Jay Butler M.D., of Anchorage, is the chief medical officer for the state of Alaska. He previously served as director of public health, state epidemiologist, director of the Centers for Disease Control's Arctic Investigation Program, and medical director of infection control at the Alaska Native Medical Center. Butler has also been a program manager or professor of epidemiology for top national labs and health agencies, including the Centers for Disease Control, National Center for Infectious Diseases, Emory University School of Medicine, and the University of Wisconsin. He fills a seat designated for the state's chief medical officer on the Alaska Health Care Commission, and is the designated chair. In this interview Dr. Butler discusses the H1N1 flu, public health policy in Alaska in the event of a serious pandemic, the future of electronic medical records in Alaska, decisions made by the Alaska Health Care Commission, and other subjects of equal interest. The interview was conducted May 6, 2009, and has been edited for length and clarity.

 
AHPR: I have to ask you, of course, about H1N1, but we are going to move on beyond that. What is your take on it as an actual or potential pandemic? The latest I've been hearing is that it really doesn't appear to be any worse than the regular, every day, common flu, which is not insignificant. ...

Butler: In some ways, you've almost answered the first part of the question. What's important with the new influenza strain is to recognize that the term "pandemic" does not necessarily imply clinical severity. The pandemics of 1957 and 1968 were relatively mild, clinically, but they were still pandemics.

What "pandemic" reflects is that it is a new virus that can be transmitted easily person-to-person and makes people sick. The designation of 'pandemic' will kick in when the WHO [World Health Organization] goes to Level Six. [That] probably won't change anything in this country because what they'll be looking for is the kind of 'three generations' of transmission in the community, such as we're already experiencing in the United States, Canada and Mexico.

Functionally, this is a pandemic already, in North America. My assumption is, that that degree of transmission will be identified on other continents as well, and we will be referring to this as the pandemic of 2009, but you never know how these things are going to pan out.

AHPR: Right, and that, of course, was my next question. Will we see it again, in a few months, only worse, as in the 1918 model?

Butler: If I had to look at scenarios, I think the best-case scenario is that we've got a new virus that causes relatively mild disease, and may very well spread globally, but basically, in terms of morbidity and mortality, the burden on the health care system ... it's like we've had an extra influenza season. And then, ultimately, what happens with this strain, will this H1N1 replace the currently circulating H1N1? I don't know. I can see advantages to that, because the current H1N1 is resistant to the neuramidase inhibitors. Whereas the new strain, the H1N1 of 2009 is susceptible.

AHPR: So the neuramidase inhibitors would be, for example ... ?

Butler: Oseltamivir, also known as Tamiflu, Zanamivir, also known as Relenza. The worst-case scenario, in my mind, would be similar to what happened in 1918, where disease in the United States was initially relatively mild. One of the theories, in fact, is that the 1918 pandemic originated in North America, I think in Haskell County, Kansas, which is sometimes identified as an early area of transmission.

Early on, there were reports of people becoming ill at the same time pigs were becoming ill. Now, whether or not that was influenza or not, we don't know, because current laboratory methodologies weren't available. In the United States, disease kind of petered out, over the summer months, very much like we normally see with influenza. But then, in September, the virus came back and at least influenza illness came back, and that's the virus we know the most about and also the one we know to be the most devastating.

Nationally, it is estimated that there were 675,000 deaths, and you are familiar with some of the amazing statistics as much as I am. There are estimates from MetLife that nearly 3 percent of the minors they covered, died. Just amazing numbers. And, of course, most devastating was rural Alaska. The Nome Nugget had reported by the end of November of 1918 that 160 of the 200 Alaska Native residents of Nome had died.

So, the worst-case scenario, in my mind, is that this virus might go through some sort of mutation and actually come back worse in the fall. To add to that worst-case scenario would be if everybody looked at the fact that this appears to be clinically mild right now, and said, "See, this pandemic stuff is overblown."

There's a middle ground here that we need to recognize: what the potential is, realizing what the current data are, and that we are not overreacting. The advantage we have in the 21st century is we may actually have a vaccine by this fall, against this strain of H1N1. That's a whole story in itself too, having a "Swine Flu" vaccine ... again.

AHPR: On the policy side, do we have policies in place, in Alaska, if in fact it comes back with a vengeance?

Butler: Well we certainly, already had the ultimate tabletop [planning exercise], and we will continue to do that over the next few weeks. And we've gone through the policy testing procedure with all of our tabletop exercises. Probably the most important policy change in Alaska was the passage of [public health preparedness legislation in 2005, HB 95]. That has really provided public health powers that are critical for responding to emergencies. Some states have much older public health acts, and actually have had to make some sort of disaster declaration in order to mobilize public health resources in ways that were needed to respond to the flu outbreak.


AHPR: Let me just mention something that's of some concern in this regard, at least to me. I recently took a tour of our harbor out here, and one of the things the tour guide was saying was that there's only a 2-1/2 day supply of food for Alaska in those boats, and there are hardly any warehouses anymore in Alaska. So, if shipping were crippled for any reason, say, or an outbreak of flu, we might have a serious food shortage in the state as well.

Butler: Yes, just-in-time marketing is a major challenge, not just in Alaska but everywhere. That problem is even more acute in Alaska. I think 9/11 is a pretty good example of the kinds of challenges we could get into. Parts of the state were running out of disposable diapers, they were running out of formula, and that was only within three days of aircraft being grounded. So, certainly, there's been a lot of consideration given to the state to be self-sufficient for a period of a few weeks. And that's been part of our recommendations for planning for individuals and families.

For a number of different events, whether it's influenza pandemic, a major earthquake, volcanic eruptions, floods ... it's a good idea to have several days, if not a two weeks supply of water on hand, and non-perishable food. I would also emphasize that that is true for medications. We emphasize hand hygiene, respiratory etiquette and stay home if you're sick with flu.

But, there are other things that are really important, including people who have prescription medications probably need to make sure they don't get below about a two-week supply. If they're sick and need to stay home, that's helpful. But say we have a major ash fall in parts of the state and people are having trouble getting out; it's really good if people are not needing to rush out because they are in need of their prescription medications.

AHPR: I just want to ask one more question along these lines. I'm thinking of Mexico right now. Does the state have the authority to forcibly shut down places of public congregation in the event that was deemed a good idea?

Butler: Under the more recent legislation, I would answer that question with a qualified 'Yes.' The degree of that power to do that would potentially be enhanced by a declaration of disaster by the governor. We don't really anticipate, with this particular outbreak, that becoming an issue.


AHPR: Thank you. Moving on to another aspect, I think that I know you've been involved with. The Department of Health and Social Services received a one-year planning grant to increase the overall awareness of health disparities of racial and ethnic minorities in Alaska and assess the feasibility of establishing an office of minority health/health disparities.

Do you think Alaska will join most other states (I believe most other states have such an office) and create an office of minority health and health disparities, or by some other name, perhaps? Do you think Alaska will have such an office in the not too distant future, and if so, what would it do?

Butler: The first question that comes to my mind is what you just asked: what would it do, and maybe even more importantly, what would it achieve, that we are not already achieving? I am all for it if it could achieve the goal of eliminating health disparities in a way that we are not currently doing. That study is ongoing, so I don't have a final answer as to whether we will establish an office of minority health or not. But, we're working closely with partners to try and identify any areas where we're not already trying to address health disparities. And this is a very important issue. We certainly see disparities in Alaska. Nationally, it is a huge issue.

I'm not sure if you're familiar with the study that is sometimes being called the "Eight Americas." If you compare a woman of Asian ancestry born in the Northeastern part of the United States, and her life expectancy, with a Native American man in the Midwest, the difference in life expectancy is over thirty years. That's quite remarkable. I recognize that there is more than just health care systems, and public health issues at play there. But it's an issue that we need to take a hard look at and address. Not just look at it, but do something about it! We need to determine what is the best thing to do.

AHPR: Exactly. Maybe this is telling tales out of class, but you and I were at the same meeting dealing with that issue, maybe a couple of months ago. I didn't hear what else you said, but I heard the words 'social justice' emanate from your lips. What were you referring to when you said that?

Butler: Well, that's a term that Bill Foege, former CDC director, used to use. The context was, I think at that time, we didn't use the term 'health disparities,' but it was addressing the fact that health and health care is very much a situation of haves and have-nots. That's true in all kinds of settings of how we deliver health care. Whether it's a capitalism-based system, or a more socialized-based system, it's one of those issues that is struggled with globally.

AHPR: Thank you. I wanted to move on to health commission questions. You seem to have your fingers in many public health pies these days. Almost every time I go to a meeting, there you are, having some critical position. And so, in this case, what exactly is your title with the health commission?

Butler: I chair the health care commission.


AHPR: I just have a few questions that came up -- some of my colleagues and I were discussing these issues. The present board, and the board size proposed in SB 172, which I understand, I'm told that Senator Olson sponsored with input from the commission. It has seven voting members and three non-voting members. Obviously, every health care group in Alaska cannot have its own seat at the table, and the governor wants to keep the size manageable and small to keep costs down. But, do you believe there are some important gaps in the composition of the commission?

Butler: If I had to identify one gap right now, it would be better representation of primary care. We have two providers, including myself. Both of us are trained in sub-specialty care. I think having that perspective of someone who provides primary care services would be helpful. Now, that being said, the commission could function without that by getting information through the Primary Care Council, which is an existing board within the Department of Health and Social Services that has representation from a number of medical, dental, nursing, and behavioral health groups.

The commission could serve a role as focal point for the recommendations to the commissioner and the governor that come out of the Primary Care Council. The question of what's the best size of the commission is one that could be debated all day. You want to have as much representation as possible, yet there are certain group dynamic issues that, beyond a certain size, it's very hard to get much done. They say that when all is said and done, more is said than done.

AHPR: That's good; I hadn't heard that one before. Moving along, I understand that the commission has decided that it will not recommend or comment on specific bills or budget items. I'm curious, why did the commission come to this decision, in light of the fact that the administrative order instructs the commission to "provide recommendations for, and foster the development of," health care policy and to make recommendations to the Legislature and the governor?

Butler: We realized that it could, very quickly, become a problem of both partisan issues, and various political sides, and it's not really a situation that the commission wants to get sucked in to. Our goal, instead, would be to make policy recommendations. But once something is set forth in legislation, from either the executive branch or the legislative branch, we step back and let that process continue. Now, the groups represented in the commission, certainly including the commissioners, can testify in support or against bills, based on the stands of the organizations they represent. But the commission, itself, will not come forth saying they are for or against any given bill.

AHPR: You were employed by the CDC for quite some time. I noticed that the CDC has highlighted 'social determinants of health.' They identified them as socioeconomic status, transportation, housing, access to services, discrimination by social grouping, race, gender, class, and social or environmental stressors. Do you believe that the health commission is prepared to address social determinants of health in Alaska?

Butler: I would say, if this is a dichotomous answer, I would say no. It's an issue you may have heard discussed during our last meeting. It is a health care commission, not a health commission. So the focus is intended to be on how we deliver health care in Alaska. And I have to say that as a public health professional, I'm not necessarily wild about that distinction, but our charge, really, is to focus on "health care" rather than "health."

The statement you just read is actually a pretty good summary of what, 20-25 years ago the CDC referred to as the role of public health in social justice, and it's just flushed out a little more. If I had to put it into my own words, it reflects the fact that almost all aspects of life impact our health. And our health - oftentimes we take for granted and we don't know how important it is until we don't have it.

AHPR: Do you believe the commission will initiate a study of health care reform models in Alaska? This comes up because that actually has been done in a number of other states.

Butler: The direction of the commission, thus far, has been to identify some priorities that could potentially have policy impact in the short term. Within that context, we are certainly looking hard at the bigger picture of health care reform. One of the areas where we want to be very ready is to be able to respond to what comes to Alaska at the national level, through health care reform at the federal level.

There hasn't been a lot of that happening in that area in recent years. We suspect, as we watch what is going on in Washington, that that could change. Certainly, the president has said one of his goals is to get a bill going on health care reform by June, which is only a month away. We may know the answer to that question by the time that this is published!

AHPR: And finally, this is a transition statement, or question. For the first time in our history, Alaska is looking at an aging demographic change. On average, we are becoming an older state. Our current Medicaid population is primarily children, and they don't cost much. On the other hand, long-term care for older persons is very expensive. Are policymakers and/or the health care commission looking at this for the future, or is it still too far away to get their attention?

Butler: No, we are there now. The overall aging of the population, I'll use the term "relatively poor health," of the population is going to be an ongoing challenge. I've gotten in trouble in the past for saying that the thing that makes my job not fun is you go around telling people 'we're all getting older and fatter," but, that is, in fact the case. There are things that we can all do about the obesity issue, but the demographic of aging is something that we need to look hard at, because that is going to be a challenge for the health care system.

The current way we deliver services through Medicare certainly creates a new challenge. One of the four priority areas that the commission is focusing on is the issue of primary care services for Medicare patients. That's an area where we are looking a number of models that are being implemented in various areas, and at the most recent meeting we looked at models in Anchorage. That, I think, is not a problem that is just going to go away. Even though we are a relatively young state compared to other states, we like everyone, have a rapidly growing population of people who are age 65 and older.

AHPR: I'd like to jump to electronic medical information. You are on the board of directors of Alaska eHealth Network. What is the purpose of this organization?

Butler: There is a mission statement for AeHN, as we call it. If I were to paraphrase it, the goal is to promote use of electronic medical records and to create a statewide network of information exchange of health information for all Alaskans.

AHPR: Has AeHN actually made any progress?

Butler: That's always a hard question to answer. They've certainly made some progress in terms of pulling in some federal monies. One of the challenges in health information technology is that this is one of those areas where it's hard to make a lot of progress without capital investment in the system. A return on investment, from what I've seen, is not something you're going to see up front. It may take a number of years before the savings are realized.

What I hear from clinicians, who use electronic medical records in office settings, is that initially it can be quite a challenge, both in terms of the capital investment and the time it takes to be able to adapt to that system. So, that is a major paradigm shift in how we deliver medical care. Now, that said, it is a little ironic that medical care is one of the last areas where we are going to electronic-based records and communications.

I think there certainly is a lot of potential for eliminating waste. For myself, being seen in a clinic and follow-up to a problem I had evaluated at a hospital, I had to get some X-rays repeated because it was going to take too long, be too much of a hassle, for the clinic to get copies of what had already been done. That's the kind of thing that seems very wasteful. It should have been available to them, and it should have been available to me!

AHPR: Sure, and I understand that it's not just a financial issue; it's a quality of care issue.

Butler: Yes, I very much see electronic medical records as a quality of care issue for just that reason. Plus, the electronic health record does a number of things: it provides opportunity to provide more prompts to make sure that various, recommended both treatment and prevention measures are done. It can pop up red flags, for example, if there are drug allergies, and it can also get the patient more engaged in their own health -- whether it's entry of health data collected at home, for example, in the management of diabetes. Someone could be able to enter their blood sugars so it is then available not only for their own tracking, but for their care provider or case manager, to be able to review those data and be able to fine-tune their regimen.

AHPR: Thank you. Didn't a bill just pass in the Legislature that did, in fact, provide some funding for these activities?

Butler: Yes. SB 133, and this does provide for capital money that would be supplemented by ARRA [federal stimulus] funding from the feds.

AHPR: And where do you think, this is the last question on this issue but it's a very interesting and important issue - where do you think we will be five years down the road on this issue?

Butler: I think we will be further along (laughter).

AHPR: Great answer!

Butler: Which is better than where we are now compared with where we were five years ago. The two things I would hope would happen between now and then is that we would have more availability of electronic medical records at the clinic level throughout the state. But equally if not even more importantly, is that the existing medical records that we have in the state can communicate to one another. So that when I see that clinician that I saw, he could connect into the health information exchange and be able to create a brief virtual record of all of my medical encounters, potentially at least those of the past year that are potentially relevant to answer the questions that he would want no matter where I had been seen.

AHPR: And you think that we'll be there in five years?

Butler: I don't know.

AHPR: Okay, but we'll be closer?

Butler: I have to say, I'm always challenged by the partnership between health care and IT [information technology]. It's a different way of thinking, and I respect the people who work in that field, but I don't claim to have any understanding of the challenges that they face.


AHPR: I'm just sliding in under my deadline here for one half hour. If you could accomplish one thing as your legacy as chief medical officer, what would that be?

Butler: That's a good question. I actually had answers to that question when I first stepped into this role, and of course, things never turn out quite like you would like. There are multiple medium-term goals, but the ultimate is that the health of Alaskans would be better when I leave than when I came in.

Some of the focus areas for that include making sure that prevention services are available. That aspect of access is something that we can improve on. Our ability to be prepared and respond to the unexpected is something I think we actually have made progress on. Once this influenza situation plays out it will be very interesting to go through the After-Action report and see how does it compare to earlier infectious disease emergencies such as SARS and the anthrax situation in 2001.

I guess the third would be that people have better health care -- "health care" and not just "disease care."

AHPR: Really, there is one last question: Is there anything else you would like to tell the readers of the Alaska Health Policy Review?

Butler: Yes, given the current situation with influenza, tell them to wash their hands! I never miss a chance [to say that]!

AHPR: [Laughter] You are the ultimate health educator!

Butler: Practice good respiratory etiquette, and stay home if you are sick.

AHPR: Thank you very much for that final word of caution.

Butler: It's been a fun job, I have to say. I feel like I've gone from being a very focused sub-specialist to being the ultimate generalist. Learning more about the political process is a challenge. It's not the world of science, but, kind of like medicine, there is science and art involved.

AHPR: Thank you very much for taking the time to participate in this interview.

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The ninety days of the legislative session seemed to fly by, yet what was accomplished in the way of improving the lives and health of Alaskans? Fortunately, there were some "wins," with four important bills passing and awaiting the expected signature of the governor. HB 26 Medicaid for Adult Dental Services, HJR 10 Veterans' Health Care, CSSB 116 Approp: Energy Assistance, SB 133 Electronic Health Info Exchange System, all of which have the potential to improve quality of, and access to, health care, are waiting to be signed.

However, there were several "almost-wins" that stalled in committees, as well as a few losses. For example, the three bills aimed at increasing the number of pregnant women and children eligible for medical care through Denali KidCare stalled in committee despite overwhelming support from both legislators and the community. Additionally, SB 172 Alaska Health Care Commission, which establishes the commission as a permanent entity, was stalled in late April due to cancellations of hearings in the Senate Finance committee. Overall, the majority of health-related bills stalled or remained idle during the 2009 legislative session.

Following is a summary of the legislative activity surrounding health-related issues of the first 90 days of the 26th session. All updates are current as of May 7, at 5 pm. Included are summary perspectives from AARP and the Alaska Primary Care Association, two critical organizations in Alaska that, like the AHPR, keep a close watch on health-related legislation. The next legislative session starts January 19, 2010.

Education

Incentives for Health Care Professionals

The March 6, 2009, Vol 3, Issue 8, of AHPR included a summary of hearings on key legislation that could have an impact on improving the health care workforce shortage in Alaska. At the time, two bills addressed this issue: SB 18 Postsecondary Medical and Other Educ Prog and HB 58 Educ Loan Repayment Program, both of which aim to retain health care workers in Alaska following the completion of their education. An additional bill was added on March 9, SB 139 Incentives for Certain Medical Providers, which also provides incentives for specific types of medical professionals to remain, and practice, in Alaska.

Senate Bill 18, which proposes an increase in the number of medical students (from 20 to 24) in the WWAMI program, as well as increase the capacity of the Alaska Physician Residency Training Program, was stalled in the Senate Finance committee on March 16. In 2007, the Legislature expanded the number of authorized medical students from ten to twenty. Representative Nancy Dahlstrom has a companion bill, HB 204, which only made it as far as House Finance (Source: Pat Luby, AARP).

House Bill 58, which proposes a loan repayment incentive program for health care professionals in areas with employee shortages, also stalled in House Finance committee at the beginning of April. It is important to note that this bill has changed over the course of the first legislative session. It was, originally, a bill for loan repayment for dentists, nurses, and other health care-related fields with employee shortages in the state. The final version includes any occupation (health care as well as non-health care) that is designated by a couple commissioners as being high-need occupations. Additionally, changes to eligibility have made it so that in order to be eligible, a person has to be a state employee. 

Senate Bill 139, which would have established the Alaska Health Care Professions Loan Repayment & Incentive Program, appeared to make significant progress, yet it did not receive a hearing in the Senate Finance Committee. The legislative proposals in SB 139 received considerable support in the committee hearings summarized earlier (AHPR, March 6, Vol 3, Issue 8). SB 139 would have created a program offering recruitment incentives for ten practitioner types to help address the workforce shortage, particularly in under-served areas of the state. The Alaska Primary Care Association notes that:


The Senate Finance Committee will have the option to hear SB 139 when the next session begins in January 2010.

General Health Policy

Electronic Health Information Exchange

One of the bills awaiting the governor's signature is SB 133 Electronic Health Info Exchange System, introduced by Senator Joe Paskvan and co-sponsored by fourteen senators and eight house members. SB 133 will create a statewide electronic health information exchange system. Pat Luby of the AARP stated that "The bill establishes a system in state government to compliment efforts that have been made by our health providers, primarily physicians and hospitals but also the VA and the Native Health System and the military to be able to confidentially exchange health records. AARP supports this effort because it will result in fewer medical errors and will lower health care costs. The state authorized an appropriation that will match federal funds at a one-to-ten ratio in the first year."

The Alaska Primary Care Association also commented on this bill:


New Funds for Low Income Energy Assistance Program (LIHEAP)

Energy costs not only affect individuals and families, but also burden the total costs of operating health care centers. Thus, energy cost assistance has remained a priority for many health care agencies so that they may continue delivering their services. The Senate Finance committee issued two bills that address the need for energy cost assistance: SB 115 Rural Energy Assistance Program, which was heard and held in Finance; and SB 116 Approp: Energy Assistance, which establishes the LIHEAP, and CSSB 116, which is the final version of SB 116 transmitted to the governor. Both AARP and the Alaska Primary Care Association (APCA) commented on the legislative activity on this issue.

The ACPA stated the following:


Pat Luby, of AARP, noted that after discussions with the governor, Senator Hoffman changed SB 116 to go statewide and cover rural and urban Alaska and the appropriation went up to $9 million, which created the final bill, CSSB 116. This money will be added to the LIHEAP program for energy assistance for low- and moderate-income Alaskans. While not the ideal funding assistance for health care centers, CSSB will reduce the financial burden of low-income families.

Regular Rate Reviews for Home and Community Based Services

Currently, hospital rates in Alaska are reviewed annually to monitor for adjustment needs. Rates for home- and community-based services (which often keep an individual in his home and community and avoids more expensive institutionalization) have in many cases not been raised for several years. As a result, some providers have left the market, others have had to reduce services and serve fewer clients. Potential providers have been discouraged from entering the market when it looked like reimbursement would not keep up with costs. Senator Johnny Ellis has authored SB 32 Medicaid: Home/Community Based Services, which would establish regularly scheduled rate reviews for home- and community based-services that serve older Alaskans and younger persons with disabilities. All health providers should have their rates reviewed on a regular basis, as do hospitals and nursing homes, and SB 32 would accomplish this. The bill passed both House and Senate Health and Social Services committees, yet was stalled in House Finance committee at the end of the session. It will be on the agenda again in January, 2010. (Source: Pat Luby, AARP)

Electronic Registry for Advance Health Care Directives

Representative Lindsey Holmes issued HB 71 Advance Health Care Directives Registry, which amends a previous statute by adding that a health care facility will not be subject to civil or criminal liability in the event that they act in reliance to an advance health care directive or fail to check an advance health care directive registry for a patient in their facility. In addition, HB 71 proposes the establishment of an advance health care directive registry within the Department of Health and Social Services, where individuals or their guardians can file advance health directives. This registry would be confidential and may not be used for another purpose.

All too often, someone appears in an emergency room without a health care directive. In some cases the individual is incapacitated and unable to make their wishes known. If HB 71 passes, Alaskans will be able to put their directives on-line and they will only be available to the individual and his/her health care provider. If an individual is traveling and in an accident, for example, the provider in another state would be able to look in the registry to determine what advanced health care directives existed. (Source: Pat Luby, AARP)
 
HB 71 passed the House Health and Social Services committee on April 14, and will be heard in House Judiciary in January 2010.

State Budget

There were a few success stories in the approved budgets of programs or practices that will improve the health and lives of some Alaskans. Pat Luby, of AARP, noted three winning budget changes for Alaskans:


However, other areas of the budget failed to meet requests of critical components in Alaska's health care delivery system. As noted by the Alaska Primary Care Association, Community Health Centers (CHCs) did not see the expected and much needed support from the state budget. Specifically, they did not receive direct state support as requested; they only received $350,000 for senior access to primary care to be divided among 26 CHC organizations operating 143 clinics. The additional requested funds were for senior access, help with high energy costs, and recruitment/retention assistance, all of which received no funding. The APCA Legislative Update has a running commentary on this CHC state support issue and can be found on their website noted below.
 
Medical Assistance and Health Insurance

Denali KidCare

Perhaps highest on the agenda of many health and social services agencies was Senator Bettye Davis' Denali KidCare bill, SB 13 Medical Assistance Eligibility. Despite support from numerous individuals and agencies throughout the state, SB 13 did not gain enough momentum to pass during the 2009 legislature, and was stalled in the House Health and Social Services (HSS) Committee. SB 13 would have restored the original eligibility requirements for medical assistance for pregnant women and children, from the current 175 percent of the Federal Poverty Level (FPL) to 200 percent FPL, which is the minimum eligibility level in most states.

The Alaska Primary Care Association stated the following on this issue:


Additional legislation affecting Denali KidCare and medical assistance eligibility includes Senator Bill Wielechowski's SB 87 Medical Assistance Eligibility, which would also raise the income eligibility to 200 percent of the FPL. Additionally, it would also allow families between 200 percent and 300 percent to purchase coverage using a sliding scale premium. Like SB 13, Wielechowski's bill had much support, but was stalled in Senate Finance Committee, with the option to be heard again during the 2010 session. Representative Gara proposed a companion bill, HB 118 Medical Assistance Eligibility, which was read and referred to House Health and Social Services committee but never heard.

Adult Dental Benefit Under Medicaid
 
One of the success stories during this session was HB 26 Medicaid for Adult Dental Services. Introduced by Representative Mike Hawker, HB 26 ensures that the adult dental benefit under Medicaid, which was set to expire June 30, 2009, is sustained indefinitely. HB 26 passed both the House and Senate and is awaiting the governor's signature.

The Alaska Primary Care Association notes that it is expected that the governor will not veto the proposal, which would remove the June 30, 2009 sunset date for the Adult Dental Medicaid Program. HB 26 benefitted from strong bi-partisan support in both chambers, with no dissenting votes. Prior to this program, adults on Medicaid were only eligible for emergency dental care; Representative Hawker had argued in favor of the extension of the preventive and restorative care services to prevent a return to a "barbaric" program. In 2008, approximately 7,600 Alaskan's received dental services through the Adult Dental Medicaid Program. Without the signing of HB 26, those 7,600 individuals will no longer have dental coverage under Medicaid after June 30, 2009.

Health Care for All Alaskans

One of the most critical bills heard during this past session is Senator Hollis French's SB 61 Mandatory Universal Health Insurance. The bill proposes affordable health insurance for all Alaskans. AARP mentions that:


SB 61 passed the Senate Health and Social Services committee, but was heard and held in Senate Labor and Commerce on April 9.

Insurance Coverage During Cancer Clinical Trials

Senator Bettye Davis introduced SB 10 Medicaid/Ins for Cancer Clinical Trials, which would require insurance companies to continue to provide normal coverage when a customer is undergoing a clinical cancer trial. Clinical trials pick up all the costs of the trial. Some insurance companies have notified their customers that, if they join a clinical trial, the insurance company will not be responsible for any of the normal costs, even though they are not related to the clinical trial. SB 10 has passed the Senate referral committees and is in Rules waiting to be sent to the Senate floor for a vote. The bill is expected to move to the floor in January 2010. (Source: Pat Luby, AARP)
 
Veterans' Health Care

Another piece of legislation awaiting the governor's signature is HJR 10 Veterans' Health Care, which urges the United States Congress to improve health care access for veterans. HJR 10 passed the Legislature with unanimous consent. The Alaska Primary Care Association has supported this legislation for some time:


State Boards and Issues

Alaska Health Care Commission

Late in the session, Senator Olson introduced SB 172 Alaska Health Care Commission, which establishes the Alaska Health Care Commission as a permanent entity. Scheduled for a hearing in the Senate Health and Social Services (HSS) Committee on Friday, April 17, SB 172 was not heard due to time constraints. An additional hearing was scheduled for the following day, yet was cancelled due to a lack of quorum. Thus, SB 172 will remain in the Senate HSS Committee for the 2010 legislative session. The Alaska Primary Care Association (APCA) commented on SB 172:


Extend the Alaska Suicide Council

One of two companion bills related to suicide prevention in Alaska is awaiting the governor's signature. HB 123 Suicide Prevention Council, which extends the Alaska Suicide Council for another five years and is sponsored by Representative Anna Fairclough, passed both the House and Senate. As noted by Pat Luby of AARP, Alaska has the highest suicide rate in the nation, including many mid-life and older Alaskans. The passing of this legislation guarantees five more years of focused suicide prevention efforts.
 
Pensions and Sick Leave

Public Pensions-Talk About Health Plan

Senator Kim Elton introduced SB 23 Repeal Defined Contrib Retirement Plans, which would reverse 2005 legislation (SB 141), which dismantled the public employee retirement pension and health care coverage systems. Overnight, Alaska went from having one of the best retirement systems in the country to having one of the worst. The legislation in 2005 replaced a defined benefit plan, which assured a monthly pension and health care premium coverage for future retirees, with a defined contribution plan, similar to a 401 (k) savings plan. This action affected every new public employee working for the state since July 1, 2006, which is approximately 6,000 public employees and growing.

Additionally, Alaska is one of only seven states in the nation that does not offer Social Security to public employees. However, Alaska is unique in that public employees have no safety net whatsoever for their economic security during retirement as a result of the 2005 legislation. If public employees had Social Security, they could not outlive it, however many older Alaskans will outlive the new defined contribution plan for municipal and state employees, firefighters and law enforcement officials, as well as teachers.  

SB 141 changed the system to one where it is possible to outlive your contributions and, without Social Security, some retirees would find themselves with no income and increased health insurance premiums. NEA, the AFL-CIO, and all the public employee unions and municipal police and firefighter organizations are backing SB 23 to return to the defined benefit program of Tier III under PERS and Tier II under TRS. AARP, the Alaska Retired Educators Association, and the Retired Public Employees Association are all supporting SB 23. At this time, eight additional senators have signed on as co-sponsors, six Democrats and two Republicans (Ellis, French, Wielechowski, Menard, Paskvan, McGuire, Thomas, and Davis). SB 23 passed out of Senate Labor and Commerce and State Affairs and was sent to Finance. It was never heard and will come up again in January 2010. A companion bill to SB 23, HB 30, was introduced in the House and has more bipartisan support than SB 23. It was heard first in House Labor and Commerce, but no vote was taken. (Source: Pat Luby, AARP)

Required Sick Leave

Senator Johnny Ellis issued SB 86 Paid Sick Leave, which mandates one hour of sick leave for every forty hours worked, totaling approximately 6.5 days of paid sick leave per year for the average full time employee. SB 86 would benefit the 120,000 Alaskans who work for employers who provide no sick leave. If they are ill or need to stay home with a sick family member, they are not paid. Employers who have any form of personal leave would be exempt. SB 86 passed one Senate Committee, Labor and Commerce, and will be up before the Finance Committee in January 2010. (Source: Pat Luby, AARP)


Stalled or Never Heard

Very little progress was made regarding legislation on mental health and family health issues. The majority of family health-related bills were read but never heard in assigned committees. Some progress was made on the few bills related to allowing mothers to nurse children in the workplace, but those bills stalled in committees, to be heard again in 2010. The April 15 Senate Finance hearing for the mental health budget appropriations bill, HB 83 Approp: Mental Health Budget, was cancelled at the last minute, so the budget will be heard again in 2010. Additionally, a bill that would bring parity in health insurance coverage for mental health, SB 21 Mental Health Care Insurance Benefit, was assigned to committees but never heard.


Looking Ahead

Fortunately, the bills that made some progress but stalled, as well as those that were never heard, will have a second chance in the second session of the 26th legislature next January. These bills will carry over when the legislature meets again, and in the interim, it is expected that advocacy efforts will continue. This will be an active period for advocates, lobbyists and other interested parties. Both the AARP and the Alaska Primary Care Association are encouraging their members and readership to pursue advocacy efforts during the legislative break, and to contact legislators in the interim.

Bibliographical Note:

With permission, many excerpts in this summary were taken from two end-of-session legislative summaries. We thank Pat Luby of the AARP and the Alaska Primary Care Association for their contributions to this document.

For a full copy of the legislative update by the APCA, go to http://www.alaskapca.org/uploadedFiles/Advocacy/4-22-09.pdf

The APCA Legislative Update is distributed regularly by email to members and interested advocates. To be added to the distribution list, email Regan@alaskapca.org.

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What is the problem?

Nearly half of the annual pregnancies in Alaska are unintended (unwanted or mistimed), and for Native women it's 20 percent higher.[1] What is even worse is that Alaska's rate is fifty percent higher than the national average.

Alaska women face many barriers to reproductive health care and contraceptive services. Staff shortages, travel expenses, practitioner skill levels, and competing health priorities impair the delivery of needed family planning services. What is available is inadequate to assist women who are most at risk of having an unplanned pregnancy. This impacts women and families, harms many of their unwanted children, increases health care costs, and over-burdens our social support systems.

Who needs help accessing family planning?

Approximately one-fourth of Alaska women (38,500) need publicly funded contraceptive services and supplies.[2] Of these women:

• most are between the ages of 26-45,
• 18 percent have incomes below 250 percent of the federal poverty level,
• most live in the Anchorage bowl,
• one-half have not finished school,
• almost a fifth lack health insurance coverage,[3]
• over 40 percent have medical problems,
• about a third suffer from mental illness or retardation,
• about a third lack transportation to get to a clinic.[4]

For low-income women, only about half are served -- by poorly staffed public clinics in Alaska.[5] Although Alaska has 26 grantees operating community health clinics in 72 sites,[6] these mostly provide primary medical, dental and mental health care. For example, in 2007, of the clinics' 15,414 female patients between ages 15-44, only 2092 were seen for "contraceptive management."[7] Available at these clinics are state funded breast and cervical health check programs for women ages 21-64, but this program excludes STD [sexually transmitted diseases] services and birth control.

Similarly, the 27 public health nursing clinics[8] have limited staff for outreach. Most are not staffed by licensed nurse practitioners and can only offer STD testing, emergency contraceptives, birth control pills and condoms -- which require patients to make repeated visits to the clinic to be effective.[9] A leading cause of unintended pregnancies arises from choice of contraceptive method; half of condom users and almost a third of pill users discontinue within a year.[10] The high rate (43 percent) of unintended pregnancies in Alaska -- increasing 7 percent from 1991-2002 -- shows these women were inadequately served.[11]
 
Why offer assistance with reproductive services?

The costs of pregnancy are far greater than that of contraception. Nationally, for every $1 spent on family planning programs, $4.02 is saved in averted Medicaid birth costs.[12] For state governments the savings can be huge since the federal government pays for 90 percent of family planning costs, but only 50-83 percent of Medicaid child and maternal health costs.  For example, in 2004, Alaska's Title X and other publicly funded clinics served 19,000 clients, spent $7 million in family planning costs but averted $38 million in associated birth costs, for a net saving of $31 million.[13]
 
In the state's FY 2009 Governor's Operating Budget, the Department of Health and Social Services pointed out how the high cost of pharmaceuticals limited the supply of effective contraceptives to low income women. The indisputable link between unintended pregnancies and their costs was recognized when the department concluded that:


Recent studies have shown that states with expanded coverage through Medicaid waivers have saved millions more dollars in their family planning budgets.[14] Public funding for effective family planning clinics saved California, Texas, and New York between $350 and $570 million each in 2004, and another eight states realized net savings of over $100 million.

Other community resources also are strained as a result of unintended pregnancies. Unwanted children too often end up in state custody and, as adults, too often are sent to prison. The schools have special needs children born of mothers who failed to seek or practice adequate prenatal care.[15] In 2006, 37 percent of the almost 11,000 live births in Alaska were to mothers who received less than adequate prenatal care. Women in jail and newly released from state corrections are underserved. The resulting emotional, institutional and financial costs to society are tremendous.

Access to family planning also protects the rights of women. Women who are poor or experience other barriers -- who suffer from limited resources because of unemployment, disability, mental illness, family breakdown, imprisonment, or bad luck -- are entitled to the same reproductive choices as those of us who are more fortunate. Too often, unwanted children over-burden an existing family, or overwhelm a woman who is unequipped to care for them. These children can end up damaged, either in utero (such as those affected by fetal alcohol syndrome) or by early childhood trauma. By safeguarding a woman's access to contraception, she will be able to produce children who are wanted and well cared for.

What are current funding sources and how are they used?

Most of the money spent here are federal dollars. In FY 2006, $1.240 million came from Title X of the Public Health Service Act, $340,000 from Medicaid, and $395,000 from Temporary Assistance for Needy Families (TANF) (e.g., the Clinton welfare program) or an average of $50 per eligible woman.[16]
 
The state uses Title X money to fund clinics run by it and two grantees -- the Municipality of Anchorage and Planned Parenthood of Alaska. The state uses its portion for a full-time administrative position, a part-time clinician, and to fund clinics in Mat-Su and Kachemak Bay. The municipality uses its share for the Anchorage Reproductive Health Clinic. Planned Parenthood funds clinics in Sitka and Soldotna.

These Title X clinics serve about 7,650 clients, only about 20 percent of the need.[17] Also, most clinics only offer contraceptive access to the pill, condoms and emergency contraceptive pills instead of the more effective long-acting, reversible types, such as IUDs and implants.[18] MCH [Maternal and Child Health] funding under Title V of the Social Security Administration Act is used to fund part-time nurse practitioners that provide family planning services for teens in Juneau and Kodiak as well as pap testing in these clinics and in Ketchikan and Fairbanks.[19] Title V funding also is used to provide pap testing at some of the rural public health nursing clinics from visiting licensed advanced nurse practitioners.

Alaska also offers some relief under Medicaid for women needing contraceptive services, a 90 percent federally funded program. Twenty-seven other states expanded access to Medicaid funds by seeking a waiver to increase participant poverty level eligibility and include some childless adults.[20] Studies in other states show this type of waiver results in substantial cost savings.[21] For inexplicable reasons, Alaska has not done so.  Accordingly, its Medicaid funds are used for women under 21 or postpartum care for only a few months.
 
Alaska also serves some needy women under TANF.[22] One TANF program goal is that its funds be used to reduce the "incidence of out-of-wedlock births"; this goal is the single exception to its ban against funding medical services. Even so, Alaska has not met this mandate.  

In FY 2008, the state allocated $375,000 of TANF monies to "out of wedlock" pregnancy prevention. However, Alaska only spent about a fourth of these monies on contraceptives, mostly in rural Alaska and some soon to be released female prisoners, for whom Long Acting Reversible Contraception (LARCs) would be most effective and require only a single visit rather than repeated care. However, because only trained clinicians can provide LARCs and their upfront costs are higher than those for other birth control methods, the state has not adequately made them available. Instead, most TANF funds are used to promote adolescent health, such as a media campaign on unhealthy relationships and training on sexual abuse. The continued high, unintended pregnancy rate in the state evidences the ineffectiveness of this allocation.

What is still needed?

Alaska needs a statewide program to cover the kind of family planning available in states like Washington and Oregon, e.g.:

• Publicly available clinics offering a broad range of family planning services for women, which includes birth control, pregnancy testing, emergency contraception, maternity screening, annual check-ups (breast exams, pap tests, and women's health exams), services for men, including vasectomies, testicular exams, and for both STD testing, HIV/AIDS testing.[23]  
  
• More trained practitioners to inform women about their choices and social workers to track these women and arrange appointments, similar to other medical services currently provided under Project Access.[24]
• LARCs. Use more TANF funds to provide effective and affordable contraception supplies with trained practitioners who can provide timely service. A wider range of options (including IUDs, implants and low dose hormonal birth control) could be used to protect those with mental health, cognitive problems and other health or access issues.
• Transportation and social workers to help needy clients to get to these services.
• Counseling and referral services to help patients with issues regarding drug and alcohol abuse, sexuality, abortion and adoption services, reproductive health and family planning.

What else is available to provide these needed services?

Readily identifiable public sources exist to increase funding for family planning services. The first, and most available, is to encourage the state Division of Public Assistance to increase the amount of TANF pregnancy prevention monies allocated to effective birth control methods. Another source is the increase in Title X monies allocated to the states under the recent stimulus package.

DHSS also should apply to the Center for Medicare and Medicaid Family Services for a Sec. 1115 family planning waiver to serve those who are uninsured and living at 200 percent FPL.[25] Alaska benefits from increased Medicaid accessibility because of its matching rate; for example, in 2003, for every dollar the state spent, it received $1.27 in federal funds.[26]

Other action that would help is to encourage passage of legislation to:

• require insurers to cover contraceptives,
• broaden the definition of dependent child under health care policies to all those under the age of 26, and
• get Congress to expand Medicaid coverage so individual states need not seek family planning waivers.

When should we take action?

Simply put, now. Notify your legislator of your concerns at http://www.legis.state.ak.us/poms, or contact Project Pill Plus at 277-7354 or at http://sites.google.com/site/pillplusproject/.

References

(1) www.epi.hss.state.ak.us/mchepi/mchdatabook/2008.htm, pg 18-21; Guttmacher Institute, "Next Steps for America's Family Planning Program," App. Table 1, 2009 ("Next Steps"). Back to article
(2) www.guttmacher.org/pubs/win/index.html (Alaska pdf. Fact sheet) Back to article
(3) covertheuninsured.org/states/?StateID=AK, p. 1. Back to article
(4) www.hss.state.ak.us/dpa/features/press/pdfs/ATAP.pdf. Back to article
(5) covertheuninsured.org/states/?StateID=AK, p. 1. Back to article
(6) http://www.hss.state.ak.us/dph/healthplanning/primarycare/CHC330.htm Back to article
(7) ftp://ftp.hrsa.gov/bphc/pdf/uds/2007/07Rollup_StateAK_08Jul2008.pdf Back to article
(8) http://www.hss.state.ak.us/dph/nursing/locations.htm Back to article
(9) http://www.hss.state.ak.us/dpa/features/press/pdfs/ATAP.pdf; Alaska Maternal and Child Epidemiology Unit, MCH Data Book 08, p. 17. Back to article
(10) Editorial, "The Potential of long-acting reversible contraception to decrease unintended pregnancy," Contraception 78, pp. 197-200 (2008). Back to article
(11) Title V Needs Assessment, Women's Children's & Family Health, Vol. 2, No. 3 (March 2005) Back to article
(12) J. Frost, L. Finer, A. Tapales, "The Impact of Publicly Funded Family Planning Clinic Services on Unintended Pregnancies and Government Cost Savings," 19 J. of Health Care for the Poor and Underserved (2008): 778-796 (hereafter "Frost"). Back to article
(13) Frost, Table 3. Back to article
(14) R. Lindrooth, J. McCullough, "The Effect of Medicaid Planning Expansions on Unplanned Births," Women's Health Issues 17 (2007) 66-74. Back to article
(15) www.hss.state.ak.us/dph/bvs/birth_statistics/Profiles_Census/body.html. Back to article
(16) Next Steps, App. 2. Back to article
(17) http://www.guttmacher.org/pubs/win/index.html. Back to article
(18) www.arhp.org/publications-and-resources/contraception-journal/september-2008. Back to article
(19) http://aspe.hhs.gov/hsp/nonmarital-births03; http://mchb.hrsa.gov/programs/ -- (State Priority no. 4). Back to article
(20) Guttmacher Institute, State Policies in Brief as of February 1, 2009, State Medicaid Family Planning Expansions; http://www.guttmacher.org/statecenter/spibs/spib_SMFPE.pdf. Back to article
(21) http://wikileaks.org/wiki/CRS-RS210. Back to article
(22) http://www.clasp.org/publications/Women_TANF.pdf.  See also, 45 CFR Part 261; A. Sonfield, C. Alrich, R. Gold, "Public Funding for Family Planning, Sterilization and Abortion Services FY 1980-2006," Occasional Report No. 38 at p. 9 (Jan. 2008) ("Report No. 38"). Back to article 
(23) http://www.kingcounty.gov/healthservices/health/personal/famplan.aspx;  http://www.oregon.gov/DHS/ph/fp/about_us.shtml Back to article
(24) www.anchorageprojectaccess.org. Back to article
(25) http://www.cms.hhs.gov/MedicaidStWaivProgDemoPGI/MWDL/list.asp; Report No. 38, p. 9-10. DHSS may need to first seek authorization from the Legislature. AS 47.07.030(c). Back to article
(26) www.ucp.org/uploads/Alaska2.doc Back to article

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