Alaska Health Policy Review

Health reform at the national level has finally arrived. What will it mean for Alaskans? A good place to start is the Families USA fact sheet titled, "Health Coverage in Alaska: How Will Reform Help?" This overview notes, for example, that "Alaskans with moderate incomes (for a family of four that is up to $110,280 in 2009) will receive sliding-scale subsidies to use toward the purchase of a high-quality health insurance plan."

Another good overview found in the Commonwealth Fund Blog discusses what kind of changes we can expect in 2010.

Many Americans will feel the effect of the reform this year, as significant changes start to go into effect. Within the year:

underwriting of children in the individual market will be prohibited;

young adults will be able to stay on their parents' health plans to age 26;

insurance companies will be prohibited from revoking coverage when people become ill, and from setting lifetime limits on benefits;

small businesses will be eligible for new tax credits to offset their premium costs;

people with preexisting conditions will be eligible for subsidized coverage through a national high-risk pool;

new limits will be set for the percent of premiums that insurers can spend on non-medical costs and, beginning in 2011, carriers that exceed those limits will be required to offer rebates to enrollees;

Medicare will provide $250 rebates beneficiaries who reach the donut hole; and

Medicare will eliminate cost-sharing for preventive services in Medicare and private plans.

Finally, a very detailed and useful resource is "A State Policymaker's Guide to Federal Health Reform," funded by the Robert Wood Johnson Foundation and published by the National Academy for State Health Policy. You don't have to be a policymaker to read this series of articles, but you probably should at least be a dedicated health policy wonk.

Nevertheless, before dancing in the streets consider these sobering observations by the leadership of Physicians for a National Health Program who support a single payer system of health care similar to Canada's.

Instead of eliminating the root of the problem -- the profit-driven, private health insurance industry -- this costly new legislation will enrich and further entrench these firms. The bill would require millions of Americans to buy private insurers' defective products, and turn over to them vast amounts of public money. The hype surrounding the new health bill is belied by the facts:

About 23 million people will remain uninsured nine years out. That figure translates into an estimated 23,000 unnecessary deaths annually and an incalculable toll of suffering.

Millions of middle-income people will be pressured to buy commercial health insurance policies costing up to 9.5 percent of their income but covering an average of only 70 percent of their medical expenses, potentially leaving them vulnerable to financial ruin if they become seriously ill. Many will find such policies too expensive to afford or, if they do buy them, too expensive to use because of the high co-pays and deductibles.

Insurance firms will be handed at least $447 billion in taxpayer money to subsidize the purchase of their shoddy products. This money will enhance their financial and political power, and with it their ability to block future reform.

The bill will drain about $40 billion from Medicare payments to safety-net hospitals, threatening the care of the tens of millions who will remain uninsured.

People with employer-based coverage will be locked into their plan's limited network of providers, face ever-rising costs and erosion of their health benefits. Many, even most, will eventually face steep taxes on their benefits as the cost of insurance grows.

Health care costs will continue to skyrocket, as the experience with the Massachusetts plan (after which this bill is patterned) amply demonstrates.

The much-vaunted insurance regulations -- e.g., ending denials on the basis of pre-existing conditions -- are riddled with loopholes, thanks to the central role that insurers played in crafting the legislation. Older people can be charged up to three times more than their younger counterparts, and large companies with a predominantly female workforce can be charged higher gender-based rates at least until 2017.

How will this all play out in the coming years? I am not sure, but I strongly suspect this is not the end of health care reform sturm und drang.

Lawrence D. Weiss PhD, MS

Editor, AHPR

ldweiss@acpp.info

Mark Foster: Health Policy, Regulation, Technology, and Economics, Part 2

This is part two of an interview with Mark A. Foster, principal of Mark A. Foster and Associates. He describes himself as a "business consultant who specializes in regulated industries" such as telecommunications, energy, and health. In this second part of the interview, Foster explains why health care is more expensive in Alaska in part because health care providers are less productive. In addition, he discusses access to health care for those who have Medicare and Medicaid, the question of transparency of cost for medical procedures, and other issues of interest. This interview was conducted February 22, 2010, and has been edited for length and clarity.

Foster: [Here, about a month before Congress passed national health reform, Foster is responding to a question about health reform at the national level and its possible impact on Alaska] It strikes me that we are a bit of an island economy, and we have some things that make us sufficiently different that we really want to be mindful of any federal template. We tend to be a high-cost state, in part driven by the need, that I think has been growing over the years, to attract and retain specialty care in order to keep up with the notion about what health care is in the U.S. Now whether or not you agree with that, I just say that that's the market, how it's evolved.

And so given that market evolution, I think the challenge is: How much do we pay to keep up? Whether it's cancer care, whether it's heart care of various kinds, diabetes care, various diagnostic related groupings that come together. And it strikes me what's happened in the Alaska market over the last, even call it 20 years, is providers, whether public or private, have attempted to expand the range of services that are available here, to be more like a metropolitan area in the rest of the country -- really grown the business service set, and the specialists to meet that service set.

The net effect of that, in my view, has been to basically pay a premium to try and keep up with that marketplace, in order to attract people to come here -- even primary care doctors. A little bit of salary survey work that I have seen suggests to me that Alaska is paying on the order of a 30 percent premium for entry-level primary care doctors, to come to the market and retain folks in the market. And that goes up, it could be 50 percent for more experienced, some specialty care could be even more than that.

Other innovations that people have come up with, is they're paying, if you will, what looks like a Lower-48 salary, but they are only paying for maybe half, or three-quarter time, and letting that doc go out and develop their own private business on the side. So there are other inventive ways to make it look as if they may not be paying the premium, but in fact we're paying the premium if we measure it on a dollars per productive hour basis.

There is a pay premium, and then there is basically the productive hour. Between the two we've got some interview information from people running practices and the hospitals, which suggests that not only are we high-priced, but because we make accommodations on the productivity side -- in terms of how many hours a year we expect, or how many patients on the panel -- we've really lowered our productivity here in Alaska and allowed doctors and dentists and nurses more flexibility in their schedules to enjoy the great outdoors, to attract them to Alaska, and to allow them to have practices beyond just the one that they have been hired for.

The net effect of all of that is that we pay more and we get fewer hours, and we have a higher price structure as a result. It's not uncommon, if I look across other industries, for example in the utilities or pipelines, electric or telecommunications -- a similar phenomenon exists there. For technical expertise I am tending to pay a premium, and I'm also not getting as much productivity as I might have in a Lower-48 market. Part of that is just because there is an expectation that people are going to have more flexible schedules for the seasonality of the work, and the logistics involved in many of those services. So it's another interesting sort of "Alaska island economy" phenomenon, that extends beyond just health care and other areas.

" ... we've really lowered our productivity here in Alaska and allowed doctors and dentists and nurses more flexibility in their schedules to enjoy the great outdoors, to attract them to Alaska, and to allow them to have practices beyond just the one that they have been hired for."

AHPR: That's a really interesting explanation, the looking at it by the cost of the hour worked. And I know, I've heard that about dentists in particular, but some physicians too. And it never, I just never put that together with the high cost of health care in Alaska, that that was a ... it sounds to me like you're saying that that's a kind of central component of it.

Foster: I think when people search for why we are high cost, I think that's one of the key pieces in what I'm doing -- trying to understand, for example, if I look at metropolitan statistical areas across the U.S., Anchorage might come in at maybe 160, 163, 165, depending on what year you're looking at. And then I want to look at other similarly-sized metropolitan statistical areas, with similar sort of demographics and purchasing. And so it's not unusual for me to grab Spokane; it's a little bit larger, but some similarities, regional hub, and just do compare and contrast. Not only on price, but on productivity of labor, utilization of various kinds of services, to try and understand the old geographic variation problem that the Dartmouth guys are trying to figure out, but I want to do it on more, sort of a point [by point] comparison, so I can better understand what's driving the differences, as opposed to large regressions on 300 things. And I go, "Okay so either we are under or over, what does that tell me?" I really want to dig farther into the system to understand how our system might be different. And so deeper looks, with smaller data sets, I think are just my bias. So I can get a better feel for what's going on.

AHPR: Right, okay. Well, that's an interesting laying the basis of at least some discussion about why the costs in Alaska are so high. The next question might be: What, if anything, do you have to say about the possibility of health reform in Alaska, like do we need it? And if so, do you think anything will be happening in the next two or three years to begin to seriously address that question?

Foster: I think the short answer is, yes, we need health reform, and on my list there is sort of an immediate problem that we have that we need to address. And that is what the Medicare reimbursements are, and the sort of reimbursement system in the Alaska marketplace is not working. In the recent work that I have done with ISER, I think we've really kind of come to the conclusion in that work, speaking for myself, that we have a significant access problem: Private physicians are not seeing Medicare patients at nearly the same level as they do in other marketplaces in the U.S. And what we're seeing as a result of that is an uptick in emergency room, folks who are 65 and over under Medicare, on both emergency rooms in Anchorage. This is Anchorage, primarily an Anchorage problem, that's starting to seep out into the neighboring communities.

It's not as dramatic yet, but you can see in the numbers that it is starting to seep out. More physicians basically opting out of Medicare, and entering into contracts directly with their patients on the primary care side, where the reimbursements are the ones that are most noteworthy for being low, relative to private insurance, relative to workers' comp [compensation], relative to Medicaid. And so I think we have a payment imbalance here in Alaska. The reason I think it's particularly problematic, is because in 48 of the 50 states, it's the other way around, with respect to Medicare and Medicaid. [In] most other states, Medicare is the better government payer than Medicaid.

[In] Alaska and Wyoming, it's flipped, where Medicaid is the better payer, the one that the state basically has some influence on the rate setting. And so, it looks like, two relatively resource rich states that have some surplus as a result of oil and gas development, were able to decide that their priority was to put reimbursements up for those who are eligible for that Medicaid program. Whereas in the rest of the country, Medicaid is a serious under-payer, relative to Medicare. And so when they have the national discussion about expanding Medicare, or early in the spring, it was Medicare plus ten percent.

Well, well there might be some complaints about that, nationally, it's certainly viewed as much better than Medicaid, because of the low reimbursement. Well, here in Alaska, because Medicare is the sort of the 'back of the bus' payer, that really doesn't help us much. It was quite striking to me, that in 2009, the Medicare program had a legislative bump in part of the geographic cost index that's used to create those rates. So basically the Medicare reimbursement rates for Alaska went up by almost 30 percent in 2009. And that doesn't look like it brought in new doctors, even though there was a bump in the Medicare reimbursement.

AHPR: A substantial one.

Foster: A substantial one! So then you go, why didn't this bump get some attention? And there are some very, little bit of modest attention and more doctors opting out, subsequent to the ISER survey. So what's going on? My conversations with providers -- from those conversations it appears to me, and this is anecdotal evidence as opposed to a survey, that many of those docs, lived through the prior bump up in Medicare reimbursements in 2004 and in 2005, where the congressional delegation got it bumped up so that Medicare was close to private insurance in Alaska. Many doctors said, "Fine, we will take more Medicare patients." That bump up didn't last.

"So I'd say that the first place for reform is, "What are we going to do about Medicare beneficiary access, recognizing it is a problem that is really acute in Anchorage?" ... Currently, in the House and the Senate in Juneau, there are conversations about how do we make a contribution to fix this federal program, the problem it's created for our seniors?"

AHPR: But the patients did!

Foster: But the patients did, and the doctors don't want to, as a general proposition, be divorcing patients, so now they have these additional patients on their panel. And now they are managing now, a patient that went from let's say $100 for a particular procedure, now it goes down to $60. Well, if I have ten percent of those, I am starting to feel that. Meanwhile, costs continue to escalate, labor costs, other various costs. Are they too high? Who knows? They were able to manage that.

But anyway, so 2009 comes along, and they put a bump up in there, and is that permanent, or not? Don't know. Plus, we have the sustainable growth rate formula lurking in Washington DC. Are they going to fix that or not? Extend it for one year, or is that going to go for two years? The uncertainty that you create in that reimbursement system, I think for many doctors, is sufficient for them to say, "I am limiting my exposure to Medicare, to somewhere around ten percent of my patient panel," for primary care doctors in Anchorage. There are some exceptions to that, but there are just a few.

So I'd say that the first place for reform is, "What are we going to do about Medicare beneficiary access, recognizing it is a problem that is really acute in Anchorage? " It looks a lot like acute Medicaid access problems in other metropolitan statistical areas. But in those areas, the state has flexibility to deal with it; whereas, the Medicare program is federal. And so the state has limited flexibility to deal with a Medicare problem. It doesn't have direct reimbursement leverage, so then it has to figure out indirect ways to do that.

Currently, in the House and the Senate in Juneau, there are conversations about how do we make a contribution to fix this federal program, the problem it's created for our seniors? There's a Medicare clinic under consideration. There's, I think, other efforts to provide funding to the community health centers, to expand that capacity. I am hopeful that both of those initiatives will be successful, in terms of creating some capacities specifically for Medicare beneficiaries, and especially our senior Medicare beneficiaries.

So I think it's an acute problem that we really need to get fixed. Because I just don't think we want to have a health care system where we are basically saying, "Sorry, no primary care doctors can afford to take you under the program you are in, and you can go to the emergency room, or the community health center. " That doesn't strike me as that's where we want to be. I think we need to figure out how we expand that capacity across the system, rather than narrowing it for primary care, for that entry into the health care system.

I do think there are some promising things that are going on, beyond those fixes that I've just mentioned, that I hope will get some funding, so expanding capacity. Nurse practitioners are also looking around in Alaska, looking for opportunities to grow their business. And I think some of them have a slightly bigger appetite than maybe a primary care practice with a doc, and all the associated sort of services that they offer. And so, my anecdotal evidence is that there are some nurse practitioner practices that are sort of experimenting with 15, 20 percent Medicare panel, payer panels, to see how that works out for them.

So there is, sort of opportunities out there, people trying to make the mix. But I don't think, given the rapid increase that we see in seniors in Alaska, those little fixes are going to get us there. I think we need to create some more capacity. That's short-term reform pitch that we need to do. I mean, there are lots of other bigger issues, but I think it's, in my mind, just sort of stepping back from that policy piece ... and I will even characterize it as sort of a pragmatic political consideration: If I can't take care of my seniors in my community, it strikes me as it's going to be hard to sell on expansion of health care to the uninsured, if I'm not even taking care of my seniors.

If I'm going to sell an expansion, it strikes me I need to sell an expansion of a system that is working, as opposed to an expansion of a system that is clearly not working. And I think that's one of my concerns, that we really need to fix some of the immediate problems, I think just to generate support for other, broader reform proposals. Now other states, they don't nearly have the same acute problem that we do. I think that's one of the challenges Alaska has, is this particular market has evolved differently than other places, it's a little bit of an island economy. And it has some unique problems we that need to work on together, I hope.

AHPR: Well, just my last question on the Medicare issue -- I want to ask it in this way, just to see how you respond. I want to ask the question: Is Medicare, the feds, paying too little, or are the physicians in Alaska charging too much?

Foster: I would say the evidence that I have suggests to me that Medicare is paying too little. And let me outline why I think that is: When I look across longitudinal studies of reimbursements and physician supply, I do see market responses to the reimbursement levels for Alaska. So that if I really do have higher reimbursement levels, I do tend to attract, all other things being equal, more physicians into the Alaska pool, and that capacity that's then available to see more patients. Now, I also believe, with more limited evidence, that if I constrain the reimbursements and basically make physician practice less attractive, that it will be more difficult to attract and retain the population of providers that we have.

And keep in mind, it really is a labor market analysis. The other evidence that I would have in support of that is looking at some studies that have been done by others in rural health matters. Going, "Okay, how do we attract doctors into the rural areas?" And frequently you find, that all other things being equal, rural doctors, on a purchase power parity basis, are making more than their urban counterparts. In other words, even though they may not be making as much nominally, let's say the physician in Seattle might be making, a primary care physician might be making $160,000 a year, and their rural counterpart in Spokane might be making -- or even further out in a more rural setting -- I think might be making $140,000. The cost of living, typically, in the smaller rural areas is less, and so when you make the adjustment for that, you frequently find the purchase power of the rural position is higher, than the one in the urban setting in primary care.

AHPR: That may not work so well in Alaska, because the rural areas are so expensive.

Foster: Yes, but they frequently, as a result, also have compensatory measures. Housing is frequently paid for, and other allowances are included in there, so when you stack it all up, it's not unusual to find that, in fact, physicians, nurses, do okay in Alaska, on a purchase power parity basis. Even though if you look at one component or another, it may look like they are not getting covered for their cost of living. When I total the packages up, it's not unusual to find that they are doing okay.

" ' ... in Maryland, for hospitals, the state said, "We want to simplify the system and not have multiple prices for the same service, ... . Let's try and get rid of that.' ... Medicare, Medicaid, and the private insurance folks agree[d] to a payment system where they are basically all paying the same amount for hospital services ... "

AHPR: Well, I appreciate the detail of your research. So, moving along towards the end, I just have one or two more questions. Recently, you and I had a kind of a brief discussion about the all-payer system in Maryland. Would you please talk about how that works, and how it may or may not be applicable in Alaska?

Foster: Sure. Basically, once upon a time, and I want to say it might be even 30 years ago now, in Maryland, for hospitals, the state said, "We want to simplify the system and not have multiple prices for the same service, so they have this discrimination between patients. Let's try and get rid of that." So they were able to get a waiver, and basically have Medicare, Medicaid, and the private insurance folks agree to a payment system where they are basically all paying the same amount for hospital services, to really levelize, if you will, the playing field between the players, and simplify the hospital's life considerably.

The net effect of that, from the point of view of Medicare in particular, has been that they have contained costs relative to cost growth in other states, so they look like a relative leader in actually keeping the costs under control, which was different than the expectation. The federal agency was very worried that the state, once it had the ability to manipulate the pricing, would be able to jack up the rates, and make the federal government pay more for Medicare, right? Well, the state only asked to put in a little bit for Medicaid, so maybe it's willing to pay a little bit more to get more reimbursement through these other different systems.

Turned out that the dynamic was much more complicated than that, because not only did you have the private insurance payers also in the mix, but you had the employers also looking over to say, "Hey, how fast am I increasing my rates?" And the net effect of simplifying the rates, and the state still having some skin in the game, if you will, in Medicaid, and being responsive to local political pressure, is that I think in net, they really did kind of contain costs, perhaps better than the other systems that evolved over the last 30 years.

And in Alaska, I think the challenge we have is that we really do have an even more fragmented system in some ways, than other states, because we have large islands of care, not only just sort of the employer-sponsored private insurance, Medicare, and Medicaid, but we have a large footprint with the Indian Health Service, and we have a large footprint with the VA Tricare, relative to other states. And so to the extent we can simplify how those various interests buy service from hospitals, doctors, nurses, etc., I think it will go a long way toward making it easier to basically focus on, "How do we provide the care?" rather than, "Okay, we have these complicated systems of reimbursement, how do we take advantage of those and work within them?"

Let's take that reimbursement system and make it very simple, so we can spend most of our time focusing on the provisioning of care, and making that effective. And so I think there is a lot of, a lot to be said for that. And I think, bundled payments and sort of paying for value, and diagnostic related groups sort of payments are steps in that direction to make it simple. I think we should try to explore even, sort of broader things that go beyond just one program or another. Let's look at all of them. We've only got 700,000 people here. It's just not that big to warrant a lot of fragmentation with these various government programs and how they pay, the rules and conditions. Now I think we really do impose a relatively high level of overhead on the providers, compared to some other places as a result of that.

AHPR: So I confess complete ignorance about how Maryland does this, or did this. Do they have a regulatory commission like ... ?

Foster: They have a rate-setting system, not unlike the regulatory commission that looks at hospital rates, yes.

AHPR: In other words they only need to get the hospitals to agree? Because, I mean normally, for example, a hospital would, or actually an insurer would negotiate with the hospital to try to get lower rates for them, or their clients, the insurer's clients. And you are saying that the hospital just says to the insurer, "I'm sorry we can't negotiate?"

Foster: The hospital says "We've got a system here that's an all-payer system," so all payers line up and have, go through the same rate-making process. And so that really reduces everybody's overhead, in terms of having to negotiate a bunch of separate contracts.

"I haven't looked at state legislation in detail. The stuff I have been looking at recently is how ... do we solve the Medicare access problem? So that's what I'm focused on, and based on what I see in terms of the population need, and the current disparities in access, I want to promote multiple solutions, rather than attempting one small one."

AHPR: Well, thanks for talking about that. Was the implication that you think this might be a good idea for Alaska someday? I haven't heard of any bills that actually promote this.

Foster: No, I haven't seen much. I've seen some work out of Yale, where the folks there have been talking about it as a potential solution for states, if federal reform doesn't go through. Are there other simple ways to help move toward reform for states? And I think that is one of them that's been kicked around. I think within the Senate bill, there's language in the bill there to have the federal agencies get together, and talk about "How do we increase access?" And so I think that would be an opportunity to go, "Okay, what can we do to improve the system and make it easier for patients to access it?" And ultimately, I think what you wind up getting to is, "How do we make it simpler for providers to access the system as well, and connect up with their patients?"

AHPR: Talking about legislation, is there any legislation right now in the state hoppers that's of interest to you? Good, bad?

Foster: I haven't looked at state legislation in detail. The stuff I have been looking at recently is how well would a Medicare clinic that's specialized, and the Community Health Center -- how do we solve the Medicare access problem? So that's what I'm focused on, and based on what I see in terms of the population need, and the current disparities in access, I want to promote multiple solutions, rather than attempting one small one. Because I think the problem is big enough it requires multiple solutions at creating capacity for the seniors.

AHPR: I just want to ask one last question: Is there anything else that you would like to say to the readers of Alaska Health Policy Review, anything in closing or any subject we didn't discuss that you feel is important to bring up?

Foster: Take care of your families. That's where health starts, I think, is basically in the household. And everyone taking care of each other, and making sure that when they have a need, they get it taken care of.

AHPR: Thank you very much.

Foster: Thank you.

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Take Alaska Health Policy Class in Fall 2010 ... In Your Jammies!

Early warning! AHPR Editor Lawrence Weiss will be teaching HS 690 Alaska Health Policy in Fall 2010, a class offered by the Master of Public Health Program at UAA. This course is also open to persons who are not in the MPH program with permission of the department. It will be entirely online so you can do most of it at 2 a.m. in your jammies if you like.

The focus will be on health-related public policy in Alaska. The educational style will be fast-moving, highly interactive, and intellectually challenging. The curriculum will explore what health policy is, what impact it has on day-to-day practical operation of health care, how it is created, who influences it, and how national policies may affect health policy in Alaska.

Teleconferenced guest speakers will include some or all of the following: state legislators, lobbyists, program administrators, and advocates. Main source materials will include selections from approximately 1,800 pages of back issues of Alaska Health Policy Review, and a variety of relevant websites and other online resources. Students will conduct a high priority health policy analysis with practical application in Alaska, and will have the opportunity to have it reviewed for possible publication in Alaska Health Policy Review.

Sound interesting? Contact Katie Frost, ankrf@uaa.alaska.edu, administrative assistant in the UAA Department of Health Sciences. Ask her to put you on the "interested" list for HS 690 Alaska Health Policy so you can learn more about it and have the opportunity to sign up later this year. This class will be interesting, fun, and a great opportunity to network with like-minded health policy wonks!

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Alaska Health Policy Review is sent to individual and group subscribers for their exclusive use. Please contact us for information regarding significant discounts for multiple subscriptions within a single organization. Distributing copies of the Alaska Health Policy Review is prohibited under copyright restrictions without written permission from the editor; however, we encourage the use of a few sentences from an issue for reviews and other "Fair Use."

We appreciate your referral of colleagues to akhealthpolicy.org in order to obtain a sample copy. The Alaska Center for Public Policy holds the copyright for Alaska Health Policy Review. Your respect for our copyright allows us to continue to provide this service to you.

For all related matters, please contact the editor, Lawrence D. Weiss, at health.policy.review@gmail.com.

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Health Policy Calendar

This calendar of health policy-related meetings is current as of March 25 at 10:00 AM. Please visit the Alaska State Legislature's list of committee hearings for the most current listings, as they are subject to change.

Friday, March 26, 1:30 PM
What: House Finance Standing Committee
Where: House Finance 519, Juneau
Other Information: HB 52 Post-Trial Juror Counseling; HB 235 Prof Student Exchange Loan Forgiveness; Bills previously heard/scheduled; Teleconferenced

Friday, March 26. 2010, 1:30 PM
What: Senate Finance Standing Committee
Where: Senate Finance 532, Juneau
Other Information: HB 302 Mental Health Budget; Bills previously heard/scheduled; Teleconferenced

April 28-30, 2010
What: The 4th Biennial Alaska Rural Health Conference
Where: Sheraton Anchorage Hotel
Other Information: "Planning for the Decade Ahead;" Access additional information and register here.

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Bill Watch: Bills on the Move

Yet another busy week for health policy bills. As with last week, several bills are making their way through committees, and being passed on to be considered in the opposing chamber. One bill, HJR 46 Supporting Denali Commission was transmitted to the governor for signature on March 19.

HB 284 Pioneer Home Rx Drug Benefit was scheduled but not heard in (H) STA on March 23. SB 215 Pioneer Home Rx Drug Benefit passed unanimously in the Senate, was transmitted to the House on March 23, and was referred to (H) STA on March 24. HB 50 Limit Overtime for Registered Nurses was heard in and moved out (H) FIN on March 23, and moved from (H) RLS to Calendar on March 25. HB 110 Psychologists' Licensing & Practice was scheduled but not heard due to a (S) EDC meeting cancellation on March 19.

HB 235 Prof Student Exchange Loan Forgiveness is scheduled to be heard in (H) FIN on March 26. HB 282 Naturopaths was heard in, amended, and CSHB 282 moved out of (H) L&C on March 19, and referred to (H) HSS on March 22. HB 392 Incentives for Certain Medical Providers was heard and held in (H) HSS on March 18, and heard and held again on March 23.

HB 260 Medicaid: Preventive Care/Disease Mgt. was heard and amended in (H) HSS on March 23, and CSHB 260 was referred to (H) FIN on March 24. HB 270 Medicaid for Medical and Intermediate Care was heard and held in (H) HSS on March 23. HB 292 Grants to Disaster Victims was heard in and moved out of (H) FIN on March 24. HB 328 Traumatic Brain Injury: Program/Medicaid (CSHB 328) was referred to (H) FIN on March 19.

SB 13 Medical Assistance Eligibility was heard in and moved out of (H) HSS on March 18, and referred to (H) FIN on March 19. SB 199 Medicaid Coverage for Dentures was heard in and moved out of (H) HSS on March 18 and referred to (H) FIN on March 19. SB 238 Medicaid for Medical and Intermediate Care was read for the second time and passed unanimously in the Senate, and was transmitted to the House for a first reading on March 23; and was referred to (H) HSS on March 24. SB 296 Long-Term Care Insurance was heard and held in (S) L&C on March 23.

HB 52 Post-Trial Juror Counseling is scheduled to be heard in (H) FIN on March 26. HB 302 Mental Health Budget is scheduled to be heard in (S) FIN daily this week. SB 263 Extend Board of Professional Counselors was heard in and moved out of (S) FIN on March 23, and moved from (S) RLS to Calendar on March 25. SB 172 Alaska Health Care Commission was referred to (S) FIN on March 18.

SB 247 Extending Board of Pharmacy was heard in and moved out of (S) FIN on March 23, and moved from (S) RLS to Calendar on March 25. SB 248 Extend Bd of Marital & Family Therapy was heard in and moved out of (S) FIN on March 23, and moved from (S) RLS to Calendar on March 25. HB 314 Workers' Compensation (CSHB 314) was heard in and moved out of (H) FIN on March 22, and referred to (H) RLS on March 23. HB 346 Workers' Compensation Advisory Board was heard and held in (H) FIN on March 22.

HR 14 Oppose Federal Health Reform Bills was heard in and moved out of (H) RLS, read for the second time, then returned again to (H) RLS on March 19. HJR 46 Supporting Denali Commission was transmitted to the governor on March 19. HB 354 AK Capstone Avionics Revolving Loan Fund was moved from (H) RLS to Calendar on March 25. HB 361 CPR Training for 911 Dispatchers
was scheduled to be heard in (H) HSS on March 25.

SCR 13 Supporting Senior Caregivers was read for the second time and passed unanimously in the Senate, and referred to the House for a first reading on March 18, and CSSCR 13 read for the first time in the House and referred to (H) HSS on March 19.

The following is a list of all health-related bills recently proposed or sitting in various legislative committees. For a description of the process of selecting and tracking health policy bills, as well as the full names of committees and their abbreviations, refer to the end of the Bill Watch section.

Bill information is current as of March 25 at 10:00 AM.

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Bill Watch: Drugs

Bill Watch: Health Professional Workforce and Health Education

Bill Watch: Medical Assistance and Health Insurance

A framework for personal choice: This bill facilitates a relationship between health insurance providers and individuals, and doesn't assume that a one size fits all solution will meet the health care needs of all Alaskans.

A unique voucher system: By pooling money from all stakeholders, a sliding scale voucher system will ensure that every Alaskan can take personal responsibility for acquiring health insurance coverage. The system will also make it easy for multiple entities to contribute towards a health plan for an individual.

A health care clearinghouse: The clearinghouse will disseminate information about quality health care products, assisting Alaskans who are utilizing vouchers under the Alaska health care plan.

The Alaska health care fund: This fund will receive contributions from individuals, businesses and government to ensure that all interested parties contribute to the health of Alaskans.

Bill Watch: Mental Health

HB 52 Post-Trial Juror Counseling
Sponsor: Rep. Kerttula
Committee(s) and date of last action: Scheduled to be heard in (H) FIN at 1:30 PM, 03/26/10
Description: This bill proposes to make available up to 10 hours of psychological counseling for any juror serving in a criminal trial where graphic images or content are presented.

HB 302 Mental Health Budget
Sponsor: Rules by request of the Governor
Committee(s) and date of last action: Scheduled to be heard in (S) FIN every day this week, 03/23/10-03/25/10
Description: Appropriates $195 million to mental health, with a $161 million operating budget from the general fund, $2 million from federal funds, and $33 million from other sources of funding.

SB 21 Mental Health Care Insurance Benefit
Sponsor: Senators Davis and Ellis
Committee(s) and date of last action: Read and referred to (S) HSS, then (S) L&C, then (S) FIN, 01/21/09
Description: This bill proposes to implement parity in the types of medical services covered under existing health insurance plans. Specifically, it proposes that health care insurance policies be prohibited from denying coverage or discriminating health care services related to mental health, alcoholism or substance abuse; that there be no difference in coverage between physical and mental health coverage; and that these changes take effect no later than July 1, 2009.

SB 66 Mental Health Patient Grievances
Sponsor: Sen. Davis
Committee(s) and date of last action: (S) HSS, 01/21/09
Description: This bill proposes new regulations related to patient grievances in a mental health setting. Specifically, it aims to streamline the grievance process so as to ensure that patients' rights are honored and are not deterred by the grievance filing process.

SB 231 Mental Health Budget
Sponsor: Rules by request of the Governor
Committee(s) and date of last action: Heard in (S) FIN, 02/10/10
Description: This is the companion bill for HB 302.

SB 263 Extend Board of Professional Counselors
Sponsor: Rules by Request of Leg Budget and Audit
Committee(s) and date of last action: Heard in and moved out of (S) FIN, 03/23/10, moved from (S) RLS to Calendar, 03/25/10
Description: This bill proposes to extend the termination date of the Board of Professional Counselors by ten years, from June 30, 2010 to June 30, 2018, to take effect immediately upon signature.

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Bill Watch: State Boards and Issues

Bill Watch: Family Health Issues

Bill Watch: Worker's Compensation

HB 314 Workers' Compensation
Sponsor: Labor and Commerce Committee
Committee(s) and date of last action: Heard in and moved out of (H) FIN, 03/22/10, referred to (H) RLS, 03/23/10
Description: This bill is "An Act relating to fees and charges for medical treatment or services, the crime of unsworn falsification, investigations, and penalties as they relate to workers' compensation; and providing for an effective date.

HB 346 Workers' Compensation Advisory Board
Sponsor: Rep. Olson
Committee(s) and date of last action: Heard and held in (H) FIN on 03/22/10
Other Information: This bill proposes that a Workers' Compensation Advisory Board be established, with a variety of members who would be required to meet every six months. If established, the bill would take effect immediately, and the Board would be in place until June 30, 2015.

SB 20 Worker's Comp Medical/Rehab Records
Sponsors: Senators French and Thomas
Committee(s) and date of last action: Read and referred to (S) L&C, then (S) JUD, 01/21/09
Description: This bill proposes that any documents containing personal and confidential information of an employee that is receiving, or has received, worker's compensation, are kept in a confidential location away from the public's view.

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Bill Watch: General Health Policy

HB 71 Advance Health Care Directives Registry

Bill Watch: Bill Tracking Methodology

Bills listed here were selected based on a series of subjective criteria to determine whether they were "health-policy related." All bills currently sitting in the Senate and House Health and Social Services committees were examined, and any that obviously dealt with non-health-related education or social services issues were eliminated. Every other House and Senate committee was then examined for health-related bills, which were included in the final list.

After determining the full set of health-related bills still in committee or pre-filed for the new session, they were divided into several general categories. This was done to facilitate finding bills that dealt with certain key health policy issues and to make overall navigation of the list easier. The remaining bills were categorized as "general" health policy-related because of the wide range of subjects they covered.

The information listed for each bill includes the bill number, the short title, the primary sponsor or sponsors, the committee in which the last action on the bill took place, and the date on which the last action on the bill took place. A short summary of each bill is also included.

Abbreviations have been used for committee names. The committee names and their abbreviations are:

(H) HSS: House Health and Social Services Committee
(S) HSS: Senate Health and Social Services Committee
(H) L&C: House Labor & Commerce Committee
(S) L&C: Senate Labor & Commerce Committee
(H) EDC: House Education Committee
(S) EDC: Senate Education Committee
(H) FIN: House Finance Committee
(S) FIN: Senate Finance Committee
(H) JUD: House Judiciary Committee
(S) JUD: Senate Judiciary Committee
(H) STA: House State Affairs Committee
(S) STA: Senate State Affairs Committee
(S) RLS: Senate Rules Committee
(H) CRA: House Community and Regional Affairs Committee

AHPR Staff and Contributors

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

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A standard 12-month subscription to Alaska Health Policy Review is available for $850. Please inquire about discount rates for multiple recipients in the same organization, legislators, and small nonprofit organizations.

Don't miss an issue! Send orders, comments, and inquiries to Lawrence D. Weiss at health.policy.review@gmail.com, or call (907) 276-2277.

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