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November 2008 Vol 2, Issue 22
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Interview with Neal Fried
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Interview with Senator Gary Stevens
Health Legislation Summary: Second Session of the 25th Legislature
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From The Editor  
 
Neal Fried is an economist working for the Alaska Department of Labor and Workforce Development. Fried notes that the health care industry is often "the largest or second largest employer in [Alaskan] communities." In this interview, Fried discusses the rather surprising fact that the health care industry in Alaska has suddenly slowed way down after many years as a driving economic force in the state. 
 
Fried also discusses the health care industry's vital role in Alaska's overall economy; tracks state growth trends compared to the rest of the nation; accounts for the important contribution of Alaska Native health care institutions; and examines health workforce turnover rates.

Senator Gary Stevens was recently selected to become the next Senate president, and has been a member of the Alaska Senate since 2003. Senator Stevens previously sponsored SB 208, which involved the collection of data and disclosure of reports on hospital-acquired infections.
 
In this interview, he talks about making hard decisions in health care funding, the future of SB 208, SB 160 -- a major health financing and access reform bill -- and priorities for the next legislative session. In the past, he served in the House of Representatives, was mayor of the city of Kodiak, and worked as a professor at the University of Alaska for twenty-five years.

We present a summary of major pieces of medical and public health legisation signed into law this year. Bills range from the somewhat controversial -- such as the prescription database and the expanded role of dental hygienists -- to the less controversal such as extending the Council on Domestic Violence. Drugs, alcohol, women, children, violence, dentists, and bureaucratic procedures. 
 
There is something for everyone this year; however, there are some notable absences too. Despite the introduction of several bills seeking to establish a state-wide health commission, none made it into law. SB 160, the most significant health reform bill introduced this year, died in committee but is very likely to be resurected -- although perhaps with significant changes.

Finally, Dennis Paul Valenzeno, Ph.D., is director & professor, WWAMI Biomedical Program, and associate dean for Medical & Premedical Programs at the University of Alaska Anchorage. He sent us this clarification regarding a brief discussion about the WWAMI program during an interview published in the last issue of the Review:

"WWAMI offers three years of the 4-year medical curriculum in Alaska, but not the first two years. A student who completes the first year here at UAA takes classes in Seattle during their second year -- in the current scheme. They can then return for nearly all of the 3rd and 4th years."

Lawrence D. Weiss PhD, MS
Editor, Alaska Health Policy Review
Office: 907.276.2277
[email protected]
Interview with Neal Fried
Neal FriedNeal Fried is an economist working for the Alaska Department of Labor and Workforce Development. The health care industry is often "the largest or second largest employer in [Alaskan] communities." In this interview ,Fried discusses the health care industry's vital role in Alaska's overall economy; tracks state growth trends compared to the rest of the nation; accounts for the important contribution of Alaskan Native health care institutions; and examines health workforce turnover rates. This interview was recorded November 6, 2008. It has been edited for length and clarity.

AHPR:
Does the health care industry in Alaska play a very important role in the state's economy?

Fried: I was presenting today to a group of lenders, and I had a graph up on the wall that showed where the job growth was between the years 2001 and 2008 in Alaska. I was basically telling them this period of time in the last 20 years is probably the most balanced kind of job growth we've ever had, and my one caveat was that health care was the industry that grew the most. It grew by 9,300 new jobs during that period, which was almost 3 times as much as any other industry. And it's not the largest industry in the state. So the clear answer is yes, it's not only a big industry in the state but it's also been the most dynamic industry in the state as well.

AHPR: How big is it in relationship to other sectors of the economy?

Fried: Well, it depends on how you look at it. As far as new jobs, let's just talk about its size. About 8 percent of all the jobs in this state are tied directly to what we call "the health care industry". And there are a few caveats there because it's a semi-conservative number. It's any industry or employer that is specifically identified as a health care provider. And the place where that sort of falls down to a small degree is the government's side.

For example, you could argue that the Department of Health and Social Services is health care, at least part of it is, and most of that I do not capture. Now the federal health care, I do -- local hospitals and stuff I do -- but you know, as far as bureaucracy in the state government, it is not very well captured. It is a giant industry. As far as employment goes, the only other industry that's that narrowly defined, that's larger on the private side, is retail. If you took full-time equivalents, retail would be smaller. And obviously if you took a payroll it would be smaller.

So it's big, and like I said, it's grown three times as fast as any other industry. You know government's a lot bigger than healthcare, but when you look at the absolute numbers of jobs created, and a percent growth, obviously, it's in its own league. There is nothing that gets even close to it.

AHPR: I read in an [University of Alaska] Institute of Social and Economic Research report that the health care industry in Alaska is approaching $6 billion a year.

Fried: I think that's right. I think that when I wrote about it they were looking at [about that], and these numbers are obviously a moving target now. But I think that it was over five, and I wouldn't be surprised if it was getting close to six now. So yeah, it's a huge industry. One of the beauties of it from a sort of labor economist standpoint -- or an opportunity for jobs kind of standpoint -- is that not all of the jobs -- like in some industries -- are concentrated in one area of the state. In fact it's probably one of the biggest providers of job opportunities in some of the more rural parts of the state. Very often it's the largest or second-largest employer in communities.

"What appears to be happening is that a lot of those health care dollars that used to be spent outside of the state, whether it was in Seattle or somewhere else, more of those dollars are being spent here ... "

AHPR: I wonder if you could comment on the multiplier effect of the industry, in terms of the impact of the health care industry on the state economy? [e.g. what is the effect of health industry spending on other sectors of the economy]

Fried: Well, I can't quote you a multiplier. You'd have to talk to Scott [Goldsmith, economist at University of Alaska]. He's "Mr. Multiplier." Health care is a very interesting industry from that standpoint in a couple of different ways, unlike a lot of others. Retail for example, is an industry where there is very little multiplier, because it's not bringing new dollars into the Alaskan economy. What it does to some extent -- as that industry grows -- it keeps more dollars in the economy. With the oil industry, of course, it represents new dollars coming into the economy, and that has a big multiplier.

Health care is sort of a mixture, a hybrid. It brings a lot of new dollars into the economy, because a lot of those are federal dollars that are coming from somewhere else. The federal government has a huge presence in Alaska's health care -- probably more so than any other state on a per capita basis -- largely because of the relationship it has with the Alaskan Natives, but also [due to] Medicare and Medicaid. [The federal government] always has a large presence so you're getting the new dollars like that into our economy.

The other sort of big role the growth of this industry has played in Alaska in the last decade or decade and a half is that as it's grown so much [in terms of health industry workers as a percent of all workers], we're getting very close to the national average. I think we're spending a lot of time catching up with the rest of the country over the last decade, decade and a half. What appears to be happening is that a lot of those health care dollars that used to be spent outside of the state, whether it was in Seattle or somewhere else, more of those dollars are being spent here; therefore, that would increase the multiplier effect. In other words, there are far fewer leakages probably in this industry than there used to be, because we have far more choice.

AHPR: So this is the import substitution argument?

Fried: Right, this is the import substitution argument. And that's all it is -- an argument. There's no proof. I don't doubt at all that that has happened, and it would be interesting to know but we'll never know whether more dollars 10 years ago spilled out of the state health care than is [the case] today, but it would be hard not to believe it. Health care has been growing fast all over the country, and, in fact, I think in a lot of places it's considered one of the fastest growing industries. So in that sense, Alaska is not unique.

There was an article that I read recently, where many more rural parts of the country see it as replacing the lost factories. In spite of it growing fast in the rest of the country, it's been growing much faster in Alaska, about twice as fast. So, yes, it's a dynamic sector all over the country, but we're sort of a couple steps ahead of that. Part of that may be because of that catch up that's been going on.

AHPR: Just so that I can be clear on this, when you say, "catching up with the rest of the country," could you just explain that a little more what that means?

Fried: If you look at 10 years ago -- that Alaska's industry was tied to health care -- and compare that to the nation -- I don't know what the exact numbers are, I can't remember -- but let's say it was like 5 percent versus say 8 percent for the rest of the country. Now we're very close. In other words, right now, I estimate that about 8 percent of the jobs in the Alaskan economy are tied to health care, whereas in the U.S., it's about 9 percent. You could almost say that maybe we have caught up, because our demographics are very different from the rest of the country. Our senior population, which is a big consumer of health care dollars, is much smaller in Alaska compared to the national average. It may be even be second or third smallest -- maybe even the smallest in the nation as a proportion of total population. That is another sort of dynamic in the future that will exist in Alaska's favor as far as growth goes.

AHPR: Because that segment of the population is growing at such a fast rate here in Alaska?

Fried: Right, faster than anywhere else in the nation. And that's also a sort of the demographic catch up kind of game in a weird way.

AHPR: Just so that I can get clarity on the import substitution argument, this would be the case where, for example, ten years ago, if somebody here in Alaska had serious heart problems they might go down to Seattle to have that addressed, but now that they would spend their health insurance dollars here in Alaska because the medical capacity is greater in that area?

Fried: Exactly. You know what also happens, Larry, as far as that's concerned, from a macro sense makes no difference in Alaska. But from a community and regional sense it does. We've seen the expansion of health care in a lot of regional places, whether it's Bethel, Dillingham, or Kotzebue, or the Mat-Su borough, or Fairbanks, they're providing more health care as well. Even in local economies in Alaska they're probably capturing more health care dollars than they were in the past.

So even on sort of a micro-economic, intrastate kind of thing, you've seen that happen as well. For example, the new hospital in the Mat-Su Valley -- I'm sure [that] had a direct effect on the medical dollar flow between the Valley and Anchorage. But it's not just happening there. We've built lots of new hospital facilities in a lot of places around the state. In Bethel, it's probably their number one business. I mean it's big business in a place like Bethel.

"Health care is a very weird sort of [industry]. I don't think there's another industry like it. it's very "hybridish" [in the sense that] there is a private nonprofit, there is private, and there is public [sector], and you have all three as big players in this industry."

AHPR: So, given the importance of the health care industry in the state, I wonder if you could comment on how or what state policies affect or influence the growth of the health care industry in Alaska?

Fried: That I'm not sure about. I don't delve into the public policy arena, but obviously we're looking at the public side of healthcare, and [that] is very important healthcare. Health care is a very weird sort of [industry]. I don't think there's another industry like it. it's very "hybridish" [in the sense that] there is a private nonprofit, there is private, and there is public [sector], and you have all three as big players in this industry. So I don't know if there is another industry like that or not. I mean, it's just strange to have all three of those, and they're all important to that industry. Obviously the amount of money the public sector spends will affect how much is consumed. One of my worries about health care -- and I've even written about this -- how some break could be applied to health care [growth if] the federal dollar flow slows down. That certainly could have an affect on the growth of healthcare.

AHPR: Right, well we'll have to wait and see what the new president is going to do.

Fried: We have this deficit, and I don't think we're seeing the growth in federal dollars to health care that we were during some of those earlier years. I think the total dollar amount has probably still increased because of Medicare, Medicaid, and some people believe that's always going to increase because of our demographics. But it's certainly not growing nearly as dynamically.

I think particularly if you look at the Indian Health Service, all you have to do is look at that physical campus over the last ten years. It's a very good example of the growth of healthcare. A special dynamic in Alaska was the privatization or nonprofitization -- however you want to call it -- of the Indian Health Service. Now that the tribes are controlling [the former Indian Health Service funds] -- Native nonprofits are now controlling that -- I think [that has] had a dynamic impact on health care growth. Far more people are employed in that now than when it was mostly federal employees.

AHPR: The latest data that you have published seems to indicate that the growth of the health care industry in Alaska has been slowing down for the last year or so. The first question is: is that true? And the second question is: why is that?

Fried: It's very true. It's been true for the last two or three years, and we're talking about 1 percent or 2 percent growth. We had years where we were growing at 8, 9, 10, 11 or 12 percent. And we don't know exactly why that is, Larry. We think part of it may be that catch up, the cycle of catch up, maybe is largely over. We're not exactly sure, but the way we're looking at it now, when we look out into the future, the two drivers there, we think, are going to be more population-driven, and driven by the economy, and of course [by] the amount of dollars that are available.

We may be wrong. Maybe it will be just a temporary thing. But it has slowed down very significantly. There were years when half the new jobs in Anchorage were tied directly to healthcare, and now we are talking about a couple hundred. It's one of the reasons our overall employment growth has slowed down  --the slowdown of the health care industry.

AHPR: In something you've written in the past, you pointed out that health care occupations vacancies are running 10 to 30 percent across the state. I wonder if that's still holding true? And second of all, I wonder if that has something to do with the decline of the growth rate?

Fried: The answer to that is probably not. My guess is the vacancy rate probably has improved some, just because it's not growing as much -- and obviously when the industry is growing a lot you're going to tend to have more vacancies than when it's more stable -- but the big thing in health care of course has been giant turnover, which we don't pick up in the growth factor. If Providence turns over 10 times in a year, 12 times a year, we still count it as one. Now, the poor employer who may have to hire someone may be dealing with 12 different bodies, have to hire 12 different times or 14 different times in a year, but as far as our numbers are concerned, that's one. That's a all whole different issue.

Generally speaking, when the growth slows down the vacancy rates should improve some. Although, because it's an industry that's growing all over the country, demand remains very strong all over the country unlike in some industries. I'm sure right now that I could get all the financial analysts you wanted to, and they would come anywhere to work, which wasn't true just six months ago. In healthcare, I don't suspect that's changed very much. My guess is that it's eased up a little, but remains a real big problem. I suspect it remains a really big problem in some of the more remote areas of the state.

AHPR: You touched on the fact that we are in fact in some possibly historic economic decline nationally and internationally right now. Is there anything that you can say about the possible affect of that on the health care industry in Alaska?

Fried: That's an interesting question. I haven't given it much thought. I have to admit. I don't think it's good news for health care. I think a healthy economy, generally speaking, is good for health care. This could mean fewer people have insurance. It could mean that there's just less money available. It could strain public budgets. Who knows? I don't think it's necessarily good news. Obviously, if you have a job in this environment, health care is probably one of the better industries to be in because it's still likely to be more stable than a lot of others are. From the career employment standpoint, I suspect nursing schools right now are seeing more applicants than they've seen in a long time because of the uncertainty and the way people look at health care -- as an area where there is stability or more stability than there might be in other industries. Although, who knows what might happen? I think, in terms of jobs, the outlook for the health care industry improves, but the industry could be hurt by a lousy economy like any other service sector.

"Southcentral Foundation is the 16th largest private sector employer in the state, and ANTHC [Alaska Native Tribal Health Consortium] is the 11th largest private sector employer. These two players, I don't think even made this list a decade ago. They are amongst the most dynamic employers."

AHPR: You had mentioned the obvious growth of the ANTHC in the Alaska Native Medical Center on the campus here in Anchorage. I am assuming that the implication is that the Native health care system is a pretty large component of the health care industry in general in Alaska. Would that be a fair characterization?

Fried: It's not only a fair characterization, but it also has been the most dynamic part of the health care sector of our economy.  Southcentral Foundation is the 16th largest private sector employer in the state, and ANTHC [Alaska Native Tribal Health Consortium] is the 11th largest private sector employer. These two players, I don't think even made this list a decade ago. They are amongst the most dynamic employers. They went from basically not existing not very long ago to becoming among the top private employers in the state. And they are not the only ones.

Another one that still impresses me is when you think about a place like Bethel, which is a relatively small community of about six thousand people. It is home to the 15th largest private sector employer in this state, which is the Yukon Kuskokwim Corporation. Everyone talks about the growing dynamic role that Native corporations are playing in Alaska's economy, and they very often forget that Native health care providers are amongst that very dynamic group, and that they are all over the state -- in Kotzebue or Bristol Bay or out in Northwest Arctic Borough.

Looking at the top ten employers in the state, Native organizations, subsidiaries -- who report to me separately -- half of them are health care providers. They are a very dynamic presence in the Alaskan economy, not only the for-profit corporations but health care providers as well, which are nonprofits. They bring a lot of money into the state. They spend a lot of money, and they employ a lot of people. Forget about the healthcare-providing part of it (laughing) -- from an economic standpoint they're big. And this is new money in our economy.

AHPR: I wanted to ask you this question even though you said that you don't get into policy matters much: in terms of the vacancy rates, both in the Native health care providers as well as the rest of the industry, I wonder if something like loan forgiveness programs might make a difference? Is that something you would care to comment on?

Fried: Well, I don't doubt that they would make some kind of difference. And I know they've talked about that. And there may even be some of that, I don't know. I know that's one thing they've pursued. We used to have that with college in general. Mary, my wife, got that for going to college, and that was for anybody. It didn't matter what profession you are looking at. It's hard to say it would not have an effect, I just don't know how much. I know that there is experience with that in other parts of the country.

I know that AHFC [Alaska Housing Finance Corporation in Alaska] has built housing specifically for health care providers or teachers. I think it might be both.

AHPR: There's been some legislation attempting to address that and there will be more legislation introduced in the coming session on these issues. Union jobs in Alaska, I expect, if it's like in the rest of the nation, union jobs are more likely to have health insurance than nonunion. And I believe there's been a shrinking of the unionized job sector in Alaska over the last few decades. Let me ask you to the best of your knowledge if those things are true?

Fried: I think that is true. I think that is true. One of the reasons why Alaska has maintained a higher percentage than the national average is that we have a bigger public sector, and that's where most of the growth in a long while has been, or the losses have tended to be in some of the other industries. Alaska I believe has always had a more unionized workforce than the nation as a whole has.

AHPR: I guess what I'm looking for are possible contributing factors to the shrinking growth rate of the health care industry in Alaska. For example, if union jobs are shrinking -- and they are more likely to have health insurance -- then there is less money for workers to spend. That goes along with employers, union or not, dropping health plans. So I think there's a growth of uninsured people in Alaska, uninsured workers, and there is also degradation in the quality of the health insurance. So I'm hypothesizing that those may be contributing factors to the shrinkage of the growth rate of the health industry.

Fried: I think [the decline of the growth rate] happened too suddenly for that to be the main explanation -- or even to be a major explanation -- because it happened very quickly. There's certainly a possibility that it may be a contributing factor, but I certainly don't think it's a major one. And I don't know what it is. We can only speculate. I think the biggest factor is -- what ever it means -- "the critical size"  [of the health sector of the economy compared to the rest]. I don't know if anyone's done a measure of that or not.

AHPR: Compared to the lower 48, the cost of health care in Alaska has been running at around 30 percent higher. Can you think of a reason or reasons why that might be true?

Fried: Well, I think that [the University of Alaska Anchorage Institute for Social and Economic Research] said Alaska spends about $1200 more per capita on health care than the national average, but I don't know how that works out as a percentage. What's interesting about that -- and maybe it's happened to health care to some degree -- when you look at a lot of the cost of living indicators out there, and there really aren't a lot of good ones -- what does jump out is the difference in the cost of goods. Even housing has narrowed considerably over time, and in Alaska's more urban places like the rail belt, it's not that different than the national average. But health care is remaining significantly different. Why that is, I don't know. It's one of those hard to answer questions. I suspect that maybe [University of Alaska economist Scott Goldsmith] has contemplated that out loud. I don't know what his conclusions have been if he's had any.

AHPR: Are there any last words you would care to say to the readers of Alaska Health Policy Review?

Fried: No, I never do that. That's when I get in trouble.

AHPR: That's why I asked. Even though apparently you won't be getting in trouble today, I do want to thank you very much for taking the time to discuss these important issues with me and the readers of Alaska Health Policy Review.

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Interview with Senator Gary Stevens
Senator Gary StevensSenator Gary Stevens was recently selected to become the next Senate
president, and has been a member of the Alaska Senate since 2003.
Senator Stevens previously sponsored SB 208, which involved the
collection of data and disclosure of reports on hospital-acquired
infections. In this interview, he talks about the future of SB 208, SB
160 -- a major health financing and access reform bill -- and priorities
for the next legislative session. In the past, he served in the House
of Representatives, was mayor of the city of Kodiak, and worked as a professor at the University of Alaska for twenty-five years. This interview was recorded November 7, 2008. It has been edited for length and clarity.


AHPR: Congratulations on your appointment as Senate president.

Stevens: Thank you.

AHPR: In the past, you have sponsored a bill to study hospital infections. What became of that bill, and what is its future?

Stevens: Well, it's pretty interesting, because I had a friend who had a hospital-acquired infection -- actually, a medical doctor, my medical doctor -- who has since retired. So it was an issue I got sort of interested in, and I started looking around and seeing where the truth is on the matter, and it's a big matter. It's a big issue. It's one that we've got to address. So I entered a piece of legislation to require reporting of incidents, and found that there is a lot of interest in it. Hospitals, Providence, my hospital in Kodiak, all the hospitals were interested in it and in trying to find a way to make it so that it wasn't so onerous that it was very expensive for them to do it -- or that it asked the wrong questions.

We were working with the state [epidemiologist] as well as with the people in the administration. So that's continuing, and we're trying to find a way -- and I'll certainly sponsor it again in the future. I'll probably have somebody else sponsor it. As Senate president, it's a little harder to carry legislation. It's an issue that will be pursued, but we want to make sure that the requirements are right. Every time I've been to a meeting with hospitals, I asked the question, "What is the record at your hospital? How many incidences have there been?" Of course, it makes hospitals very nervous, it makes doctors very nervous, but it's an enormous health issue out there. We've got to find a way.

It was always a joke in the Middle Ages that if you ever go to the hospital, you wouldn't make it out alive. Unfortunately, it's still true. Some hospitals are worse than others. The idea is not to embarrass people or to make it so difficult they can't do their job, but we've got to find a way to require reporting so that we as consumers know.

Now, there's a problem in Alaska, because we don't have that many hospitals to choose from. If you lived in Seattle, for example, you could look it up and see if this hospital has a bad record of infections, this hospital has a good record. So, we're more limited. In Kodiak, we have one hospital. In Seward, we have one hospital. And in Homer, we have one hospital.

So the areas I represent do not have multiple hospitals. It's a little bit different there. So it's a work in progress. It's not going to be dropped at all. It's very important to me that we find some way to help hospitals improve. The problem is, you just want to improve things so that the folks aren't in danger by going to the hospital. So that was the inclination to sponsor it, and it's not an issue that's going to go away. We'll be pursuing it.

"We happen to have a lot of money right now, but we have to be very careful with how we use state resources -- there are lots of needs out there --  and to put it all in some sort of universal health care is something that I'm very concerned about."

AHPR: Senator French sponsored SB 160 during the last session, and that proposed a statewide health financing and access reform bill, based on the one adopted by the state of Massachusetts. I'm certain that he'll be reintroducing that bill or a revised version of it in the coming session. I wonder if you could tell me what you think about this bill, or this kind of bill, and give me some idea of what you think the prospects of major health reform at the state level will be in the next session?

Stevens: First, you should understand that I did not sit on any committee that has heard that bill. I'm not on [the Senate Health, Education, and Social Services Committee]. I was when I was in the House, but I've not been on the HESS committee since then. Of course, my concern is, frankly, how do you finance it? Do you bankrupt the state if you go too far with the health program like that? So I don't know the bill, but I do know what's happened in other states and what's been considered. It's something we have to approach very carefully.

At this point, it's sort of a tangential issue. We have almost a $10 billion debt in the retirement system. We happen to have a lot of money right now, but we have to be very careful with how we use state resources -- there are lots of needs out there --  and to put it all in some sort of universal health care is something that I'm very concerned about. I want to make sure that we're doing the right thing, and that it would not be so expensive that we couldn't pay for it in the future.

So I'm not approaching it from the benefits. The benefits are great. I'm concerned about the cost.

AHPR: Since you brought up the retirement system, let me just pursue that for a moment. That ties into my health care policy interest. A few years ago, as you know, the state of Alaska dramatically altered the retirement system and health care benefits of retired public employees. There is a growing coalition of organizations that believe that the existing data now indicates that the old system was no more expensive for the state than the new one, but it served employees far better in terms of both having a traditional pension vs. basically a savings account, and also in terms of the health care system. What are your thoughts on this?

Stevens: First -- and I already said this -- understand the fact that we have a $10 billion debt. That's real money. That's a lot of money that we owe because of people like myself that retired from the university. When I started with the university 35 years ago I had no thought about retiring but when I did, God bless, the university had a good retirement system and a good health care system. And I certainly appreciate that, but because of me and others, the state now has this debt -- real money that we owe of $10 billion. Where is that money going to come from? It's going to be very difficult to fund that.

I can see where we had to at some point say, "We've got to stop this. It's not working. It's putting us deeper and deeper and deeper into debt. How can we solve this problem?" It seems to me that there is some compromise area possible. Maybe not the wonderful system we had -- the Cadillac system we had, and maybe not the elemental system we now have -- but maybe there's something in between. I'd certainly like to pursue that, but it has to be something that we can afford because we really have buried ourselves in debt as it extrapolates out into the future.

Two billion is an enormous amount of money when we have $1 billion funding of education every year. What do we do honestly? What is the practical result of spending that much money on people's retirement system? We are facing some serious problems. I'm certainly not against trying to find a compromise, and maybe there's some middle ground out there. I don't know what it is, it's not my area of expertise, but I'd sure like to see us trying some solution that maybe takes us at least partway toward what we used to have.

AHPR: When you say a $10 billion debt, I think that that's the debt spread over 30 years. At the end of that 30-year period, most of that is paid off at least under the earlier system that we had. My impression is that it's sort of like when you buy a house you say, "Oh my god! I owe $300,000 on this house!" that's a huge amount of money, but, actually, you have 30 years to pay it off so it becomes a monthly payment, which isn't really all that much. My impression is that we should probably be talking about the monthly payments rather than what it's going to cost us in 30 years.

Stevens: I understand what you mean, but the problem is that if we ignored it, it would only get greater and greater and greater. And so that's why it made sense to me to say, "Let's stop. Let's take our breath. Let's see if we can do something reasonable." Obviously, what we were doing was not working. You can't just continue making the system worse and worse and worse and more expensive. I understand that California, and again it's out of my area of expertise, may have something like a $250 billion debt. Because of their size, it's understandable, but still in the end ... Even though it's a monthly payment it's still real money, and it impacts what you can do for the rest of the folks in the state.

It's quite elemental, I guess, when you think of what our job is: to take the money that we have that comes into the state and try to make the best use of it. So if we give more money to a program you are in favor of, what does that do for the program for foster kids? It's a balancing act. It's not as if I'm keeping the money or any legislator is keeping the money. We've got to put what we can into savings, to carry us in the future during the bad times. We've got to spend what we can to help folks as we can, but there's just a limit to what government can do both in health and in retirement, and in all of these areas.

AHPR: There were several bills in the last session to set up a permanent -- as opposed to a temporary -- health commission or health policy advisory board to the governor and/or to the legislature. Do you have some notion of why these bills didn't go through? Why not one of them went through all the way? What are the prospects of such a bill passing in the coming session?

Stevens: No, I don't. I never heard any of those bills. I was mostly on resource and education. I was not in any committee that heard those bills; so I can't honesty tell you what happened to them or why they didn't progress. They didn't progress because there wasn't the support, I assume. I don't know the details, but that's probably a pretty good bet. There [were not] enough votes to get it out of committee, or that there were concerns about the way that it was written. And maybe it needed further study, further rewriting. The legislative process is a long, dreadfully long, painful, painful process, and it's just not built for speed. It takes time.

AHPR: Well, I wonder if I could ask it in this way: just in general terms, do you think it would be a good idea if there were a statewide health commission of relatively well-informed people that advise the legislature and governor on long-term health policy issues for the state of Alaska?

Stevens: I don't think that I'd have any problem with that. I assume that you're talking about a volunteer commission of some kind, a group of experts that could advise. The more minds that are there, the more knowledge that is there, the more information there, the better off we are.

"In my area, what I've tried to work on for some time is educational loan assistance. We've tried to help nurses; we tried to help fund training for doctors."

AHPR: I believe that your district, as you mentioned before, covers Kodiak, Seward, and Homer, among other rural areas, and the costs faced by health care providers in these areas are higher than in more urban locations. Further, the ability of these rural communities to recruit providers is notoriously difficult, so I'm wondering what types of things can this state do, do you think, to address these issues?

For example, a couple of the things that have come up include our loan forgiveness programs to attract, recruit, and maintain health care providers here. Also [there is] the whole issue of additional support for the Community Health Centers. I think that there is one in each one of these communities, and there's 125 of them around the state.

Stevens: In my area, what I've tried to work on for some time is educational loan assistance. We've tried to help nurses; we tried to help fund training for doctors. Passing through Seattle, I read an article in the Seattle Times, a front-page story about a young couple, husband and wife, married, trying to finish medical school.

They estimated that when they finished school they would owe half a million dollars. Wow! What does that do to a young couple that's trying to establish a practice or go into a specialty business, whatever that might be? To have to pay back a half million dollars in their lifetime, that really does change what they can do. Could they afford to move to Old Harbor and be the family medical doctors there? No, they could not do that.

I'm sure you're more familiar than I am with the WWAMI Program [a collaborative medical school among five western states including Alaska]. We did double that in size. It's quite expensive, but I think it's recognized by the legislature that it's a very valuable program. We've tried to address issues of assisting nurses in their loan programs, to get them back into Alaska.

We used to have a much better system, where people in any field could to go to graduate school and be forgiven half their education expenses if they came back to Alaska -- of course, that being so expensive the problem was that it was bankrupting the system, and we weren't getting the money back to loan [in the] future to them. So, major change occurred there, and that 50 percent forgiveness went away.

I was looking at maybe mandating that we do that, but then realized very quickly that it would destroy the system that we have. Several million dollars were put into a loan system, but it's based on the fact that those loans are returned. I really can't answer much of your question except to say that it's an enormous problem.

I got a call today from a woman in Kodiak, Brenda, asking if we could meet in the next couple of days about the Community Health Center. They're doing a major expansion of that, and it sounds like it's an important part in each of those communities.

AHPR: I'm glad that you are seriously thinking about the Community Health Centers because, just from my point of view, they're often the only medical clinics that serve people on Medicare or that serve the uninsured in many communities here in Alaska.

Stevens: Well, I personally know the problems. My doctor, who I told you had a health issue, has now retired, and I had to go find another family doctor. And it's a problem. I've got to say though that in Kodiak, there are some twenty doctors. I don't know why they would have so many there, and why there'd be such problems in the other areas.

Of course they do have the needed medical clinics too, which do a wonderful job, it seems to me. But they still have limited doctors and the one in Kodiak -- and I know they're under a lot of pressure to try and also serve veterans as well as natives -- and I hope the federal government can find a way to make that work.

"As those revenues keep declining, declining, declining, and now that we see that oil is declining in value as well, to promise everything or even to get money to the Community Health Centers, which is a good thing -- we can't promise you that that's going to be there in 10 years or five years. But while we've got the money, let's do it."

AHPR: You may be aware that for the first time ever the state of Alaska actually gave the Community Health Centers a few million dollars this year. Should the state continue providing these subsidies to Community Health Centers, because they are non-profit organizations, and like I say they are now trying to serve the veterans as well as people on Medicare and the uninsured? Their list is getting longer.

Stevens: Sure, it's a very good program. I'd sure like to see us continue funding it. Maybe we'll look at that in future. But I've got to say, the problem is -- and I can't say that this is going to last forever -- right now we're rolling in cash, but every year the amount of oil [that goes down the] pipeline decreases. If we don't get a gas pipeline or open ANWR or further the development of Prudhoe Bay, I'm just afraid of what's going to happen in the future for Alaskans. As those revenues keep declining, declining, declining, and now that we see that oil is declining in value as well, to promise everything or even to get money to the Community Health Centers, which is a good thing -- we can't promise you that that's going to be there in 10 years or five years. But while we've got the money, let's do it.

AHPR: I agree completely. While we have the money, let's do it. I would like to turn now to the final report of the Alaska Health Care Strategies Council. Governor Palin established a council with volunteers from all over the state to meet for a few months, to come up with health policy strategies. They put out a final report a year or two ago, and they came up with this mission statement: to develop strategies, including performance measures, to provide health care access to all Alaskans by 2014. I would like to ask: Do you support this goal that the council came up with? From a state public policy point of view, what do you think it would take to achieve it?

Stevens: I'm really concerned about that. And I'm certainly not going to say that I support it because it would be such an enormous expense. By 2014, how do we know we're going to be able to pay for it? God bless you and what you're doing and what your interests are. They're very important, but there also are so many other interests out there, so many other concerns out there. We could wind up with a wonderful health care system and no foster kid program, or no whatever -- no education. I'm not in a position to say that I support something like this. It's very big, it's important, I understand. It affects a lot of people, but if we were to just do this and nothing else -- there are so many needs.

We have kids in school that are dropping out. We have an enormous dropout rate. That's not your concern, that's not your interest. Obviously you're not here to fix that. To me, that's even as big a concern as health. What do we do about the dropouts? What are they going to do in life? How are they going to proceed in life without a high school diploma? I appreciate what your interest is, and it's a portion -- a piece -- of what it is important to all of Alaska, but it's not the [whole] enchilada.

AHPR: Just to clarify, our organization is the Alaska Center for Public Policy. We are interested in all public policy that affects low- and moderate-income families in Alaska. It's just that one interest of ours focuses on health policy. So, in terms of the big picture, we do have an interest in education.

Stevens: Then you know how you have to balance things out. You can't have a Cadillac program in one area and nothing in the other.

AHPR: May I ask you this question, since you bring it up: How do you determine as a legislator, particularly as one in an important position such as yours, how do you determine how to make that balance?

"How you balance it out? It's very delicate, very careful, and it's not a decision that I as one individual makes. That's what the legislative process is -- it's 20 people in the Senate getting together and trying to hash out, discuss, learn, and come up with some policy ... It takes a lot of time, a lot of sensitivity, and a willingness to try to answer the tough questions."

Stevens: It's very difficult. That balancing process is the key to how legislators operate. We are just forming a new coalition. We don't even exist right now, and you're talking to someone who has no position right now. The president-elect doesn't occur until January. I haven't even had a chance to meet with my caucus. I don't even know who my caucus is at this point. I think it will be a little bit larger by the time we get to January. But in January, I'm hoping that we can flesh out the policies that we want to pursue in the next two years. One of them is going to be on the development of a gas line -- nothing to do with the public policy you're talking about, but an essential element if we're going to proceed and have the money to fund the programs that you want to do.

How you balance it out? It's very delicate, very careful, and it's not a decision that I as one individual makes. That's what the legislative process is -- it's 20 people in the Senate getting together and trying to hash out, discuss, learn, and come up with some policy, and then deal with the House of Representatives, and then deal with the governor as well, and then the public as well. We started talking out about what a long drawn out process this is. Establishing, building, developing public policy is very complex. It takes a lot of time, a lot of sensitivity, and a willingness to try to answer the tough questions.

"I would encourage people to talk to their legislators, and make sure they know how important these issues are, but not to be one-sided, and realize that there's a big picture here that includes so many elements of the state."

AHPR: I just have one or two more questions. First, is there anything else you would like to say to the readers of Alaska Health Policy Review?

Stevens: Well, I think it's very important that Alaskans -- I assume that Alaskans are your primary readers -- that they communicate with us. I am the last person in the world to say that I am an expert in health issues. I need input. I need to have the public let me know, my public; I am most concerned about the people I represent, District 35 and 36.

I would encourage people to talk to their legislators, and make sure they know how important these issues are, but not to be one-sided, and realize that there's a big picture here that includes so many elements of the state. It's Pollyannaish to think that we can just deal with one issue and not every issue. I think that public involvement is essential.

We're talking about the length of the legislative process. For example, my intention would be to send almost any bill to three different committees. Almost any bill in the House would go to three different committees. So when you think about it that way, there's plenty of opportunity for people to listen to a bill being presented, to give their input, to call in -- from an LIO if they are outside of Anchorage or outside of Juneau -- to come to Juneau if they care to testify in public, or testify through the LIO, or even write a letter to their legislator.

The public input is just extremely important in this whole area. There is every opportunity for people to let us know what they want and what they think we should be doing. I just ask people to realize that there is a broad base of what the state has to do. Often people get sort of tunnel vision about their area of interest, and need to realize that there's a lot of things we need to fund.

AHPR: There's just one final opinion of yours that I would like to ask about. A number of us, of organizations involved in health issues in the state of Alaska are planning a training session for legislators and legislative aides. I think it's just two or three hours right now, in Juneau. Do you think that would be valuable? Health issues are very difficult policies, as you pointed out. This would be a way of introducing the basic concepts. Especially since you say that any of these bills is going to be heard in three or four committees.

So, there are a lot of legislators who might need to know about the basics of health care and health care reform --  the basic issues. Do you think that would be a valuable thing to do, to hold such a meeting?

Stevens: You know, I think it would be as long as it could be done at the right time. There's generally a little more time at the beginning of the session. We are now in a 90-day session, so we have to set up pretty smartly and move through quickly. As the more time passes, the more complex things become.

We have some legislators who will have obligations at home and some will leave on the weekends. So probably weekends are out, though I'm always there on the weekend. And I would be glad to attend anything, particularly on the weekend because you're free of committee meetings. So it's got to be scheduled at the right time that wouldn't be interfering with the other issues.

But I would think that, working with the chairs of both the House and the Senate, there could be some kind of a joint session, two or three hours. Do it early and make sure that the two co-chairs are behind it and that invitations go out and that people know about it. I think there would be a real interest in it because those of us who don't come with that academic background need to know more about it.

AHPR: Thanks, Senator Stevens, for taking the time to have this discussion with the readers of Alaska Health Policy Review.

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Health Legislation Summary: Second Session of the 25th Legislature

Overall, the health legislation passed during the second session reflected a theme of increasing access to care, with bills that addressed health systems, providers, consumers, and government support for quality-based health care improvement. For example, two bills passed during the second session focus on increasing the number of licensed dental professionals in Alaska. This is important in our state, where many residents in rural areas have limited or no access to dental care. Passed budget appropriations included specific funding for mental health grants for agencies utilizing evidence-based practices; this action may help us find the best methods for treating mental health disorders and substance abuse that affect Alaska residents. Changes in eligibility requirements for Medicaid, as done with SB 27, have already led to increased numbers of women and children receiving free or low-cost health care; the second session added to this increased coverage for children by requiring that insurance companies cover well-baby exams.

Increasing public safety was another focus of legislation passed during the second session. Laws aimed at decreasing injuries and deaths related to alcohol use among minors could translate into greater awareness about the effects of alcohol among our youth, and ultimately to better health outcomes. Extending the Council on Domestic Abuse and Sexual Assault, a decision based on task force findings, has the potential to reduce Alaska's high rates of domestic abuse and to protect women and children in shelters. Volunteer and professional firefighters, who are frequently exposed to toxic and life-threatening chemicals, will now have more health care benefits once they retire.

The health legislation that has become law, mentioned above, indicates positive changes for residents of Alaska. There is something for everyone this year; however, there are some notable absences too. For example, despite the introduction of several bills seeking to establish a state-wide health commission, none made it into law. SB 160, the most significant health reform bill introduced this year, died in committee but is very likely to be resurected -- although perhaps with significant changes.

This list of health-related legislation passed during the second session of the House and Senate was compiled using the Alaska Legislature's BASIS website. A list of bills was selected by searching for passed legislation in the House and Senate during the second session of the 25th legislature; these bills were then reviewed for their applicability to health policy issues. Non-health policy legislation was removed, and a careful analysis of each remaining bill was then conducted to create the summaries below, which are grouped together by subject.

In our broad determination of "health policy legislation," we included in our criteria issues such as alcohol use, mental health, insurance, senior citizens, as well as general budget appropriations bills that directed funds to the Department of Health and Social Services. The resulting list contains a broad spectrum of issues relating to the physical, mental, and social well being of Alaska residents. Note that all bill numbers are live links, and will take you to the appropriate "Bill History/Action for 25th Legislature" page.

Medical and Dental Care: Licensing, Access and Assistance
   
HB 319
SHORT TITLE: DENTISTS/DENTAL ASSISTANTS/HYGENISTS
PRIMARY SPONSOR(S): RAMRAS
DATE SIGNED INTO LAW/EFFECTIVE DATE: 6/25/2008; 9/23/2008

Because oral health impacts overall health, prevention of disease and health promotion involves the care and maintenance of personal oral hygiene as well as regular dental care with a provider. Many Alaskans do not have access to a licensed dentist due to geography or other factors. The purpose of HB 319 is to increase access to and decrease costs for dental care for Alaskans by expanding the duties of dental assistants and hygienists. Specifically, this bill will allow certified dental hygienists to perform procedures such as filling replacements, polishing, and other duties per contract with a licensed dentist; some of these duties may or may not require the presence of the licensed dentist.

HB 383
SHORT TITLE: DENTIST LICENSE EXAM EXCEPTION
PRIMARY SPONSOR(s): COGHILL
DATE SIGNED INTO LAW/EFFECTIVE DATE: 6/6/2008; 9/4/2208

This bill addresses the requirements for obtaining licenses to practice dentistry in Alaska, with an explicit determination for military personnel who have served as dentists during their time of duty. This group of professionals has been excluded from utilizing their time served as dentists during military duty when applying for dentist licensure in Alaska. House Bill 383 will contribute to a greater number of skilled dentists in our state by allowing these qualified professionals eligibility to practice dentistry.

Alcohol, Tobacco and Controlled Substances

HB75
SHORT TITLE: DRIVERS LICENSE: ALCOHOL AWARENESS/MINOR
PRIMARY SPONSOR(s): RAMRAS
DATE SIGNED INTO LAW/EFFECTIVE DATE: 7/24/2008; 10/21/2008

This bill requires that all drivers' licenses issued to minors will expire 90 days after the individual turns 21. Furthermore, prior to obtaining an adult Alaska driver's license, individuals will be required to take a test regarding alcohol and drug awareness, safety, and laws related to drinking and driving. This action serves to increase alcohol and drug awareness among youth, and to prevent alcohol- related injuries and fatalities that plague Alaska's residents.

HB 400
SHORT TITLE: MITIGATING FACTOR: CARE FOR DRUG OVERDOSE
PRIMARY SPONSOR(s): KERTTULA
DATE SIGNED INTO LAW/EFFECTIVE DATE: 6/10/2008; 9/8/2008

This bill seeks to increase the likelihood that emergency personnel will be called in the event of a drug overdose. It is based on the presumption that fear of legal action against those present often prevents those witnessing the overdose from calling 911. House Bill 400 alters the sentencing maximums for such individuals by outlining a series of mitigating factors that will be considered when determining sentencing for crimes related to a drug overdose.

SB 196
SHORT TITLE: PRESCRIPTION DATABASE
PRIMARY SPONSOR(s): GREEN
DATE SIGNED INTO LAW/EFFECTIVE DATE: 6/9/2008; 9/7/2008

Senate Bill 196 addresses the fact that after alcohol and tobacco, abuse of prescription medication is second to marijuana in substances of abuse. Prescription Drug Monitoring Programs have been implemented in 40 states over the last decade, and have shown to be effective in reducing the overuse and abuse of prescription pain medication. This legislation follows those programs by requiring the establishment and maintenance of a controlled substance prescription database for the state, to be established in the Board of Pharmacy. Goals of this bill include a reduction in the unnecessary delivery of pain medication, and prevention of prescription drug dependence.

Mental Health

SB 8
SHORT TITLE: MENTAL HEALTH PATIENT RIGHTS: STAFF GENDER
PRIMARY SPONSOR(s): DAVIS
DATE SIGNED INTO LAW/EFFECTIVE DATE: 6/4/2008; 9/2/2008

Individuals receiving mental health care are often victims of physical or sexual abuse, and thus the gender of the caregiver is of great importance in appropriate care delivery and patient outcomes. Senate Bill 8 addresses this issuing by requiring that adult (18 years or older) mental health patients receiving intimate care in hospitals have the right to request a caregiver of a specific gender. Notice of this right must be placed in noticeable areas, and the mental health patient must be informed of this right. Should someone of a requested gender not be available due to staffing issues or scheduling, noncompliance must be documented in the patient's file. Such documentation will support not only the efforts of the institution to comply with patient rights, it will serve to improve understanding when assessing patient outcomes.

Domestic Violence and Public Safety

HB 334
SHORT TITLE: EXTENDING COUNCIL ON DOMESTIC VIOLENCE
PRIMARY SPONSOR (s): FAIRCLOUGH
DATE SIGNED INTO LAW/EFFECTIVE DATE: 6/6/2008; 6/7/2008

For the past 10 years, Alaska has ranked among the top three in the nation for domestic violence and sexual assault. Alaska has the highest rate per capita of men murdering women. This law extends the life of the Alaska Council of Domestic Violence and Sexual Assault (CDVSA), which aims to increase communication and coordination between state agencies and victims' service providers, and decrease the incidence of interpersonal violence. To date, this council has funded two prison-based and three community-based batterers' programs, as well as 20 community-based victim's services programs. The extension of the CDVSA in Alaska will help ensure that domestic violence and sexual assault prevention and service programs receive adequate federal funding to address a great need. This bill follows the actions of previous bills, HB 120 and HB 215, and responds to the findings of the CDVSA Task Force by extending the termination date of the CDVSA to 2014.

Employee Health

HB 200
SHORT TITLE: WORKERS' COMP: DISEASE PRESUMPTION
PRIMARY SPONSOR (s): DAHLSTROM
DATE SIGNED INTO LAW/EFFECTIVE DATE: 5/21/2008; 8/19/2008

Firefighters are frequently exposed to chemicals such as benzene, carbon monoxide, and asbestos, yet the health complications resulting from exposure often take years to develop or display obvious symptoms. This law provides firefighters in Alaska with benefits related to disabilities, cancers and disease conditions commonly associated with occupational exposure to toxins and chemicals. House Bill 200 extends benefits to professional and volunteer firefighters with at least 7 years of service, and requires that claims must be made within 5 years of service termination.

Senior Citizens

SB 209
SHORT TITLE: EXTEND ALASKA COMMISSION ON AGING
PRIMARY SPONSOR(s): DAVIS
DATE SIGNED INTO LAW/EFFECTIVE DATE: 5/22/2008; 5/23/2008

The Alaska Commission on Aging provides needed services and advocates for senior citizens through policy, public and private partnerships, state/federal projects, and citizen involvement. This bill extends the termination date of the Alaska Commission on Aging to June 30, 2016.

SB 243
SHORT TITLE: COMMISSION ON AGING/DHSS DUTIES
PRIMARY SPONSOR(s): DAVIS
DATE SIGNED INTO LAW/EFFECTIVE DATE: 5/22/2008; 8/20/2008

This bill outlines the duties of the Department of Health and Social Services (DHSS) with regard to previous action following the placement of the Alaska Commission of Aging (ACoA) and the Division of Senior Services (DSS) within DHSS. Following this placement, duties previously assigned specifically to the ACoA and DSS fall under the duties assigned to DHSS. Included in these duties are: the administration, maintenance, and reporting of the older Alaskan service grants as well as the adult day care and family respite care grants. DHSS must deliver grants for pilot projects related to services and care for older Alaskans, ensure compliance with grantees, and complete progress reports related to these grants.

Women and Children

SB 170
SHORT TITLE: INSURANCE FOR WELL-BABY EXAMS
PRIMARY SPONSOR(s): MCGUIRE
DATE SIGNED INTO LAW/EFFECTIVE DATE: 6/4/2008; 9/2/2008

This bill amends a statute relating to health insurance coverage for plans that cover a dependent. Specifically, it adds that a health insurer must cover the cost of well-baby exams, which are given from birth to 24 months. These exams are crucial to the health and vitality of infants, have proven critical for health outcomes, and are cost-effective in the long term.

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Alaska Health Policy Review Staff and Contributors

Lawrence D. Weiss, PhD, MS, Editor
Kelby Murphy, Associate Policy Analyst
Keith Liles, Project Coordinator
Jacqueline Yeagle, Newsletter design and editing

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