Alaska Health Policy Review

Dear Reader,

These days the big question among local health policy wonks as well as families and business owners is, "How will health reform at the national level affect Alaskans?" Let me just say that those who want to analyze the facts as well as those who want to spin their story are not standing idly by the wayside. Oh, no. The churning of fact, analysis, and spin has begun in earnest, and we will be focusing on much of it in the coming months.

Early yesterday morning, (April 15, 2010) I attended a two-hour meeting sponsored by the Commonwealth North Health Care Action Coalition. I have attended meetings by the coalition before, and the presentations are usually very interesting and informative. This morning's meeting was no exception.

The first hour was taken up by a dense and extremely informative presentation by Deb Erickson, executive director of the Alaska Health Care Commission. Impressively, she plopped on the table a four-inch thick binder full of little colored sticky notes popping out every which way. Yes, she has read The Patient Protection and Affordable Care Act (H.R. 3590) and the accompanying Health Care and Education Reconciliation Act -- a total of nearly 1,200 single-spaced pages -- and summarized her first take on how it will affect Alaskans. Fascinating!

Her presentation was followed closely by three teleconferenced presentations which took up the entire second hour, with no time for more than one or two questions during the entire morning. The first speaker was Bruce Scandling, Senator Begich's legislative aide on health policy. The second speaker was Holly Croft, Representative Don Young's legislative aide on health policy, and the third was Amanda Makki, Senator Murkowski's legislative aide on health policy. Let's just say that Scandling's cup was half-full, while Croft's and Makki's cups were half empty.

Our tape recorder was running the entire time, and our intention is to produce a transcript of all these discussions. Right now, we are worn out from the intense pace of the session and the weekly publication schedule of Alaska Health Policy Review, but I suspect we will send out the next issue of the Review the first week of May with this series of presentations transcribed for your reading edification.

In the meantime, I am pleased to present an interview with Wayne Stevens, long-time president and chief executive Officer of the Alaska State Chamber of Commerce. He has concerns about what national health reform will bring business owners, and he does not mince his words in the interview that follows.

Lawrence D. Weiss PhD, MS

Editor, AHPR

ldweiss@acpp.info

Interview with Wayne Stevens from Alaska State Chamber of Commerce

Wayne Stevens, president and chief executive officer of the Alaska State Chamber of Commerce since 2004, came to Alaska in 1971. Since 1982, he has participated in 15 different public service organizations throughout the state including the Kodiak Island Borough Mental Health Advisory Board, Foraker operations board, and in various leadership positions for Kodiak's hospital. He served as executive director of the Kodiak Chamber of Commerce from 1985 to 2004, and is currently a voting member of the Alaska Health Care Commission. In this interview, he discusses his view on the interconnectedness of corporate profits, taxes, health care costs, and distorted perceptions about doctors and health care. Cheeseburgers, alcohol, and cigarettes figure prominently in the discussion. We discuss some novel ideas for improving access to health care in Alaska, and Stevens shares his pride in the strengths of the current health care commission and the need to make it a permanent entity in Alaska. This interview, conducted March 25, has been edited for length and clarity.

Links to selected topics

New Hospital and New Medical Culture in Kodiak
The Expectation That Government Will Take Care of Us
The Words "Profit" and "Obscene"
Some Guy From the Governor's Office Called
Legislation Followed By The Chamber
2,800 Pages of Health Reform
Two Interesting Concepts

AHPR: You have had an historic involvement with health policy issues going back to the days when you were living in Kodiak. You were on the borough Mental Health Advisory Board, and you had various leadership positions in Kodiak's hospital. Currently you are on the Alaska Health Care Commission. That's a pretty substantial background in health issues for somebody, I would think, in your current position.

New Hospital and New Medical Culture in Kodiak

Stevens: I got elected to the Kodiak Island borough assembly in 1986, and won my election by three votes. I thought I did three years of good duty, and did what I thought was right for the community. When it came time for reelection, then I promptly got unelected by 200 votes or so. The mayor asked me if I would stay involved, and he needed somebody to volunteer to sit on the hospital board. I [said,] "Sure." I have a management background. My mom was a nurse [and my] two sisters are nurses, so I have at least a passing knowledge of some of the issues.

I've served on a hospital board, [so there was] obviously the opportunity to learn and gain insight and knowledge. I will never profess to be fluent in all aspects of health care, but I have at least a passing interest in it, and have through my volunteer service been involved in it for almost 20 plus years now -- serving on the hospital board in Kodiak, the mental health board for, as the assembly representative to the mental health board, and then the health care commission. Off and on over 20 years I've had opportunity to participate in the discussion and offer my nickel ninety-eight of input into processes and discussions about where we go and how we do things.

In Kodiak we had a very small local community hospital and clearly needed to grow the facility, to grow the business, and to lessen the impact of people leaving the community to get health care -- so we did an almost 65,000 square foot addition to the hospital facility in Kodiak, and [we] did a capital campaign. Folks told us we would never raise $1 million, and we did in no time flat. It was interesting to watch traffic volumes, patient visits, and the change in attitude of people working at the facility when they had a nice new facility to work in, and space, and improved flow. You take something built in the '60s, and try to do something 30 years later with technology and requirements and all of the things have changed, it just makes it very, very difficult to get excited about coming in to work every day sometimes.

So the change in perceptions, the increase in utilization of the facility, and the increase of the specialties offered at the facility over a ten-year period were just remarkable. It changed the whole perception of health care in Kodiak, in terms of accessibility, availability -- and the specialties that were offered just exponentially increased. That wasn't to say that there weren't good people there, it's just there were a lot more good people there now, that are doing a lot more. You have a family doc, but then now you've got a urologist, and a gynecologist, and a cardiologist, and all the specialties [such as] asthma and things that were coming and adding to the offerings of the facility.

It was really, I thought, pretty remarkable, and excited me about the possibilities. For some reason in Alaska, my observation is that we've had this perception that if you're in Alaska, you're not as good as if you were at Minneapolis, or Seattle, or somewhere else -- whether it be health care, or a lawyer, or whatever position you're in. I think we've, over time, changed that perception.

Do you recall the days where no matter what you were doing, you always had to go to Seattle to do it? I mean, look at what Providence [Hospital] has done, and Alaska Regional. Look at the facilities in Fairbanks that exist and what the Native health community has done. The need to leave the state to get good care has diminished dramatically, but there's still people who, because of the way they were introduced to Alaska and its conditions and the economy at the time, still feel like to get good whatever it is, whether it's health care [or] otherwise, you have to go to Seattle or somewhere else. You know, there's been this dramatic shift. You don't hear people talking about having to go out of state to do some of the things you need and get done. Back to selected topics list

"I think we've had a significant change in public perception about how things work in this country, and not just health care. We have created an expectation, rightly or wrongly, that government will take care of us."

AHPR: So now, coming up a couple of decades, you're in the Alaska Health Care Commission. What is your perception of the current issues in health care, perhaps as compared to the days when you were in Kodiak?

The Expectation That Government Will Take Care of Us

Stevens: Well, I think the issues are far more complex, the emotions are far rawer. I think we've had a significant change in public perception about how things work in this country, and not just health care. We have created an expectation, rightly or wrongly, that government will take care of us. [Considering] that we don't have to pay income tax in the state of Alaska, we are very fortunate as a state. We don't, as individuals, contribute to the greater good of the state. We contribute to the greater good of our communities whether that be through sales tax or property tax, but we don't contribute at the state level unless you're in business and pay corporate taxes or royalties. But as citizens, every year for just being here and breathing, we get a dividend based on the hard work of someone else and the willingness to take risks by someone else.

We've removed ourselves as individuals and citizens from where stuff comes from. Milk comes from Safeway, electricity comes from the socket out of the wall. We've forgotten [that] to put that electricity to be available at that socket in the wall, you had to burn coal, or you had to burn diesel, or you had to burn natural gas, and that takes resource extraction. You have to have the oil industry to get milk home from the grocery store. It would be very difficult to be laying in the emergency room, and look around the emergency room at all the things they're using -- including the IV bag and the line to put the saline solution or whatever they're pumping in to you -- to save your sorry soul at that moment you're in the emergency room, without the oil industry.

Yet we collectively, not individually, we have this "us against them" mentality instead of viewing people as our partners. Pre-pipeline, if a community decided they wanted to build something in their community, whether it be a gym or a pool or a new road or a fire hall, they sat down and talked about what it would take, what their needs were, how much they were all willing to put in the pot to make it happen, and then assess themselves. Today we go, "Well, the government needs to give me X amount of dollars to get this done." We've disconnected ourselves from those processes, rightly or wrongly -- my observation.

" ... how do we engage the nation, the country, the community, the state, in acknowledging that health care is your own responsibility? It's not the governments job to take care of me."

AHPR: Is this an issue that came up somehow in the health commission meetings?

Stevens: Well, I'm going to lead to there. We as a society -- gross generalization probably -- the perception is that we have the world's best medical care, so I can do whatever I want, and all I have to do is go the hospital and they'll give me a pill and do a quick something or other and fix me, and I'll be okay. But again, there's no involvement by the individual on the front end. Now whether it be where my milk comes from, where my electricity comes from, or where my health comes from, it's just, "Somebody will take care of it."

It wasn't until about May [2009], with a series of presentations that we were getting, and there were just this myriad of presentations on different facets of health care. I just was thinking to myself, listening to some of these presentations, that in a year's time, a group of eight volunteers and a couple of staff people are never going to be able to winnow this discussion down to something that people can get their arms around, in terms of how do we wrestle the issue of health care, its costs, to the ground. We can blame tort, we can blame insurance companies, we can blame anybody we want, but ultimately whose responsible for our health? Us.

It seems simple, but when you read some of the reports about childhood diabetes, obesity, and you look around and you start observing those kinds of conditions, you think, "My goodness, we have just let ourselves just go to hell in hand basket." Myself included. I need to lose 40 pounds. I'll be the first to admit it, but we haven't acknowledged that.

In May we had a presentation on the drivers of health care costs. In the interest of simplification, we have [1] personal behavior as a driver of costs -- cheeseburgers, alcohol, cigarettes, things you do your body [or] don't do your body, exercise; [2] environment, where you live, what you live next to, who you live with; [3] genetics, which most of us have very little control over. We got what we got from whence we got it, and you can't change it. Then, the [4] actual costs of health care which is the cost of getting an MRI, or going to the hospital, or seeing a doctor, or all of those things. The percentages, roughly, are 50, 20, 20, and 10. We're holding this national debate about 10 percent of the problem and ignoring the easiest part of it, which is 50 percent of the problem, which is us, our personal behaviors.

It hit me that we've wrapped our whole nation around the axle on 10 percent of the problem, and we're literally ignoring the 50 percent elephant in the room. In terms of how you convey that message -- I mean nobody wants to be told, "Wayne, you're overweight, you need exercise, you need to do this, you need to do this." Yeah, yeah, yeah, I know, but you don't change your behavior. You think about it maybe more, because somebody is chippin' at you about it, but how do we engage the nation, the country, the community, the state, in acknowledging that health care is your own responsibility? It's not the governments job to take care of me.

Again, that's a gross oversimplification, but as a country, as a society, we deal in sound bites. How do you take an exceptionally complex problem and winnow down to something manageable? It's not the insurance companies fault that I am 40 pounds overweight, and my blood pressure goes up, and whatever comes from your behavior. It's not the insurance company's fault that you use the system far more than others. Every time we use the system it drives the cost up, so if they charge $100 and you take $200 out of the system, they need to charge more to cover paying for those costs. Back to selected topics list

The Words "Profit" and "Obscene"

Somewhere along the trail, I don't know when, but for some reason profits have become a bad thing. Whether it's an oil company or an insurance company or a bank, profits have become bad. When did the words "profit" and "obscene" become inextricably intertwined? On the same hand, everybody's got a retirement account, and they're expecting from their financial advisors and whoever's managing their money to get 15 percent return on investment. Well if your financial advisor and the company buys stock in an insurance company, or stock in an oil company, they're holding those companies' feet to the fire to get that return on investment, so your retirement portfolio grows.

But we're not connecting all the dots. If I don't take care of my health and I cost the insurance company more money to pay for the things that I go use and they can't be profitable, then they can't pay profit dividends to the retirement company, who is in turn, paying me at the end of the game for investing and growing my nest egg. It's all intertwined.

I guess where I'm trying to go is, it's bigger than health care. But how do you take it and reduce it down to that 30-second sound bite? Nobody wants to be told that, "You can fix everything by just being a better person." Well, yeah, I know that but that's not the problem.

"If business isn't profitable, there's nothing for government to tax. If the government has nothing to tax, then there is nothing to spend on the things that we have dictated as a society that we want them to spend it on."

AHPR: Can you talk just a little bit about the mission, the membership, and the activities of the Alaska State Chamber of Commerce?

Stevens: The mission is to promote a positive business environment in Alaska. Our membership ranges from small mom-and-pop operations with two or three employees, to some of the largest employers in the state. Unlike a local chamber we don't get involved with litter control, we don't get involved with running the crab festival in Kodiak, or whatever. We take on statewide issues that impact all business whether they be in Kodiak, Anchorage, Fairbanks, or Ketchikan or Barrow; whether that be workers' comp [compensation] issues or health care issues -- trying to create an environment where business can be successful, where they can be profitable.

Back to my profit issue ... A lot of what we spend on health care, whether it be for Medicare or Medicaid -- all the myriad of programs that come from the government -- the government gets its money from one place. Each of us individually may contribute a little bit in income tax, but [looking at] percentages, business pays the lion's share of taxes to government. If business isn't profitable, there's nothing for government to tax. If the government has nothing to tax, then there is nothing to spend on the things that we have dictated as a society that we want them to spend it on.

Again, things are all connected, and profits aren't bad. If a company is profitable, it's paying taxes, and if it's paying taxes, then there's money to pay for things like Medicare and Medicaid. Somehow we have to connect the dots. [If] you live in Anchorage and you own property as an individual, it seems like a lot of money when the $5000 bill comes at the end of the year, but who are the top 10 taxpayers in the city of Anchorage? They aren't individuals, they're business. If the business community isn't here, then it changes the dynamics of it. Back to selected topics list

Some Guy From the Governor's Office Called

AHPR: How did you end up on the Alaska Health Care Commission, if I may ask?

Stevens: Some guy from the governor's office called and said, "Hey, we just issued this administrative order last month, and you guys are named in it." And I went, "Really?" He said, "Can you get somebody for us to volunteer?" I said, "Well, okay." So I reached out to some of my board members, and they weren't inclined to serve. I said, "Well, I don't know if what you're looking for, or who you want, but I've got a background with being involved with health care issues in Kodiak, and I have a little bit of interest in the issue, and I have a modicum of understanding of some of the top three percent of the problem." They said, "Oh, okay." I checked with the board and they said, "Oh, okay, good, we don't have to do it."

AHPR: And there you are!

Stevens: And there I am, going, "How the hell did that happen?"

"If your mechanic sees you flying your airplane more than 100 hours, he's having a conniption fit. Yet we've taken a piece of equipment, our body, that's far more complex than an airplane, and drive it by the hundred-hour checkup all the time."

AHPR: I think this is pretty recent news, that the Alaska State Chamber of Commerce recently joined the Foraker Group to offer their health plan. And of course, the health plan with the Foraker Group was developed specifically for nonprofit organizations. Apparently they have expanded beyond that. How did that happen, or why was the Alaska State Chamber of Commerce interested in a health plan developed for nonprofit organizations?

Stevens: Many years ago there was a program available to Chambers of Commerce in Alaska, United Chambers Insurance Plan (UCIP). In Kodiak we participated in it, and it offered access to our members to be able to be part of a larger pool. At some juncture in the mid-90s I guess -- my dates are fuzzy at this juncture -- the rules of engagement for the health insurance industry changed in Alaska. Many companies just couldn't participate and left the state. In Kodiak, and then with the state chamber, I continued to look for and seek out [the answer to this question], "How can we find some way to access a program that allows our membership the opportunity to participate in a larger pool?"

I have been serving on the Foraker operations board for a number of years, working with Dennis McMillian. I have watched and participated as Foraker went through the exercise of trying to create a pool for nonprofits. I kind of watched and observed and thought, "Gee, be creative and they could get this thing going" [if] I could figure out a way to bring our pool of potential insurers to their pool of potential insurers. Over time Dennis and I would talk about how we might do that, but we couldn't do anything until they got the plan up and running. It took a number of years to get their process plan approved.

After a year of running their plan, we had continued that conversation about how do you grow their pool, and how do we meet the requirements of the state insurance, all that stuff. Dennis and Jeff Ranf with Wallace Group, worked very diligently to say, "Okay, this is for nonprofits, and the state chamber's a nonprofit. Can we connect the two and via the state chamber as a portal and allow their members to access the plan?" With lots of work from a lot of folks -- Linda Hall at the division of insurance, lots of folks -- we were able to provide our members an additional opportunity, or benefit, to access the health care plan.

Now, I'm not an insurance broker nor licensed to do so, but as I understand it, it's more of a wellness insurance versus sickness insurance. It focuses on wellness. They want to ensure healthy people. They want to encourage healthy people to do the right things -- exercise, watch their diet, go get your annual physical.

In Alaska we've got more pilots than anywhere else in the country. If your mechanic sees you flying your airplane more than 100 hours, he's having a conniption fit. Yet we've taken a piece of equipment, our body, that's far more complex than an airplane, and drive it by the hundred-hour checkup all the time. Drive it right by the thousand-hour checkup all the time, and think nothing of it. Then, when it breaks down, expect somebody to work miracles to put it all back together. But we don't do that to our boat, we don't do that to our airplanes, why do we do it to ourselves? The program intrigued me. We were able to kind of put all the pieces together, and we were able to bring our membership a new opportunity.

AHPR: Is this health plan being offered to business owners, or business employees, or both?

Stevens: The business has to be a member of the state chamber, and the employer has to buy the plan for their employees. I don't believe that, as an individual working [at] a company, I could come and buy it for myself. I'd have to do it through my employer.

AHPR: Is the chamber following any particular pieces of state legislation regarding health policy or health issues? For example, it appears as though the chamber is interested in a couple of pieces of legislation dealing with workers' compensation in this state. What are the chamber's interests in that kind of health legislation in general in the state? Back to selected topics list

Legislation Followed By The Chamber

Stevens: Senator Olson introduced a bill to create the health care commission in statute [SB 172 "An Act establishing the Alaska Health Care Commission in the Department of Health and Social Services; and providing for an effective date."]. The commission, as it currently is comprised, ends here very shortly, or has ended, under the administrative order administered by the governor. To continue that body and to continue the work and recommendations that came out of the health care commission, one of them was to create the health care commission as an ongoing entity, advising the governor and the state legislature on health care issues. The state chamber has a position supporting that.

In terms of workers' comp, one of the big costs of doing business is buying and providing, as required by law, workers' compensation for your employees. Any time you have changes to that system, the potential for those costs to escalate goes up very quickly. Workers' comp is not an arbitrary thing where I can say, "Well, I only want to buy this piece of it, or this piece of it." It's not an a la carte operation. You either buy it or you're in trouble, if you have employees. If I'm a sole proprietor, I don't have to buy it, but I'm also responsible if I fall down and hurt myself on the job.
I don't have the bills in front of me so I can't speak specifically, but we've been involved in the issue of worker's comp for many, many years on behalf of business trying to help find ways to control costs, and to make sure that as the decisions are made, those decision makers understand the implications of what they're suggesting. There are, as in any discussion, examples of issues from one end of the spectrum to the other, that cause people to want to change law or change statute.
So we try to say, "Well if you do this, here's what we think is going to happen, here's what it's going to do to costs. And when costs go [up], well, you're just passing that on to the consumer." If a 16-year old cuts themself with a slicer at the deli shop, and they implement a new law saying, "16-year olds can't run the slicer," now you got to hire 18-year olds. There's fewer 18-year olds interested in working in that arena, then you have to pay more money to attract them, and that drives the cost of deli sandwiches up. So again, there is cause and effect in understanding how all of those things interconnect. Part of what we try to do is make sure that that information gets into the discussion.

"Maybe incrementally we've at least started some of the dialogue. ... Conversely, it [may be that] nothing happens. I guess I'm always the eternal optimist. Good people can do good things if they stay focused."

AHPR: Going back to the bill that Senator Olson introduced, does the chamber have an interest in seeing that a statewide health commission exists on a permanent basis?

Stevens: Oh, absolutely. Health care costs for the individual, for the employer, continue to escalate. Somehow we've got to a find a way to arrest that escalation. The Foraker health plan is one method by which we might start to do that. The work of the commission is to at least get the dialogue going about some of the issues -- back to earlier in the conversation -- about personal behaviors and accepting responsibility for those personal behaviors. If you can at least get the dialogue started, then you've made incremental progress.

Interestingly enough, in the last couple, three weeks -- both in the [Anchorage] Daily News and [Alaska] Journal of Commerce -- there were articles about some of the drivers of health care cost [are] the things we do or don't do. Maybe incrementally we've at least started some of the dialogue. I'm hopeful that having the commission discussing issues, addressing concerns, being able to make recommendations to the legislator and the governor on a path forward, has a huge upside. Conversely, it [may be that] nothing happens. I guess I'm always the eternal optimist. Good people can do good things if they stay focused.

After a year plus on the health care commission, I was exceptionally proud of the work that we did. It wasn't a large group -- seven or eight people -- and each of those individuals work or have a specific interest but were able to think beyond just their personal interest and acknowledge other concerns and other parties and fields of interest in the discussion in a way that I think was pretty inclusive. My greatest fear is that we create a new commission that becomes a "Me, too." Suddenly you've got 50 or 60 people -- that's the outward extreme obviously. Well, if all of these people have to have a seat at the table, then pretty soon you become factionalized and gridlock occurs.

The beauty of the recommendation for a small group was the right people at the table being able to think beyond just their slice of interest and expertise and say, "But what about, how do we incorporate, how do we make sure that all of these issues are brought to the table?" The process of presentations and information gathering, from a wide range of sources and interests, I think, provided the basis from which seven or eight people could hold a dialogue and say, "What about this, or what about this, and how do we package it in a way to where we get where we need to go?"

AHPR: And did that process seem to work well in the current Health Care Commission?

Stevens: I thought it worked remarkably well. You had a group of individuals who were willing to work together, willing to set aside their own personal quiver for a moment and say, "We're working on something bigger than me and my interest." I was pleasantly surprised and very proud of the product that we produced and then turned into the governor on time. Now what gets done with that remains to be seen, and what the legislature will do, because certainly the minute you start talking about creating something long-term, well, you have to have this representation and that representation and this perspective and that perspective. It kind of starts very small and becomes the big mushroom. It's not to say it can't work, just my experience is that the bigger the group, the harder it is to come to consensus and come to conclusions and get traction and go forward. Back to selected topics list

2,800 Pages of Health Reform

AHPR: Moving on to a larger issue, nationally, we've had some pretty monumental health reform legislation passed.

Stevens: I've not read the 2,800 pages, so I have no idea what's in there.

"Nobody wants a child to have a need for good health and it not be met, but if they live with a smoker and they've got asthma, is it the state's responsibility to pay for the asthma or is the parent's responsibility to quit smoking?"

AHPR: Does the state chamber have a position on that, or have suggestions, or have a take on it?

Stevens: That's the challenge: you got a 2700, 2800, 2900-page bill that most people, myself included, have not read. Even if I read it, you can take this piece of the puzzle, and I'll keep this piece, so you're trying to reduce whatever the volume of information is, down to the 30-second sound bite, "health care for all." Great sound bite, but they don't ask the question, "At what cost?" Once you determine cost, then whose going to pay for it? Well, if we don't want people to make profits, and there aren't any taxes, how are you going to pay for it? It's all interconnected.

So, do we have a take on it? It's so overwhelming we've not entered into it. It's a federal issue, and we've tried to stay focused on the state issue. The health care commission seems to be one way that on a smaller regional basis we can have a dialogue and discussion about how we can impact our costs. What people need to remember is that every state, even though federal government runs the program, there's still a contribution that comes out of the state coffers every year for Medicare and Medicaid. We talk about controlling the costs of state government, and when you talk about state government we usually talk about the people all in the building around the corner [i.e. legislative offices in down town Anchorage], as our vision of what state government is.

But you could eliminate every position in the state of Alaska and their employment, and the budget's still going to continue to grow rather rapidly because of the cost of entitlement programs like Medicare, Medicaid and others. How do you weigh that? Nobody wants a child to have a need for good health and it not be met, but if they live with a smoker and they've got asthma, is it the state's responsibility to pay for the asthma or is the parent's responsibility to quit smoking? [It's] just a rhetorical question and I don't have a quick answer to it. Again, that's back to personal behavior and environment which is about 70 percent of the problem.

AHPR: Is it your general impression that business owners value the ability to provide health insurance, or health coverage for employees?

Stevens: Generally I would say, to be competitive in the employee market, those kinds of benefits and the provision of those kinds of benefits have been sort of an accepted way of attracting and retaining top-notch people. Look at the number of people in the state of Alaska who have gone back to work for the state in the last four or five years because the clock was ticking towards the end of anybody who had some Tier 1 eligibility but were not yet vested in the program. They're not going back to work for the state because of the retirement or because of the joy of working for a large bureaucracy. They're going back because of the health care benefit to them at retirement that's huge.

Employers I think recognize the value of benefits to their employees beyond just the compensation, remuneration for work. The challenge becomes how to continue to pay for it without driving the cost of cheeseburgers to the point where nobody can afford them. As an aside, and I don't have an opinion, a fellow was up here when they were doing the Best Beginnings early childhood education stuff, from North Carolina. He and I had a long conversation about health care. There was a book, Tyranny of Dead Ideas, and the guy talks about when did it become businesses' responsibility to provide for the social well-being of their employees? He has some interesting premises and I'm still kind of churning that whole thing around in my brain. I haven't really come to any conclusions, but he raises some interesting questions about how did we get here and where do we go from here? I'm not sure I agree with all of his conclusions, but it's an interesting discussion.

" ... something that I think we've spent far too much time in the last 50 years ingraining into people -- that government is the solution to everything and it's the cure for what ails you. Government will take care of it."

AHPR: Let me ask you about an idea that has come up in a number of other states and is growing very rapidly in our neighbor state of Washington. That is the idea of pre-paid primary care. I'm not sure if you're familiar with this idea or not. I would just like to get your take on it, whether you think the business community might be interested in this idea.

The premise is that health insurance, even through Foraker's health insurance, costs quite a bit per person. We know that here in Alaska as well as nationwide, small and medium-sized businesses have been shedding health insurance altogether for employees. This organization, Qliance -- which is the one I know in Seattle that does this, but there are many others across the nation -- has come up as a way of kind of bridging the gap in terms of the cost of health insurance, and dealing with both employers and people that don't have it.

They run a primary care clinic, like a family practice clinic, but a rather large one. They sell memberships to it, just as if they were a health club, for example. You pay a monthly fee, and for that monthly fee you can use it basically all you want. The monthly fees in Seattle range from $40-$80 a month. It's based entirely on your age, so for young people it's $40 and for elderly people it's $80. You sign an agreement when you sign up for this, and the agreement lists in great detail all the services you get for that amount of money per month. It's all the basic primary care stuff. A lot of it is prevention, a lot of it is health education, but then there's all the standard stuff like vaccinations, and annual exams. It's all written in their contract, and in fact you can find that on their website where they have a copy of it.

This is called, "pre-paid primary care," or "direct-pay primary care," and it's an idea that's kind of spreading across the nation. In health care, the general concept of pre-payment is kind of an old idea, but doing it in this way for just primary care, for basically at a fraction of the cost of regular health insurance, is a really interesting idea, I think. It doesn't replace full health insurance so, for example, in some places there are insurance brokers who are combining a "catastrophic" or "high deductible" health insurance policy with a subscription to Qliance or some other pre-paid primary care health clinic. There are no co-payments, there are no deductibles, you just pay that monthly fee and in you go. Does that sound conceptually like an interesting idea, do you think? Back to selected topics list

Two Interesting Concepts

Stevens: When you just said, "pre-paid health care club," like a gym subscription or membership ...

AHPR: It's just an analogy.

Stevens: I understand, but my first thought was, "That's a great deal for the guy who's selling it," because most people with all honorable intentions, buy a membership at the health club and then never use it. So you have to wonder how many people who subscribe to a pre-paid health plan actually go in and use it. I have no idea. That was just sort of my first out-of-the-box thought in the head. It's certainly an interesting concept. There are a number of programs and plans along those lines, that's sort of a la carte. A lot of health care plans don't include dental coverage because from an insurance perspective, if you collect $1000 in premiums for insurance for dental care, in a year's times you spend $1000 on dental care, so it's a wash.

There are programs were you can buy a la carte. I guess in premise, it's almost the same as a pre-paid, "I'm going to buy some dental health insurance." It'll cover my annual exam every year, it's a basic cleaning and repair of minor stuff, but it doesn't cover crowns and the whole surgery or those kinds of things where the cost escalates very quickly. So it's certainly probably not a totally new idea. I haven't done any sort of in-depth reading or research on the process, but it's well worth pursuing.

The model I find intriguing is what the folks [are doing] over at the [Alaska Native Tribal Health Consortium] -- Val Davidson and Dr. Eby and those folks. Just a remarkable approach to the delivery of health care, and it combines some of that personal responsibility stuff. My girlfriend works for SEARHC [SouthEast Alaska Regional Health Consortium], and they're slowly inching their way trying to replicate the model that the Tribal ANTHC has put together here. It's probably a little easier to do, where you have a defined population in a region, to be able to put that kind of plan together.

In the pure consumer market where there are multiple choices and multiple opportunities to come and go, it might be a little more of a challenge but certainly offers a model that has great interest. We invited Dr. Eby to our conference in Homer in September. You've heard Dr. Eby speak before I'm sure. He's enthusiastic and he tends to go well beyond the allotted time slot. We had him speak at lunch on the second day, and there were 100 people in the room at the start of lunch, and there were almost 100 people there at 30 minutes beyond the allotted time because he was engaging and entertaining and had a message that was resonating within the business community.

I was very encouraged because business people have a propensity to, if they don't see a direct applicability to what they're doing at the moment, they're wandering off to the next thing -- going to check their e-mail, go to answer phone messages, deal with the next crisis du jour -- but they stayed and they listened. And so back to an earlier part of our conversation, I think there's an opportunity here to at least get the dialogue going, that while we have come to expect that there's a silver bullet to cure everything that's wrong with us, and all you have to do is sit at home every night and watch the medical shows. In an hour's time you can find that you're deathly ill and be cured, and if it doesn't work out perfectly, you go to the next show and the law firms will take care of it for you.

Our expectations are clouded by messaging we get from outside, but we don't put enough thought into what really drives the cost of health care. If you and I make a pool, and I am perfectly healthy and you suddenly have a heart attack, and we're both putting $100 in the pot, suddenly I've put a lot more money in to cover your heart attack and vice versa. If we both are working to be healthy, there's a higher likelihood that both of our costs will stay low. Somehow [we have to] reduce that conversation down to, "It's not up to somebody else to take care of you, it's up to you to take care of you." That is something that I think we've spent far too much time in the last 50 years ingraining into people -- that government is the solution to everything and it's the cure for what ails you. Government will take care of it.

AHPR: Do you have any last comments you'd like to tell our readers, as we wrap up the interview?

Stevens: There are no easy answers. In spite of what the politicians will tell you in their 30-second sound bite, it's a hugely complex problem with multitudes of interest, top to bottom, that aren't necessarily always in alignment. The one thing that we should be able to agree on is that it is not somebody else's responsibility to take care of me, it's my responsibility to take care of me. If I do the things that can help me be healthy, then the cost of taking care of me will go down, and ultimately the cost of insurance will go down.

I can remember as a kid going to see the doctor, Dr. Brown. Mom, as an RN, was always loathe to take us to a doctor when she was sure that she knew what it was. I never had stitches until I was an adult because mom's cure for everything, a deep cut, was butterfly bandages. "You don't need stitches. Butterfly bandage." Her frugality is annoying, but I don't have too many scars that I can't live with.

He'd look at you and talk to you and make a diagnosis, and on you go. He didn't send out for a CT scan or an MRI, or nuclear, or whatever. Our expectations have been altered. If I go to the doctor and he just looks at me and says, "Well, this is what I think is wrong, and based on all the information you've given me and all the knowledge I have, here's what you need to do." Well, if I'm not happy with that, [I might think] "Why didn't I get a CT scan, and why didn't he order this?"

We end up with this set of expectations that if I go to the doctor, I need lots of corresponding testing to affirm the opinion and knowledge of the doctor. If for some reason he doesn't do it right, then I go to the lawyer to seek compensation for his inability, so now even if he knows what's exactly wrong with me, he's going to order a battery of tests to protect his insurance so he doesn't get a visit from the lawyer. We've created this system, again, all interconnected and all intertwined, based on expectations.

If we don't change our expectations, then we're not going to change the outcome. The expectation should be that [if] I am responsible for my 100-hour maintenance on my airplane, I should be responsible for my maintenance on my body. We can go on for hours whether that's a good idea or bad idea, and they're certainly examples of why people less fortunate don't have that ability, and all of those things. But we can at least start the dialogue -- the dialogue being that I have some responsibility, that it's not somebody else's responsibility to take care of me, and that there are no easy answers to any of it. Because if it were easy, I would've lost 40 pounds a long time ago! But it is what it is. Back to selected topics list

AHPR: Thank you very much for taking the time to share your ideas with the readers of Alaska Health Policy Review.

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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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Health Policy Calendar

This calendar of health policy-related meetings is current as of April 1 at 9:00 AM. Please visit the Alaska State Legislature's list of committee hearings for the most current listings, as they are subject to change.

April 22-23
What: Alaska Tobacco Control Alliance Annual Summit
Where: Challenger Learning Center of Alaska; Kenai, Alaska.
Other Information:Nursing CEUs will be offered for much of the summit, and there will be outstanding national and local experts presenting. Special hotel rates are available for attendees. For specific details on the summit, see the schedule at-a-glance, and email alaskatca@gmail.comif you have any additional questions.

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

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: Heard and held in (S) FIN, 04/13/10
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: Receiving hearings in both the House and Senate, 04/15/10
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: Passed in the House and is awaiting transmittal to the Governor, 04/14/10
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: Scheduled to be heard in (S) FIN, 04/15/10
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

Sponsors: Representatives Holmes, Dahlstrom, Millett, and Kawasaki
Committee(s) and date of last action: Heard in and moved out of (H) JUD, 03/15/10, referred to (H) FIN, 03/17/10
Description: This bill 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.

HB 168 Trauma Care Centers/Fund
Sponsor: Rep. Coghill
Committee(s) and date of last action: Passed in the House and referred to the Senate, 04/09/10; Read for the first time and referred to (S) FIN, where it was heard and held on 04/14/10
Description: "An Act relating to state certification and designation of trauma centers; creating the uncompensated trauma care fund to offset uncompensated trauma care provided at certified and designated trauma centers; and providing for an effective date."

HB 304 Ban Smoking in Public Places
Sponsors: Representatives Salmon and Buch
Committee(s) and date of last action: Read and referred to (H) STA, then (H) JUD, 01/19/10
Description: This bill proposes to amend current laws related to smoking in public places, as well as smoking in any enclosed establishment serving as a place of employment. It includes several specific areas where smoking should be prohibited, including waiting areas for public transportation, facilities providing mental health services, legislative buildings, and health clubs.

HB 354 AK Capstone Avionics Revolving Loan Fund
Sponsor: Rep. Keller
Committee(s) and date of last action: Heard and moved out of (S) FIN, referred to (S) RLS, 04/13/10
Other Information: This bill proposes an amendment to existing legislation on avionics loan funding, to include both owners and leasers of aircraft. The legislation would apply to medevac carriers who lease their aircraft. Representative Keller proposed the bill to increase air traffic safety, stating on his website, "The program was developed to provide low-interest loans to in-state private and commercial aircraft owners to upgrade their avionics, or on-board navigational aids and computer systems."

HB 361 CPR Training for 911 Dispatchers
Sponsor: Rep. Fairclough
Committee(s) and date of last action: Heard and held in (H) FIN, 04/05/10
Other Information: This bill proposes that all 911 dispatchers be required to have certification in cardiopulmonary resuscitation (CPR) prior to their employment.

HB 399 Community Health Assessments
Sponsor: Rep. Cissna
Committee(s) and date of last action: Introduced and referred to (H) HSS, 02/23/10
Other Information: This bill would establish a health impact assessment program within the Department of Health and Social Services, with the goal of creating healthy communities and reducing health disparities, to take effect July 1, 2012.

HB 423 Policy for Securing Health Care Services
Sponsor: House Judiciary Committee
Committee(s) and date of last action: Heard and amended in (H) HSS, 04/09/10; heard in and moved CSHB 423 out of (H) JUD, 04/12/10
Other Information: This bill is also known as the "Alaska Health Freedom Act." It proposes that the Attorney General enforce a new policy in the Alaska Statutes that states that Alaska residents have the right to choose or decline any form of health care and health insurance, and without a penalty or fine.

HJR 46 Supporting Denali Commission
Sponsor: Community and Regional Affairs committee (CRA)
Committee(s) and date of last action: Transmitted to the Governor, 3/19/10
Other Information: This bill urges Congressional support of the Denali Commission.

HR 14 Oppose Federal Health Reform Bills
Sponsor: Rep. Chenault
Committee(s) and date of last action: Heard in and moved out of (H) RLS, read for the second time, then returned again to (H) RLS, 3/19/10
Other Information: This bill proposes a list of negative consequences to Alaska, and suggests "that the House of Representatives urges the Alaska Congressional delegation to vote against the current health care reform bills and to develop health care reform that is affordable and accessible to all legal residents," and "that the House of Representatives urges Governor Parnell and the Administration to review the constitutionality of the special deal for other states contained in the current federal health care reform bills." Once passed, it is requested that the resolution be sent to President Obama.

SB 41 New Driver's/Permit: CPR/First Aid
Sponsor: Sen. Ellis by request of the Governor
Committee(s) and date of last action: Read and referred to (S) HSS, then to (S) STA, 01/20/09
Description: This bill requests that new applications for driver's permits or licenses only be issued to individuals who have completed cardiopulmonary resuscitation and first aid training in the one year prior to the application. This does not apply for individuals who have already obtained a driver's license or permit in Alaska or another state, and is to be effective January 1, 2010.

SB 49 Blood Donation Awareness Fund
Sponsor: Sen. McGuire
Committee(s) and date of last action: Moved to (S) FIN, 02/27/09
Description: This bill requests that the opportunity to donate $1 or more to the Blood Donation Fund be made available to all applicants for motor vehicle or identification documents. These donations would be place in the Blood Donation Awareness Fund, and would be used to promote blood donation activities throughout Alaska.

SB 168 Trauma Care Centers/Fund
Sponsor: Health and Social Services, by request of the Governor
Committee(s) and date of last action: Scheduled to be heard in (S) HSS at 1:30 PM on February 10
Description: This is the Senate companion bill to HB 168, and is identical.

SB 169 Approp: Trauma Care Fund
Sponsor: Health and Social Services, by request of the Governor
Committee(s) and date of last action: Heard in (S) FIN, 03/10/10
Description: "An Act appropriating $5,000,000 to the uncompensated trauma care fund; and providing for an effective date."

SCR 13 Supporting Senior Caregivers
Sponsors: Senators Bund and McGuire
Committee(s) and date of last action: Heard in and moved out of (H) HSS, 04/05/10; Read for the second time and passed in the House, 04/06/10; Awaiting transmittal to Governor, 04/07/10
Other Information: This bill proposes, "Supporting senior caregivers and encouraging the Department of Health and Social Services to provide additional education on the effects of aging and the importance of senior caregivers."

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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.

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