top Alaska Health Policy Review
comprehensive, authoritative, nonpartisan
June 9, 2009 Vol 3, Issue 16


Click Title to Read Article
Interview with Bill Bobrick
Please Respect Our Copyright
Guest Commentary: Massachusetts Style Health Reform and Alaska
Guest Commentary: Measurable Success in Massachusetts
What Has the Alaska Health Care Commission Been Doing?
Alaska Research: Computer Simulation to Guide Policy and Program
AHPR Staff and Contributors
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From the Editor

Dear Reader,

At the national level the concept of health reform is in constant tumult. The president has been pushing a kind of centrist plan, something like the Massachusetts health reform plan which would keep the private health insurance industry in place but at least nominally in check. Meanwhile, the health insurance industry has thrown all its political and financial resources against the "public option," something like the idea that people could buy into Medicare at a reasonable price to offer real competition to private health insurance regional and local near-monopolies.

At the same time the single payer concept has won the support of a majority of Americans according to most polls, and won the support of a sizable grouping of legislators in Washington, but the idea is off the table, at least for those formally in the health reform driver's seat. Many other organizations, industries, groups, coalitions, lobbyists, and activists are major players in this drama of colluding and colliding social forces. How do you keep track, and what will be the practical outcomes for us here in Alaska?

Fear not! Help is at hand. A couple of local places to look include Deb Erickson's periodic summaries of national health reform issues, which can be found on the Alaska Health Care Commission web site. Senator Hollis French recently established a health reform information service. On roughly a biweekly basis, his office will compile articles and provide a brief analysis of recent actions and what they would mean for the state. Anyone wishing to receive these updates should contact Senator French's office by e-mail at [email protected] or by telephone at 907-269-0234.

In terms of national resources you can hardly do better than the Kaiser Family Foundation Health Reform Gateway. See also the comprehensive Commonwealth Fund Health Reform web site. Finally, for a web site that offers an intelligent and well-researched argument for a single-payer system, see the Physicians for a National Health Plan web site.

Returning to a more local perspective, in this issue of Alaska Health Policy Review we feature an interview with Bill Bobrick, 20-year lobbyist in Alaska, whose career recently abruptly ended with a felony public corruption charge. His candid discussion covers a range of issues including the influences on public health policy in Alaska, how he systematically formulated lobbying campaigns, and a few words about his mistake and the resulting consequences he has faced.

Local health policy commentator Neil Davis faces off with Senator Hollis French in dueling discussions about health reform in Alaska. We let you know what has been going on in the Alaska Health Care Commission, and we present a summary of health policy-related research conducted by Dr. Dan Kiley, local dentist and graduate of the UAA MPH program.

Your comments and suggestions are invited.

Lawrence D. Weiss PhD, MS
editor, AHPR
[email protected]

Interview with Bill Bobrick
  Bill Bobrick
In 1985, Bill Bobrick became the executive director of the Alaska State Democratic Party, a position he held for about four years. In 1988 he formed Bobrick and Associates, representing clients before state and municipal governmental bodies and designing grass-roots lobbying campaigns for non-profits -- a business he operated for most of two decades. Bobrick pleaded guilty in May 2007 to felony public corruption charges. He served five months in prison and was released in June 2008. In this candid and revealing interview, Bobrick talks about his work and observations as a lobbyist, the process of influencing health policy, and his aspirations for the future. For more information about Bill Bobrick, please visit his web site. This interview was conducted June 1, 2009, and has been edited for clarity and length.

AHPR: In light of your history as a lobbyist in the state, let us say that some corporate or non-profit advocate interest comes knocking at your door, and they say that they want to, "get a piece of legislation enacted." How would you go about designing a campaign toward the goal of having their desired policy enacted? What are the elements, what are the processes, what kinds of questions would you ask them?

Bobrick: Well, as a real example of exactly how I would approach it: I have gotten calls from companies in the past, but most of them knew that I was specialized and that I specialized in municipal issues. I never was, or pretended to be, a Juneau lobbyist, however I know a little bit about how government works in Juneau.

It's a two-part process in that I would meet with these people, and before I met with them I would try to find out as much as I could about them. As a side note, not all lobbyists are complete prostitutes; some of them are discriminating in their customers that they would associate with. I wouldn't represent a tobacco company that wanted to make it easier for people to smoke cigarettes or things like that or, I probably wouldn't represent a pharmaceutical company that wanted to be able to charge people more for their pills. That being said, I would try to find as much as I could about their issue, and I would meet with them. I would first tell them, "Now, understand that I am not a Juneau lobbyist, but if you would like someone to consult, as a paid consultant, I will tell you how it can be done," and go through all the steps with them.

As most lobbyists will do, a lobbyist will oftentimes adjust their fees, according to how much they think you can pay. If they like your issue, and you don't seem to have a lot of money, they'll either do it pro bono or at a reduced fee. If they think that you're like the Bill and Melinda Gates Foundation, and that you have huge amounts of money, they will probably charge you the most that they could charge.

I would also circle back, and ask people about the policy change if I didn't know what effects that it would have by talking to people like Jeff Jessie of the Alaska Mental Health Trust, Johnny Ellis, or Dennis McMillian of the Foraker Group, and assuming that it was a positive thing, then I would continue to talk with [the client]. So let's assume that it's a positive thing, [but] because of some bureaucratic roadblock, it's an issue that keeps a company from making a difference in people's lives and making a profit at the same time, because we live in a capitalistic system.

The first thing I would have them do is an inventory of their resources. If they are based in Alaska and based [on] community groups, I would say, "You need to compile a list of everybody that works for you, that benefits from your company, your vendors, everybody on the planet that somehow benefits from your existence or would benefit from this legislative change" because it's always a numbers game.

The political system is a numbers game. In the Legislature in Juneau, you need 21 House members, you need 11 Senate members, you need a governor to sign a bill, you need a commissioner to sign off on it. It's pretty cut and dried. So, the more groups that we can brainstorm together [and] think of that will support this, the more people that have personal connections with legislators, the more people to write letters to the editor, ultimately when it comes election time, the more people to contribute to elected officials that are supportive -- those are all part of the inventory.

So, the first thing, after you do an inventory, you have a very clearly defined piece of legislation written out, or a goal, and you begin meeting with legislators who are known to be leaders in the health care area in the Legislature. And you would identify somebody, a floor leader, or a champion, for lack of a better word, in both the House and the Senate. Because you want companion bills introduced in both the House and the Senate, so that they would run on concurrent tracks, and get through with as few committee referrals as possible. The goal is that it would be passed by both the House and the Senate and then sent to the governor's desk for signature.

"Every step of the way, it's reinforcing your message, it's targeting your message to various legislators. ... [That way] it is not just, for example, Anchorage people calling up a legislator from Juneau."

There are many, many things you do concurrently. While [you are doing] your inventory, you identify people that are good at public speaking [and] have a personal story to tell. You identify people who are willing to write, or even sign letters to the editor that somebody else might write for them. You identify people that are willing to call in to talk shows. You try to think of every opportunity, first of all, when you can use so-called "free media," or "earned media," meaning, instead of making a bunch of radio or TV spots, you try to do as much of it for free as possible. Your client loves that, and it's also seen as more genuine than someone coming in and doing a bunch of glitzy ads and trying to influence public policy that way.

So, you've identified your goal, you've written your legislation, and hopefully you've identified at least one or more champions in the respective bodies in the House and the Senate of the Alaska State Legislature. Certainly, at the same time you're meeting with those floor leaders, you would want to bring the commissioner of Health and Social Services up to speed on what it is you're trying to do, and why it would be good for the executive branch, and Alaskans as a whole, to implement this.

Every step of the way, it's reinforcing your message, it's targeting your message to various legislators. For example, if one of your legislative champions is from Fairbanks, obviously you would identify as many supporters and people who either are employed by the company who live in Fairbanks, or somehow have a Fairbanks connection so that you have Fairbanks constituents contacting your legislative champion who is from Fairbanks. [That way] it is not just, for example, Anchorage people calling up a legislator from Juneau.

The old adage in campaigns of any stripe is that you have teachers talk to teachers, and doctors talk to doctors, and laborers talk to laborers. That simply means that you mobilize people of every stripe to support the policy change, and you have it done within their own respective organizations. You would look for allies, surrogates, anybody that can speak positively, and you build a coalition if possible. Hopefully, it is a broad enough change that it benefits many, many people. As part of your inventory, you sat down and identified all kinds of other groups, and hopefully they are also organized, and they also are list builders, and they also have the ability to contact people within their organization, so that they can get the word out to their people, which will in turn backstop your direct efforts.

Basically, you just keep adding supporters, you keep identifying opportunities to bring people into the fold, you just look for commonalities, and you just keep trying to get as many people on the planet to be supportive as possible, within your time line, and within your resources, whether you're doing this [with] volunteers, or if they actually have employees that they assign to help work on this stuff.

AHPR: Do you have certain benchmarks you can measure progress against?

Bobrick: Certainly, you do. Most lobbyists, if they're any good, they have really good relations with legislative staffers. Just as much important -- or if not more -- to their relationship with legislators themselves. Because legislative staffers can give you feedback, in that, "Oh, yes, we got ten letters, or thirty e-mails from people who live in the district and they are registered voters, and Representative so-and-so was impressed that a bunch of people wrote in, they knew about the issue, some of them were people who he or she had known for a long time." And, that was effective. That's one example: a benchmark. The ability to actually have -- not just the voice of a lobbyist -- but as many surrogates and other champions be able to weigh in.

"The first thing I tell clients, is that the way our democracy is set up, and I think it was done on purpose by the founding fathers and mothers, is that it is much easier to kill things than it is to pass things. I think that was done to keep bad laws from being passed. It's difficult to pass legislation."

AHPR: So, let's say you do all of this successfully; you come down to a situation where both houses have to vote, I assume, to pass the legislation. So is there anything you want to say about the process, or act, of voting or getting close to it, or counting numbers, what can you tell us about that part?

Bobrick: Well, certainly ... given the nature of Juneau, it is isolated and things happen quickly. Someone would have to be on the ground, watching them. That's why they line the hallways; that's why lobbyists sit on the benches. They are there. They watch what goes on, and have to. And as things develop, you have to be able to respond to them. None of these things are done in a vacuum. All of these people have other relationships, and there are other issues that come up, that may impinge on yours, or you could get caught up in some struggle, on an unrelated issue, and have to play a role of extricating your issue from theirs, or helping to work on other issues, simply to get your own passed.

There are no two ways about it. You'd have to be there on the ground, checking in, constantly shepherding it. The first thing I tell clients, is that the way our democracy is set up, and I think it was done on purpose by the founding fathers and mothers, is that it is much easier to kill things than it is to pass things. I think that was done to keep bad laws from being passed. It's difficult to pass legislation. It's not something that can just happen overnight. It takes a lot of work, and it's got to have a lot of support behind it. It's very easy to kill things. There are so many little opportunities to send [legislation] to a committee to never be seen again, to have it just be voted down.

AHPR: So let's say you work your heart out, your clients and all their associates work their hearts out, and it doesn't make it by the end of the legislative session. Maybe it gets stuck in a committee, or whatever the situation is. Is there anything you'd care to say about the next year?

Bobrick: Well, it depends on if it is an election year or not. So, in the interim, you're going to be scurrying around, educating elected officials. You're going to be continuing to try to build your network, pile up more voters in the district, figure out where it went wrong, and try desperately to educate whoever voted against it. It's not uncommon, but it is risk-big, win-big, lose-big, to then get involved in the political process. And, obviously, if there are people who are real champions and saw the value of it, it's incumbent upon you to help those people, if you can. Because those are seen, by all your supporters, as "good government people." So, you bet, you better get out there and get people who put up signs in yards, or who walk door-to-door, or who will contribute, or who will write letters together. Same techniques, but in support of those candidates that supported you.

Now, it's not a good idea to pick fights with incumbent legislators. That's why most lobbyists always support incumbents, even if they voted against their stuff. Because, the way it is in America, ninety-nine, or ninety-eight or ninety-seven percent of all incumbents are re-elected. So, it's very, very risky to go out after people just because they didn't vote for your issue. Most lobbyists are in a conservative influence in that they almost always go for incumbents. There are lobbyists who will only really hang out with Republicans, because for so many years Republicans really were the people in power, so they just naturally supported them regardless of whether they were Republicans themselves or they didn't care. It was all about access to power.

AHPR: Are there certain lobbyists, for example, who specialize in working with Alaska non-profits versus for-profits?

Bobrick: There are some. And there are some who are very powerful lobbyists in their own right, with other corporate clients, but will work for non-profits because they are non-profits who serve people who the lobbyists identify with, whether they are people who experience disabilities, or maybe they're like the tobacco-free coalition, things like that. Hiring a lobbyist in Juneau is expensive, and they charge a lot, and, effective ones make good money.

AHPR: Is there any way to characterize the differences between those lobbyists who may specialize in working for non-profits versus those who specialize in working for for-profit organizations?

Bobrick: Yeah, the ones that work for non-profits are poorer than the other ones.

AHPR: They are paid less?

Bobrick: Yes.

AHPR: One thing I've often heard in political campaigns of various kinds is people say, "Oh, that's kind of a fake organization, it's all supported by Outside interests."

Bobrick: "Astroturf."

"You stay in political office, or you leave political office as an elected official because more people voted for you than your opponent. So that's the ultimate goal: to be able to say to any elected official, "I'm with organization X, and I have 10,000 employees in Alaska," or "I have 10,000 members ... "

AHPR: Astroturf, yes. Could you tell us about that a little bit?

Bobrick: Sure. That is a technique that is used, ultimately going back to the idea of a numbers game. You stay in political office, or you leave political office as an elected official because more people voted for you than your opponent. So that's the ultimate goal: to be able to say to any elected official, "I'm with organization X, and I have 10,000 employees in Alaska," or "I have 10,000 members," and a lot of them pay close attention because we've educated them, and [they] listen very carefully to the recommendations we make. ... That's the ultimate way by which people get in office and stay in office.

So, to foster that perception through a so-called Astroturf is not an uncommon technique. It's happened more and more. You can see it in the fight over Pebble Mine, you can see it [in] any high-profile initiative. You'll start [with] Alaskans who Love Polar Bears but who doesn't love a polar bear? Or Alaskans Against Child Molesters. And then you try to cast a big shadow by making people think that this is some spontaneous organization that just sprung up in righteousness to foster, or to kill, a public policy initiative.

AHPR: So what was going on behind the scenes to make it Astroturf?

Bobrick: Well, you would have a corporate entity hire a public relations firm to gin up the whole thing and to file with APOC [the Alaska Public Offices Commission] as a group. You would create a letterhead [and] you would set up a little boiler room. I remember -- I think it was in the big battles over oil taxation policy -- that ... one oil company in particular hired a public relations firm to contact Alaskans. They would actually set up a boiler room -- it was fairly sophisticated for the time -- and they would call people up and they would say, "Do you know that this legislation in Juneau is going to kill jobs and hurt the industry, and do you agree with this?" And if they said, "Yes, I agree with what you are saying," they would say, "Would you be willing to say that to a legislator if I can connect you?" And then they would push a button and then their call would be transferred to a respective legislator's office in Juneau. Hopefully that person would stay on script and say, "Well, I just found out about this, that what you're voting for (or against) is going to be bad for the oil industry, and I want you to stop it." That's a classic example that was employed in the state that could be termed Astroturf.

AHPR: There is a lot of talk about the use of the electronic communications media in politics. Many analysts attribute the election of our current president to the use of these new tools. Can you talk about how that in terms of how it may be increasingly used in Alaska, or its value, or any observations you may have on the subject?

Bobrick: Certainly. Public opinion messages used to be the standard by which one influenced people, [but] then those became so commonplace that they would pile them up in stacks rather than really read them. One stack's higher than the other -- is that the 'yes stack' or the 'no stack?' So, it really hasn't [been] a revolution. For example, you don't have to mail people things. It's free with e-mail addresses. A lot of Obama's people were brilliant enough to recognize and harness groups that had formed spontaneously simply because they were really excited about the candidate or the candidate's message, and that's where they [shined].

You know, it's generational -- people who are really familiar and comfortable with Twitter, and with Facebook, and with MySpace and things like that. Certainly, those are just the modern versions of phone trees, the old system where you'd have three hundred people on a list. I remember doing this, giving each of your ten people thirty names, and so it was their responsibility as soon as we got the notice that Senator So-and-so needed to have a phone call, we'd spring into action and start dialing each other up: "Call so-and-so, call so-and-so." That's the old classic phone tree.

Well now, it's more like push a button on your computer and you copy fifty e-mail addresses that were Reply to All [into] which you could, in turn, cut and paste an e-mail message that is sent to you, which you would then forward on. So, at each step of the way, you've got advances in technology, but on the other end, you've got staffers who are increasingly sophisticated at recognizing things where all the messages are the same. The Daily News, they hire people who can specifically recognize so-called grass roots letter writing campaigns, where they all say the same thing. It's not unlike a political arms race as far as getting your messages in, or having your messages blocked.

AHPR: I understand that most of your lobbying experience was at the municipality of Anchorage level?

Bobrick: I specialized in that. I was never a Juneau lobbyist.

"Going back just a bit: you know our governor, regardless of whether you like her or you don't, I think she's probably one of the most tech-savvy governors we've had. This is a woman that carries around not one, but two Blackberries, and is constantly e-mailing people and texting people."

AHPR: Is there anything significantly different about lobbying techniques or other issues at the municipality of Anchorage level compared to being a lobbyist at the state level?

Bobrick: I think it is simpler in that they didn't really rely on the committee process as much in the assembly, and only having eleven people. They are also year-round, versus Juneau, which has very specific sessions. Having the ability to be in the city where half the state's population [lives] meant you could actually bring a lot of people to bear, in a much more concentrated fashion, on those eleven people versus trying to corral a statewide group of voters or people to bear on sixty-one [elected officials - the legislators plus the governor].

Going back just a bit: you know our governor, regardless of whether you like her or you don't, I think she's probably one of the most tech-savvy governors we've had. This is a woman that carries around not one, but two Blackberries, and is constantly e-mailing people and texting people. I don't know if it's generational, I don't know if she's just more comfortable, if she grew up [with it], if it's her kids, or what, but certainly Sarah Palin is no stranger to modern communication techniques.  

AHPR: I understand that you have some comments about Certificate of Need [a state facilities review process used to promote cost-effective health facility and service development, and rational health planning]. I'm not sure what your working relationship with it was, but I'd be very interested to hear more about your comments.

Bobrick: Well, an issue that I was working on got caught up in the Certificate of Need [CON] process. A whole bunch of various entities that hadn't been part of the CON legislation in the past, were swept up on the rewrite, or the reauthorization, of the CON. That was, specifically, psychiatric treatment centers for youth, and that was a client I had that wanted to offer services in Anchorage. They were swept up into a bill that would require them to get a Certificate of Need; whereas in the past, I don't think they were required -- it's been a while.

And so, one of the things ... I noticed [was] that, there are many entities in this town now like the Spine Institute, people who offer a lot of services that normally -- years ago -- you only found in hospitals. MRIs, all kinds of high-tech specialty services, that not only did you only find them in hospitals in the past, but these were profit centers for hospitals in the past. So you had providers who came into the market, just offering these services alone, and this alarmed hospitals because they saw this as "cherry-picking" of services. And they saw themselves as being burdened with emergency rooms, on one hand, and having to underwrite those, and on the other hand, here are these people taking services that normally were their profit centers. So these became swept up in CON battles as well.

Of course, Providence, being one of the largest hospitals in Alaska, and one that doesn't pay property taxes, because they are non-profit ... I saw a pitched battle being fought between their lobbyists and other providers of services.

AHPR: Was there anything else you wanted to say on Certificate of Need, or it is time to perhaps move on to something else?

Bobrick: Move on.

AHPR: Okay, good. I understand that you were also involved with the first smoke-free ordinance that made restaurants smoke-free in the municipality of Anchorage?

Bobrick: Yes.

AHPR: Could you enlighten us?

Bobrick: I was approached by a coalition of people in the Alaska Lung Association and American Cancer Society, and the Alaska Native Tribal Health Consortium was part of it as well. I was very honored and that's the one I'm most proud of. It's an effort that was fought very bitterly by [Alaska Restaurant and Beverage Association, ARBA] and Anchorage Cabaret Hotel Restaurant & Retailer's Association [CHARR]. So, you know, rightfully so, the bar owners fought that because they said they would probably be next, and you bet, they were. It wasn't until years later ...

"We used to joke that, "Oh, tobacco companies are weighing in. I'd like to see their shoes that cover up their little cloven feet." That was an easy mark. And so they, too, used surrogates. And their surrogates were local bar owners."

AHPR: When was the first one, roughly the year?

Bobrick: It was in the early nineties. ... You had all kinds of people weighing in on that. Some people thought it was impeding on their right to smoke cigarettes. [Also] we had to explain to people that the idea of having a smoking and a non-smoking section of a restaurant is like having a peeing and a non-peeing section of a pool. It's ridiculous.

Then you had this whole phony deal about how they'd bring in these super filters and they would suck all the smoke away. Well, you know, there is no safe exposure to secondhand smoke. You cannot suck all the secondhand smoke away. Not only that, even if you could, you're still subjecting your waiters and your waitresses and your busboys and your bartenders to incredible amounts of secondhand smoke in the smoking section.

Then there would be people that would say, "Well, they choose to work there." Like hell they do. You know, some people can't get a job someplace else. Does that mean that we should just let asbestos fly through the air because you choose to abate asbestos without protection? So, it took on a whole lot of dimensions about freedom, and of course Alaskans love to talk about freedom while they're taking government money, and things like that. I digress.

Again, it was a classic example of identifying doctors, and nurses who would weigh in on the subject. Somebody that was gold to us was like a restaurant owner that decided, "I knew that this was a better thing for my business." Because instantly, what you had [were] people from the Lower 48 [states] pounce on elected officials and tell them that we were going to drive all these people from restaurants and bars out of business, if we had to go smoke-free. And so we had huge battles about whose data was correct. Was it true that secondhand smoke was harmful? Or was it just something [that was] made up?

We used to point to things like, "Do you see smoking on airplanes anymore?" No, because the reason why is there's no such thing as a smoking or non-smoking section on an airplane. Same thing inside a restaurant. And so you had Outside tobacco companies weighing in on that issue, but they worked through the local liquor and bar owners. And [those were] their surrogates. We used to joke that, "Oh, tobacco companies are weighing in. I'd like to see their shoes that cover up their little cloven feet." That was an easy mark. And so they, too, used surrogates. And their surrogates were local bar owners.

AHPR: ... Who had the cover that they were local, small businesses.

Bobrick: Right, exactly. A perfect example of a guy that turned into gold was the guy that owned Club Paris. Club Paris -- famous dark place where you get steaks and puff away in there. He decided before the ordinance passed to go smoke-free. He closed his place up, and apparently it took him like two weeks to scrub all the tobacco off the walls and off the paintings and everything. And then when he opened, smoke-free, he told us that his first January, smoke-free, he made an extra eight-thousand bucks, that he'd never taken in, in the thirty years or more, that he'd operated, and that he was born-again. He thought, "My God, these people were right. It didn't hurt my business. People came in, and it was a good thing to do." We've touted his story, we'd love to trot him out, if we could've we'd have drug him with us, pushed him forward. "Here, talk to Stan."

That was just one example of what I talked about earlier: is that identifying surrogates, or allies, that can talk to you.    

AHPR: In light of the legal problems that you...

Bobrick: My guilty plea?

"If an elected official, or a lobbyist, wants to behave in an illegal manner, they're going to figure out a way to do so. It doesn't matter how many laws there are, it doesn't matter what the penalties are."

AHPR: Yes, your guilty plea. I wonder if you could talk about any ethics issues that should be strengthened by law. Do we need public policy that actually strengthens the legitimacy of the forces that shape public policy? Or, would you say that those laws are good and sufficient but rather it's a matter of the enforcement? What is your take on that?

Bobrick: First of all, I'd like to just say a couple things as far as my own situation. And that is that not everybody that pleads guilty actually is guilty. When the federal government says you're guilty of something, you're guilty, regardless of what the truth is. Some people don't have the resources to hire Brendan Sullivan and to spend two to five million dollars on a defense. That being said, really, it's all about just reporting.

If an elected official, or a lobbyist, wants to behave in an illegal manner, they're going to figure out a way to do so. It doesn't matter how many laws there are, it doesn't matter what the penalties are. Ninety-nine point nine nine percent of all lobbyists and elected officials are honest people. And that's true in the state of Alaska as well.

The right to petition your government is an incredibly sacred one. I do think that the fact that, for example, in Congress, you have to start raising money the day after you are elected, is intolerable. I don't think that that's a good situation, and I do know that money is speech, according to the Supreme Court. But it's just human nature that if you've got a person, whether they're a lobbyist or not, and they're able to raise you huge amounts of money, that you can then use to hire staff and pay for TV and print materials, that it's not uncommon for that person to have pretty easy access to it.

So, I guess if I were to speak to reform: Americans don't seem to want to have public financing, but I think that's a direction that I would recommend. Either that or make TV or cable stations give you free airtime. Or, have it that you limit ... it's very difficult, in our Constitution, to put limits on speech, and I'm not a proponent of that. But, money and politics can foster unhealthy relationships. Did that answer your question?

AHPR: Some of it. It sounds like most of your answers dealt with money and influence at the federal level. What about for the state?

Bobrick: Same thing for the state.

AHPR: What about for the municipality? Are there any reforms that might be useful, significant, that could be made at that level?

Bobrick: I used to report my clients even before I was required to. So reporting clients isn't a bad thing, but then you have all kinds of people who still play on the edges. I mean, they say, "Well, I'm an engineer," or "I'm a planner and I work for an engineering company." Well, you bet. They're raising money for people, they're talking to them, they're trying to get a road that goes through a neighborhood that people may not want. They don't register as lobbyists.

So, how could it be strengthened on the local level? Really, again, it's all about public exposure; it's all about making it transparent. I think in this day and age with the Internet, I like the fact that, for example, Senator Begich posts his schedule online, and you can see everybody that meets with him. And there's no reason why an assembly member or school board member couldn't do the same. At the very least, you see that they're meeting with so-and-so, and so if you want, whether or not it's an election time, or in a meeting, or in a phone conversation, or a reporter. What were you guys talking about?

"I'll confess to being disappointed that I'm not being forgiven for the mistakes that I've made. I believe, and still want to believe, that if you make a mistake, you publicly acknowledge it and take responsibility for it, and apologize for it, and atone for it, and accept your punishment for it, that you'll be forgiven, that you can start over. That hasn't been my experience."

AHPR: You know, with your long history of being a lobbyist here in Alaska, and in light of your guilty plea, would you be interested in talking about the kind of contribution you would like to make from this point forward?

Bobrick: I came up here in 1975 to work on the pipeline, and this was my home for the last thirty-four years. I was always taught that you give back to your community. I'm completely independent of my lobbying work. People can look and see the non-profits I've volunteered for, over the last thirty-four years. So, I'm willing to do whatever would benefit further my state. I don't know what that is. I'll confess to being disappointed that I'm not being forgiven for the mistakes that I've made. I believe, and still want to believe, that if you make a mistake, you publicly acknowledge it and take responsibility for it, and apologize for it, and atone for it, and accept your punishment for it, that you'll be forgiven, that you can start over. That hasn't been my experience.

That being said, regardless of whether it's toward the goal of being forgiven, or improving the state that I've lived in for the last thirty-four years and helped build, it's not really for me to decide what my contribution could be, but I guess for me to work with others as to what would be appropriate and helpful.

AHPR: But you do have a whole skill-set, and you do have experiences all in a certain area, that might be valuable for teaching, might be valuable for writing.

Bobrick: I think so.

AHPR: In this interview you've given a lot of specific information about how, for example, a non-profit could launch a campaign, a kind of lobbying campaign, or influence a public policy campaign. That's a skill right there that most people don't have. Could you just talk about, for example, apart from the forgiveness issue, are there skills that you have that you might offer that people might find valuable, given your history?

Bobrick: I have more than twenty years experience designing successful grass roots lobbying campaigns, and I enjoy that. I've always enjoyed it, and I'll do it again. Whether it's for money, or for free.

AHPR: Is there anything else you would like to say to the readers of Alaska Health Policy Review, on any of these or related issues?

Bobrick: You can fight city hall, you can take on large corporate interests and win. It's not easy, but you can, with organizing, and identifying, and believing in your cause, you can make a difference. This is a small state, population-wise, and your elected officials are very accessible. I actually think they are more accessible than say, New York, or California, and not just because of the population. So, I would say that, you know, if you just go through the motions then you're going to get the government you deserve. But if you are involved, you can get a responsive government.

AHPR: Thank you very much for your candid comments and for taking the time to do this interview.

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Guest Commentary: Massachusetts Style Health Reform and Alaska

Neil DavisA UAF emeritus professor of geophysics, Neil Davis has several fiction and nonfiction works published by the University of Alaska Press and McRoy & Blackburn Publishers. Mired in the Health Care Morass, his newest book is about the U.S. health care situation and how to fix it. He writes Dose of Reality, a column about health care and health insurance, for The Ester Republic. You can read more about his books at his website, www.neildavisalaska.com. We wish to thank Professor Davis and the Ester Republic for giving us permission to republish this commentary. The views expressed by Professor Davis are his own and do not necessarily reflect those of the Alaska Center for Public Policy or the Alaska Health Policy Review. This commentary was originally published as a Dose of Reality column under the title "Massachusetts' Failed Experiment with Health Care Reform."

Much touted as a model for Alaska and the rest of the nation to follow, the Massachusetts Health Reform Law of 2006 has proven to be a failure. Not only has the reform failed to improve access to health care and reduce costs in Massachusetts, it has made the situation worse on both counts.

There is of course a reason for the failure. The framers of the Massachusetts legislation refused to address head-on the major problem with American health care: the control exerted upon it by the private for-profit health insurance industry. They did not just ignore the problem, they exacerbated it by giving the industry even more power than it had before to dictate to many more Massachusetts residents who gets health care and how much.

A key provision in the Massachusetts 2006 legislation mandated that everyone in the state not yet insured would have to buy private health insurance. They would buy it or get fined-up to $1,068 each in 2009. Realizing that there is no profit in fining a person who does not have enough money to buy the required health insurance, the Massachusetts legislation exempted some residents from fines, and also provided subsidies to poor and near-poor residents to purchase health insurance (but not health care).

The legislation was intended to make sure all 6.4 million residents of the state would have health insurance of some sort. When the bill passed, some 550,000 to 650,000, roughly one in ten persons, were uninsured. But it didn't work. Despite the good intentions -- and the fines and the subsidies -- at least 100,000 and perhaps as many as 300,000 Massachusetts residents are still without health insurance.

Those without health insurance and the poorer of the insured residents are worse off than they were before because, in passing the 2006 legislation, Massachusetts cut funding to safety-net providers. Evidently the idea was that if everybody had insurance there was no longer any need for safety nets. The end effect is that both the poor uninsured and the middle-class underinsured in Massachusetts are experiencing reduced access to health care. People seem to forget that health insurance typically pays only a part of the health care bill, and so heavy users of health care get hit hard when the safety-net disappears. In addition to their premiums, these heavy users have increased deductibles, co-pays, and other out-of-pocket expenses. Furthermore, their illnesses too often prevent them from working and that may lead them into bankruptcy.

"What it boils down to is that Massachusetts' reform program has turned out to be much more costly than expected, and instead of improving access to health care the reform has made it worse for many low-and middle-income residents."

Unfortunately, the Massachusetts experiment has led to increased overall health care costs. One reason is that the legislation set up a new agency to help people buy health insurance (but not health care), and the operation of this agency has added another 4 to 5 percent to the cost of private health insurance premiums. Those premiums have escalated since the legislation was passed, increasing by over 9 percent in 2009 alone. And this is at a time when wages are stable or falling. The legislation also put new administrative burdens on hospitals that have driven up their costs.

What it boils down to is that Massachusetts' reform program has turned out to be much more costly than expected, and instead of improving access to health care the reform has made it worse for many low-and middle-income residents. The Massachusetts experiment has not helped the public, the health care providers, or the hospitals. The only player in the mix to gain from the reform has been the private health insurance industry. (For details, see: Health Letter, Vol. 25, No. 3, March 2009; also www.citizen.org/hrg/.)

Despite the failure of the Massachusetts health insurance reform, Alaska may find itself led down the same garden path to higher health care costs and decreasing access to health care. An attempt to push the state in that unfortunate direction was made in the 2008 legislative session by the introduction of SB 160. The sponsors emphasized that the bill was patterned after the Massachusetts legislation enacted earlier. Senate Bill 160 failed to pass the Senate, but Senators Hollis French and Johnny Ellis, both Democrats, resurrected it as SB 61 (short-titled Mandatory Universal Health Insurance) during the just-concluded 2009 session. Although SB 61 went through several hearings, it was in committee when the session ended and is still alive for consideration during the next legislative session.

By the time that rolls around we can hope that our legislators will become more aware of the failure of the Massachusetts experiment to cut costs and improve access to health care. If so, they surely will use their good judgment to let Alaska's ill-conceived copy-cat, pro-insurance-industry legislation Senate Bill 61 die a natural death. We need to reduce the role of the for-profit health insurance industry, not enhance it. What we really need is to institute a national single-payer health care system.

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Guest Commentary: Measurable Success in Massachusetts

Hollis FrenchSenator Hollis French was elected to the Senate in 2002 and 2004. He is chair of Senate Judiciary, and a member of Senate State Affairs, Senate Finance Subcommittee Revenue, and several other committees. In April 2007 Senator French introduced SB 160, legislation that would establish a health reform framework in Alaska similar to the structure of health reform in Massachusetts, with the intention of making health insurance affordable for all state residents. The bill has evolved into SB 61. Detailed information about the bill can be found on Senator French's website, Health Insurance For All Alaskans.

Is Massachusetts working? In this issue of the Alaska Health Policy Review, Neil Davis argues that the Massachusetts Health Reform of 2006 "has proven to be a failure." That seems like an overly harsh judgment on an innovative state health reform that has, among other incremental improvements, produced the lowest percentage of uninsured residents in the country. The plan adopted by Massachusetts is certainly not perfect, but instead of labeling it a failure, health policy analysts and policymakers would be better off learning from the experience there and improving on it instead of simply waiting for the salvation of single payer. Don't get me wrong, I support single payer. But in the absence of any real national momentum behind that idea, working with the Massachusetts model is the way to go.

Let's begin by looking at some of the metrics of success there. The most significant factor is the 439,000 newly insured residents, giving Massachusetts a population that is 95% insured. Moreover, those residents are seeking health care from primary care physicians, which has admittedly highlighted the national primary care physician shortage.

As we all know, health insurance does not equal health access, but numerous reports show that health access has increased in Massachusetts since the 2006 reforms. Health Affairs -- a journal the Washington Post has referred to as, "the bible of health policy" -- reported last month that "access to and the affordability of care in the commonwealth have improved" in the state since 2006. Contrary to the assertion by Mr. Davis, the article specifically notes that "gains in access under health reform were strongest for lower-income adults."

Let me suggest this experiment: ask an uninsured working Alaskan making $20,800 a year whether he or she would be willing to pay $39 per month for a health insurance policy that charges a $10 co-pay for a visit to a primary care physician and see if there's a complaint about there not being a single-payer option. 

Mr. Davis mentions a decrease in funding for safety net providers, but he fails to point out that these cuts parallel a decrease in utilization of the health safety net. The Key Indicators report, published by the Massachusetts Division of Health Care Finance and Policy, shows a 36 percent decrease in utilization of health safety net services, coupled with a corresponding 38 percent decrease in payments. This was the intention of the framers of the reform -- as less dollars were paid out for uncompensated care, the balance was to be transferred to help finance the reform effort.

Massachusetts expanded health access by making private health insurance affordable, and this coverage often requires copayments for medical services. But this element of the reform doesn't mean that plan recipients are chronically underinsured in times of medical need. To ensure affordability of care, the Connector board sets premium and copayment criteria for state subsidized plans. As an example of the criteria they have set, an individual who works full time (40/hrs a week) and earns $10 an hour will owe a $10 copayment when visiting a primary care provider, and nothing for radiology, imaging or lab work. The premium cost for someone at this income level (192 percent FPL) is $39 per month. Let me suggest this experiment: ask an uninsured working Alaskan making $20,800 a year whether he or she would be willing to pay $39 per month for a health insurance policy that charges a $10 co-pay for a visit to a primary care physician and see if there's a complaint about there not being a single-payer option.

I do agree with Mr. Davis that there is a need to continue to improve our health care system. And I will communicate to our federal delegation that the national plan must include a public policy option. The ball is now in Congress' court. However, until Congress actually passes comprehensive reform that improves health access for the 100,000 uninsured residents of this state, I'll continue to learn from the Massachusetts effort, and advocate for similar legislation here in Alaska.

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What Has the Alaska Health Care Commission Been Doing?

The Alaska Health Care Commission (i.e., the Commission) was established by Governor Palin on December 4, 2008 under Administrative Order #246. The Commission consists of 10 members, which include the state's chief medical officer (who also serves as chairperson of the commission), an Alaska health care provider and an Alaska health care consumer, and one representative each from the Alaska tribal health system, the Alaska health insurance industry, the Alaska State Chamber of Commerce, and the Alaska State Hospital and Nursing Home Association. Three nonvoting members are representatives from the state Senate, House of Representatives, and executive branch. Governor Palin announced the appointment of the members to the commission on January 27, 2009. 
 
The Alaska Health Care Commission has met several times since the appointment of its members, with a critical 2-day meeting in February that laid the foundation for the activities, roles, and goals of the Commission. This narrative is based on the comprehensive meeting notes taken from Deb Erickson, from meetings held on February 27-28, March 18, March 25, and May 26 of this year. Content has been paraphrased for clarity and to meet space requirements, and direct quotes are referenced when appropriate.
 
Health Care Reform in Alaska: An Informed Approach

The overall theme in the Commission's discussions is approaching health care reform in Alaska from a comprehensive, informed, and realistic perspective. All sides of health care reform have been discussed at these meetings, including policy, access, personal responsibility, and managing the unique needs and health status of Alaskans.
 
The Commission recognizes that health care reform must be approached cautiously and with comprehensive background research that addresses Alaska's unique needs while considering models of health care reform in other states and countries. In the February 27-28 meeting, the Commission discussed the findings from two groups who have researched health care reform in Alaska: the Alaska Health Care Strategies Planning Council and the Alaska Health Care Roundtable. Following are the summaries of the discussions regarding the Alaska Health Care Reform Findings and Recommendations from these two groups.
 
Alaska Health Care Strategies Planning Council - Dennis McMillian, President, Foraker Group
 
The planning council was established under Administrative Order #232 in February 2007 by the Governor to identify short and long term strategies that would include a combination of public and private solutions for addressing the issues of health care access, cost and quality. The council identified issues of interest as: Access to health care, Quality of health care, Cost of health care, Prevention/public health, Provider recruitment/retention, Care for very young, Care for elders. Recommendations were developed around seven goals:
  1. Health costs for all Alaskans will consistently be below the national average
  2. Alaska will have a sustainable health care workforce
  3. All Alaskan communities will have clean and safe water and waste water systems
  4. Quality health care will be accessible to all Alaskans to meet their health care needs
  5. Personal responsibility and prevention in health care will be top priority
  6. Develop and foster the statewide leadership for statewide health and health care policy
  7. Increase the number of Alaskans covered by health insurance 
Alaska Health Care Roundtable (AHCR) - Duane Heyman, former AHCR Executive Director
 
Mr. Heyman first provided a brief background on Commonwealth North and the Alaska Health Care Roundtable. Commonwealth North is a non-partisan public policy forum created by former Governors Walter Hickel and William Egan. Commonwealth North identified health care as a priority issue in 2004, and spent a year studying primary health care. Because of that study, the Alaska Health Care Roundtable, a coalition of business and health care stakeholders, was created and met for two years to continue the dialogue.
 
Principles of reform identified by the Roundtable included the need to:
  • create healthier people
  • support individual responsibility
  • improve value for health care dollars
Mr. Heyman reviewed guiding principles recommended for the
commission's process, which included:
  • the need to acknowledge this problem is complex and will take more than a few months to solve
  • the importance of getting all the best ideas out on the table for
  • consideration and not just taking one path
  • the opportunity for learning from other states and national initiatives
  • the need for conducting sufficient Alaska research to evaluate policy alternatives
  • the importance of involving the right stakeholders (including those who will have to implement the reforms) in the decision making process
  • working at both the federal and state levels
Additional Sources of Health Care Reform Research in Alaska

The Commission reviewed the principles for health care reform produced by the Alaska State Hospital & Nursing Home Association (ASHNHA), which was presented by voting member, Mr. Ryan Smith. This document came out of discussions held at the ASHNHA annual meeting last fall in Talkeetna. ASHNHA's principles for guiding health care reform are to:
      
1. Continue to improve health care quality and efficiency
2. Establish health care accountability
3. Improve and expand health care coverage and access
4. Strengthen public and private health care programs
      
Mr. Smith also provided a copy of a summary report on a public opinion survey, commissioned by ASHNHA (survey conducted December 2007), to determine attitudes toward health care in Alaska and evaluate acceptance of various healthcare reform measures.
      
It was noted that early evaluations of online data systems on comparative health care quality measures demonstrate few (less than 5 percent) consumers utilize them. People want access to high quality services as close to home as possible, but willingness to pay more to expand access is pretty evenly divided (forty-six percent strongly or somewhat agree; forty-one percent strongly or somewhat disagree). However, eighty-three percent think that setting up a sliding?scale co?pay system would be a good idea. A member mentioned attending two community forums under the state insurance planning grant initiative, at which public participants largely agreed they would be willing to contribute what they could for health insurance, but the amount consistently identified by the participants as affordable was $100/month. The question of whether the general public really knows how much health care, and how much insurance premiums, actually cost was raised. [Erickson, Meeting Notes, February 27-28]

Follow-Up Discussion on Health Care Reform

Additional discussion on health care reform occurred during a teleconferenced meeting held on May 26. Members discussed national health care reform efforts, and the Commission's next steps related to following and addressing those efforts.
   
The group agreed that there is an important role for the Commission to play in informing the Governor's Office and Alaska's congressional delegation about potential impacts of reform proposals on Alaska. They decided it would be prudent to wait until legislation is drafted, so that there are more specific proposals on which to focus, rather than spending time analyzing numerous options being considered by the various committees at this point. Committees in both houses are targeting mid?June for mark?up of legislation, and so the Commission decided to hold its next teleconference in late June to discuss major components of emerging legislation and potential response.

There was a brief discussion on the need for evaluation benchmarks and measures. That is, medical inflation rate data for Alaska and the U.S. is necessary in order to measure the cost control component of the commission's vision and plan. The group discussed the availability of medical inflation data specific to Alaska, and noted that the Bureau of Labor and Statistics website could be a resource for Consumer Price Index for medical care data. [Erickson, Meeting Notes, May 26]

Meeting in the Middle: Juggling Single-Payer with Private Coverage

There was a great amount of discussion at the February meeting surrounding the dilemma of universal coverage versus private coverage. The focus of these discussions was on Premera BlueCross BlueShield of Alaska (Premera), which currently insures 205,000 Alaskans. Mr. Jeff Davis, voting member of the commission, shared two documents from Premera: a list of Premera's public policy principles for health care reform, and a report from BlueCross/BlueShield Association (BC/BS) on recommendations for reform.
   
Recommendations from BC/BS include increasing research on effectiveness of medical care, refocusing incentives on outcomes, empowering consumers, promoting health and wellness, and fostering public/private solutions. The BC/BS health care reform document indicated that fifty-six percent of individuals with no insurance are not eligible for public programs but cannot afford private insurance. Additionally, twenty-five percent are eligible for public programs but not enrolled, and twenty percent have high enough incomes that they could afford some out?of?pocket costs on their own.

There was a question about migration from private to public coverage, with a response that the CBO report addresses this issue, termed " crowd?out." That is, it has been proven that people will drop private coverage when they become eligible for public coverage under an expansion, and we should be concerned about it (e.g., we will expect to see some low?income workers drop employer coverage for their kids and enroll in SCHIP if expansion proposals pass).

A question was asked about the BC/BS recommendation to "encourage research on what works." Do they have specific points of view on comparative effectiveness? Mr. Davis referenced the report, noting that ineffective, redundant, inappropriate care is estimated to be thirty percent of health care spending, and fifty-four percent of acute care is based on evidence?based recommended treatment. Mr. Davis asked if we would accept this type of performance from a cell phone company - what if our cell phones worked only half of the time? Premera and BC/BS believe that it is a legitimate role of government to identify what works, and help eliminate inefficiency in the system. [Erickson, Meeting Notes, February 27-28]

Private Market versus Government Insurance

Another question was asked regarding private market versus government insurance. Mr. Davis noted that Medicare does not administer health benefits - that work is contracted to private carriers because innovation and efficiency is better in the private market. Private market solutions also allow more choice for the consumer. The government's role is to help the otherwise uninsurable. He questioned why we would dismantle the system (private insurance) that currently covers eighty-three percent of the population.

Mr. Davis indicated the importance of separating out cost, funding, and financing, and the need to truly reduce cost, not just shift funding. We need to reduce the rate of growth as it compares to growth of GDP, so health care expenditures are growing at a slower rate. Then he discussed the importance of improving quality through evidence?based medicine, faster adoption of best practices, and reduction in errors . the need to base practice on clinical studies that demonstrate what works, then provide incentives for consumers and providers who comply. We should pay providers for outcomes. This is not rationing - but paying for what works. He gave an example of a pilot project Premera has in Seattle with a large group practice for diabetes care where consumers are incentivized to participate with lower deductibles/co?pays, and providers are incentivized with pay for performance (based on improved outcomes).

Another question was asked about what drives choice on the part of consumers for deciding what coverage to buy - the balance between cost vs. perception of risk? Yes, but consumers need more information regarding costs and options, and ability to adapt packages of coverage to the needs of the group. For example, the Foraker Group has developed a pilot project with Premera that includes an element of personal responsibility through the inclusion of both a health savings account (HSA), and a health risk management program. There's a high deductible, but the employer contributes to the HSA and the employee has some of their own money in the game. [Erickson, Meeting Notes, February 27-28]

Health Care Reform Sustainability in Alaska

Representative Keller noted that he doesn't have a health care background, but has exposure to public policy making on health issues in the legislative arena for the past ten years and can bring that to the table in support of getting this work accomplished. He emphasized that sustainability of our solution is going to be key, and the amount of public money that will be needed for the health care solution will be an important factor in its success. He thinks about recommendations for health care reform as being on either end of a scale, from self?directed, market driven on one end, to universal coverage on the other end. He could argue for either end of the scale, but in reality we're going to end up somewhere in the middle.

Representative Keller identified the fact that the commission may have a bit of a credibility problem with the legislature, since members have a vested interest in the health care solution, so if the group makes recommendations that just move toward putting more public money into health care as the solution it may be viewed somewhat skeptically. One way to address this could be to limit the very first recommendations that come out of the Commission to strategies that actually save public money, rather than cost more.

Mr. Davis responded that he was in agreement about needing to start small and "take one bite of the elephant at a time." One thing that may be doable and have a net savings is the Alaska eHealth Network (AKeHN), noting both he and Dr. Butler are on the AKeHN Board of DIrectors, which is working to connect physician offices that have their own electronic medical records systems. Research has shown that if you can connect the systems, you can reduce costs by about 5 percent by eliminating duplication of medical services and improving quality. [Erickson, Meeting Notes, February 27-28]

Meeting in the Middle: The Four Pillars

Mr. Campbell suggested that we need to find the spot on the continuum between the two ends of the spectrum that could give us the efficiencies of a single?payer system, but still have the flexibility and other benefits of a market?driven system, noting that the single?payer system in Canada is very administratively efficient, but certainly limits choice. He also noted the need to find solutions to relieve providers from continuing to accumulate bad debt from individuals who can't afford their high deductibles.
 
Dr. Butler shared his perspective on health care reform, viewing it as based on four pillars - Cost, Quality, Access, and Prevention. Referring to cost, he noted that sixteen percent of the nation's GDP goes to health care today with a projected increase to twenty percent by 2018 if we don't change course. Regarding quality, quality combined with cost equals value, but there is also a safety issue, and the Institute of Medicine estimates 90,000 deaths per year in this country are due to medical errors.

Access includes two components - insurance coverage and health care workforce availability/accessibility. He referred to conversation with colleague in Massachusetts who noted their reform effort as covering more people with health insurance, but having problems finding health care providers. Prevention is the fourth pillar, which ties back to cost. He explained he's been working on getting at specifics of what we are spending in the state Medicaid program as a result of obesity, and in 2008 we were up to $45 million on treatment of type 2 diabetes. It amazes him that forty-two percent of the kids on Medicaid who have diabetes have type 2 disease, which was very rare when he trained as a physician and now it's nearly half of these diabetic kids, and this disease type is almost exclusively related to obesity.

Dr. Butler also commented that we can learn from other states and countries, but there won't be another model out there that will fit Alaska perfectly. What we do in Alaska will have to be appropriate for Alaska and will have to represent all Alaskans, not just those around the table. Senator Olson mentioned the commission should consider learning more about Canada's approach to caring for the elderly and kids, the most vulnerable populations, and also about the efficiencies in their system. [Erickson, Meeting Notes, February 27-28]

Addressing the Ethics of the Commission

Many ethical issues have surfaced in the meetings of the Commission. The Commission has discussed their role regarding legislation at multiple meetings, and added a Conflict of Interest section to the Commission's bylaws.

Role of the Commission regarding Pending Legislation
In February, the group discussed potential drawbacks to taking positions on legislation:
  • loss of credibility by politicizing the work of the commission,
  • alienating constituents of bills the commission might oppose,
  • complexity of managing work on bills for which commission members' employers or constituents may take a differing position from the commission,
  • placing the commission in a reactive rather than proactive mode,
  • resources required for analyzing bills, and
  • making the commission a target for lobbyists.
The group agreed that a more positive approach will be to develop their own policy statements on recommendations they want to see advanced, and will possibly draft their own legislation at times for either governor or friendly legislator sponsorship. [Erickson, Meeting Notes, February 27-28]

On March 18, the Commission discussed the need for clarification of the Commission's role in working on legislation. The group agreed at their first meeting that the Commission would not take positions on pending legislation. They identified additional problems:
  • becoming a target for every stakeholder group lobbying various aspects of all the different bills related to health care reform strategies;
  • the amount of time and resources it would take to analyze and respond to proposed bills and amendments;
  • the threat of becoming alienated from groups and legislators supporting bills the commission might choose to oppose (and visa versa); and,
  • the complexity of managing work with bills for which the commission may take a different position than the constituency they represent or organization for which they work.
It was decided that the role of the Commission is to develop policy recommendations and plans and so, in this case, the Commission is making a policy recommendation that a permanent body be established in statute, and is offering the draft bill as a good starting point for legislation to enact that policy. Following approval of this draft bill, the commission will step back from and not be directly involved with the legislative process. [Erickson, Meeting Notes, March 18]

Conflicts of Interest

The ethics discussion continued on May 26, with an extensive discussion regarding conflicts of interest and the legislation on the Commission's makeup.
   
They noted a change that had been made that removed the conflict of interest provision under the ethics article (Article VIII), which had been too restrictive as written in the previous draft. The idea to look into the language used by the Medical Board had been suggested, but the Medical Board has no bylaws and utilizes only the State Ethics Act and related guidelines from the Department of Law.

Senator Olson and Representative Keller both pointed out the importance of always noting for the record any potential conflict of interest so that there is transparency in the processes and decisions of the Commission. The group concurred, and after a brief discussion on clarifying questions, agreed to include the newly proposed conflict of interest section, added as a new Section B under Article VIII of the bylaws. The added Section reads:
   
B) Conflict of Interest

1. A member of the commission who has a direct and substantial conflict of interest in an official action of the commission shall declare such interest on the record, and shall request to be excused from voting on such action.
2. Any person who believes that a member of the commission has a conflict of interest may so advise the Chair of the commission.
3. The Chair of the commission shall make a ruling regarding commission member ineligibility to vote on an issue due to conflict of interest. The ruling of the Chair may be overruled by a majority vote. [Erickson, Meeting Notes, May 26]
   
Establishing the Need, Size, and Permanency of the Commission

The Commission held a teleconference March 18, with the purpose to consider legislation drafted by the subcommittee to establish the health care commission in statute. Discussions surrounding this goal include establishing a need for the group, determining the most appropriate size of the group, and finalizing the legislation proposing that the group be made permanent through Alaska statute.

Need for the Commission

The conversation initially focused on intent - a reminder regarding why we are doing this. As discussed when the need for legislation was identified as a short?term priority at the Commission's February meeting, both the Alaska Health Care Roundtable and the Alaska Health Care Strategies Planning Council previously identified the need for a permanent body to address health care reform. The Commission agrees, recognizing that the problem of health care reform is too great in scope and too complex to be able to plan and follow?through in just one or two years time through an ad?hoc body. [Erickson, Meeting Notes, March 28]

Size of the Commission

There was substantive discussion on the size and make?up of the group as set forth in the draft bill. It keeps the membership the same as specified in Admin Order 246. There is already lobbying from other groups who want to have a seat added to this table. The group concurred that the current small size seems to facilitate valuable dialogue on the issues and effective decision?making. The current group is representative of the basic core of the health care delivery system, and if expanded it would be hard to limit to just one or two stakeholder groups. The importance of identifying and recognizing the other key constituent and stakeholder groups and coming up with a process to ensure they are able to participate in the planning processes was discussed. In the end, the group agreed to leave the size and make?up of the Commission unchanged; the commission has to be small to be able to work together effectively. [Erickson, Meeting Notes, March 18]

Permanency of the Commission

 The Commission met again on March 25 to finalize the legislation that would permanently establish the group in statute. They considered the following motion:

The Alaska Health Care Commission formally recommends that a permanent health care commission be established in statute to address the need for health care reform in Alaska.

This draft bill is endorsed by the Commission as a good public policy statement for the beginning of the legislative process to establish the commission in statute. The background on the motion came from a University of Alaska study in 2006,which indicated the need for focused and comprehensive work to reform health care in Alaska. [Erickson, Meeting Notes, March 25]

Discussion on the Commission's Priorities

Issues that came up during the February brainstorming session included:
  • Cost
  • Workforce
  • Health Information Technology
  • Consumer's Role
  • Fragmentation and Duplication in the health care delivery
  • Regulatory Environment
  • Fraud
  • Quality
  • Access

From the issues and potential solutions brainstorming session, the group identified 5 priorities, and at least one next?step action item for each:
  1. The Role of the consumer in Health Care:Compile info on incentivizing wellness
  2. Access to Primary Care for Medicare Patients:Compile info on the two Medicare clinic pilot projects/models being planned for Anchorage (one 330?clinic; one private physician practice model); Compile info on 330 clinics in Alaska - where they are and how they're funded (note that there are 2 billion dollars in the stimulus package for 330 clinics)
  3. Workforce Shortage/Distribution:Compile information on Loan
  4. Repayment/Scholarship Programs Medical education - compile information on WWAMI seat increase; compile information on post-graduate medical education (residency programs for internal medicine, pediatrics, and psychiatry)
  5. Health Information Technology: Compile information on the Alaska eHealth Network - general info on status and next steps; economic stimulus package opportunity; pending legislation
  6. Establish Commission in Statute: In process [Erickson, Meeting Notes, February 27-28]
 Vision & Values of the Alaska Health Care Commission

One of the most recent activities of the Commission was the completion of the group's Vision and Values, which were approved of at their meeting held on May 26.

Vision

The Alaska Health Care Commission envisions the future health care system for Alaska as
one that:
  • Produces improved health status,
  • Provides value for Alaskans' health care dollar,
  • Delivers consumer and provider satisfaction, and
  • Is sustainable.
Health Care Reform Components

Four critical components of health care delivery require improvement in order to support
attainment of the vision:
  • Access: Access to affordable health care coverage and to a viable and vital health care delivery system is improved.
  • Cost: The cost of health care is controlled so that the medical inflation rate in Alaska is below the national rate.
  • Quality: Alaskans can be assured that health care services they receive in Alaska meet the highest quality and safety standards.
  •  Prevention: A focus on preventive services, both clinical preventive services for individuals and community prevention policies, will support improved health status and control costs by reducing the burden of preventable disease and injury.
Values
  • Sustainability: A redesigned health care system for Alaska must be sustainable in terms of:
  1. government, private sector, and individual ability to financially support implementation over the long term; and
  2. health care provider ability to deliver quality care while maintaining a sound business operation.
  • Efficiency: A redesigned health care system for Alaska will minimize waste in clinical care and administrative processes.
  • Effectiveness: A redesigned health care system for Alaska will support practices best known to produce the best outcomes.
  • Individual Choice: A redesigned health care system for Alaska will provide information and options for Alaskans in terms of health care coverage and service providers.
  • Personal Engagement: Alaskans are encouraged and empowered to exercise personal responsibility for healthy living and for obtaining health care.
Continued Progress of the Commission

The Alaska Health Policy Review will continue to track and report the activities of the Alaska Health Care Commission. The next Commission meeting is scheduled for late June, and an agenda will be posted to the group's website prior to that meeting. To access the documents, agendas, full meeting summaries, and other Commission-related materials, please visit their web site.

The Alaska Health Policy Review appreciates the work of Deb Erickson and the use of her extensive meeting notes for this narrative.

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Alaska Research: Computer Simulation to Guide Policy and Program

Dennis McMillian
Dan Kiley is a family practice dentist in Anchorage, Alaska and a graduate of UCLA Dental School. He is also a Fellow, Academy of General Dentistry. The development of a simulation model of dental health outcomes in Alaska was the subject of his thesis for a Master's degree in Public Health from the University of Alaska Anchorage. His co-researchers were Sharman Haley PhD, Ben Saylor, and Brian Saylor PhD, MPH. The research was funded in part through a grant from the Ford Foundation. For additional information, you may contact Dr. Kiley at [email protected].

Abstract: The value of evidence-based computer simulation of oral health outcomes for management analysis of the Alaska dental health aide program.

Objectives: To create an evidence-based research tool to inform and guide policy and program managers as they develop and deploy new service delivery models for oral disease prevention and intervention.

Methods:A village-level discrete event simulation was developed to project outcomes associated with different service delivery patterns. Evidence-based outcomes were associated with dental health aide activities, and projected indicators (DMFT, F+ST, T-health, SiC, CPI, ECC) were proxy for oral health outcomes. Model runs representing the planned program implementation, a more intensive staffing scenario, and a more robust prevention scenario, generated 20-year projections of clinical indicators; graphs and tallies were analyzed for trends and differences.

Results: Outcomes associated with alternative patterns of service delivery indicate there is potential for substantial improvement in clinical outcomes with modest program changes. Not all segments of the population derive equal benefit when program variables are altered. Children benefit more from increased prevention, while adults benefit more from intensive staffing.

Conclusions: Evidence-based simulation is a useful tool to analyze the impact of changing program variables on program outcome measures. This simulation informs dental managers of the clinical outcomes associated with policy and service delivery variables. Simulation tools can assist public health managers in analyzing and understanding the relationship between their policy decisions and long-term clinical outcomes.

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AHPR Staff and Contributors

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

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