Deborah Erickson, executive director of the Alaska Health Care Commission, recently served as acting director of the Alaska Division of Public Health, and has served the state of Alaska for more than two decades including as deputy director of Public Health (2001-2007). Her professional contributions at the national level include chairing the Turning Point Public Health Statute Modernization Collaborative, a four-year project that culminated in the development of a model public health law for states that was awarded the first American Public Health Law Association Distinguished Achievement Award in 2004. She has published numerous articles and has been the recipient of various professional awards and accolades. In this talk -- presented at the Alaska Public Health Association Health Summit December 8, 2009 -- Erickson discusses past, present, and future issues and activities of the Alaska Health Care Commission. Note in particular the presence in her discussion of both elephants and gorillas. Note also that this presentation has been edited by AHPR for length and clarity.
 
Links to Selected Topics
 
Crossing the $100 Million Threshold
Need for a Permanent Body
Health Care Commission Challenges
The Elephant: Cost of Health Care
The Commission Priorities
Health Care Workforce Shortages
Medicare Access
Future of the Commission
 
History of Health Care Commission Groups in Alaska
 
I thought it would be helpful to just share a little bit of the history of some of the [health care planning] groups in Alaska that have met previously, just over the past couple of decades. In 1987, Governor Cooper established under administrative order, the Governor's Interim Health Care Commission. Actually, that was just a nickname. The full name of this group was "The Governor's Interim Commission on the Status of Health Care and the Health Care Industry in Alaska." That group held a number of meetings slightly over a year's period, and produced a report in 1988. I think that was really the first report, [in which] they were looking at increased insurance, access to insurance. But, I remember in this report there was a focus and a whole chapter devoted to long-term care, and how long-term care was starting to be a significant cost driver, and increasing health care costs, and a series of recommendations about that.
 
Then, in 1991 the Alaska Legislature created the Health Resources and Access Task Force, affectionately referred to as the H-RAT back then. Karen Perdue, actually Karen, you were the consumer rep on that group, weren't you? I don't know if there was anybody else in the room who served on any of these groups before. I wouldn't be surprised if there were more, but that was a significantly-sized group. There were about 17 people on that group, [including] quite a few legislators as well as representatives in the health care industry and the private sector. They came out with a number of recommendations, but the central recommendation from that group was that a single payer system for the state should be formed.
 
[However,] it wasn't long after 1994 when Republicans swept Congress and the same thing happened in our state legislature. That primary recommendation from the H-RAT didn't go anywhere, but I think a number of the other recommendations probably were implemented. The one that I remember was creation of a high-risk pool for Alaskans with pre-existing conditions that didn't have an opportunity to access health insurance. The Alaska Comprehensive Health Insurance Association was formed as a result of the work of the H-RAT.
 
Then nothing, at least very formal or official, that I am aware of happened for a 10-year period, but then in 2003 a private group, Commonwealth North, became interested and concerned about the rising costs of health care and how it was impacting business. [They] formed the Alaska Health Care Roundtable and funded that group. [It] had a number of private industry, and also health care industry partners who underwrote a two-year study and a plan that focused on improving primary care in our state. Then, in 2007, just two years ago, Governor Palin formed the Alaska Health Strategies Planning Council under administrative order. That group -- it was another large group, about 17 people -- met over the course of six months and came up with a list of goals and strategies for improving health and health care in the state. Back to selected topics
 
Crossing the $100 Million Threshold
 
One of the things I wanted to share is this picture [Referring to slide 28 in this slide series. Note that the Erickson presentation begins with slide 25]. I scanned it out of a H-RAT report. This is a picture that has been stuck in my mind ever since I started on this process a little under a year ago. I could remember this picture so vividly from back when the H-RAT was meeting, in 1991, 1992, 1993. Looking at this picture, which was the projection at the time of how health care expenditures in Alaska were going to grow over the next 15 or so years, from 1991 to 2003. At the time, total health care expenditures in this state were a little over one and a half billion dollars. It was starting to really consume, from our perspective, our state Department of Health and Social Services' budget and impact on the Medicaid program. At the time I remember we were approaching $100 million in state general fund expenditures from Medicaid -- and not being able to imagine how we could cross and be able to afford that $100 million threshold.
   
[I was] looking at this graph and understanding the sorts of choices that state government would have to make if health care kept consuming a greater and greater piece of the pie, and the potential that it could increase overall total expenditures to five and a half billion dollars by the middle of now, this decade. All I could think at the time was that somebody has to do something about this because we can't afford it. Today health care costs in our state [are] estimated to be over $6 billion. Since that time Alaska's Medicaid expenditures, general fund expenditures, have increased 500 percent. This past year we spent $450 million in state general fund on Medicaid expenditures alone. Total Medicaid expenditures were over $1 billion this past year in our state. Back to selected topics
 
Recent Health Care Recommendations: Need for a Permanent Body
 
[In both] the last two groups that met -- the Commonwealth North Roundtable, and the Health Care Strategies Planning Council -- one of the recommendations was that a permanent body needed to be established in statute that would have the responsibility for measuring over time, and planning, and evaluating over time, improvements in the health care system. There actually had been a bill in the previous year that had been introduced but it had certificate of need program elimination as part of it, and it didn't go anywhere. Governor Palin again established a new group, our Alaska Health Care Commission, under administrative order 246. [It was] really an attempt to try to jumpstart implementation of that strategy that the previous groups had recommended. The members were appointed last January, and the purpose of the group is to foster development of a statewide plan to address quality and accessibility of health care.


The administrative order actually designates that the department's chief medical officer be the chair of this group. This is the smallest of any of the groups that have been formed before. We have a representative from the tribal health system, insurance industry, the consumer, hospitals, business, and health care provider. Those are our seven voting members, and then we have three ex officio members -- Senator Olson and Representative Keller representing their two bodies, and Linda Hall is the director of the Division of Insurance.
 
The duties of the commission are laid out in the administrative order. The commission is intended to be a state planning and coordinating body. That was something that we struggled with a little bit -- because of our ad hoc nature with one year's time -- thinking about how we might actually coordinate all of the health planning activities that happen in the state. [It] was a little bit daunting, but also then fostering development of a comprehensive statewide health policy, and developing a strategy for improving the health of Alaskans.
 
It lists six different goals, essentially, that have been developed by the Health Care Strategies Planning Council: personal responsibility, cost, improving quality, strengthening the workforce,  increasing insurance coverage, and ensuring access to the safe water and wastewater. And then, finally, our last duty is to deliver a report to the governor and the Legislature on January 15 [2010]. Back to selected topics
 
Health Care Commission Challenges
 
I want to take just a couple of minutes to talk about some of our challenges in getting off the ground this year, only for the purpose of providing some context for what was going on while this work was happening, and also to support, in the future, making sure, if we're going to have a permanent body in statute, insuring that there is sufficient resources and staffing and leadership. The department included an increment to fund the commission in their budget.
 
There are now three bills pending in the Legislature, and I will tell you about those in a few minutes in a little more detail, but they all include fiscal notes. There was a little bit of a leap of faith. The leadership in the department wanted to go ahead and get the commission started even though we didn't have any funding, with the hope that funding would come from the Legislature -- either through the increment or through a fiscal note this past legislative session -- but, the Legislature chose not to fund the increment unless one of the bills passed. And since the bills passed this past session, there has been no funding for any sort of original research or staffing support for the group.
 
Dr. Hurlburt acknowledged Dr. Butler and his role, and [Dr. Butler's] having to leave to go help with the national response to H1N1 and the vaccine taskforce. Dr. Butler had started out as the chair of this group, and then when he left in June, Commissioner Hogan took over chairing the group until Dr. Hurlburt started. The commission has had four face-to-face meetings this past year, and they've had three different chairmen for those four meetings. Then, I was reassigned for about half the time the commission has been in place, to serve as the acting director for Public Health when Bev [Beverly Wooley] had to leave.
 
One of the other challenges that the group faced and talked about periodically was what was going on at the national level with health care reform, and how that was going to drive, or affect, or impact in any way, the work that we were doing. Just to give one example, the group actually decided to table for now any discussion, any work or analysis or recommendation development on expansion of access to health insurance since what's happening at the national level really is focusing very much on expanding access to insurance. Not knowing what was going to happen, they did not feel as though they could come up with any really meaningful recommendations without having a better understanding of the new [national] framework first, [what] health insurance expansion might be.
 
The uncertain future of the group itself -- the reason that the previous two groups, the Roundtable and the Health Care Strategies Planning Council, had recommended that a permanent body needed to be established in statute -- was their ad hoc nature. Understanding the health care delivery system and the way it's financed and the way it's structured, is so complex that one or two years really is not enough time to get a handle on all of the problems, and to be able to weed out and identify some strategies, that in an incremental fashion is going to turn the Titanic here.
   
After they put their recommendations out on the table, there really wasn't any ability to follow through, follow-up, evaluate if they are being implemented, [or look at] the effectiveness and outcomes of implementation of those strategies, and make sure that there was some transparency for the public in the process as well. That's why those two groups had previously made those recommendations, and this group, in their very first meeting, said, "Well, what are we going to be able to accomplish in a year?" and they identified that as a priority. Not knowing what their future is, if they were going to be a one-year group, or a five- or a ten-year group, [they] had framed their approach to planning this year.
 
They've been able to accomplish a number of things even with those challenges that I just mentioned: established some formalizing documents that will be in place, at least something that a future group could use if this group doesn't stick around for much longer. They've established bylaws and developed a job description for the executive director, established a website and a listserv and some other tools -- including a compilation of all of the groups involved in any sort of health care planning at all, as well as an inventory of all the current plans that are in place -- just to facilitate the beginning of the coordination role if we continue beyond the first year.
 
Then the group identified their vision and values for a transformed health care system for Alaska, and a number of priorities that they did develop some recommendations around. Some of you might have seen this yesterday; we issued a press release releasing a preliminary draft of the commission's first year report for public comments -- specifically on the findings and recommendations statement, and to the commission's proposed approach and overall strategy that I'm going to tell you about here in a minute. We would like to hear from the public, their thoughts about these ideas before we finalize the report for the governor and the legislature. [Note: the comment period has already passed. -- ldw] Back to selected topics
 

The Elephant in the Room
 
Before I share some of the details about the vision and the values, and goals and strategies that this group's identified so far, I thought it would be helpful to share a little bit, a couple of the themes, the threads that ran through their conversations from the beginning of their meetings. The elephant in the room is something that one of our commission members asks about periodically. At the last meeting, even, he was saying, "When are we going to address the elephant in the room? We keep talking around this problem."
 
What is elephant in the room? This is a graph of national health expenditures per capita, showing how the United States, the top line there, of course approaching $8000 a year in 2007, and how health care costs are so much higher in the United States compared to these other industrialized nations. There's Canada, France, Germany, the Netherlands, and the UK.
 
And, not just why is the cost of health care in the United States so much higher than in other countries, but why is the cost of health care in Alaska higher than in other states? And that, the elephant in the room really became more about how, why are prices of health care in Alaska so much higher than these other states?
   
This graph is showing the rise in cost of premiums, the cumulative change in the cost of premiums. The top line is insurance premium increase, compared to workers' earnings and consumer price index. Approaching an increase over the period of eight or nine years, a 125 percent increase in insurance premiums, compared to just 25 percent for workers' earnings and consumer price index. What is driving that significant inflation rate? Is it prices, is it utilization, is it something else?
 

And then, another strong thing that has woven through all of their conversations, that, actually I have to give Dr. Nighswander credit for referring to this question. This question is the 800-pound gorilla. But, from day one, folks wanted to talk about what is really driving health, and what are the determinants of health? And if, 40 percent of health is determined by individual behaviors, why are we focusing on the ten percent of the pie, which is health care? Of course, we're focusing on the 10 percent of the pie because it is a much greater percent of the cost, where all the money is going.
 
We had a great presentation from the Division of Public Health's, chronic disease staff, and the commission learned that three health behaviors -- tobacco use, eating habits, and physical activity -- were driving four of the most significant chronic diseases. [They also learned that] that 70 percent of all deaths in the United States are due to chronic disease, and in Alaska chronic diseases account for four of five of the top leading causes of death. [Further,] that 75 percent of the over $2 trillion now spent nationally on health care each year, is due to chronic disease. This graph shows that the increase in expenditures, about 75 percent of the increase in expenditures, or at least two-thirds of the increase in expenditures for health care, over the period from 1987 to the year 2000, were due to the increase in chronic disease, not just due to chronic disease. This study found that the country could have saved $200 billion if the level of chronic disease in the population had stayed the same, or where it was in 1987.
 
Something that we probably didn't need an economist to teach us, but at one point in another related meeting, Mark Foster got up as we were all scratching our heads over the cost of health care, and drew this simple equation on the whiteboard for us, reminding us that cost is really made up of two components: price and utilization. To what extent [are] the elephant in the room and the 800-pound gorilla driving the increases in costs, and then what are some of the other issues? Waste and medical procedures that aren't evidence-based, is just one other example of something that might be driving utilization overly high. Back to selected topics
 
Health Care Commission Vision, Values, and Priorities
 
I just wanted to give you a sense of some of the conversations and the learning the commission was doing over the course of their meetings that framed the development and identification of their visions and their values. The vision that the commission has identified for the Alaska health care system is that it improves health, and this was the key factor. It had to be about the health of the population, and having healthy Alaskans. [Additionally] that it provides value for Alaskans' health care dollars, and that consumers and providers both will be satisfied with the delivery of care in the way the system is structured, and that the system is sustainable. [Moreover], the goals that they identified improved access to care, controlled costs, improved quality, and that it would be prevention-based. [Regarding] values of sustainability, that for both the payer's perspective as well as the provider's perspective, this system is going to be sustainable over time, that it is efficient in terms of the delivery of clinical care, as well as administrative processes, and effective. [Finally], that, individuals have choice in their care and that they are also engaged and empowered to take personal responsibility for their own health, that they have the tools to be able to do that.
   
And one other equation that I thought I would put up. Two of the goals, the reform goals of the commission -- controlled costs and improved quality -- as we started looking at some of the potential strategies to address those. Increasingly, it's hard to find examples of strategies that have been tried in other places, that separate out these two issues of cost and quality. More and more, where Medicare is an example, a more simplistic approach to controlling costs that would just cap physician reimbursement fees -- the way that works with Medicare right now -- is moving more and more towards pay-for-performance, where quality indicators and financial incentives are included as part of the cost-control measure. Overall, these strategies really are just focusing on value, so those four goals, actually, are starting to collapse into three goals, with the cost and quality aspects being all about improving value.
 
The top of the slide is cut off there, but at the top, these are the year-one priorities that the commission identified in their first meeting. They are not necessarily in a priority order, but I'm going to go through them real quickly and go on to a graphic that gives a picture of how these have come together into more of a comprehensive strategy. The consumer's role in health care -- with two aspects of that, both related to individual behaviors and healthy lifestyles. And also, the consumer's role in their health care experience -- the patient needs to be the center of their health care experience, not the health care system or the health care provider necessarily.
 
Statewide leadership, both in terms of response to national health reform, and following what was going on there and being responsive to that, [needs to be] prepared to be responsive to whatever ends up being implemented at the national level. And the need, again, for a permanent state health planning body.
 
The third area, health care workforce development. In this year, since this group had very limited resources and time, they chose one specific issue related to workforce to focus on, and that is physician supply. That wasn't meant to imply that that was even the highest priority problem and that that would be the only thing that this group would ever address related to workforce. They recognize this as really a key to improving the health care delivery system and supporting the workforce and workforce development.
 
Health information technology, both the health information exchange and electronic health records, as well as delivery through tele-health, telemedicine, technologies.
 
A fifth issue that this group identified as a priority is primary care access for Medicare enrollees.
 
This diagram is a picture of how four of those high priorities have come together to form a preliminary design of the commission's strategy for transforming the health care system for Alaska. At the pinnacle of the peak there is that consumer's role, and two aspects of that. Looking for ways to be more innovative in the delivery of primary care, they learned from South Central Foundation about their new approach to delivering primary care [discussed at length in the November 17, 2009 issue of AHPR. -- ldw] through the Nuka model of care. [Commission members] were really quite taken with the success that that program has demonstrated in terms of reducing utilization of health care services and improved satisfaction on the part of both the patients and the providers. It really is a very different approach to provision of primary care.
 
Innovations in primary care, as well as the healthy lifestyles aspect are the peak of the strategy for transformation for the system. Supporting that is a foundation of a strong workforce, information management tools available for that workforce and utilized, and the statewide leadership overall to continue working on the problem over time, [and] being available to support changes that are driven from the federal level, as well as evaluating any strategies that are implemented in continuing policy development.
 
Then, the question about this fifth priority area, the Medicare access problem. It really doesn't address that comprehensive strategy, it's not a component of a comprehensive strategy, but the question is, is that problem -- that's really an immediate crisis -- is that an early warning, an indicator for us of a looming crisis that is much greater, that is going to be affecting many more people if we don't manage to do something about that [by] improving our health care system? It's unfortunate that our elders are the ones having to suffer right now.
 
I mentioned that the group released just a preliminary draft of the report, just yesterday [December 7, 2009]. There are 37 different recommendations contained in the report, across those five different priority areas. And I'm just going to not give you the specific recommendation statements. The document is available on the website [http://hss.state.ak.us/healthcommission/].
Related to the consumer's role, there really are just a couple of very general recommendations, just to get started. Again, this is just the beginning of a long journey.
 
General recommendations about the importance of the governor and the state Legislature supporting strategies that lead to healthy lifestyles and creating cultures of wellness. And also, a little more specific strategy about the state needing to aggressively pursue development of patient-centered primary care models. We've laid out some of the characteristics of that patient-centered primary care model, of integrated care teams and improved coordination of the delivery of services -- a couple of examples of those characteristics.
 
The state [should] look at payment reform strategies for supporting primary care innovations, as well as identification and removal of any statutory and regulatory barriers. The commission also recommends that the state investigate development of pilot projects, and that we use those payment reforms and begin starting to see if we could develop use of this new model outside the tribal health system.

 
I mentioned the presentation that the group had from the chronic disease staff. I just wanted to throw one more slide up from our health indicators for this past year. At the first meeting [of the commission] when they were expressing concern over how individual health behaviors are affecting and causing health problems and chronic disease, the question became, "So how do we incentivize, what can we do, and what works to incentivize improvements in health behavior?" They learned about the success of the tobacco program in reducing adult smoking from 27 to 21 percent over just a few years time. We want to continue delving into that area and answering that question.
 
Related to statewide leadership, the group recommended that the state invest in health policy infrastructure to respond to the national reform. We expect something is going to come out of the national reform [proposals] in Congress. Even if it doesn't, there is enough concern over the rapidly escalating costs and the lack of access, that we expect something is going to happen at some point. Whatever happens, it is not going to be just the federal government doing it for and to us. The state government is going to play a real significant role in implementing. It's going to be impacted both financially and with new administrative responsibilities. The Department of Health and Social Services estimates that Medicaid expansions that are being proposed over a period of five years will cost the state an additional $450 million in GF [General Fund]. So, that's just an example of increased financial responsibility that the state will incur. The development of a state insurance exchange is something that the state would have a significant role in helping to implement -- a new administrative responsibility.
 
We need the resources in place to be able to study and analyze and understand the impacts of these changes in Alaska. [We need them] also to be able to respond to it, and to develop recommendations for how we would implement it at the state level. I mentioned earlier this group's concern and the prior group's recommendation for a state health planning board. This recommendation led to a third bill being introduced in the legislature by Senator Olson that would create a state health commission in statute. I'll share those bill numbers with you in a moment.
Back to selected topics
 
Alaska's Physician and Health Care Workforce Shortages
 
Related to workforce, I mentioned that they really focused primarily on physician supply, but didn't want to just leave the impression that there wasn't a greater importance to the overall workforce question. There are a number of more general recommendations related to workforce that the governor and the legislature should keep workforce development and support for the workforce a high priority on health care reform and economic development agendas for the state, and that they pay attention to the early part of the pipeline -- development of training programs from K-12, through graduate medical education, including on-the-job training.
 
[The commission also recommended] that the state support strategies for innovations in workforce, and helping the workforce to adapt to the evolving health care delivery system and changing care models. The commission also recognized that there are number of groups that have been working on different aspects of planning. More and more there is collaboration going on around planning with the university [of Alaska], the Department of Health and Social Services, and Alaska Mental Health Trust Authority. [They] actually had partnered in creating a shared position to help coordinate workforce development plans for behavioral health specifically. Now there is a coalition that has been working together to develop a comprehensive health care workforce strategy for Alaska. I think their document was released in February, I believe.
 
There is a recognition that there is a lot of coordination and collaboration going on already, and acknowledging that, and recommending to the governor and the Legislature that a specific entity perhaps needs to be identified to be the lead entity responsible for making sure that that coordination and collaboration goes on in an ongoing basis.
 
And then specific to physician development, this group I think was very impressed with the work of the Alaska Physician Supply Task Force from a couple of years ago, with the level and quality of the analysis that was done, but, pushed back a little bit on some of the assumptions that were made in that report, in terms of comparing the need and identifying the need based on whatever the national average is right now. [The commission questioned] whether we have as big a crisis in physician supply in this state as that report suggested, but also agree there still is a problem and something needs to be done to address it.
 
Recognizing the state has limited resources, their recommendation to the governor and to the Legislature is -- to the extent they're putting money into physician supply developments -- specifically that those dollars need to be focused and targeted on primary care physicians. The group makes a specific recommendation that the state needs a loan repayment program to improve recruitment and retention, and that could include and should include financial incentives, not just not loan repayment for folks who have paid off their loans already. They recommend that WWAMI [http://biomed.uaa.alaska.edu/] seats be increased to 24 seats, and that the state support graduate medical education for development of a pediatric residency program, psychiatric residency program, and a primary care and internal medicine program.
 
There are a number of more general recommendations related to health information technology as well -- related to electronic health record development and health information exchange, and also telemedicine. [There are] general statements of support for adoption and utilization, and the importance of continuing to track over time what is going on. There is a lot going on right now. This state has an RFP [request for proposal] out to solicit a contract for the group that will become the designated state entity for a health information exchange for the state. And, the state is also in the process of modernizing and updating the Medicaid's Management Information System.
 
There are continuing questions about privacy and security, as we move forward with all of this, so one of the recommendations is just to make sure that there is a group designated to be responsible for overseeing privacy and security protections are implemented. [There is] also acknowledgment that a lot of progress has been made in terms of improving reimbursement for telemedicine, and [improving] access to the telecommunications infrastructure that's needed in rural Alaska in the most remote villages in our state, but there's still a lot of work that needs to be done. There are some recommendations related to those issues as well. Back to selected topics
 
The Medicare Access Problem: A Sign of Things to Come?
 
And then specific to Medicare, the group considered a number of general strategy areas. One of those was specific to increasing the supply of primary care providers. The commission felt that at least part of what was driving this problem was an inadequate supply of primary care providers in the state, so their recommendations, at least at this point in this first year, focus very much on those workforce development strategies.
 
One of the areas where seniors in Anchorage had been able to access services, is in the family medicine residency program. They recognized that since that program had to cap the number of seniors they were seeing -- otherwise they weren't going to be able to see anybody other than seniors -- that the development of this other residency program really could be a benefit in the shorter term as well as the long run.

The group pushed back a little bit and questioned the reports from physicians for reasons why some of them refuse to see Medicare beneficiaries because their costs are too high, and the reimbursement levels are too low. [Consequently,] findings related to physicians' perceptions of insufficient reimbursement are couched a little bit, in terms of "physicians' perceptions." [As a result,] the commission did not come out with the recommendation to continue to work with the Congressional delegation to continue to get special provisions in for Alaska providers, for increased fees. [Commissioners] thought that we needed to do more work on studying the cost burden and the administrative burden, and the cost differential before we'd make a specific recommendation about that.
 
PACE stands for Programs of All-Inclusive Care for the Elderly. This is a Medicaid waiver program that is specifically for seniors who are frail enough to meet nursing home level of care requirements. [PACE] would actually develop a capitated, managed-care program for those seniors. This is just a new care model that the commission recommend the department apply to CMS [Centers for Medicare and Medicaid Services] to get a Medicaid waiver to facilitate the development of these programs in the state. Back to selected topics
 
Outstanding Issues and Strategies
 
I am going to skip over outstanding issues and strategies so we have time for some questions, but in the report you'll see that there's a whole section that's devoted to all of the outstanding issues and strategies the group didn't have time to address this year. Health insurance coverage is at the top of the list of course. Continuing work on health care workforce development, needing to understand and integrate the issues related to behavioral health, and long-term care delivery were some of those. [Additional issues included a] number of different approaches to payment reform, continuing study of the cost of care, looking at private use control, tort reform, and continuing work on different prevention strategies.  Back to selected topics
 
Future of the Commission: Pending Bills in the Legislature
 
If the administrative order is not extended, or a new administrative order does not reestablish this commission or another commission, then this commission will end at the end of April 2010. There are currently three bills pending in the Legislature right now. House Bill 25, House Bill 75, and Senate Bill 172. Any of those bills would establish a permanent health planning and policy development board in statute.
 
I just wanted to wrap up with one more cartoon. We have a line of folks outside the emergency room, and one doctor asking the other, "Is this swine flu?" And [the response from the other doctor], "Sore throats from screaming about health care reform." I thought that was a good way to end the discussion today, because this really has been a significant year for both public health and for health care, with all of the focus at the national level on health care reform, and with the work that the health public health sector has had to do in response to the pandemic.
 
I don't know if it's just because I'm looking at it so closely now, but I really am feeling as though there is a blurring in the line, where it always seems like such a hard line between public health and health care. That line seems to really be blurring more and more these days, from my perspective. [It is blurring] in terms of the work that we've been doing in public health -- [working] more closely with our partners in the health care sector to make sure that they have the capacity they need and are appropriately prepared to be able to respond to the pandemic. [It is blurring] as well from the other side in increasing recognition of the importance of population-based health, health promotion, disease prevention, and the importance of prevention and the work that public health does in the health care reform discussions.
 
And I think the Alaska Health Care Commission really does recognize both the importance of healthy lifestyles and the importance of prevention with the now combined position of the chief medical officer for the department, with the Division of Public Health director role being designated as the chair of the health care commission. As this commission continues with the structure, I think we will just continue to see a breakdown in the barriers between public health and health care and the work on health care reform. And I think that is a really good thing. Back to selected topics

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We will start by reviewing last year's health policy legislation as we approach the beginning of the second session of the 26th Alaska State Legislature. First, to clarify the Alaska State Legislature process, below is a description of legislative sessions as well as the rules associated with bills proposed during each session.
 
Each legislature (e.g. the 26th Legislature) consists of two regular sessions, each convening annually on the third Tuesday in January. Each session lasts no longer than 90 consecutive calendar days from the start of the session. However, the session may be extended once, for a period up to 10 days, with the approval of at least a 2/3 vote from each house. Additionally, the governor or the Legislature may call a special session, which is limited to no more than 30 days.
 
Sponsors of bills (e.g. legislators) have two opportunities to introduce new bills before the Legislature meets officially each January. Bills proposed during this time are referred to as "prefiles," and they are introduced on the first and second Friday immediately preceding the first day of the session. The prefile process is described in more detail in the following Bill Watch section of this issue of AHPR. Bills that are introduced, but are stalled or not passed during the first legislative session of each Legislature, may be carried over into the second session. Unless a special session is called, bills that are stalled at the end of the first session cannot be acted upon in the interim between sessions. However, bills that passed during a session may be signed by the governor during the interim between sessions.
 
Overview of Last Year's Health Policy Activity
 
Last year's legislative session ended with a few successes, several "almost-wins" that stalled in committees, as well as a few losses. The May 2009 issue of AHPR included an extensive summary of the actions of key health policy bills during the first session. The summary contained key excerpts from two organizations that are also tracking health policy in Alaska: AARP and the Alaska Primary Care Association. Since the May 2009 issue of AHPR, four of the bills awaiting Governor Palin's signature were signed before she left office. Each of these new laws has the potential to improve quality and access to health care: HB 26 Medicaid for Adult Dental Services, HJR 10 Veterans' Health Care, CSSB 116 Approp: Energy Assistance, SB 133 Electronic Health Info Exchange System, all described in more detail below.
 
There were several bills that stalled during the last session, despite overwhelming support from legislators and community organizations. For example, three bills aimed at improving eligibility for medical care through Denali KidCare had momentum and support at the start of the first session, yet were stalled in committees. Additionally, SB 172 Alaska Health Care Commission, which establishes the commission as a permanent entity, was stalled in late April due to cancellations of hearings in the Senate Finance committee. Another bill with substantial community support is SB 139 Incentives for Certain Medical Providers, which stalled in the Senate Finance committee in April 2009. Overall, the majority of health-related bills stalled or remained idle during the 2009 legislative session, and will be heard again during the second session.
 
The following is a brief summary of the legislative activity related to health policy for the first session of the 26th Alaska State Legislature, based on the more extensive summary published in the May 2009 issue of AHPR. Included are some of the perspectives from AARP and the Alaska Primary Care Association, also excerpted from last year's summary. The second session of the 26th Legislature starts Tuesday, January 19, 2010.
 
Education
 
Incentives for Health Care Professionals
 
The March 6, 2009 Vol 3, Issue 8 of AHPR included a summary of hearings on key legislation that could have an impact on improving the health care workforce shortage in Alaska. At the time, two bills addressed this issue: SB 18 Postsecondary Medical and Other Educ Prog and HB 58 Educ Loan Repayment Program, both of which aim to retain health care workers in Alaska following the completion of their education. An additional bill was added on March 9, SB 139 Incentives for Certain Medical Providers, which also provides incentives for recruitment and retention of specific medical professionals.
 
Senate Bill 18, which proposes an increase in the number of medical students (from 20 to 24) in the WWAMI program, as well as increase the capacity of the Alaska Physician Residency Training Program, was stalled in the Senate Finance committee on March 16. Representative Nancy Dahlstrom has a companion bill, HB 204, which only made it as far as House Finance (Source: Pat Luby, AARP).
 
House Bill 58, which proposes a loan repayment incentive program for health care professionals in areas with employee shortages, was also stalled in House Finance committee at the beginning of April. It is important to note that this bill was altered over the course of the first legislative session. It was, originally, a bill for loan repayment for dentists, nurses, and other health care-related fields with employee shortages in the state. The final version includes any occupation (health care as well as non-health care) designated as being high-need occupations. Additionally, changes to eligibility have made it so that in order to be eligible, a person has to be a state employee. 
 
Senate Bill 139, which would establish the Alaska Health Care Professions Loan Repayment & Incentive Program, appeared to make significant progress, yet it did not receive a hearing in the Senate Finance Committee. The legislative proposals in SB 139 received considerable support in the committee hearings summarized earlier (AHPR, March 6, Vol 3, Issue 8). SB 139 would create a program offering recruitment incentives for ten practitioner types to help address the workforce shortage, particularly in underserved areas of the state. The Alaska Primary Care Association notes that:
 
 
The Senate Finance Committee will have the option to hear SB 139 again this session, and any hearings on the bill will be on the Health Policy Calendar.
 
General Health Policy
 
Electronic Health Information Exchange
 
One of the bills signed into law was SB 133 Electronic Health Info Exchange System, introduced by Senator Joe Paskvan. SB 133 creates a statewide electronic health information exchange system. Senator Paskvan states the following in his sponsor statement on SB 133:
 
 
 
The Alaska Primary Care Association also commented on this bill:
 
 
New Funds for Low Income Energy Assistance Program (LIHEAP)
 
Energy costs not only affect individuals and families, but also burden the total costs of operating health care centers. Thus, energy cost assistance has remained a priority for many health care agencies so that they may continue delivering their services. The Senate Finance committee issued two bills that address the need for energy cost assistance: SB 115 Rural Energy Assistance Program, which was heard and held in Finance; SB 116 Approp: Energy Assistance, which establishes the LIHEAP, and CSSB 116, which is the final version of SB 116, signed into law in August 2009.
 
Although the passing and signing of CSSB 116 creates a substantial amount of financial assistance for low income Alaskans who are struggling to pay energy bills, additional funding for Alaska's health care safety net, community health centers (CHCs), was not a part of this bill. Additionally, the Alaska Primary Care Association (APCA) had requested specifically that additions be made to the energy bills presented last year to assist CHCs with their energy costs. The APCA stated the following on this issue:
 
 
Regular Rate Reviews for Home and Community Based Services
 
Currently, hospital rates in Alaska are reviewed annually to monitor for adjustment needs. Rates for home and community based services (which often allow for an individual to remain at home and in their own community, avoiding more expensive institutionalization) have in many cases not been raised for several years. As a result, some providers have left the market; others have had to reduce services and serve fewer clients. Potential providers have been discouraged from entering the market when it looked like reimbursement would not keep up with costs.
 
Senator Johnny Ellis authored SB 32 Medicaid: Home/Community Based Services, which would establish regularly scheduled rate reviews for home and community-based services that serve older Alaskans and younger persons with disabilities. All health providers should have their rates reviewed on a regular basis, as do hospitals and nursing homes, and SB 32 would accomplish this. The bill passed both House and Senate Health and Social Services committees, yet was stalled in House Finance committee at the end of the session. It will be on the agenda again during the second session.
 
Electronic Registry for Advance Health Care Directives
 
Representative Lindsey Holmes issued HB 71 Advance Health Care Directives Registry, which amends a previous statute by adding that a health care facility will not be subject to civil or criminal liability in the event that they act in reliance to an advance health care directive or fail to check an advance health care directive registry for a patient in their facility. In addition, HB 71 proposes the establishment of an advance health care directive registry within the Department of Health and Social Services, where individuals or their guardians can file advance health directives. This registry would be confidential and may not be used for another purpose.
 
 
State Budget
 
There were a few success stories in the approved budgets of programs or practices that will improve the health and lives of some Alaskans. At the end of last year's session, Pat Luby of AARP identified three winning budget changes for Alaskans:
 
 
Unfortunately, other areas of the budget failed to meet requests of critical components in Alaska's health care delivery system. As noted by the Alaska Primary Care Association, Community Health Centers (CHCs) did not see the expected and much needed support from the state budget. Specifically, they did not receive direct state support as requested; they only received $350,000 for senior access to primary care, to be divided among the 26 CHC organizations operating 143 clinics. The additional requested funds were for senior access, help with high energy costs, and provider recruitment and retention assistance, all of which received no funding. The APCA Legislative Update has a running commentary on this CHC state support issue, which can be found on their website noted below.
 
Medical Assistance and Health Insurance
 
Denali KidCare
 
Perhaps highest on the agenda of many health and social services agencies was Senator Bettye Davis' Denali KidCare bill, SB 13 Medical Assistance Eligibility. Despite support from numerous individuals and agencies throughout the state, SB 13 did not gain enough momentum to pass during the 2009 legislature, and was stalled in the House Health and Social Services (HSS) Committee. SB 13 would restore the original eligibility requirements for medical assistance for pregnant women and children, from the current 175 percent of the Federal Poverty Level (FPL) to 200 percent FPL, which is the minimum eligibility level in most states.
 
The Alaska Primary Care Association stated the following on this issue:
 
 
Additional legislation affecting Denali KidCare and medical assistance eligibility includes Senator Bill Wielechowski's SB 87 Medical Assistance Eligibility, which would also raise the income eligibility to 200 percent of the FPL. Additionally, it would also allow families between 200 and 300 percent of the FPL to purchase coverage using a sliding scale premium. Like SB 13, Wielechowski's bill had much support, but was stalled in Senate Finance Committee, with the option to be heard again this coming session. Representative Gara proposed a companion bill, HB 118 Medical Assistance Eligibility, which was read and referred to House Health and Social Services committee but never heard.
 
Adult Dental Benefit Under Medicaid 
 
One of the success stories during last year's session was HB26 Medicaid for Adult Dental Services. Introduced by Representative Mike Hawker, HB 26 ensures that the adult dental benefit under Medicaid, which was set to expire June 30, 2009, is sustained indefinitely. HB 26 passed both the House and Senate, and was signed into law.
 
Prior to this program, adults on Medicaid were only eligible for emergency dental care; Representative Hawker had argued in favor of the extension of the preventive and restorative care services to prevent a return to a "barbaric" program. In 2008, approximately 7,600 Alaskan's received dental services through the Adult Dental Medicaid Program. Without the signing of HB 26, those 7,600 individuals would have lost their dental coverage under Medicaid after June 30, 2009.
 
Health Care for All Alaskans
 
One of the most critical bills heard during this past session is Senator Hollis French's SB 61 Mandatory Universal Health Insurance. The bill proposes affordable health insurance for all Alaskans. AARP mentioned that:
 
 
SB 61 passed the Senate Health and Social Services committee, but was heard and held in Senate Labor and Commerce on April 9. Watch the Health Policy Calendar for updates on hearings for this bill.
 
Insurance Coverage During Cancer Clinical Trials
 
Senator Bettye Davis introduced SB 10 Medicaid/Ins for Cancer Clinical Trials, which would require insurance companies to continue to provide normal coverage when a customer is undergoing a clinical cancer trial. Clinical trials pick up all the costs of the trial. Some insurance companies have notified their customers that, if they join a clinical trial, the insurance company will not be responsible for any of the normal costs, even though they are not related to the clinical trial. SB 10 has passed the Senate referral committees and is in Rules waiting to be sent to the Senate floor for a vote. The bill is expected to move to the floor in January 2010. (Source: Pat Luby, AARP)
 
Veterans' Health Care
 
Another piece of legislation signed into law last year is HJR 10 Veterans' Health Care, which urges the United States Congress to improve health care access for veterans. HJR 10 passed the Legislature with unanimous consent. The Alaska Primary Care Association has supported this legislation for some time:
 
 
State Boards and Issues
 
Alaska Health Care Commission
 
Late in the session, Senator Olson introduced SB 172 Alaska Health Care Commission, which establishes the Alaska Health Care Commission as a permanent entity. Scheduled for a hearing in the Senate Health and Social Services (HSS) Committee during the end of last year's session, SB 172 was not heard due to time constraints. Thus, SB 172 will remain in the Senate HSS Committee for the 2010 legislative session. The Alaska Primary Care Association (APCA) commented on SB 172:
 
 
Extend the Alaska Suicide Council
 
One of two companion bills related to suicide prevention in Alaska was signed into law  in June of last year. HB 123 Suicide Prevention Council, which extends the Alaska Suicide Council for another five years, was sponsored by Representative Anna Fairclough. As noted by Pat Luby of AARP, Alaska has the highest suicide rate in the nation, including many mid-life and older Alaskans. The passing of this legislation guarantees five more years of focused suicide prevention efforts.
 
Pensions and Sick Leave
 
Public Pensions and Retirement Health Plan
 
Senator Kim Elton introduced SB 23 Repeal Defined Contrib Retirement Plans, which would reverse 2005 legislation (SB 141), which dismantled the public employee retirement pension and health care coverage systems. Overnight, Alaska went from having one of the best retirement systems in the country to having one of the worst. The legislation in 2005 replaced a defined benefit plan, which assured a monthly pension and health care premium coverage for future retirees, with a defined contribution plan, similar to a 401 (k) savings plan. This action affected every new public employee working for the state since July 1, 2006, which is approximately 6,000 public employees and growing.
 
 
Required Sick Leave
 
Senator Johnny Ellis issued SB 86 Paid Sick Leave, which mandates one hour of sick leave for every forty hours worked, totaling approximately 6.5 days of paid sick leave per year for the average full time employee. SB 86 would benefit the 120,000 Alaskans who work for employers who provide no sick leave. If they are ill or need to stay home with a sick family member, they are not paid. Employers who have any form of personal leave would be exempt. SB 86 passed one Senate Committee, Labor and Commerce, and will be up before the Finance Committee this year. (Source: Pat Luby, AARP)
 
Stalled or Never Heard
 
Very little progress was made regarding legislation on mental health or family health issues. The majority of family health-related bills were read but never heard in assigned committees. Some progress was made on the few bills related to allowing mothers to nurse children in the workplace, but those bills stalled in committees, to be heard again in 2010. Although the new mental health budget was signed into law, a bill proposed by Senator Davis that would bring parity in health insurance coverage for mental health, SB 21 Mental Health Care Insurance Benefit, was assigned to committees but never heard.
 
Looking Ahead to the 2010 Legislative Session
 
As mentioned above, the bills that stalled during last year's session will carry over when the legislature meets for the second session starting next week. See the Health Policy Calendar for updates on when these bills are scheduled to be heard in committees. The Bill Watch section of this issue of AHPR, which follows this summary, includes descriptions of the health policy bills issued during the first of two prefile releases.  
 
Notes and Acknowledgements
 
With permission, many excerpts in this summary were taken from two end-of-session legislative summaries issued at the end of the 2009 legislative session. We thank Pat Luby of the AARP and the Alaska Primary Care Association for their contributions to this document.
 
For a full copy of the legislative update by the APCA, go to http://www.alaskapca.org/uploadedFiles/Advocacy/4-22-09.pdf
 
The APCA Legislative Update is distributed regularly by email to members and interested advocates. To be added to the distribution list, email Regan@alaskapca.org.

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