Interview with Matt Claman
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 Matt Claman is chair of the Anchorage Assembly. He is a member of the Budget & Finance Committee, the Public Safety Committee, and ex-officio member of the Legislative Committee. He is also liaison for the Anchorage Cultural Council, and alternate liaison for Military &Veterans Affairs. He is a trial attorney with a diverse law practice, and is president of the Board of Governors of the Alaska Bar Association. This interview was conducted July 7, 2008, and has been edited for length and clarity.
AHPR: This first question comes up because I recently heard a rather discouraging statement from another assembly member about their perception of the relationship between public health and the role of government. In your view, what is the role of government in general, and the role of the Municipality of Anchorage in particular, in terms of the responsibility for the health and well-being of the residents of Anchorage?
For example, there appears to be little controversy over the fact that the Municipality of Anchorage should fix potholes and put stoplights on busy intersections. Would you say that there is a comparable perceived obligation to support health services for Anchorage residents who can least afford them, or to plan a city that encourages walking and physical exercise, which is related to prevention and other public health precepts?
Claman: The primary responsibility on a national level and the state level for providing medical care for those who can least afford to pay for themselves has been for many years first the federal government, and then with some federal assistance and some state monies, the state governments -- and that hasn't changed. Then, some municipalities and some counties in other states can choose to create public health departments that take on some small, medium, or large amounts of that responsibility.
Within Alaska, under the Alaska constitution and the powers of the municipalities, the municipality has to actually take some active steps to decide that they want to get more engaged in that. At least so far, it is my understanding that, especially with regard to providing health care itself, the municipality has never taken that step; so, at least as we are here today, the municipality does not have legal authority. At least that is my understanding: [that] we don't have legal authority to pay for health care in that kind of role.
A different question that you asked in the long question was what about sidewalks, healthy living, better eating habits, a number of other programs that are not specifically the provision of health care but are things that impact healthy living. Certainly I think that, making it easier to walk around town and making it easier to bike around town are really important things. Healthy eating patterns -- a big issue is the school district wanting to encourage the food that is available in the school district to be healthier food. So those are all things that the municipality is involved with, and I think it should be.
AHPR: I am somewhat intrigued by the notion that you don't think the municipality has legal authority for medical care because there are certain steps that need to be taken that haven't been taken. I raise the question of the Health Department clinic that exists now because it does actually see patients on a limited basis, such as well baby, vaccinations, and that sort of thing. It seems like a threshold has been breached. So, the question I want to ask is: Do you believe that the municipality has the obligation or the right to provide as much care as it does already through the Health Department, and might it expand that under some circumstances?
Claman: Certainly the municipality has the authority to provide the care that it is providing today. You are correct. It is a limited amount of care that they can provide, and much of the funding for that comes heavily from state and federal sources. We do have limited powers in health care, and what we are doing is consistent with that power to the extent that we have elected to exercise it.
AHPR: When you say you have limited powers, were you implying that you would somehow need to petition the state to have expanded powers or is this a strictly an internal discussion or decision?
Claman: This is a question I haven't been asked before, so I can't give you an accurate answer. I don't know. I think that the state, under the constitution, gives us a certain amount of power as a municipality, and even though that's available, we have to take affirmative steps to actually say we are going to exercise that power, for example taxing authority. The state gives the municipality taxing authority, including sales taxing authority. In Anchorage, we have made an election not to exercise that authority.
"I did have an
interesting call from one of the state senators who was pondering about
universal health care, whether it might be feasible to try to pick a
community in Alaska, possibly Anchorage, in which to try something like
a pilot program for some kind of universal health care."
AHPR: In light of the limited authority for health care that the municipality chooses to exercise, I would be particularly interested in your comments on this: Some time ago, the city of San Francisco initiated a policy that no one in the city of San Francisco should be without access to health care. It is not, an "everyone should be insured" policy. Their plan actually involves contracting directly with some private providers of health care, not insurers, and they also have a very extensive network of their own primary care clinics that are operated through their city public health department. It is a little bit early to evaluate the success of this, and they are facing at least one lawsuit, but I think it's a very interesting and potentially cost effective idea. Has this kind of idea ever come up in the municipality, or is it a possibility for the future?
Claman: I can't speak to the whole history of the municipality, but it has not come up in the time that I have been on the assembly. The topic of universal health care is a very live and much debated topic in both our state and our country, and there are a lot of different ways that people talk about how to deliver that. I am not ready to take a position on what is the best way.
I did have an interesting call from one of the state senators who was pondering about universal health care, whether it might be feasible to try to pick a community in Alaska, possibly Anchorage, in which to try something like a pilot program for some kind of universal health care. I am not exactly clear about what that pilot program would look like, but [its purpose would be] to see if you provided a program like that, what would be the impact in terms of general public health. I don't know the answer, and it was kind of a preliminary discussion.
The first question I always ask in that is how much is that going to cost, and if the city is being asked to do it, where is the city going to come up with the money? Because one of our great challenges in Anchorage as a community is [that we have] a tax cap that limits how much money is available for the municipal government to spend -- at least that's coming from our taxpayers. There are limits on how much we can actually do. It might be very different if the state wanted to give us a $2 billion grant and say, "Anchorage, go provide universal health care and see how it works." That would be a very different scenario.
AHPR: I would just like to add, parenthetically, that if the Municipality of Anchorage really were interested in such a program, I am certain that there are private foundations that would fall over themselves to provide some funding for that. In any case, that is a lot of fun to think about.
Moving on to a different subject: the Anchorage Neighborhood Health Center is a nonprofit, federally recognized Community Health Center. Unlike nearly all other private clinics in Anchorage, the Anchorage Neighborhood Health Center will see new Medicare patients, and it will see Anchorage low-income residents who do not have health insurance. In fact, it is the principle medical safety net for Anchorage residents. However, every year it is required to see more patients while their funding remains relatively flat, while their facility is too old and too small, and in an environment where it is increasingly difficult to recruit health care providers not only for them, but in general.
In light of these facts, I understand that the municipality and the Anchorage Neighborhood Health Center have been discussing some kind of arrangement whereby the Municipality of Anchorage may give land and/or facility space so that the Anchorage Neighborhood Health Center can expand and improve services. I wonder if you could tell me what the current status of these discussions is, and what kinds of provisions are likely to be in the final agreement, if you could project that?
Claman: I think that the efforts of the Neighborhood Health Center to expand by getting a larger facility have been going on for about two years, to get state and federal funding to do that. I think that they have been having some success in getting state and federal funding. They are in discussions with the municipality. I spoke with Jon Zasada earlier today who works at the Neighborhood Health Center, and he was actually meeting with the people from the municipality at the same time we are talking today, to further discuss their efforts.
My general understanding of what their direction is: is to try to get state and federal money to pay for building a new facility, and then try to work with the municipality to get municipal land to build the facility on. I think the municipality in partnership with the state and federal government is very supportive and working towards that same goal. I don't think anything has been finalized in terms of the actual specifics of the agreement. As a legislator as opposed to a member of the executive branch, I wouldn't be in any position to comment on the final form of the agreement.
" ...in general I am very supportive of the Neighborhood Health Center. I've
been very impressed with the quality of the medical care they have
provided their patients."
AHPR: In your opinion, is there general support for this kind of agreement or this kind of approach on the assembly?
Claman: Without having asked the question at an assembly meeting I don't know how others would vote, but I certainly support it. I always want to look at the details of any proposal, but in general I am very supportive of the Neighborhood Health Center. I've been very impressed with the quality of the medical care they have provided their patients. I recognize that if we didn't have that facility and those doctors providing care to many Anchorage residents, our community would really be in trouble.
AHPR: Has the Aassembly or the mayor considered any other ways in which the Anchorage Neighborhood Health Center can be supported by the Municipality of Anchorage; for example, direct grants or contracts to provide services to certain segments of Anchorage residents?
Claman: My understanding on this is similar to an earlier question. That is, under the current exercise of limited municipal authority, the state constitution and the state statutes, right now Anchorage doesn't have a means to provide grants to the Neighborhood Health Center. Right now their sources of funding are state government monies, federal government monies, and private monies.
You and I could go there and get treated for anything we want, and if we had insurance they would take the insurance and bill the insurance at the normal rates, and they have a sliding scale, but there's no means right now for the city to be providing money to support what they do. But that doesn't mean that at some point in the future legislatively the city could change its authority in that way, and it may or may not need a statutory change in the legislature. That doesn't mean it couldn't be done, but as of today I don't think we have the authority to do that.
AHPR: My understanding is that nationally there's quite a bit of precedent for this, with San Francisco being kind of an extreme case in a way, but many other municipalities do provide funds, kind of as an extension of the municipal or county public health responsibilities.
Claman: And those are counties that have legislatively chosen to take on a wider authority with regard to public health than this municipal legislative body has done so far.
AHPR: The Salvation Army Clitheroe Center has closed its detox unit due to a shortage of funding. Anchorage Mental Health Services, one of the state's largest providers, remains open, however they stopped taking new adult clients earlier this year due in large part to a funding shortfall. What role if any should the Municipality of Anchorage have in assuring access to basic mental health and detox services for Anchorage residents?
Claman: It gets a little confusing with Clitheroe because I know the point was to close the Point Woronzof facility at the end of the year or maybe this summer, but they have been unable to identify a new facility so the exact status of what Clitheroe is doing is a little bit uncertain to me at this time. I know they are still operating the facility at Point Woronzof.
I have known for quite a while that the availability of detox facilities and other care programs for people with drug and alcohol problems has challenged our community for some time. And I know from discussions with others on the assembly that there is real concern about what we can do to improve how we deal with chronic inebriates and chronically addicted individuals. I think that the municipality realizes that the first step is a public safety issue, and there is a lot of support for trying to do better.
I think we are working to do better, but unfortunately it is a slow process. I have just seen so many people that try to do better, but a month later they are back, they have fallen off the wagon. They are back drinking and committing petty crimes and going back on the cycle. We have seen statistics about people that are at the sleep-off center, and who's there, and who are the people that are there most often. You have the top 100 people that are there 200 plus nights a year, and they need help, and a lot of them are interested in help, but those are just steady community challenges. We have to get better. I think there's real support to do that.
Clitheroe has been for many years a very important part of that effort, but I think that we probably need more alternatives in the community and just what Clitheroe offers. I know there's a project in Mountain View called the Chanlyut project that the Cook Inlet Tribal Council is involved with to try to give an alternative means for drug and alcohol defendant folks to try to break out of the pattern. That's patterned after some Delancey Street Project in San Francisco that has been very successful. We need more of those kinds of programs, and we need more support for the programs that are there.
AHPR: Does the assembly have any more authority to give direct support to some of these kinds of programs such as Clitheroe and the Chanlyut program than medical services for indigents?
Claman: I don't know the answer to that question. That is a good question.
AHPR: The municipal Health and Human Services Commission was established years ago by ordinance. In your opinion, what do you believe or perceive as the role of the commission, and/or what should the role of the commission be vis-à-vis the assembly?
"In my time on the assembly, the Health Commission has not been very active, at least from my perspective on the assembly."
Claman: All health commission-like [organizations such as the] Parks and Recreation Commission, the Urban Design Commission, like the Budget Advisory Commission, like the Heritage Land Bank [Commission] -- all these have an advisory role to the municipal executive and to the municipal legislature, or more informally, the mayor and the assembly. They provide us advice on different issues that are presented to them.
In my time on the assembly, the Health Commission has not been very active, at least from my perspective on the assembly. That doesn't mean they haven't been active in other ways, but I haven't seen a lot from them. That may mean they are working more with the executive, the administration, the mayor, than with the assembly. But I think their role is important because we tend to get a lot more expertise in a particular area than any one or two or 11 assembly members can ever have.
AHPR: When you say you haven't seen much of them, do you mean as in direct participation in workgroups and in testimony?
Claman: Exactly. There haven't been legislative proposals that would come before us that we would ask you to comment on. For example if one of the assembly members proposed an ordinance that expanded the city's authority in terms of providing health care services, that would be a typical thing that we would ask for commentary from the Health Commission.
AHPR: Clean air is obviously a desirable public health goal. The assembly has been wrestling with the I/M ordinance for some time. Where does that stand now and what you believe is likely to happen?
Claman: We have proposed an ordinance that would bring -- well, it wouldn't really bring it back because the existing program is still in effect, and even under the vote taken last fall that would terminate the program, that wouldn't take effect until at the earliest 2010. We've introduced legislation to keep it going and not to terminate the program, but shrink the program and make it so that fewer cars would be inspected and change some of the ways the program is operated so it is more cost effective.
That legislation will be before us on the 15th of July. I can't say how the votes are going to shake out. I am optimistic because I introduced the ordinance and I support it. I am optimistic that there will be enough votes on the assembly to approve the new ordinance and keep the emissions testing program in effect after January of 2010, although have it in a shrunk down form.
AHPR: I note that among the list of the committees on the Anchorage assembly web site, there is no committee with the primary charge of policy matters relating to public health. In fact, there does not to appear to be any existing committee that lists public health among its responsibilities at all. Given the importance of public health as a policy matter in Anchorage, do you believe it is time to review this situation?
Claman: As chair of the assembly, I have the authority to create more committees than we currently have. For example, after the last election, Sheila Selkregg expressed an interest, as did other of assembly members, in having a new committee dealing with planning issues -- not Title 21 specifically, but more about how is the city going to look, so we created a new committee under that name. I certainly have authority as chair to create an additional committee.
[As] part of my perspective, again, in the role of limited government and limited time of assembly members, I'm not anxious to create a committee that wouldn't have anything on its immediate agenda. This is not to say that public health isn't on everyone's agenda, which I think it is, and the cost of public health is on everybody's agenda. It's certainly on mine. The issue is, are there a ton of issues that as an assembly we need to address with regard to public health? It would mean that we need to create a public health committee that meets regularly and addresses issues. We have a public safety committee. We have a Title 21 committee. The Title 21 is a temporary committee. It is not a permanent standing committee of the assembly. The budget advisory committee is permanent standing committee of the assembly because we are always dealing with budget issues.
If I believed there was both a need as a community to address health-related issues and have a committee to do that I would be pleased to create such a committee, but as we are sitting here today I haven't had a string of e-mails and phone calls saying, "We need a public health committee to address these five issues." A lot of those things have been pretty quiet, so creating a committee to address something that doesn't seem to be raising issues doesn't seem like a wise use of our committee time.
"I'm somebody that is very concerned about public health and I'm really
committed to trying to look at community ways to address public health
in ways that we can do that as a municipality I support."
AHPR: The last question I would like to ask you is this: Is there anything else you'd like to say to the readers of the Alaska Health Policy Review?
Claman: I'm never quite sure of what issues are of particular interest. I'm somebody that is very concerned about public health and I'm really committed to trying to look at community ways to address public health in ways that we can do that as a municipality I support. My father is now retired but he was a doctor. My brother is a doctor and is on the faculty at the University of California San Francisco Medical Center. In my legal work I've done a lot of work with doctors in a variety of different cases. I am consistently impressed with the quality of the medical treatment providers at all levels of the medical community both in this state and throughout the country. I really want to help however I can.
AHPR: Thank you very much.
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Interview with Karen Perdue
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 Karen Perdue has been the associate vice president for Health Programs at the University of Alaska since October 2001. The position was created to help develop health and social sciences capacity throughout the university. From 1994 to 2001, Perdue served as Alaska's Commissioner of Health and Social Services. During her tenure, she led the state's efforts in welfare reform, the development of Denali KidCare, Smart Start -- a comprehensive initiative in primary care and fetal alcohol syndrome -- and other initiatives. She co-founded the Governor's Children's Cabinet. Among other positions, Perdue serves as a member of the National Rural Advisory Commission on Health and Human Services, and as the U.S. representative on Sustainable Development for the Arctic Council. This interview was conducted June 5, 2008, and has been edited for length and clarity.
AHPR: The first question I want to ask is: What is your vision for the University of Alaska's role in terms of health workforce development?
Perdue: We have a huge role to play in workforce, and we are stepping up to the plate. It takes time to do this right -- and to do it in a way that's responsive to industry -- but we've organized all the parts of the university enough to be working towards this goal of filling the hole that we can reasonably fill in all the different professions that we have. We've got so many things that we don't have, so many professional programs that we don't have, and paraprofessional programs, that we've just been filling big holes the last three or four years.
But you know it's not been difficult to explain this and to sell leadership of the university or the legislature on the question of: if we don't have trained people, our own people, to take these jobs -- these are good jobs, they're all over the state -- if we don't have them, then we're filling them with people who are probably not as committed to our communities, aren't going to stay as long, and cost more money, so it adds to the cost of care.
It arguably can be viewed as not adding to the continuity of care and certainly the cultural competence of care. So it's kind of like a mission, it's kind of like a passion, that you can really get into this because you're not only training people for great jobs but you're fulfilling this pretty big responsibility in the health care community.
"Today we have roughly 4500 health students at the University of Alaska ... as you know from being in this
business, it's not only how many students you have but also how many
graduates you have."
AHPR: Would you please give us a brief overview of the University of Alaska's contribution to health workforce development? I was reading a pamphlet that you have posted on your website and I was amazed to see the tremendous variety of health-related occupations that the university is currently educating.
Perdue: We just finished an academic plan for health -- the first discipline-focused academic plans the UA system has ever had -- and let's say we have 100 programs. We have upped our investment each year that I've been here, and I've been here six years, so our enrollments have grown in the last five years over 67%, so we have 67% more students majoring in the health field.
Today we have roughly 4500 health students at the University of Alaska. And our graduates have grown 57%, so, as you know from being in this business, it's not only how many students you have but also how many graduates you have. [Some] students can never graduate. So we seem like we have very directed students as well. The growth has come because of leadership, attention to the issue, and investment, but also because of the tremendous use of distance education, I think. So I don't know if that answers your question.
AHPR: Those are certainly important elements. I noticed that the University of Alaska trains the full spectrum, starting with physicians all the way down to unlicensed health aides and direct service workers of various kinds.
Perdue: We have a community college mission, we have a PhD mission, and yes, we are, we should be a full-service university.
AHPR: I want to ask a question, which might be a little bit off to the side. It seems like the University of Alaska fills almost the whole picture, but I'm guessing that there are some contributions by non-University of Alaska organizations to health workforce development in Alaska. For example I'm thinking of Charter College, APU, Providence with the family practice residency, the military, and perhaps others. Can you talk about the contributions that these other programs make to the issue of health workforce development in Alaska?
Perdue: At the paraprofessional level or at the professional development level we have a lot of different programs that are available to students, and that's good because students then have choices. The thing about the professional programs is, and you know this, they have to be accredited, and students want to go to accredited programs. Many of them result in licensures so they have national exams at the end of them.
So in that range there are probably fewer programs of choice for students in Alaska. APU offers some and I think that's mainly the other place although maybe Ilisagvik College [in Barrow] does offer some, and so we have to be mindful and work with those programs, but we also are a state university so we have a duty to really try to respond to across the state and that's what we try to do.
In the area of graduate medical education, we are actually continuing to look at our role because right now it's all on industry to support graduate medical education in Alaska and it's a crime. Providence Hospital supports it at a tune of a couple of million dollars, and most states invest in their graduate medical education pretty heavily.
We only have one residency program in Alaska and we need more than one. We need different kinds of residencies. The university has a responsibility, even though we don't provide that and we aren't anticipating providing graduate medical education, we have a responsibility to help figure out how to get it done.
"We do have a responsibility to graduate the students and to get them to
the work force in the most competent way possible, but we also have a
responsibility beyond that to do what we can to help with the
specialized training."
AHPR: Let me just make a distinction here. When you say, "graduate medical education" you're talking about post-WWAMI? [WWAMI is a collaborative medical school among universities in five northwestern states (Washington, Wyoming, Alaska, Montana, and Idaho) and the University of Washington School of Medicine]
Perdue: Right. That's the traditional definition of graduate medical education, is physician education. But there [are] also other things that we should be -- and are looking at -- doing, like other professional development, helping industry respond, or preceptorships in hospitals, that kind of thing. We do have a responsibility to graduate the students and to get them to the work force in the most competent way possible, but we also have a responsibility beyond that to do what we can to help with the specialized training.
AHPR: Parenthetically, I wonder if you could comment on this: I've heard from several sources that one of the biggest obstacles to residency training, clerkships, preceptorships, and similar educational experiences for health care students, is saturating the available clinics and hospitals that take in students.
Perdue: Well, I know that's definitely the case in nursing. There is a problem with the number of clinical slots, and we're not the only state. I just returned from another rural state where this is the same question, the same issue. I don't know if other states have the kind of distributed education program we have in nursing in the 12 sites, but it's a limiting factor in terms of the number of slots we can offer.
I just thought of another thing that we're doing that's related to postgraduate, and that's the PhD in psychology. We're going to embark on setting up an accredited internship program for doctoral psychology students so that they don't leave the state to get their accredited experience. We're footing the bill, along with the Mental Health Trust, to set that up.
AHPR: And that doctoral program is available through UAF, is that correct?
Perdue: Both UAA and UAF -- it's a joint PhD program. Eight students are admitted at UAA and eight are admitted at UAF.
AHPR: I wonder if you would talk about the principal barriers to comprehensive, timely health workforce development in Alaska.
Perdue: One of the principal obstacles is not money. The principal obstacle is coming up with a reasonable plan that we can execute: making sure we can find the faculty to teach, making sure we've hit the mark in terms of the number of students that need and would be in the program, and also not training for something that industry does not want or cannot use. So I think a principal obstacle has been planning, but I think we actually are getting more focused on planning.
An example would be two big things that we've got in front of us in the next couple of years in the therapy area -- occupational therapy, physical therapy, speech therapy. Everywhere you look those are high shortage areas, those are positions that are desperately needed across the state. Okay, so the strategy would be: Do we have our own school? Do we simply prepare students to track into other programs, or do we affiliate with another university to offer them?
We have a critical mass problem even if we had all the money in the world; we have a critical mass problem. Money is an issue because these programs are expensive, but really the issue is what's the most realistic way that we can build academic programs? So, our challenges are critical mass and planning.
" ... I'm so glad you called me because I wanted to put in a big thank you to
the Palin administration for the investments they made last year. We
had a banner year in health care at the university. We requested $2.6
million in new program investments and we got $2.3 million ... "
AHPR: Moving from the planning to the active, what high-priority legislation would you like to see addressed in the 2009 Legislature in terms of health workforce development?
Perdue: Well, before I answer that, I'm so glad you called me because I wanted to put in a big thank you to the Palin administration for the investments they made last year. We had a banner year in health care at the university. We requested $2.6 million in new program investments and we got $2.3 million, so we're pretty pleased with all the different things that that gave us the opportunity to do.
It extends to everything from continuing to expand the nursing program -- especially in Anchorage where nursing really has not been expanded [but] it's been expanded outside of Anchorage -- dental hygiene -- starting a dental hygiene program in Fairbanks and shoring up the one in Anchorage -- paramedic expansion across the state; heavy investments in behavioral health; money for the Masters in Public Health program so that they can sit for their accreditation; money for starting planning on occupational and physical therapy and pharmacy programs; the beginning of our investment in bringing the physician assistant program to Anchorage which will happen in 2009 -- 18 seats -- shoring up the academic liaison between the Community Health Aide program and the university; money for the bachelors in Health Sciences program; money to help Bristol Bay start their health faculty and health focus.
So you can see it's just amazing. So, we've had a great year and we're planning, again, to try to put together similar kinds of good proposals for next year. So one of the things that we would ask for from the legislature is continued support in the operating budget for these programs, and then in terms of legislation, on workforce the single biggest thing would be to help students with the cost of going to school in these programs -- supporting them, whether that's loan forgiveness or repayment or stipends for students that have financial need. That would be on my Christmas list.
AHPR: There is already some amount of loan repayment I think, is that correct? Or is this a new concept for the legislature?
Perdue: Employers do loan repayment on signing bonus, and there is a pilot project the Mental Health Trust has to do loan repayment for. I'm talking about state investment, not federal investment, so the trust is looking into that issue and trying to design a program for its beneficiary providers. But as far as I know those are the only ones.
AHPR: Would this be something you would be aiming for in the 2009 legislature -- expanding the state's role?
Perdue: Yes, I think so. Again, these do different things. Like the loan repayment is really good for employers because it focuses on after the student is already trained. And whether that's a University of Alaska student or not, it doesn't really matter, it gets the supply to the provider, it gives them a tool. Then there's the need that we have for assisting students in going through the program, because we're the only state in the union, I guess, that doesn't have needs-based aid.
So, while students do get needs-based aid, that's not something the state provides. [In] a lot of these programs you can't go to school and work at the same time, they're too intense: the nursing program, the [radiologic technology] program, the [medical laboratory technology] program. I don't think you can work, or at least work full time, and go to school. So students really struggle with that issue.
"We have a good supply of certain professions in Anchorage. Why would we
offer loan repayment for those [professions] in which we just have a
maldistribution of providers?"
AHPR: Just extending the conversation on this issue a little bit more, in terms of strengthening Alaska's primary health care safety net: What do you think of the concept of tying loan repayment and/or loan forgiveness for some health professions to the requirement for service in Alaska, or more specifically, even service at a community health center?
Perdue: Absolutely. I think a loan repayment program or a forgiveness program without indebtedness or obligation is not a good idea. It can be targeted in various ways but underserved areas is a traditional way to do it and probably a really good one for us. We have a good supply of certain professions in Anchorage. Why would we offer loan repayment for those [professions] in which we just have a maldistribution of providers?
AHPR: So you theoretically could target geographical areas?
Perdue: Right. Or underserved agencies, public agencies, for instance, versus private.
AHPR: What key legislation, even conceptually, legislation would you like to see enacted within the next five to 10 years in terms of health workforce development here in Alaska?
Perdue: I would like to see us really solidify our AHEC [Area Health Education Center] system. It's a [federal] HRSA [Health Resources and Services Administration] program that is an employer-based program that comes out of a university setting, so it's an academic/industry partnership. It focuses on the "pipeline" activities, it focuses on organizing all the different clinical rotations and shadowing experiences that students need to expose themselves to, underserved areas would be a good example.
It also works on CME [Continuing Medical Education] and professional development. Right now we have three sites: one is in Bethel at YKHC [Yukon-Kuskokwim Health Corporation], one is at Fairbanks Memorial Hospital, one is at Providence, and we hope to have a fourth and a fifth site. For the first time we'll have a university/industry full-time relationship, and we've seen already the fruits of that.
For instance, at [YKHC] all the different activities they're doing going into the schools, exposing kids to health careers, advising students what to take to get themselves prepared. All the students have run through the hospital there, with just the tremendous amount of organization that that's requiring. Eventually that's going to be paying off in getting providers, local providers, and providers that want to be there. I think this is really an organized way to deal with some of the lack of coordination that we have, and lack of on-the-ground resources that local providers have.
So I don't know if that takes legislation, or if it takes funding, or both, but to me that's kind of a basic. I just returned from North Carolina and they have the longest history of AHECs, they probably have 10 different regional AHECs in their state, and they really provide the kind of organization to this issue that we have not had.
AHPR: Could you just give us a notion of which professions you are talking about that are affected by AHEC?
Perdue: All the different professions could be affected. Anything from nursing to social work to physician. There's no limit.
"Behavioral health does not just mean substance abuse and mental health
services, it means behavioral health so those public health aspects
like obesity and chronic disease and so on, and [it involves] really
focusing in on preparing the workforce for just those very complicated
problems that are going to see in our health statistics."
AHPR: Any other key legislation you'd like to see enacted within the next five to 10 years?
Perdue: I suppose if we got universal healthcare, or we got more access to health care we'd have a less uneven system for providers. That would be fundamental. We're working a lot with the Mental Health Trust on behavioral health. Behavioral health does not just mean substance abuse and mental health services, it means behavioral health so those public health aspects like obesity and chronic disease and so on, and [it involves] really focusing in on preparing the workforce for just those very complicated problems that are going to see in our health statistics.
Health reform would give us the kind of infrastructure money in our system to really expand and make solid some of these professions. One thing we don't have in this state: you cannot get a four-year degree in nutrition. We do have a dietetic internship program but we don't have a four-year degree in nutrition so we are going to ask the legislature for money to do that this year.
AHPR: Moving beyond the legislature, what kind of working relationships does the University of Alaska have with Native and tribal health organizations across the state?
Perdue: We've had good relationships and we've had ones that we're still working on, that we need to work on. To some extent, sometimes the university seems irrelevant to some crisis problems that are right there in your door. On the other hand, we've got these incredible community campuses like Kotzebue, Nome, Bethel, Dillingham, and Kenai. They're working at the local level to try to articulate the workforce needs in those regions and really bring that forward.
The university really tries to be relevant, it always has a lot of ways to go, but there have been some really good examples over the years where we have been relevant. It used to be, maybe, that the thought was the tribal organizations were basically focused on entry-level positions, but that has not been the case in the last 10 years. We have so many qualified Native students in our social work program and our Masters in Public Health program, and in our nursing program. The RRANN program [Recruitment and Retention of Alaska Natives into Nursing] has graduated 70 Alaska Native nurses.
" ... we focused on the health aide program, and on jobs like medical lab,
radiography, billing and coding -- those kinds of things that would be
really good jobs in local communities, that are there because of the
health care system and the investment that Denali Commission has made
in the clinics."
AHPR: I recently interviewed George Cannelos at Denali Commission and he implied that there was a relationship between Denali Commission and University of Alaska in terms of health programs. I wonder if you could just talk about that?
Perdue: They have funded us for the last five years to do allied health training in small communities and build programs. That comes from their philosophy that they want to not only build clinics, but they want to build the workforce that works in the clinics. So we focused on the health aide program, and on jobs like medical lab, radiography, billing and coding -- those kinds of things that would be really good jobs in local communities, that are there because of the health care system and the investment that Denali Commission has made in the clinics.
I am looking at this document that I have on my website, Pathways to Alaska Health Care Careers, and if you looked in there, there is a section on the Denali Commission. It's a short section but it describes that since the project inception 50 courses have been developed covering eight occupational areas, and by the end of the 2006-2007 academic year, about a thousand people have been involved in training for the Denali Commission project.
AHPR: You had mentioned that University of Alaska has a relationship with the Alaska Mental Health Trust Authority in terms of workforce development. Please develop that a little bit more.
Perdue: We started about four years ago. We had a series of summits or big meetings on workforce in behavioral health, and the trust and the university began investing together and expanding our workforce programs in behavioral health. That has grown from a fairly small effort to -- I think this year it will be about $2.8 million of investment, both from the state and the trust and university together in enhanced programs -- and probably as importantly, the trust has focused on workforce as one of their five focus areas.
AHPR: Were there any other partners that the university works with that you want to talk about in the same regard, ones that might give the University of Alaska a considerable amount of support, for example?
Perdue: The hospitals. They've been fabulous. They've given us money for nursing, it's made the program just come alive and the university matched that through state donations, I want to say $5 million over the last five years. And as you know we've doubled the number of nursing graduates, not just students but graduates, and we're now up to 12 programs. In 2000 we had one program in Anchorage, and we now have 12 programs.
AHPR: I recall animated discussions about the fact that the hospitals were looking for more of the associate-trained nurses whereas the School of Nursing believed, I apologize if I am mischaracterizing this, that it was more important to turn out nurses with at least bachelors degrees. But it sounds like since nurse training capacity appears to have been greatly expanded, that this issue may have been mitigated.
Perdue: I think it's probably an issue in the profession. The bachelors program on campus in Anchorage has been expanded, and actually because there were so many qualified students, we actually were able to move students through there in two years as well. So in terms of the employers they were getting associate and bachelor students in two years because there was such a backlog of qualified students.
But the other thing that the School of Nursing has done is develop this distance "R.N. to B.S.N" program, and that actually is one of the things that the legislature funded this year. [The program] is more structured, [and there are] more faculty for that program so students that are in these distant sites can get their associates [degree] and they can continue on and get their bachelors degree. So it's a matter of sequencing, but it's complicated because the sequencing is different, but it's been worked out and it's available statewide.
AHPR: We are drawing to the close of this interview. Would you like to comment on any other related subject? Is there anything that's important that I failed to ask or that you would like to mention?
Perdue: Two things. One is we've been working on facilities. Facilities are a limiting factor as well, and another victory this year was the $46 million appropriation for the health sciences building in Anchorage. That's going to be very positive and that will be a facility that will serve students statewide through distance learning.
The other thing is people who have been skeptical about the university's ability to respond to industry in this area. Hopefully they'll take a look at what we've gotten started over the last several years and see that we're really on the path to trying to respond. We can't do everything at once, and we won't be perfect, but we really are devoting a lot of energy and a lot of leadership to this career area.
" ... the supply issue is with us just because of the demographics. It's really with us for probably the rest of our lifetimes."
AHPR: In your estimation, will there be a time in the next three or four years -- some time period -- when most of the workforce supply issues in terms of health-related fields will in fact be successfully addressed here in Alaska?
Perdue: No, no I don't think so. But I do think we'll have programs, we'll have a continuum of programs that are articulated and coordinated hopefully across the campuses so we'll have professional holes plugged. But the supply issue is with us just because of the demographics. It's really with us for probably the rest of our lifetimes.
As hard as we feel we're working now, we're probably going to have to double those efforts to really feel like we are meeting needs because of the aging of our population and the fact that the demographics of the number of people in the young cohort that are entering these programs is just going to be smaller.
AHPR: I was just reading a report from Massachusetts saying that their primary care provider shortages have been exacerbated by the fact that their program to give the uninsured access has been fairly successful.
Perdue: We're competing with the rest of the nation and probably the world too, so as much as we like to say that we're on our own and by ourselves, we're not, and we are for the foreseeable future going to be a net importer of physicians, we're going to be a net importer of a lot of professions, and even if we have our own strategies, which we need to have and we need to invest in those, we're still going to net import and we're still going to be at a huge disadvantage in competition with other states. So, as much as we think we're doing now, we could do twice as much and still not address the need.
AHPR: I think that's a great statement to end on. Thank you very much, Karen. I really appreciate that you have taken the time for this interview.
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Book Review: Mired in the Health Care Morass
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 Mired in the Health Care Morass, By Neil Davis
A co-publication of Esther Republic Press and Alaska-Yukon Press. 2007.
The subtitle of Mired in the Health Care Morass is "An Alaskan takes on America's dysfunctional medical system for his uninsured daughter." Author Neil Davis does not have the kind of occupational and educational history that one would immediately associate with a critical work exposing the inner workings of health care in the United States, and specifically in Alaska. For many years Davis was employed as a geophysicist with NASA and with the Geophysical Institute of the University of Alaska in Fairbanks.
Until recently, the esoterica of health care financing was not on his radar. Now, however, in addition to authoring Mired in the Health Care Morass, he is the author of a newspaper column called "Dose of Reality," which focuses on issues relating to medical finances.
Davis has also written two novels, a collection of short stories, and several nonfiction books on history and science. On the face of it, it seems a curious transition from noted geophysicist to noted health critic, but that transition itself sets the organizational framework for the course of this book:
The story really begins in early November 2004 when Patricia, the elder daughter of our three offspring, told us that she had just been diagnosed with stage III non-small-cell lung cancer. At that time Patricia was a 52-year-old self-employed artist and part-time teacher who had no health insurance in effect.
After a period of time it became clear to Davis that his daughter was under a great deal of stress due to the course of the illness itself and the added obligations of seeking medical care and attempting to pay for it, so he offered to pay the bills to the best of his ability and take care of the related paperwork. He was immediately struck by the lack of consistency in charges, by the complexity of the bills, and by the lack of explanations accompanying the charges. His daughter needed medications -- lots of medications -- so Davis systematically explored how drugs are priced, why drug prices vary, and how to determine the lowest available price. Chapter 2 recounts this process in a concise and easy-to-follow style.
Chapter 3 is titled, "The Powerful Pharmaceutical Industry." The title page of this chapter is illustrated with a photograph of a potbellied gargoyle creature, which with a little imagination might illustrate one view of the pharmaceutical industry. In fact, each chapter is illustrated by ceramic or other types of artwork created by Patricia, Davis's daughter. Many of the ceramic pieces, like the one on the opening page of Chapter 3, seem to evoke at the same time both whimsy and dread. Not surprisingly, Chapter 3 entails a discussion of the pharmaceutical industry focusing on economics, marketing, and political influence.
Chapter 4, "Paying for Doctors and Medical Services," is illustrated with a particularly dreadful, repulsive creature with a multitude of grasping hands and clawed feet. Despite the image, Davis sets out with a reasonable goal:
... I began to look at Patricia's doctor and laboratory bills, which by this time were quite substantial. I wanted to pay these bills, but I was wondering if they were inflated in the same fashion as the bills she was getting for chemotherapy injections [explained earlier in the book]. If they were, then I did not want to pay the full billed amounts; instead I wanted to pay amounts that seemed proper, amounts that would adequately compensate the providers for their services, but no more. My problem was that I have not the slightest idea of what would constitute fair pay.
Warning: this is not an easy chapter to read. In fact, aside from the first couple of pages and the last few pages, you don't really read this chapter at all; you study it. Much of this chapter is an in-depth, technical discussion about the intricacies of actual billings from Alaska health care providers compared to each other, and compared to Medicare billings. The bottom line, however, is much more readily apparent. With the detailed knowledge that Davis has acquired and discusses in this chapter, he successfully negotiates much lower bills from nearly every health care provider that treated his daughter.
The illustrating image at the top of Chapter 5, "Paying for Hospitals," looks as if he were assembled from parts of an elephant, a dragon, and a human being. Nevertheless, he is not in any way a frightening creature, but rather he looks sad and doleful, perhaps resigned to the task of learning how hospital charges are determined so that he can negotiate lower charges.
Again, like the previous chapter, most of this chapter needs to be studied and perhaps read more than once in order to fully understand all the factors involved in hospital billing and price setting. In the end, however, Davis and his readers understand the extent to which hospitals have the ability to steeply discount their charges if pressed to do so.
Davis's writing style is straightforward and factual, but every now and then his basic values of decency and caring are revealed between the matter-of-fact sentences. For example:
... it was obvious that the hospital's discounts to Patricia had resulted in payments well below what Medicare or Medicaid would have paid were she a beneficiary. I also thought Patricia's oncologist had been underpaid, and wanting to make it right for both, I consulted with the oncologist and hospital authorities about the best way to rectify the situation. Their recommendations were to contribute to a local organization that helps low-income cancer patients, and a local hospice, and that is what we did.
Chapter 6 is titled, "America's Health Care System." The illustration appears to be a juvenile monster with big feet, big claws, and a very hungry look. In any case, the chapter itself is a general, easy-to-follow but comprehensive discussion of the characteristics of the American health care system. This includes discussions of features such as national health care spending, a general description of the health insurance industry, a discussion of health care spending in Alaska, examples of how a multiple payer health care system works, and even a brief section on the international health tourism industry.
Chapter 7 is titled, "Comparison of Our System with that of Canada and Other Countries." Perhaps as a prelude to the ensuing discussion, the illustration is a set of earrings, which feature tiny whimsical dancing figures as opposed to the gargoyles of previous chapters. This chapter offers concise descriptions of the structure and cost of health care systems in several European countries and in Canada in a generally favorable light. The chapter is well documented, as are all the chapters.
Chapter 8, "How to Fix the American Health Care System," is adorned with the image of another of Patricia's ceramic gargoyle figures, but in this case it is an upbeat image of a smiling mother gargoyle holding her beaming baby gargoyle. In this chapter, Davis characterizes liberal and right perspectives about health care reform, lists a description of positive characteristics he thinks should be in health care reform, and finally concludes that, "What is needed is single-payer universal health care ... " The book includes an excellent glossary and, unlike many books in recent years, a detailed and useful index.
"Epilogue: the Rest of Patricia's Story" is the space in the book where Neil Davis, "geophysicist" and Neil Davis, "emerging health-care analyst," allows himself to be Neil Davis, "father." In this brief chapter Davis discusses a few anecdotes in the day-to-day encounters with the medical care system during his daughter's struggle for life. He ends the narrative with these words:
On the morning of July 31, 2006, I was holding Patricia in my arms as Rosemary and I were giving her a morphine injection [for pain]. I felt her whole body suddenly relaxed, and I knew then that our daughter was dead. We cannot know for sure, but things might have gone differently if, back in 2004, Patricia had been in a situation where she felt financially able to visit a doctor prior to being in stage three of her lung cancer at the time of diagnosis.
I found this book to be interesting, challenging in some of the more technical areas, extremely informative in those same areas, and especially interesting because of the Alaska focus. I recommend this book to anyone faced with large medical bills. I recommend this book to anyone who has a serious interest in the structure of health care financing in Alaska or nationally. I recommend this book to all health care and public health professionals, and I think this would be an excellent book for classroom use at the university. I commend the author for his ability and desire to turn personal tragedy into a public resource that will educate and help others.
Recently Davis confided in me that book sales are doing well. He has received mostly positive reviews both here and in Canada. He noted, perhaps with a hint of justifiable pride, that one physician purchased dozens of copies to give away, and a major health insurer purchased a hundred copies to distribute to employees.
Finally, take a look at Neil Davis's blog, http://healthcaremorass.blogspot.com/. He has some good postings on health care issues, lots of resources, and ordering details for the book.
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