On June 30, 2009, Senator Lisa Murkowski met for about one hour and forty-five minutes with 25 to 30 Alaskans to discuss a broad spectrum of health reform issues. The meeting took place at a conference room in the North Terminal of the Ted Stevens International Airport in Anchorage. The event was by invitation only. It was sponsored by the Alaska Health Assurance Advocacy Team (AHAAT: pronounced "a hat"), a coalition of organizations and businesses working toward the expansion of affordable access to health care for Alaskans. The discussion ranged from the for-profit practice of medicine to the "public option," and from national drug policy to "personal responsibility." Abstract policy melded with the stories of cancer survivors. We recorded and transcribed the entire meeting, and are pleased to present it here for you. The transcript has been edited for length and clarity. We have included names of attendees who spoke when we could identify them with certainty.

Pat Luby: OK, we want to welcome all of you to this meeting with Senator Murkowski. Obviously this is a pretty critical issue for everyone and I think most of you know that the Senator's been involved on the health committee, and is probably up to her ears working on health care reform on a day-to-day basis. We made a late call on this just hoping that we might be able to find out where the Senator was going to be meeting to talk about health care while she was here on vacation.

Senator Lisa Murkowski: Vacation? [Laughter] Do I get one?

Luby: District work period. And she made time for us for 90 minutes, which as you know is a lot of time in the United States Senator's schedule, to talk about some of the work she sees on healthcare reform, some of the work that's going on in the health committee, what she's hearing from some of her colleagues, as well as anything that she might like that might help her make some decisions as she deals with health care reform in the Senate over the summer. It's going to be a busy summer, obviously. Emily, do you want to talk about the AHAAT?

Emily Nenon: Sure. Many of you have been members of the Alaska Health Advocacy Assurance Team, or AHAAT. We formed a couple of years ago now and have been sort of a clearinghouse to figure out what's going on around access to care. We specifically chose the word health "assurance" because we know there's more to accessing care than just having insurance -- insurance being one of the keys, but only one.

As a group, one of the activities that we did last year during the legislative session was to bring in some folks to talk about models that different states were looking at as far as increasing access to health care. We had a tremendously successful legislative forum in Juneau, which was great, and certainly demonstrated a tremendous amount of broad interest and concern on this issue across the state.

As a group, we're a diverse gang. We haven't taken a lot of positions on issues. One of the things however that we did take a strong stance on was expanding SCHIP/Denali kid care. [We] worked on that on the state level and we want to thank you, Senator, for your help and advocacy on that on the federal level and making some of that possible, and particularly for the tobacco tax, as a nice bonus too, so thank you for that.

Murkowski: It's been a good year so far, really.

Nenon: Yeah, we're doing well [Laughter] So that's a little bit of background on AHAAT, our coalition. There are also some folks here who are with Commonwealth North's health action group. This group has reformed recently, and has "action" in the name for a reason, again, very intentional -- to look at these issues and see where there are opportunities for action. So with that, we're thrilled to have the opportunity to sit down and visit with you, Senator.

Nenon: And so I'll just share that right now Pat Luby and I are the co-chairs of AHAAT, and we have a number of our past leadership with us and thank those folks.

Luby: Including the birth mother [Laughter] It was Shelley's idea [Shelley Hughes of the Alaska Primary Care Association] ...

Murkowski: I should have known!

Nenon: And Jeff Ranf with the Health Insurance Underwriters is not able to be here today, but he is our vice chair. We've had a wonderful group of people, like I said, diverse, coming together and seeing what we can figure out. You know, we have some unique challenges and unique opportunities in Alaska and are eager to continue the conversation. All right, thank you.

Luby: Senator, it's all yours.


Murkowski: Well thank you, and I will apologize to you that I'm not going to stand. I've already done a couple of public things and the nurses and providers in the room would tell me to just keep seated and don't put too much stress on my leg, and I do want you all to notice that I'm out of my brace today. It's like my second or third day so I'm still a little wobbly, but the walk down the hall was good for me, Pat, I appreciate it [Laughter] Get a little exercise there.

I want to thank you for the opportunity to sit down with you. When we got the e-mail asking if there was something that you all could be part of during this time when I'm back up in the state, I immediately signed off on it and said let's figure out a time to make it happen. So it's short order for me, but it was also short order for you, and I appreciate you taking the time to be here to have just a discussion about where we are. I really don't want this to be me lecturing to you about what is bad in the health bill vs. what might be good coming out of the finance bill. What I would like to do is kind of give you an update as to where we are right now in the process, what we are seeing, perhaps share some of the concerns that I am hearing, and then really try to get as much feedback from you as possible.

Where we are right now with health care reform, in the Senate anyway, is a very interactive, very volatile situation in the sense that there is so much happening. Every day things change a little bit, and you think you know what we have done, and then the next day we realize that we're going a different way here. So our opportunity to weigh in as Alaskans in something that is clearly evolving ... I mean the time is now! We could have pushed this meeting off until I had more time on my schedule in August, but then that we would have been behind the eight ball, so the timing on this is perfect. I appreciate the diversity of the group here.

One of the things that I have learned is that there is not a community that I go to -- I was in Naknek, King Salmon, and Dillingham yesterday, I was in Barrow on Saturday, I'm going to be down in Kenai tonight and tomorrow -- there's not a community that I go to where people are not talking about health care and some aspect of it, and how I get it, and why I'm being dinged like this, and what the options are. I just came from a meeting over at Conoco Phillips and I thought that they'd want to talk primarily about what we just did in the energy bill two weeks ago -- all of the Q and A, All of the Q &A was on health care -- and these are folks that have a pretty good plan over there. So this is the issue that we are clearly focused on.

So let me let me give you kind of an update. As Pat and Emily said, I'm on the health committee. That committee is looking at one draft bill only and that's the Kennedy version. That does not mean that there aren't multiple versions of a health care proposal that are out there, but what we have in markup, in other words under consideration by the committee, subject to amendment, is the Kennedy bill. It's a really expansive bill. It is, as I'm sure you've seen, an incredibly expensive bill -- one of the things that we're dealing with. But let's just talk about the process and where we are with it.

We started this markup a week and a half ago, and we go into the committee and there's a stack -- the bill at this point in time is about that high [indicating a stack about six or eight inches high] -- 1200 pages, and it does not contain draft language for the government option plan or the employer mandate. These are not only two of the more controversial areas but clearly the areas where, in terms of cost, that's where you're going to see it. So when CBO scored the bill, all they could score was what they had in front of them, so they weren't able to score the government plan, and they weren't able to score the employer mandate. So what we got was $1.3 trillion based on what we had presented to the committee.

Now, we were told that we would get language for the employer mandate as well as the government plan, it was supposedly to be to us before the 4th of July break. We didn't get it, so now I anticipate we'll get it when we come back. But there is a very, very, very aggressive effort to move this legislation through the health committee yesterday. We have got to address health care reform, there's no option there. We've got to do it. But what is happening in our committee seems to be a race to meet a deadline as opposed to a goal to define some good policy. I think that that's unfortunate for us. But we're not the only thing going in the Senate right now.

The finance committee is also taking up their version of health care reform. Senator Baucus, the chairman of that committee, and Senator Grassley, the ranking member, have been working to really put together a bipartisan package. I have talked with both Senator Grassley about the approach and Senator Baucus about it. They are working with a smaller group from finance and some of us that are not on the finance committee but who are committed to doing something. They're really working to see if they can't come out with a bill that is lower in cost than what we're seeing out of the health committee, [and that] really addresses the issue of how we provide for true access.

As you've heard, under the Kennedy bill that we have in the health committee, the proposal would only add insurance for an additional 16,000,000 people, [but] we've got 46-47 million that are uninsured. This proposal at $1.3 trillion only brings in another 16, so if the goal that the president has and the Congress has and that I have is that we are covering everybody, this doesn't get us there.

So the finance proposal is looking at how we make sure that we really are keeping the commitment to coverage. And then of course their job is to figure out how you pay for it. And you want to talk about the devil being in the details, this is where all the controversy will come. There are proposals all over -- you know, we're going to increase the tax on sugary drinks and products, and alcohol. That's a lot of alcohol and pop. But there's also the controversial pieces, [for example] that we would tax the benefits of an employer plan. There is so much yet to be resolved.

So what I want to leave you with, in terms of where we are in the process is, at a minimum, a couple of different proposals coming out of the two committees -- very different in their approach, and very different in their approach to the process. Our product, coming out of the health committee, unfortunately, is not a bipartisan bill. They have accepted probably, maybe 30 of my amendments, maybe not quite that many, maybe 20 of my amendments, but they've all been very technical in nature. But they're saying, "Wait, we've taken all these Republican amendments." Well -- and Angel, you know what I'm talking about -- we made sure that within the language, Tribal entities would qualify for these grants so you change the language to allow for that. That to me is not taking a major Republican amendment.

So there is, again, a push to get a product out of committee quickly. What happens next week when we come back and we have the language on the government plan and the employer mandate, things may change. Senator Dodd who is chairing the committee in Senator Kennedy's absence, has stated quite publicly, when the CBO score came out he said, "I can't vote for a bill out of committee that doesn't provide for full coverage for everybody that only gets us an additional 16,000,000 [insured individuals] and that is in excess of a trillion dollars." So he knows that we've got to figure out a way to be more realistic.

One of the proposals that is out on the table that has not yet vetted but is intriguing to a lot of people, is instead of a government option, the government-run plan, is this concept of a co-op so that it can be more regional in scope and in nature. We've asked for further details, [but] they're still fleshing it out. This is a proposal that's coming from Senator Conrad from North Dakota. He's got a lot of the same issues that Alaska has, very rural, you look at a one size fits all national mandate for health care and coverage and he knows that they may be facing the same issue of access to providers that we face here in Alaska.

I've talked with Senator Baucus and said I know that Medicare works good in certain states, [but] it doesn't work in Alaska, and if what our proposal is is to call health care reform really just plussing up Medicare, and increasing the reimbursement of Medicare by 10 percent -- I said that's not a model that's going to work for us in Alaska. And he said, "I know, because that doesn't work for us in Montana too." So there is an appreciation that maybe we need to look at how you could do some form of a government option that does give you an option to allow for a competitor to the private insurance plans, but we've got to do it smart, we've got to do it in a way that makes sense in all parts of the country.

And if you think about the co-op approach that we have utilized with our utilities, it works because its regional in nature and you take advantage of what the commonalities are within your region. So health care, if you pattern it in that same way, there may be some opportunities, some options there. At this point in time we don't know enough of the details of a co-op to know whether it's a winner or whether it just creates more complications. But that is something that is out there that is being considered and, again, language has not been put on the table, but it's up and out for review. Let's see, what else do I need to give in terms of updates?

One of the things that we have been pushed on is, is that it is imperative to get health care reform moved through the Senate, moved through the House and to the president for his signature by October. I am certainly supportive of expediency in the process, but I am very concerned that we make sure that we do this right. Think about when we put Medicare on the books back in 1965, you know, we will agree, here in Alaska there are certain aspects of Medicare that just don't work and haven't worked over a period of time. Once we get this in place folks, we are living with it. And it's not like what we're doing on the energy committee where we introduced language on a loan guarantee for renewable energy projects. This is a system that we're putting in place for the nation, for all of us.

So I don't think that it is a bad thing to make sure that we're going do it as close to right as we possibly can. So I understand the president's desire to move on this as a priority issue and I believe that we must, but I will remind you all that at the same time as this is a priority, we've got a Supreme Court nominee that we're moving through in this next month, we have climate change legislation that just came over to us on Friday, we've got an energy bill that we just moved through that is a priority for the administration, and the president has just announced that he wants us to resolve immigration before the end of the year.

Now these are no small tasks. And I admire the president for setting the bar high, but if he were in this room I would say, "Yeah, but when you were sitting with the rest of us here, you appreciated the demands on all of us." I think we should make health care reform our number one priority and I think we should figure out how we ensure that we've reduced our costs, that we've increased our access, that we allow for a level of assurance -- and that's the key word here -- a level of assurance to the quality of care that I think we all expect and, quite honestly, deserve.

So with that, what I'd like to do is hear from some of you. I put an Op Ed piece out that was designed to provoke some thought, to have people ask some questions, about how we feel about a government plan. And I've taken some potshots in some of the letters to the editor, and that's OK. I appreciate that feedback. Some of the criticism that I've seen is, well, "Lisa's just saying that it cost too much and that she's not putting the ideas out there so much as she saying 'no,' and the Republican plan is no to health care reform." That is nobody's plan so far as I know.

Even some of the most ardent opponents to what we have in front of us in the health committee, the desire is not to say no to health care reform, the desire is to figure out how we get this right, and push back on some aspects of the plan. So we have been working on some of the initiatives, whether it's the prevention and wellness piece, how we can particularly in rural areas because that's what I've got to be focusing on, how we can ensure that you've got a level of participation in a plan and really providing access for people.

I don't want us to be in a situation here in Alaska where we've got a national plan going on -- we're all paying into it because we're taxpayers -- but in fact we get no benefit because we don't have any providers or providers who will take those in the plan. It has to work for us as well as it works for the people in a major city in the United States. So, help me with some of your proposals and your ideas. I appreciate Commonwealth North -- you all have been working this issue since before it was popular to be working the issue. Those of you that work within the health care sector have long been focused on it and one of the things that I need to go back to Washington with are either "This absolutely positively cannot work because ... " or "Let's try this approach and this process."

Nenon: As a segue, while we did skip the introductions, I did want folks to know that from your staff, Amanda Mackie is on the phone, and Amy Erickson is here in the room. Anybody who has spent time around elected officials knows the value of the staff, so we want to certainly recognize them.

Murkowski: And I think Amanda has had opportunities to talk to many of you and to try to solicit your ideas. When I was here last week I guess it was, I got off the plane and sat down with a group of about a dozen providers just kind of talking to them, "OK tell me what happens to you in your practice," so we've got a broader group here and I'd like to try to get a little bit more from that perspective.

Nenon: And that's exactly what we're thinking about today, so we should have plenty of time for a great discussion. I think we'll do this pretty informally, especially since many of the people in the room know each other anyway. We'll [go] until around two, with some back and forth questions, and then will have an opportunity to do some wrap up to see how it is congealing.

Luby: I'll start. [Laughter]

Murkowski: Somebody has to do it Pat, thank you.

Luby: One of the issues that I know you're dealing with right now in the health committee is what is referred to as "biologic drugs." For those of you who are not familiar with that, most of us get chemically-developed drugs from the pharmaceutical company but some of them are biologically developed. They're usually the most expensive drugs too, and older people frankly are the ones most likely to need them.

Currently there are two pitches being made to the health committee. One of them is from the pharmaceutical industry to try to extend the patent so that you could not develop a generic substitute until ten or twelve years after a company has developed the original biologic.

AARP and some other organizations are arguing that five years ought to be a legitimate period where a company can recoup all of their research costs and still have a legitimate profit. But also then older people who need these very expensive drugs are not going to have to wait 12 years until they can get a less expensive generic. I was wondering where you were in the debate on that one.

Murkowski: Well I think that we recognize one of the huge drivers with our health care costs has been with the cost of the pharmaceuticals and how we can meaningfully reduce that, and I think that the issue with the biologics is absolutely one of them. Amanda, have we gotten the language on the biologics yet? Because I know that that was, in addition to the employer-mandate, and the government plan, that we didn't have that yet. Have we received it?

Makki: No, we haven't received any language, and just to kind of let you know what we did, biologics last time [we looked at this issue] we had different language. I know that there's been some back and forth on new language, but as of right now we don't have any language. I know that this is an important issue for AARP and one that they've been talking to Senator Kennedy staff on, but we don't have any new language. And there's quite a disparity between the language that passed out of the health committee in 2007 as compared to now.


Murkowski: Well I'm glad that you reminded me of that, Pat, because it is an area that we can look to as an opportunity to help reduce our cost. We've got to make sure that the way that we provide for this not only makes sense, but that we're doing right to encourage the production of new drugs as they come on line too. But I recognize that it's things that you wouldn't ordinarily think about, how this whole process of bringing a drug on line comes into play, and then the politics that comes into play to keep that product under your control.

I think we recognize that there's money that is being made, and politics are being played, and we need to be in there addressing that, so that's an important part of our bill. And again, one where they haven't worked out the language yet, so I'm not quite sure what we're going to be dealing with or how we're going to be responding to the committee in terms of where they're coming from. But that's been, I think, AARP's number one issue and initiative so we're all over that one.

Another issue that I might throw out there too: tort reform is something that gets everyone's attention for lots of different reasons depending on your perspective. I think we have recognized that it is one of those cost drivers when doctors are practicing defensive medicine, and ordering up additional and perhaps unnecessary tests just to kind of make sure that all their bases are covered, so if they get slapped with a lawsuit they can say, "Look, I did it all."

When I talked to the providers they point this out as an area where we've got to get control of it. We haven't been able to make the headway that we need with that. That's one issue that will probably enter more partisan tones in the debate, and that's too bad. We've got to figure out how to get a hold of it. I didn't mean to go on too long about biologics but I was just prompted to [discuss it].

Makki: One thing about biologics that I wanted to bring up is, do you know Pat if MedPAC [The Medicare Payment Advisory Commission: an independent Congressional agency to advise the U.S. Congress on issues affecting the Medicare program] has come out with their assessment on where this should be? Because I know that that's something that the health committee was looking for receiving from MedPAC.

Luby: Jim Jordan is shaking his head no.

Makki: I think that is something that's critical too because Medicare is obviously, we know, one of the biggest buyers of healthcare, and for this issue in particular, I think it would be key for us to know where Medicare is on this.

Murkowski: Yes. What else is out there? Who's starting? Shelley.


Hughes: I'm Shelley [Hughes] with Alaska Primary Care. I just wanted to thank you for sponsoring the resolution recently in regard to community health centers. [I was] going through the Washington Post Wall Street Journal [reading about] what's happening with health reform this morning. There was a note that community health centers are the largest health care system in the U.S., treating one out of eighteen people in the United States. In Alaska that's one out of nine. Together with the Tribal clinics, they are so core, and they exist in a place where there's not a competitive market place, and so I really appreciate your protection for those because that is definitely, as you know, very very unique in this state.

I think Angel might agree with me [that] two of the biggest concerns we have are the workforce, and [also] energy is tough for these clinics. At the state level there's no way to get help with that right now, and that's been a real drain. [I see] the workforce situation for primary care as a real system change [issue, but] a lot of the things that we're doing are band-aids. [We need to be] really revamping the system so that primary care is strengthened, whether in the private sector, and other sectors. If you look in other places of the world where they have decent health outcomes, primary care is more prevalent than it is here. The ratio is about four to three, to one over specialty care [but] it's flip-flopped here. So I think that anything in health reform that can be done to strengthen primary care [is important].

As you know only two percent of American medical students are going into primary care, and that is a real serious concern. There's going to have to be some very serious reform to reverse that trend and it's got to start happening. It cannot happen overnight, but it needs to happen, and whether that's in payment reform, in loan repayment programs, whatever can be done to encourage young students to go into the field of primary care is very important. I don't believe that health reform will be successful unless that is a key component.

Murkowski: I think that we acknowledge that we can put together the best system, but if you don't have anybody who is a provider, we haven't done anything for you. This takes us back to the debate that we had about Medicare part D and the prescription drug. I was saying, "Hey, we can have the best prescription drug plan, but if you don't have a doctor that's writing the prescription, what have we done for people?" And at that point in time that was a message that was just kind of over everyone's head because, you know, nobody has problems quite like that. Well, Alaska has them and now more parts of rural America are experiencing the same issues.

We do have, I think, some relatively good provisions within the Kennedy bill that go to the issue of how we attract primary care providers, and providing for levels of loan forgiveness within certain areas, but we know that we can and need to do more. It's not just the loan forgiveness, [but also] it's making sure that we have the ability to bring people out into areas, into parts of Alaska and having them do their residency there so that, say they get hooked on it [or] whatever it takes. But [it requires] a level of exposure away from the training that they receive in the cities, and then [they] end up practicing within 100 miles of where they have been focused.

So I think the work force development piece is one where we actually are in agreement that we've got to be beefing up aspects of this. We've also got to be turning almost on its head how we provide for the incentives through pay. Right now, it's no wonder that people are going into the specialties as opposed to primary care. You know, you can work less and get paid more. We've got to change that dynamic. And I think that aspect of it is also recognized as one where it's not a Republican or Democratic idea. We realize that that aspect is something that needs to be changed.

Hughes: Thank you. We know that you're aware of it and have been working on that. I want to throw out the frontier extended stay clinic -- trying to get that language in. Those are the clinics that actually turn into mini-hospitals, but they only get paid for seeing a patient for about 30 minutes when they might have a patient for two or three days. It's time for them to be reimbursed according to the care and the extra staffing, and all that's involved in becoming a [garbled] hospital.

Murkowski: Amanda, do you have any update on the frontier extended stay provision?

Makki: Yeah, I think we had an issue on our side. We got it cleared by most of the members, but I think we had an issue on our side with Enzi's office. The National Rural Health Association has been working with HHS in trying to loop in Senator Enci to see if we can address their concerns to get this passed because we pretty much had unanimous consent on this when we offered it as an amendment to the bill.

Murkowski: Good. Cathy.

Giessel: Senator, we really appreciate the fact that you understand also when we're talking about primary health care providers that that includes nurse practitioners and PAs [physician assistants] in Alaska as we have full scope of practice here. And you know, as we talk about rural care, one of the things that keeps physicians from going into rural areas, at least this is what they have spoken about, is the isolation, the lack of opportunities for their families, or if they are single individuals, the socialization. I actually spoke to nurse practitioners who are in a rural Alaska practicing by themselves, and those same issues affect them.

So a way that practitioners, health care providers, could communicate and be supported in rural areas is also important, as they are out there by themselves. Another thing that one of them brought up is, you know, the loan repayment idea is a really great one, except that then you're recruiting a new graduate without a lot of experience, into a rural area that can be quite isolated. Is that really where you want to put them by themselves?

Murkowski: Right, when they're first starting out.

Giessel: Exactly. That can be very traumatic. So again, that's a subtlety, but it can make a difference in the quality of care and the willingness for people to go into a rural area. So just something to think about. I think professional organizations actually could create that network of support. We have the Internet. We can be much more connected, but having mentors assigned, or something like that, encouraging the professional organizations along those lines, could be a solution there.

Murkowski: Well, it's interesting to think about that because we're doing that quite aggressively in the state right now when it comes to our teachers. We recognize that the first three years are key to that new teacher. And if they are going to leave the profession, it's going to be right around year three. They'll stick it out but then decide, you know, "maybe I am too isolated, maybe I don't have the support that I need."

The state has been very aggressive. We've worked with them in getting funding at the federal level and the state has been kicking in money too for these mentor/mentee relationships where you pair a young teacher, a new teacher with somebody who has that level of experience, and you just kind of work with them. It has really helped in our effort to retain the teachers because we can recruit them, but we can't retain them.

It's the same situation that we're facing, oftentimes, within the profession of nurse practitioners. There's no reason that we couldn't figure out how you do some kind of mentor/mentee approach, particularly with some of the folks who are out in rural Alaska. That might be something that we include in our workforce piece because I don't think that, in terms of mentoring, there's anything that would come close to what you're talking about. It's a good idea.

Giessel: It was some insight that a rural nurse practitioner offered to me. [The nurse practitioner] said, you know, this is something that's kind of overlooked. And the other thing of course is funding for nurse practitioner education. Medical education gets a lot of funding, but nurse practitioners, as primary care providers, could use some assistance also. Everyone's asking for money so we might as well throw that in. [Laughter]

Murkowski: But I think it's important that we recognize when we talk about those that are providing the care, you don't just think of the physician. It is the others that are providing for that level of service, and as we know here in Alaska, in so many of our communities, in most of our communities you will not have a doctor, and you will not ever have a doctor. You will have PAs, and you will have nurse practitioners, and you'll have your community health aides, and you will have those that are delivering a level of care that is certainly appropriate to the area, and we need to support them.

Makki: Just one thing on that issue ... We introduced the nurses' higher education and loan repayment act with Senator Bayh in May, and that's also another way to provide for funding for nurses who decide to go on to teach, which we know is something critical to getting more nurses into the workforce.

Murkowski: Rosemary.

Rosemary: Do either of these bills that you have been working on have any section in them that addresses the deficiencies in behavioral health [such as] access to behavioral health, payment for behavioral health, some of these issues? I mean, this is a very big issue in Alaska, and I suspect in other parts of the country as well.

Murkowski: Amanda, do you know? I don't know whether in the prevention and wellness piece, if there's anything in there?

Makki: Yeah, there is. There are a lot of grant programs that we've gone through in the last two weeks. In those sections, there are. Everything includes behavioral health, and the medical home concept, and the grants programs -- they did include behavioral health. One of the things that we're going to probably address in the coverage section is actually where the benefits go to pay for behavioral health services for this new expansion -- whether it be a government plan, or in other government plans that they have currently in place and in Medicaid and in Medicare. So right now they have certainly addressed it, but the coverage piece, which we still don't have the language on, is really where we're going to see the impact of behavioral health on insurance be addressed.

Murkowski: I think one thing, the benefit of where we are now, the debate over mental health parity raged for years and of course, was successfully passed, I guess it was just last Congress.

Makki: October.


Murkowski: It really pushed to the forefront the issues of mental health, and how we ensure that as we are providing for a level of care for an individual [and that] it's not just fixing the bones and settling the fever. It's addressing also what is happening within the mind and the brain. I think there is just a much greater awareness now amongst lawmakers as we try to really advance a meaningful health care reform package that behavioral health must be part of the discussion and must be part of what we're dealing with, as we provide for coverage.
I think the situation also, [where] we're seeing so many of our veterans coming back -- they look fine in physical body -- but they've got issues that we know must be addressed, and our failure to do so is really at our peril and their loss, truly. So I think there's a much greater awareness and acceptance that this is the right thing to do, and that we must do it.

Attendee: Another piece that we have been particularly concerned with -- and I've been in contact with your office and everybody else I can find to talk about it -- is the regulatory climate once legislation becomes a reality. And seeing that the Department of Health and Human Services, who interprets the law -- and we've seen that in particular with end of life issues -- are very, very concerned about that. I don't know if that will be included in this legislation, but it's a very significant and real issue.

Murkowski: Explain to me a little bit more what you mean. Give me an example.

Attendee: Right now the Medicare folks are entertaining some regulatory language that would provide some reductions to the Medicare hospice benefit and that actually has been dealt with by Congress in the stimulus bill. Those regulations were put on hold for a year, and that year is rapidly coming to an end, at the end of September. Unless something is done at the congressional level or the administration is convinced to change their approach on that, those will become a reality.

That has a significant effect in the rural population states, I think [it] would certainly affect programs that we administer, and I can't imagine that they wouldn't have a significant effect in many of the western states, California probably being the exception. It's a very serious problem. It will affect some organizations' ability to stay viable and to keep the doors open. In certain situations, ours included, we're the only opportunity for that kind of service.

Murkowski: But it would mean a reduction in your funding from Medicare ...

Attendee: Correct.

Murkowski: Based on ...

Attendee: There'd be a reimbursement. ...

Murkowski: Right. But not necessarily tied in to what they're talking about -- the 21 percent cut to providers for Medicare. It's separate.

Attendee: It's separate. It's a MedPAC recommendation, and it's sort of a one-size fits all, and once you get west of the Mississippi, one size definitely does not fit all.

Murkowski: OK, all right. We'll pay attention.

Attendee: Thank you.


Vasileff: I'm Dr.Vasileff and I represent the state medical association. I'd like to hear what your thoughts are on private insurance. Jim Jordan and I were in Washington, DC last week, two weeks ago, and we heard the president talk about health care reform. One of the things he pointed out early in his speech is he wasn't going to try to change what already works, and this is private insurance. So my patients and my colleagues' patients tell us they are afraid of having their insurance monkeyed with. [If it] changes, how many of us would be happy with the Medicare system today? I don't know how you would feel or the other legislators or the president would feel about that.

And there's a great concern that the changes that could come down could be quite Draconian, and they're very concerned that they would be taxed if they do -- if we are able to maintain, hopefully we'd be able to maintain private insurance -- that the taxes on us individually would be significant. So that's a very big concern of ours, of mine personally, and my patients, and my colleagues. I don't know about [how] you and the other people in this room would feel if you were put into a Medicare situation today or tomorrow and have to deal with that.

Murkowski: Well, it's a subject that I think generates a fair amount of angst because the people that have insurance in this country -- and we've been focusing a lot of this debate on those that don't have insurance -- but we have to remember that the majority do have insurance and the majority actually are satisfied with their insurance. They don't like the fact that it cost as much as it does, but it's something that we all reckon with. But for the most part, people are saying that they want to be able to keep what it is that I have. The president has said we want a plan that will ensure that that is the case.

Unfortunately, and again keep in mind that the discussions that I have been having have been focused on the version that we have in front of the health committee and not something that they're working on in the finance or otherwise, but in that plan the concern is -- and CBO is the one that has done the analysis, it's not Lisa and Amanda sitting down and saying that this is what's going to happen -- the concern has been that it will shift the employers who have plans, [they] will take a look at their bottom line and say, "You know, this is just an expense that I can't continue to provide," and they drop their coverage. [This] moves people over to a private plan, or excuse me, excuse me, the government-run plan, and so the promise that has been made of that -- if you like your insurance you'll be able to keep it -- is no longer a kept promise. So how do you keep those who have been providing for the plan, how do you ensure that they continue with it? That's something that we have not yet been able to answer.

The analysis that has been out there is really quite troubling for those who are proponents of the plan. As far as taxing the employer-based plans, this was a question that came up at the meeting I had earlier with the industry folks. They've got a good plan over there, they're concerned, "So what does this mean for me and the affordability of my plan? I don't know that this is something that I embrace," was kind of the feedback I got from them.

There's a couple different ideas that are floating right now. One is that employer-based plans would be taxed. There's other suggestions that it would just be kind of the Cadillac plans -- anything in excess of, I think it was $13,000 -- would be taxed, so any plan that is lower than $13,000 in terms of its coverage or your expenses for the plan, you wouldn't be taxed on, so there's a great deal of discussion as to where that might go. But the bottom line for that is that [it] is probably the biggest chunk, the biggest opportunity to gain revenue to pay for this health care reform that they can find.

Attendee: Would those taxes then go in to a general revenue fund, or would those taxes go directly into health care?

Murkowski: Typically, you don't fence off the funds. They go into the treasury, the black hole of the treasury, and that clearly is not defined. This is the big issue that we're dealing with now. How do you fund a government-run plan? And the real answer at the end of the day is going to be, you've got to, you're taxing it. Whether you're taxing an employer-based plan, or whether you're taxing sugar products, alcohol, or whether you just going to keep it simple and say well we're just going to tax you, the American taxpayer, and we've got to figure out a way to pay for that. But those are some of the ideas that are out on the table that are causing some people some consternation.

Attendee: Senator, talk about how you pay for it. Is there a way to basically reduce the overall cost? I know the Roundtable put on programs where they showed a significant savings by having wellness programs [Garbled]. So if we looked at not how you pay for extra stuff but how do you have less stuff to pay for, it just seems like you'd have less losers and more healthier people and you'd have people like the head of one of our larger hospitals in town we talked to last week who pointed out that you spend so much on people who come to the emergency room, because they can't go to primary care or because they don't have any money.

They come too late in their condition and it costs a lot of time in hospitalization and treatment that would have not been necessary if they just had some way to go visit somebody and get some drugs. I was just wondering how that plays into the legislation that you're working on. It seems like you're talking about how you would pay for it, but it seems like if you did it well, it might not cost any more. I mean, that to me would be a goal to do something like that rather than say, "Well it's going to cost the insurer [Garbled], and it's going to cost and be taken out of somebody's hide."

Murkowski: Well your point is absolutely right on and it's well taken. If we do it right, there should be that reduction in overall costs because we're operating a system that is focused on prevention as opposed to a system like we have now, which is focused on sick care. We will take care of you when you're sick, but we're going to darn well make sure you're really sick, and then we're really going to pay for it.

We have a system that the incentives are off right now. The fact that it's an issue as to whether not your insurance is going to cover certain preventive screenings, whether it's a colonoscopy, or a mammogram, or a screening for prostate cancer. There should never be a discussion as to whether not that is covered by your insurance. You know, these preventive things should just be an automatic. They are not. One of the things that Dr. Coburn [?], who sits on our committee, has repeatedly said is that right now the insurance companies will pay for a full colonoscopy, but they won't pay for the newer treatment -- he called it a virtual one -- because you know the technology is new enough or something like that but it's less invasive, and it's less expensive, but the way our system is set up, it is just what it is.

We recognize that we will derive greater benefit through a focus on enhanced prevention. This is an area where we recognize there are gains to be had and reductions in cost to be had but it's going to be important as to how you provide for the level of incentives. Right now, in the prevention piece, if you are basically an individual that doesn't take care of themselves and you're a smoker, you're going to be treated the same as somebody who watches their weight, gets good exercise, basically engages in a healthy lifestyle. Everybody is treated the same.

Well it seems to me that if you're going to be a smoker and you're going to help increase the risk to yourself and others, and subsequent health care costs, is it right that we kind of treat you the same, or do we give the individual who has been taking care of himself and his family and really working hard to get the cholesterol down and to pay attention to what's going on, is there a way that we can give them incentives?

There are good things happening all over the country with companies that have said, "We've got to rein in healthcare costs." Safeway has been very, very aggressive in this in providing for incentives for their employees through a series of bonuses, through a series of incentives. If you can bring down your BMI, your body mass index, if you decide that you're going to stop smoking, there's all kinds of incentives that are built in and their health care costs, as a major employer, have dropped off noticeably. We should be looking to how we can adopt some of those incentives.

We know that our health care costs, when we're dealing with those individuals that have the chronic diseases, these are where the costs just skyrocket. If we can work with those who have pre-diabetes, and look into how we can work with you on your diet and your exercise, to really be more proactive with your health, we know that we can be reducing our costs. So your point is right. We can't get too fixated on, "We can't do this until we can figure out a way to pay for it." I don't think that that's one of our options, because again, I think we've got a system that is flat out broke, so we are going to be paying for it one way or another. If we keep it at the status quo, we're paying for it. And if we reform it, we're going to pay for it, so let's figure out how we do it smart, and let's figure out how we get quality care and good access to the maximum extent possible.

Attendee: I just had a brainstorm. [Laughter] I know that's scary.

Murkowski: Good. I want to be able to write down the brainstorm. [Laughter]


Attendee: Well, just sitting here talking about how we can't get people to go into primary care because they all want to go into specialties because they make a lot more money doing procedures. Well if people were healthier and took care of themselves, there would be fewer procedures to do.

Murkowski: Right.

Attendee: And more people need to be, would perhaps move into primary care so maybe it's related.

Attendee: Unless they ski. ...

Attendee: Unless they what? Well, skiers [garbled] [Laughter]

Murkowski: They're in that high-risk category! [Laughter]

Attendee: Yes, that's high risk.

Attendee: Somehow maybe there is some connection there, maybe because we're encouraging people to go out and not be healthy and [then] they need to get more radical care, probably.

Murkowski: The encouragement has got to be on keeping out of the system rather than not.

Attendee: One final comment, just from a personal perspective. I'm a retired state employee. I have state health care, [and] it provides zero for physicals, and you only get the colonoscopy if you show that you need one, which is weird because it's a diagnostic test.

Murkowski: Under the state plan you don't get an annual physical?

Attendee: Under the state retirement plan you do not get a physical.

Attendee: We're working on that. [Laughter]

Attendee: I appreciate it, that's great. So I'm looking at a colonoscopy, but I'm going to use my wife's insurance because through CIRI they actually pay for colonoscopy because they know that it's a diagnostic test. I talked to the lady with state insurance who said, "Well yeah, we will pay a hundred percent if you can show that you need it."

Attendee: If it's diagnostic instead of screening.

Murkowski: That's the wrong approach. Absolutely the wrong approach. [pause] You've been patient ...

Attendee: That's fine, thanks. I'm Roland Shanks with the Cancer Society as a volunteer, but I'm also a three-year lung cancer survivor. I never smoked, so there is a way to get this without going through that route. But as a consumer, a medical consumer, you know, I've joked since I've been sick that not only have I had to become a doctor to understand the treatment that I'm being offered and what the ramifications are, but I've also had to become a tax attorney. I've also had to become an insurance attorney.

I think that most of the people who really like their insurance have never had to use their insurance for a serious issue. A broken leg, or something that's fairly straightforward or fairly simple, is one thing, but I can tell you that three years of cancer treatments, including three rounds of chemotherapy, gets pretty complicated -- trying to get all that billed, and all that paid.

One thing that's concerned me a little bit about this idea of taxing insurance benefits is -- I'm not opposed to the idea of it -- the way the structure is currently set up, the people who will go over the limit will be the old sick folks because your rate is higher because you're sick, [and] your rate is higher because you're old. That's if you can find any insurance. So in that whole taxing thing, [someone] needs to look at that. I realize that other places in the bill that's supposed to be level, but I'll believe that when I see it.

And that kind of brings me to the third, last problem, and that's this whole idea of portability. You know, I'm currently working still, but it's coming to the point where I'm not going to be able to work. But I have to keep working so I can keep my insurance, but I really can't work so I get into this whole thing and, you know, the choice[s] I get to make when I leave my job [are] not the normal ones [such as] can I find another job? What's the economy like? It's like do I want to end up in a situation where I don't have insurance, where my choices are to die or to go bankrupt, or do I want to end up with a choice of dying and leaving my wife bankrupt because there's not an insurance company in the world that's going to touch me.

So I guess from my standpoint we can talk about individual provisions in the bill, but I'm not an individual provision. I am an individual. I'm looking at how this bill is going to affect my health care over the remainder of my life and how it can impact my wife's health care, who has some behavioral health issues. I mean, when we did our taxes last year our tax write-off from medical issues was $28,000. That's a hell of a lot of money.

I'm looking at this as how is this going to resolve issues for people like me and for families like mine, because that's where the rubber meets the road. I think that we also need to keep in mind how does this affect the larger issues? How does health care cost affect the competitiveness of American companies? We see two of the three major car companies going out of business, and we always hear about how the Japanese can make cars so much cheaper.

Well, if you take off the health care benefits that the car companies are paying -- they're not as out of line as is being shown -- but it's because those Japanese companies don't have those health care costs to deal with that they can be more competitive. So we need to look at this not only for fixing the American family, but for fixing the American economy so that we can continue to move forward.


Murkowski: And I think your last point there, Roland, is why I believe that we will enact health care reform this year. I think I made the point earlier today, you know, there've been a lot of initiatives that are "must fix, must do," [such as] Social Security reform. We were at the edge of the crisis when President Clinton was in office and we had to fix health care then and we didn't do it, and we didn't fix immigration last go around. I truly believe that as difficult as this issue is that you will see health care reform legislation that will be substantive reform. I believe that that will happen.

If it's not this year, it will be next year early, simply because of what you're talking about and what happens to us as the general health of a nation yes, but also our economic competitiveness -- that whole aspect as it's tied in. It has affected us as a country to the extent that no one can avoid it, no one can ignore it, and the solutions are very difficult, but some of the points that you have raised about portability, [and] making sure that you cannot be denied insurance because of preexisting condition if you were to leave your position now and move to something else. The caps that we currently see on your insurance plan, you know sorry, you get something like a cancer as you're facing, and you're maxed out in a year.
That's not what I think Americans expect from their health care system.

So I haven't given you any great suggestions as to how we deal with your particular situation but I think you represent so many people in this country who feel that they have been paying in to receive a benefit only to find out that what we all would assume would be covered by our insurance company, we find out that is not. We end up in constant hassles and fights over every claim that's submitted, and [we find] a level of just breakdown between what the promise is of what your insurance provides, and what you actually receive. It's not acceptable.


Shanks: I mean, because you have a situation where you hear this talk, "Do you want the government to get between you and your provider?" Well, my insurance company is between me and my provider.

Murkowski: That's exactly right.

Shanks: My provider prescribes treatment and then I go and argue with the insurance company to get them to pay for it. Realistically I'd rather argue with a bureaucrat than the insurance company. [Laughter]

I don't know why we make government people to be such bad people. I mean I used to be a government bureaucrat and I don't think I was that bad. But I know that they're not getting their compensation based on their approval rating.

Murkowski: That's right. That's right. Your comment is absolutely spot on. It is the insurance company that is between you and your doctor. We want to work to reduce costs, and one of the proposals out there is this comparative effectiveness [research]. It's all fine and well if each one of us is exactly the same and we all respond to exactly the same way to whatever the treatment is or whatever the drug is, but that is not the case. If I've got allergies in Washington DC in the summer, and they say that for allergies you should be taking Claritin, well Claritin doesn't work for me. I need Allegra, but they cover Claritin, but they don't cover Allegra. What do I do?

When I went in for my knee, I was basically told you're doing all this [Garbled] for your knee. It should be day surgery in and out. I was in the hospital for three days, had a great doctor working on my leg, doctor, so don't worry about that part, but I didn't respond well to how the pain medication was, so what box do you check? How do you decide how much we're going to cover? And when you've got to go in for your knee or for cancer or whatever, it's not like we're sitting around and shopping for the best deal in terms of where you're going to get your radiation. Duane?

Heyman: Senator, the co-op approach that you've mentioned is intriguing for both economy of scale and meeting regional sensitivities. Something maybe to keep in mind though, is the experience of the electrical co-ops here in the state and look how they've gotten politicized over distribution of electricity, and this is a much more dynamic situation. If it does start to go in that direction, whatever type of insulation can be built in ...

Murkowski: Maybe we should have them come and do an assessment of our regional co-ops here before they make a determination. [Laughter] Debbie.

Debbie: Senator, I just want to go back -- and it kind of ties into all of this -- which is the medical home or better defined patient center care, which as a nurse I've been doing that for 30 something years, that's what we do, where the patients the center of care and I think it's a fabulous option that can help us if it's done correctly, because in that environment primary care becomes the center with the patient, and putting the patient in the middle instead of the government, the insurance company, or the provider. The concern I have is that, and I haven't read the bill, I didn't get to the 600 pages ...

Murkowski: Well, there's more to come. [Laughter]


Debbie: One of the plans and there is that the early Kaiser model would be implemented so if I had a medical home and you were my patient and I ordered a couple of extra MRIs it would come out of my pay. That's when in the early days of managed care they would hold back 10 - 20 percent out of your reimbursement and if you order too much stuff for your patients, and if you advocated for your patients you'd be punished. That would pretty much destroy anyway that that would work, because the providers are not the bad guy here.

When I go to work, I don't look to see how much money I can squeeze out of Medicare today, as I look at my write-off from Medicare, you know, it's just not the way it happens. I worry about where my Medicare patients are going to get help so I want to advocate for the concept of patient-centered care, or the medical home, but it really shouldn't have those strings in it that are just going to kill it. Sometimes it takes a number of years, you know. I work in a specialty practice, and it will take me three or four years -- I get the relationship, and then I get them to go get primary care.

But they go because they trust me, or they'll call me, "I went to the emergency room. Did they tell me the right thing? He was [a] nephrologist, I guess he did." But they trust me because they know me. That trust is where we lose a lot of that in this adversarial relationship [that] gets set up. And then [I have] one more advocacy thing here. The mental health system in Anchorage is past imploding, as I'm sure everyone knows, and the good news for the VA is that they are actually the best staffed for mental health now because they took two of our best psychiatrists.

Murkowski: Yeah, that's right. It's absolutely cannibalism that goes on.

Debbie: Instead of bringing them from outside, they went from inside, and my concern is if the plan is for the community mental health centers, in our very small market -- when we have a number of private practice people and then the money goes to the community mental health, and that doesn't work -- then you have a cadre of people who aren't available. Am I making sense? If I have a private practice and I can't be reimbursed because the funding has been put to grants to the community mental health center that isn't able to get providers, then we have someone over here who can't be paid and we have a huge need.

And a number of years ago the decision was made that you had to be seriously mentally ill to get the behavioral health, so we wait until you're really sick and then we pay a lot of money to fix you and your children. It's not working. So that area really is key in looking at all of the providers and using everyone to the limit of their license and their training.

Attendee: Senator, obviously all of these are important. I think, from my perspective working with rural communities, I hope you continue to support the health information technology and the broadband aspects of this, because these communities, as we've talked about, are never going to have physicians in some cases, or RNs. But today we are certainly capable of bringing to them services regardless of what's present in their communities, and I think we absolutely have to remember that and focus on it. It's an infrastructure matter that once in place will serve us incredibly well for many years. So I really hope that, as you're looking at these provisions that the really important aspects of telehealth -- and what that would allow us to do -- are primary in your thinking, too.

Murkowski: Well, it has to be, because as you say, in many of our areas we will never have the providers that we need. But it's a reminder to you that when we talk about this broad vision of health care reform, it's not just making sure that Medicare reimbursement is adequate. In Alaska it's so much bigger. If our energy costs are through the roof and, you know, whether it's the IHS facilities or the community health centers, all of a sudden you've got fuel bills that are beyond what you have anticipated, beyond what you budget, it's like, "Well gosh, I've got to squeeze it from somewhere else," and that impacts the level of service and care. It's about workforce development and how we build that out in a state where we don't have a medical school, we don't have the level of training.

I mean, we're happy to have 20 students in the WWAMI program for crying out loud. It's so much bigger, and then when we talk about how we're able to communicate and the limitations that we have -- we've got more Internet usage than any other state, but it doesn't mean that it's fast -- you're laughing because we all realize that we just don't have that broadband capability. But there's so much that goes in to what we will need if we're going to do any kind of meaningful reform. And it's perhaps more accentuated in a state like ours that is rural beyond definition. You had a point back there.

Louden: Yeah, you started us off by asking whether we supported the government option, the public plan option. [I am] Greg Louden, Alaska Health Underwriters, insurance broker. We oppose the public plan option for a lot of the reasons that we've discussed already. I just wanted to bring up something that happened about 10 days ago. Pat's organization [AARP] sponsored a healthcare forum with Senator Begich, and one of the questions that we ended with at the end of that was how many people supported a government plan option. Senator Begich defined it as not run by the insurance companies and examples of that he gave was the Safeway/Carrs self-insured plan, the Municipality of Anchorage self-insured plan, and the IBEW of Alaska electrical health plan. Those are all private health plans that are self-insured, not run by the insurance company, but a lot of pretty critical costs and containment measures are in effect. We support that kind of a plan, but that does not mean the definition of what a government plan option is in either the Bacchus bill or the Kennedy Bill. The Daily News reported that there was overwhelming support for public plan option; I just wanted to make sure you understood that was not really reported [accurately].

Murkowski: Right, I appreciate that clarification. Well, we haven't really defined what the public plan option is or what the government option is. And, again, until the proponents put it down in language and say this is what we mean, it's tough to say, "OK, well this part of it is workable and this part of it is not workable."

So there's a lot of words that are being thrown around that, right now, don't have a lot of definition or clarity to them. My sense is, and help me out with this, my sense is that people are looking for assurance -- I was going to say assistance, but I'll use assurance -- from the government that there is going to be some kind of assistance or backstop out there so that if you're in a situation like Roland is, where you've been good and responsible and taking care of yourself and been a taxpayer your whole working life, and paid into the system so that when you turn 65 you're eligible, you're doing all the right things, but then stuff happens that you could not anticipate, you could not count on, and a person who has done all the right planning in their lives and is hit with a situation that can literally take them down and their family down in bankruptcy and just truly wipe them out. But there ought to be some form of assurance out there from the government's side.

Attendee: Senator, in order to have the other aspect of this, which is the prevention piece, I mean if we're truly serious about lowering health care by providing prevention, I think that requires fairly some aspect of the public plan, or some assurance that my child, my mother, whoever it might be has, can get the preventative care they need so they don't later on need and I don't know how we afford that, or how we pay for that except through some kind of general plan that's covering most of our citizens.


Murkowski: Well, and as we have had discussions, I guess in the back of my mind I'm thinking that if we move to some government option type of a program, it would be one that is focused on the prevention, you know, on basic screening, on an annual checkup, as opposed to some full on Cadillac type of a plan. Now, we've got a situation in this country, well certainly in this state, all the states require that if you're going to drive you have insurance and the sky didn't fall when we made that requirement. Now we're talking about, one of the requirements would be that there be an individual mandate that you have insurance.

Now of course the devil's in the details. What kind of insurance are you going to require me to have? Is it going to be a kind of the preventive package piece? Is it going to be a catastrophic model? Or is it going to be something that Pat Luby concocts based on what he thinks is best? You know, again, we haven't gotten to that point, that's where these discussions are so important.

Attendee: I vote for the Pat Luby one. [Laughter].

Attendee: Duh! [Laughter].

Attendee: We're going to cover athletic U.S. Senators that like to ski! [Laughter]

Murkowski: That's the catastrophic! [Laughter]. Angel.

Dotomain: Senator, first of all, Tribal healthcare wants to thank you for all the work that you've done on behalf of the [Garbled] Tribal positions [Garbled].

Murkowski: That's important.

Attendee: Self governance Tribes in Alaska who are part of Tribal health organizations have worked within a system for years that is completely under funded. We've had to find many different ways to fund the programs that we believe are best suited for our people, and our people are out there asking [Garbled]. Self governance Tribes in Alaska have moved, are moving, from a system of dealing with catastrophic care, dealing with tertiary secondary care, to actually working with tobacco cessation programs, working with colonoscopy screening grants.

We want to make sure that all these innovative programs and projects that we've put in place aren't hindered because of health care reform. We want to make sure that our opportunity to provide culturally specific care, to provide care that our people want and deserve, within an infrastructure that is suited to our villages, suited to our people, aren't hurt because of health care reform. So we've been working with the national health board to ensure that the voice[s] of Tribes all over this nation are heard.

I really appreciate the comments from the gentleman -- I can't see his face -- but the comment about electronic health records and health information technology. Telehealth is a major piece of how we provide care within Tribal health systems. CMS has introduced, they have these provisions now about the meaningful use of electronic health records. And how can we as a system ensure that we have true meaningful use without being vested in that infrastructure first. We still have within the Tribal health care whole organizations or regions are still operating on paper. And they can't get the funding because they are on the road system, [Garbled].

But one of the major things, and I'm going to continue to repeat this, we're looking for ensuring that this long term health care reform [Garbled] that we don't hurt these opportunities to provide integrated care. The community health aide model is a great example. We appreciate the inclusion of dental health therapists in the bill, and ensuring that we have access. We still have some villages using facilities that are 30, 40, 60 years old. Some of them are using facilities that were barged over from another village who got another clinic 20 years ago, but the building was already 40 years old, into their village. So now they're operating out of facility that's 60 years old. Individuals deserve care. And we want to make sure that they have the opportunity, especially Tribal members and descendents, to utilize the system they trust, to utilize the system that provides access, [and] that provides high quality care. [Garbled]

Murkowski: Well I appreciate you making the comments and the work that you do on behalf of so many in the state. I think we recognize that we've been challenged within the system here, to be more innovative, to utilize the assets that we have, even given very difficult fiscal restraints that we have seen. The IHS budget has been so woefully under funded over the years and yet somehow or other, good things continue to happen out in so many parts of rural Alaska. And the dental health therapist initiative is just one where you forced yourself to be creative in really making a difference.

But what is sad is that as squeezed as the IHS budget is, as you were trying to do so much given so little, that we then take another government system, if you will, you take the veterans who were out in rural Alaska, and they can't go into town to get a level of care so they end up coming to your clinics. You don't turn them away, you do the good job, you take care of them, but VA doesn't compensate you who are already woefully under funded. This is something that we will get resolved. We have got to have those health care dollars following that veteran so that wherever he or she goes, that funding is there. The thing that just gets me really agitated about this whole situation is that if you're a veteran and you happen to live on the road system where there is access to care, we take care of you. But otherwise you're kind of on your own and that's not the promise the government made when you signed up.

One of the things that you mention about keeping in place the things that you have -- we still have to reauthorize the Indian Healthcare Reauthorization Act. And when we talk about behavioral health issues, right now under the Indian healthcare authorization program, we don't even mention mental health. And so this is something that is 16 years behind the times in terms of being updated and reauthorized. This is one of our key priorities coming out of Indian affairs. We're working with Senator Dorgan to make this happen again, but we've got three government-run systems here in this state of Alaska. We've got more than that, but we've got Medicare, we've got the VA, and we've got IHS. I think we would recognize as people that are involved in either providing the services or just knowing who our neighbors are, in far too many areas in all three of these we fail them.

We fail our veterans who don't happen to be able to access the level of care where they live, we fail our Alaska Natives out in the villages when we short-fund their programs, and with Medicare you pay into a system and then you turn 65 and you don't have anybody who will see you. That's a promise we're not able to deliver on for a multitude of different reasons. I remain hopeful, again, that with this reform, we don't just try to stick band-aids on systems that are inadequate, because if we do that then we're going to be in a situation where two years from now we'll say, "Gosh, that didn't work very well," and the response back, I can guarantee it, will be, but we did health care reform. We don't need to do that for another five or 10 years. That's not where we need to be. So doing the band-aid approach, I think is actually more dangerous than being wildly progressive on a plan. Which is interesting, but let's move on here. ...

Attendee: I just have two questions. One is that I'm a Tribal health consumer as well as I work for the lung association, and I just have to agree with everything Angel said about the importance of self-governance in Tribal health because it is just as important as health care. Self-governance and the unique approach is just as important, especially because cultural health and emotional health and who you are is just as important as the health part. The other part is that I'm a "tobacco person," and I am so tickled and you are my hero.

Murkowski: What kind of a tobacco person?

Attendee: Tobacco as in youth tobacco prevention. The things that you guys did with FDA regulations specifically related to kids -- when we're talking about prevention -- I think you specifically helped prevent the next generation of people who are going to smoke. Tobacco is the number one cause of preventative death and you can't have any discussion about health care or prevention without talking about tobacco. If we can prevent the kids from starting, then we're in great shape and the marketing stuff that you guys passed is just ... I'm going to be high all summer. [Laughter] so I just want to say thank you about that.

Murkowski: Thank you. Thanks for your advocacy there. Rosemary?


Rosemary: I just, I know we're almost out of time, but I think probably it's important to mention the 500-pound elephant in the room is the aging of the population and the extreme pressure that is going to be put on all of the systems, because as people age of course their medical conditions become far more complex. I think there's lots of research out there that will tell us that the last couple of years of anyone's life are probably their most expensive in the system. Somehow or another we have to figure out some counterbalances that take care of that. I'm reading your Op Ed here where you talk about Medicare being in serious fiscal ...

Murkowski: Yeah, we're running out of money by 2017.

Rosemary: Yeah by 2017. I'm sort of a brand new Medicare recipient and I'll tell you it's definitely worsened, but I think it's really hard to get your hands around what's coming with the changing of the population dynamics, and it's going to affect all of this.

Murkowski: Well it's probably more dramatic here in Alaska.

Rosemary: Because we see it.

Murkowski: We see it. We have always been a state, was then a young state, and when you got senior enough to move out of the state, that's what happened, people would move south, and now, what we're seeing is a migration north of seniors. Individuals that are bringing their parents up from the lower 48, we're seeing Alaskans that are choosing to retire and stay here, and when you consider that our senior population is growing faster than any other state except Nevada, it almost takes your breath away in terms of, well wait a minute, where were we just 15 years ago?

Aging was not something that was a subject of discussion at a cocktail party or around a dinner table. In other states, you kind of just deal with it because you've always had that aging population, families stayed in place, so you had nursing homes to accommodate people, you had assisted living facilities. As I go around the state talking to communities about their needs, everybody is asking for help with assisted living facilities, a place for their Elders to be, some level of care as we deal with our aging population. And it's just exploded. We are not ready; we're not ready as a state.

Attendee: And you layer onto that the life expectancy issues now that change the dynamic considerably too.

Luby: Well, we are ready to let the Senator catch her plane though, Emily, do you want to wrap this up?

Nenon: Yes, on behalf of the American Cancer Society, AARP, AAHAAT, Commonwealth North, we certainly want to thank you for making the time in your schedule, and thank everybody for the great short notice turnout here.

Murkowski: Good participation.

Attendee: And be watching for more exciting opportunities in your local access to care coalitions, and so thank you.

Murkowski: Well thank you. You're going to think this is trite, but I'm going to ask for it anyway. Give me one quick take away. What would your take away be, Randall? If you want to say I want to know that Lisa knows one thing from me, what is it?

Randall: The importance of being able to serve rural populations, the difficulties that rural populations have, and continuing to keep in mind the way that we can get that care delivered to them -- their access to care issues.

Murkowski: OK, Ken?

Osterkamp: I want to stick with the Biologics issue.

Murkowski: OK. Cathy?

Giessel: Patient choice. Choice of insurance companies and the public option that there would be choice there.

Murkowski: OK.

Attendee: Preventative care and wellness.

Murkowski: OK.

Attendee: There are cost savings to be had over the long run on [if] preventative care is promoted and funded.

Murkowski: Yeah.

Attendee: Do it soon because I want to see it happen before I die.

Murkowski: Roger?

Roger: That we really need bipartisan support for this bill no matter what it is because if one-half side doesn't support it nothing will happen.

Attendee: That any system pass the common sense test. That you can look at all these different situations with the average person saying that it really has some common sense to it.

Murkowski: Rosemary.

Rosemary: Please don't model it after Medicare.

Murkowski: Yeah. [Laughter].

Attendee: I'm representing companies that hire thousands of our workers on the PCA level, and I aspire to be able to afford health care for them.

Murkowski: As an employer. What else?

Attendee: Stronger primary care.

Luby: No more band-aids.

Murkowski: No more band-aids.

Luby: That we're going to do it right and do it this year.

Murkowski: Angel?

Dotomain: Saving opportunities for innovation.

Murkowski: Innovation.

Attendee: That tort reform has to be on the table because, as all of us would suggest, the defensive medicine that has to be practiced in our environment, in our nation, is part of the cost drivers that [fuels] our over utilization of services, because physicians and others just cannot afford the risk in our current system.

Attendee: I would recognize our local state health department for providing preventative care in the community.

Attendee: Access for all.

Murkowski: Good.

Attendee: To preserve private plans and increase the supply of primary care doctors.

Nenon: Access on both ends of the spectrum: prevention, and then what happens. You mentioned people being satisfied with their insurance -- people that call the American cancer society office, at that point people are much less satisfied with how the health system works.

Murkowski: Any others?

Weiss: I would say that it's very important to pay attention to the public sector in general and its role in providing health care, and the nonprofit sector. I would wager in the state of Alaska those two sectors provide much more healthcare to people here than the private for profits.

Murkowski: That's a good point. OK, anything else? Good feedback.

Luby: Thank you, Senator.

[Applause]

Murkowski: OK, I've got my mission now.

 
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