I start picking up signs that there might be problems, I stick with it longer and I've gotten some pretty strong feedback that tells me the problem is alive and well in my district. [There is] a growing amount of uninsured or underinsured that I don't think shows up; you're not seeing it, and the severity of the impact on the families that it's hitting.

AHPR: Yes, and it sounds to me like your concept for this task force would in some way be different than the concept of the Governor's Health Strategy Planning Council.

Representative Cissna: Well, the Council, I think they're doing a good job, but their job is looking at health care. See, I've changed my view. I'm looking at health. I think health care comes after you've lost your health--then you need health care. Screening is important. I think [the whole] medical palette is really very important, but the most important is health education that keeps you healthy before anything else happens. Then we actually have the capacity of health care workers to do a great job on our population [and that] means that you stay healthier longer because we've got the people who could really help you [to] postpone those problems until much later.

AHPR: I think your message has come through loud and clear in this interview. Do you have any final words you'd like to tell the Alaska Health Policy Review readership?

Representative Cissna: It is a political issue, and the political issue part of this is that we will not solve our problems until politicians see health as a really important issue and a political issue. Right now, it's not seen as an important issue and so people entering a campaign are really happy to talk about it, they're happy to talk [about] taking care of children, they're happy to do all of that during a campaign. Getting re-elected is the number one dynamic there. There's very little incentive for legislators to really solve some of these problems because how are you going to prove that you're going to be the better candidate if in fact everything's fixed.

And actually, the public health people say kind of the same thing, you know. If there's no problem then nobody wants to hire you, right? Keeping people healthy is just harder to sell. So that's the big problem. That's why I think we need a citizens' task force or advisory to all the departments in the state that deal with health issues. For instance corrections, which some think is the last intensive service for the mentally ill, has huge problems caused by human behavior.

AHPR: Do you have a written version or concept paper or something for the citizens' task force, or is this something you're in the process of preparing?

Representative Cissna: It is a bill, but we did an outline and we want to put flesh on it. I'm getting my UMed fest out of the way and then we're jumping into a work group and try to get to people across the state. There's four of us that are sponsoring it: Representative Doogan, Representative Kawasaki, Representative Doll and myself. So we're planning on working on that this fall.

AHPR: Well we look forward to that.

Representative Cissna: Thank you.

AHPR: And thank you very much for this interview.

Representative Cissna: Thank you.

Brief Summary of Work-to-Date

Governor Palin signed Administrative Order No. 232 on February 15, 2007, establishing the Alaska Health Care Strategies Planning Council (AHSPC) in the Office of the Governor. The Order notes in part that:

Previous and ongoing public and private health care planning efforts have produced a number of reports and initiatives to address various aspects of Alaska's health care system. The new planning initiative provided for in this Order will not duplicate previous efforts, but will synthesize and build upon them.

The purpose of this Order is to recognize the need to develop a statewide plan to identify short-term and long-term strategies to effectively address the issues of access to, and cost and quality of, health care for Alaskans. The council's development of a health care action plan should serve to educate all Alaskans about the myriad of public policy choices regarding health care issues and should engage both governmental agencies and the private sector in finding solutions to these problems.

The council will prepare and submit a health care action plan to the governor and the Legislature, by January 1, 2008. The following are included in the action plan:

• a description of the current health care system in Alaska;
• an inventory and analysis of all existing private and public health care plans, reports, and initiatives in Alaska,  [followed by a list of specific reports]
• short-term and long-term statewide strategic plans designed to improve health care access, cost, and quality within the next ten years;
• involve non-traditional stakeholders, including business, philanthropic, faith-based, and other community organizations; and
• promote integration across public and private health care delivery systems; and
• performance measures and accountability mechanisms to provide policy makers with tools to assess the success of the strategic plans over time.

The Council members are supposed to accomplish this Herculean task over the course of seven 4-hour monthly meetings. The June, July, and August meetings have already occurred. The next meeting is to take place September 17 (1 p.m. - 5 p.m.) at the Alaska Native Tribal Health Consortium Office Building, Anchorage, 4000 Ambassador Drive. Call-in at 1-800-315-6338 Code: 7800. Technology willing, a Live Web Stream of the proceedings will be available at this and subsequent meetings.

Council members, according to the Order, were to be "appointed by the governor, to serve at the pleasure of the governor." On May 8, 2007, Governor Sarah Palin announced the appointment of 14 Alaskans to the Alaska Health Care Strategies Planning Council. They are:

• Jeff Davis of Anchorage who has served as president of Premera Blue Cross Blue Shield of Alaska for nine years.
• Cathy Giessel of Anchorage is a registered nurse and advanced nurse practitioner. Giessel chaired Governor Palin's Department of Health, Education and Social Services Transition Advisory Team. She is the current chair of the Alaska Board of Nursing.
• Dr. Derek Hagen of Anchorage is a doctor of osteopathy. In 1997, Hagen opened Anchorage Family Practice and Sports Medicine and later merged with Primary Care Associates in 2001 to become the largest private family practice in the state.
• Thomas Hendrix, PhD, of Anchorage is an assistant professor at the University of Alaska School of Nursing.
• Don Kashevaroff of Anchorage is the chairman and president of the Alaska Native Tribal Health Consortium.
• Brian Slocum of Fairbanks is the administrator at Tanana Valley Clinic, the largest multi-specialty, multi-site practice in Alaska.
• Dr. Michael Carroll of Fairbanks is a private practice physician. He is a member of the Fairbanks Memorial Hospital Committee, the Alaska Healthcare Network, and is treasurer of the Alaska State Medical Society.
• Donna Fenske of Homer served the State of Alaska as a public health nurse from 1979 to 2004. Most recently, Fenske has provided community health aide and nursing services in rural communities.
• Steve Horn of Soldotna is the executive director of the Alaska Behavioral Health Association whose members are the businesses that provide direct services to recipients of behavioral health services throughout the state.
• Dr. Cathy Baldwin-Johnson of Wasilla is a private practice family physician.
• Karen Rhoades of Wasilla is the owner and operator of Northern Living Centers, a five bed assisted-living home. She has also served on the Alaska Human Rights Commission.
• Tim Joyce of Cordova is a three-term mayor of the City of Cordova. Joyce played a pivotal role in working with the city council and the Native Village of Eyak to obtain a community health care grant for primary care support in Cordova's medically underserved area.
• Rod Betit of Juneau is the president and CEO of the Alaska State Hospital and Nursing Home Association (ASHNA), a not-for-profit association with members representing hospitals, nursing homes, and Native Alaska health care providers. Betit came to ASHNA from Utah where he served as the Executive Director of the Utah Department of Health. Betit is also the chair of the Alaska Primary Care Council.
• Dr. Bob Urata of Juneau has served as a family physician for over 23 years. Urata has served on the Bartlett Regional Hospital Board of Directors for the past fourteen years.
• Commissioner Karleen Jackson "manages" the Health Council.
• Serving as ex-officio, non-voting members are Senator Bettye Davis and Representative Peggy Wilson, chairs of the Health, Education and Social Services committees in the Alaska State Legislature.
• Dennis McMillian, President of the nonprofit Foraker Group, is the Council facilitator.

 The First Council Meeting

The first meeting of the Council met the afternoon of June 11, 2007, at the BP Energy Center in Anchorage. A couple of outside consultants presented summaries of health reform plans in others states such as Massachusetts, Maine, and California. Their takeaway message was,

Lessons Learned:

1. No one has tried single-payer system.

2. Pure voluntary enrollment model doesn't seem to work.

3. Purchasing pools haven't been all that effective.

4. There are legal barriers: Employer Retirement Security Act (ERSA) issue, legal constraints within state and federal government.

5. Employer mandates are not politically viable.

6. Changing practice patterns (implementation) is difficult. Even if it looks good on paper, it is important to determine what is feasible when trying to change practice.

Challenges to Address:

1. Get clear about the primary goal or mission. i.e. coverage expansion, cost control, quality.

2. Determine the motivation behind the primary goal.

3. Identify the major barriers. i.e. legal, political, financial

4. Consider goal and strengths and determine best short-term & long-term options.

After the break, Council members assembled into smaller groups to "discuss the purpose of the council." A summary from each group was presented to the larger body. The discussion during most of the meeting was rambling and somewhat unfocused as members discussed their own concerns and anecdotes about health care, but at the very end of the meeting Rod Betit suggested a Health Council Mission Statement accepted by concensus, "Council Develop strategies, including performance measures, to provide health care access for all Alaskans by 2014 with the goal of making Alaskans the healthiest population in the nation." The definition of "access" was further refined to include coverage, affordability, timely service, quality of care, prevention, managing chronic conditions, workforce issues and cost.

The Second Council Meeting

The second council meeting met all afternoon at the BP Conference Center July 30, 2007. During the first part of the meeting, there were several presentations.  There was an excellent presentation by Dr. Alice Rarig and Patricia Carr, both with the Alaska Department of Health and Social Services. They related information about an ongoing study in Alaska about a range of issues pertaining to those without health insurance in the state. Melissa Stone, Director of DHSS Division of Behavioral Health, together with Mark Haines-Simeon, Policy and Planning Manager, presented an extremely informative discussion about behavioral health issues in Alaska. Finally, Dr. Jay Butler, the state's first Chief Medical Officer, made an interesting and useful presentation entitled "Status of Alaskans--Health Status Indicators," about what and how to measure health indicators in Alaska. Copies of all these presentations and those mentioned below, are available on the HCPSC website. 

After a break, facilitator Dennis McMillian asked Council members to cite health-related facts that they thought were important to the Council's mission, and that could be documented based on readings or presentations. Dozens of facts were cited and duly recorded on sheets of paper hanging from the walls. Then Council members were asked to vote on those facts that they thought were most important. The resulting list of facts listed in order by number of votes was included in the official meeting minutes. Facts with 11 votes, the highest possible number, included statements such as "The suicide rate for Alaska is twice the U.S. average--and it is the #1 cause of death among Alaska youths," and "Lifestyle choice is a significant driver of health care--although the direct link may not be concrete." Examples of low scoring facts with just one or two votes included, "To the user, there is no difference between 'no insurance' and 'no health care,'" and "It costs over $200,000 to recruit a new doctor in Alaska." The process by which these facts will lead to policy recommendations to the Governor has not yet been revealed. A few other decisions reached at this meeting include:

·      An online public forum will be established for public feedback

·      The council clarified that it is not a Legislative Committee to which bills are referred, but a short-term Governor's Advisory Council that will recommend short and long term strategies to the Governor and the Legislature.

·      The House and Senate HESS Chairs have agreed to hold hearings during the summer to provide opportunities for testimony on issues that the Health Council members might be interested in--including issues that are addressed in current bills under consideration (such as Certificate of Need and Denali KidCare).

Third Meeting

The third meeting of the Council was held August 27, 2007 in the afternoon at the Alaska Native Tribal Health Consortium Office Building near APU. The first half or more of the afternoon was taken up with several presentations. Dr. Kenneth Thorp, a well known and highly respected health economist from Emory University, gave a short but excellent presentation on the impact of chronic disease and obesity to the cost of health care. Jim Frogue gave a considerably longer presentation focusing on the role of personal responsibility and health care reform. He is on the staff of the Center for Health Transformation, which was founded by Newt Gingrich. Dr. Thomas Nighswander gave a fascinating account of the promise and practical obstacles of "Electronic Health Records and Information Exchange." Jerry Fuller with DHSS made a presentation regarding the current status and some discussion of the future of Medicaid in Alaska--an extremely important topic that looms large in the total discussion of health care in Alaska.

The second period of the afternoon was spent engaged in a process very similar to the latter half of the Council meeting the month before. "Facts" from the most recent presentations and readings were raised and discussed among council members, and written on large sheets of paper taped to the walls. After some time so engaged, Council members were urged to mill about and "vote" on the facts they thought most useful and credible. As of this writing, the minutes with a tally of the votes and facts has not been made publicly available.

Note that the AHSPC website has copies of all visual presentations (e.g. PowerPoint's) used by presenters, and an extraordinary collection of Alaska-specific documents about health policy and health policy-related research.

Future Meetings

All are open to the public, but public comments will only be accepted at the December meeting.

September 17 (1 p.m. - 5 p.m.)
Location: Alaska Native Tribal Health Consortium Office Building
4000 Ambassador Drive, Anchorage
Call-in: 1-800-315-6338 Code: 7800
Live Web Stream URL: TBA

October 15 (1 p.m. - 5 p.m.)
Location: Alaska Native Tribal Health Consortium Office Building,
4000 Ambassador Drive, Anchorage
Call-in: 1-800-315-6338 Code: 7800
Live Web Stream URL: TBA

November 12 (1 p.m. - 5 p.m.)
Location: Alaska Native Tribal Health Consortium Office Building, 4000 Ambassador Drive, Anchorage
Call-in: 1-800-315-6338 Code: 7800
Live Web Stream URL: TBA

December 3 (1 p.m. - 5 p.m.)
Location: Sheraton Anchorage Hotel, Room TBA
Anchorage, 401 E. Sixth Avenue
Call-in: 1-800-315-6338 Code: 7800
Live Web Stream URL: TBA
Open to the public: Public Comment

Contact Information:  Tara Horton - 907-269-8021
Department of Health and Social Services

AHPR

Alaska Health Policy Review is sent to individual subscribers for their exclusive use. Please contact us for information regarding significant discounts for multiple subscriptions within a single organization.  Distributing copies of the Alaska Health Policy Review is prohibited under copyright restrictions without written permission from the Editor; however, we encourage the use of a few sentences from an issue for reviews and other "Fair Use." We appreciate your referral of colleagues to www.acpp.info/review in order to obtain a sample copy. The Alaska Center for Public Policy holds the copyright for Alaska Health Policy Review. Your respect for our copyright allows us to continue to provide this service to you. For all related matters, please contact the Editor, Lawrence D. Weiss, health.policy.review@gmail.com.

The Review is issued electronically weekly during the regular legislative session and monthly the rest of the year. A 12-month subscription to Alaska Health Policy Review is available for $850. Please inquire about discounts for multiple issues for the same organization, and for smaller nonprofit organizations. Don't miss an issue! Send orders, comments, and inquiries to Lawrence D. Weiss at health.policy.review@gmail.com, or call (907) 276-2277.