Alaska Health Policy Review
comprehensive, authoritative, nonpartisan
July 26, 2010 - Vol 4, Issue 17
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From the Editor
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Dear Reader:
We have three great feature articles in this issue of Alaska Health Policy Review. Read what Dr. Jay Butler has to say from his new vantage point in the Alaska Native Tribal Health Center. Peruse what Pat Luby has to say as advocacy director of AARP Alaska. Finally, visualize the players around the table in Wilson Justin's up-close commentary on negotiating compacting with the IHS.
"But wait, there's more!" as the Ronco ad man on TV yells into the microphone. Feeling antsy? Perhaps you are thinking, "I want to leap out of my chair and help make national policy!" If this is what you are thinking, we have just the thing for you. Here are some excerpts of very interesting opportunities and resources sent my way in a recent communication by Jessica Larochelle, field director, Families USA:
The Departments of Health and Human Services, Labor, and Treasury released several regulations to implement a new Patients' Bill of Rights under the Patient Protection and Affordable Care Act. The regulations will prohibit discrimination based on pre-existing conditions for children; ban lifetime limits on coverage, as well as place restrictions on annual limits; forbid unfair rescissions of coverage; restrict cost-sharing for emergency services; and put into place many other patient protections. Comments are due by August 27, 2010 and the rules go into effect September 23, 2010. You can comment directly to HHS. And, if you have not already commented on previously released regulations, you still have time! The interim final rules on dependent coverage and grandfathered plans are still open for comment until August 11 and August 16, respectively. Information on all the rules can be found here. On July 1, the Administration also launched the web portal, www.healthcare.gov, to help consumers navigate their coverage options and understand their rights under the new law. As you navigate the site, you'll see many yellow comment boxes to submit your suggestions. While healthcare.gov is already a tremendous clearinghouse for information, please provide any insights you might have to make the site even stronger. To stay up-to-the-minute on health reform implementation, please also sign up for email updates at www.hhs.gov and www.healthcare.gov.
Yes, these are exciting times in health policy locally and nationally. We'll try our best to keep you informed.
Lawrence D. Weiss PhD, MS
Editor, AHPR
ldweiss@acpp.info
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Interview with Dr. Jay Butler of Alaska Native Tribal Health Consortium
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 Dr. Jay Butler has a long and varied career in health policy in and out of Alaska. However, about three months ago he assumed the position of director for Community Health Services at the Alaska Native Tribal Health Consortium (ANTHC). In this interview, we discuss the construction and destruction of silos; the relationship between public health, sewage, and water; and the likely consequences of new federal policy on the health status of Alaska Natives. We caught up with Dr. Butler in his office and interviewed him June 24, 2010. This transcript of the interview has been edited for clarity and length.
Links to Selected Topics
ANTHC Making the Transition to a Tribally-administered Health Care Nonprofit
"A broad palette of opportunities" for ANTHC
Living Together: Who Brings What to the House
The Challenge of the 21st Century: Improving Health, Not Just Delivering "Health Care"
Silos Have a Place But Should Function As Part of a Larger System of Health Care Provision
ANTHC Making the Transition to a Tribally-administered Health Care Nonprofit
AHPR: Over the years you've held various positions in and out of Alaska with the CDC, the state and now ANTHC [Alaska Native Tribal Health Consortium], and maybe other places that I don't even know about. I wonder if you could give us sort of the progression of your career over the last ten, dozen years.
Butler: I would describe it as a progression that's a little bit opposite from the way a lot of people do -- at least in academic medicine. It's been from a real subspecialty emphasis when before I came to Alaska, when I was in Atlanta. Clinically, I was doing specialty work in infectious diseases but in the two thirds of my time that I spent at CDC I was really subspecialized specifically on bacterial causes of respiratory tract infections. Very focused in. Coming to Alaska, working for the Arctic Investigations Program, backing off a little bit, much more broad range of infectious diseases, which I found very satisfying. Getting more into, on the clinical side, issues surrounding infection control which began to open a more general door to me in things like health care quality. When I went over to the state, indeed that opened up even more.
AHPR: And roughly when was that? When you went to the state.
Butler: 2005. As state epidemiologist really beginning to look at the broader array of public health programs, and what we do to address the emerging problems facing Americans, which are more and more chronic diseases. I was from a background where emerging generally talked about new viruses, but looking at what are the trends and the things that are making people ill. As the chief medical officer for two years with the state, then that really gave me a big generalist's view in terms of how health systems work together and how does that impact health, and things that we don't traditionally think of as health-related issues that really do impact our health, such as economic development -- very important in terms of one of the drivers for quality of life as well as length of life.
Coming to the consortium, I'm getting a little different perspective as the generalist now. I feel fortunate that I've been able to look at issues from a number of perspectives at least on the government side, -- state, federal, and now tribal -- and then working for the consortium is also giving me a chance to learn more about how health care looks from the perspective of a private industry or the private sector. This is an organization that is very much in that transition from being a government agency back more than 10 years ago when the services that were provided were done so under the Indian Health Service to now being a tribally-administered health care nonprofit.
"ANTHC is the organization that now operates practically all of the
statewide activities that were previously administered by the area
office of the Indian Health Service. ... the Alaska Native Medical Center, the Division of Environmental
Health and Engineering, and then the Division of Community Health
Services."
AHPR: Great. Let me just jump right in then and ask you this question which is not necessarily in the context of the interview, but I'm really interested in your take on what apparently is a pertussis epidemic in California. Do we need to start being aware of that here in Alaska?
Butler: You raise a number of important issues. One is, infectious diseases are very much global issues and California is not that far from Alaska so any time you have it transmissible disease occurring on the west coast of the Lower 48 we have to consider it in Alaska. I actually don't know the specifics of that particular outbreak, but in sort of a way of background, we have tools now that we didn't have 10 years ago for controlling pertussis, specifically the acellular pertussis vaccine that's now licensed for people our age even, up to age 65.
AHPR: Well, okay thank you. So for some of the readers that may not be particularly familiar with ANTHC, could you just give us a brief overview -- what does it do, what is its budget, how many people does it serve ... that kind of thing? I apologize for asking you questions that may be a little too detailed considering you've only been here a couple months. Still, I'll try. So anyway, did you want to address any of that? Any of those questions like, for example, just in general terms what is ANTHC and what does it do?
Butler: ANTHC is the organization that now operates practically all of the statewide activities that were previously administered by the area office of the Indian Health Service. There are three major business units: the Alaska Native Medical Center, the Division of Environmental Health and Engineering, and then the Division of Community Health Services. It makes ANTHC a fairly unique organization because our business units are direct health care with ANMC, which serves as the secondary or perhaps tertiary care hospital for the Alaska Native Health Systems statewide. DEHE [Division of Environmental Health and Engineering] -- which is really a construction company -- focuses on providing sanitation in rural areas, which is an important component of public health and improving wellness. And then the Division of Community Health Services, which functions in many ways as a partner and to a certain extent as a public health agency carrying out prevention programs. We have the Epidemiology Center in our group, we have also the training program for the Community Health Aide program, so also addressing access to care particularly in the more rural areas.
AHPR: And what is your current position in this structure?
Butler: The title, for what it's worth, is senior director for Community Health Services. I feel like a middle-aged director most of the time not a senior one. I participate in the consortium executive team, so directly report to the president and CEO of the organization who in turn report to the consortium board. I have six departments under me which include wellness and prevention, the epidemiology center, the health aide training program, which includes both the community health aides and the new dental health aide program, behavioral health department which includes the behavioral health aide program, environmental health and safety, and the department of clinical and research support services, which includes both the research activities and some of the direct clinical services activities -- probably the two that are the big players are the hepatitis clinic and the HIV clinic.
AHPR: And those are physically located in ANMC?
Butler: Well, they're on campus here and those clinical services are provided at ANMC. Back to selected topics list
"A broad palette of opportunities" for ANTHC
AHPR: I'd like to jump into just a few of the many programs in your division. To be honest, I was somewhat overwhelmed when I started reading through the list of all the different programs that are under you and in the Division of Community Health Services. I just wanted to ask you about a handful of them because there are just way too many.
Butler: I'll do what I can because it is a very broad palette of activities.
AHPR: Very broad. This is kind of an aside, but you said that the dental health aides are under your purview. If I recall correctly, this was a somewhat controversial program when it first started up. Now I understand that trainings have begun here in Alaska versus New Zealand, and I'm wondering if there's a little less controversy and a little smoother relationships now around this program, or is it still kind of the center of that controversy?
Butler: Well I certainly hope that we have gotten through the time of controversy and that particularly working with the dental society, we are able to define some common goals that we can work together on because I think ultimately our goals are very similar, and that is to improve the health of Alaska Native people, particularly those in rural areas where oral health has become a major health problem.
Recently, I was able to have a meeting with our lieutenant governor who was previously the general over the Alaska Guard, and one of his comments was that poor oral health is one of the major reasons why they are not able to accept people into the National Guard. You've heard some of the news probably about how the obesity epidemic is impacting our military workforce and the flow of new recruits into the national military. We have similar problems more locally because of poor oral health.
AHPR: I had never heard that.
Butler: I hadn't either. I thought that was quite astounding.
AHPR: Moving on again to just a handful of ...
Butler: Let me say just a little more about the dental health aide program. You are correct, that's being done in Alaska now. We've had two classes actually graduate. I think there's been 11 graduates all together. This program is modeled after one that was developed in New Zealand. One time we actually had our first health aides going down there and receiving their training there.
"What I would really hope is that we'll move towards an increasing
partnership where rather than competing for grants ... because I think none of
us will in any time soon be very robust on a national scale in and of
ourselves ... "
AHPR: Well, I'm glad to hear that's happening because I think it will make a major impact on oral health in the rural areas. Moving on to just a couple of your other programs ... The program that I was able to find out the least about is the Department of Clinical and Research Services. I wonder if you could just outline what goes on in that department, and then I'm also particularly interested in the question of recruitment and retention of health care providers. Is that an issue that's addressed in that department?
Butler: This department is the one that is probably the least firmed up into a group. At this point, there are a number of activities that have been put together in one administrative unit. At this point I would have to say I don't think it's entirely gelled yet. Currently we only have an acting director of that group, so I'm going through the process now of looking at what's the best way to manage that group in terms of leadership and administration, exactly what kind of person to have in there. I think another unknown is just where does research fit into the palette of activities in the division and within the consortium. I believe that there is an increasingly good opportunity to do good health research in Alaska, but I do believe it's going to require everybody working together.
We have research activities at the CDC Arctic Investigations Program, in fact the Division of Community Health Services has some of our staff embedded over there, such as Dr. Ross Singleton who oversees the [ANTHC] Immunization Program. There's the Institute of Circumpolar Health Studies. Southcentral Foundation has a research program now. The University of Alaska at Anchorage, of course, has biomedical research as well. What I would really hope is that we'll move towards an increasing partnership where rather than competing for grants we are working together to share resources and achieve the goal because I think none of us will in any time soon be very robust on a national scale in and of ourselves, but working together we could become a player. I'm thinking hard about just what is the niche, what's the piece of that team that ANTHC can contribute best. Back to selected topics list
Living Together: Who Brings What to the House
AHPR: You mentioned a number of major players in the field of medical and health research here in the state. Is there any active collaboration or networking going on at this time with that group that you outlined?
Butler: There's certainly communication that occurs in a number of venues right now. Sometimes it can be fairly informal; we actually had an ad hoc meeting a few weeks ago where the players I just mentioned gathered around the table and used it as an opportunity to update one another on what was going on. We also had a chance to look at that question of what are the partnership opportunities that we're not capitalizing on, so I presented it to the group as this: Okay, we're starting a new semester and we're all going to be moving in together as roommates and there's this wonderful laboratory that's fallen from the sky that we all get to live in as long as we're working together. So let's talk about what we are bringing into the house that we're going to be living together in.
In the course of that conversation, we identified particularly one piece of equipment that very much was needed by the hepatitis program here at ANMC, which actually was available and being underutilized at the university. So that was great because we were already trying to think through what grant can that be in. Instead maybe we can focus now our grant application process on things that will really move us all forward instead of just meeting the needs of our individual studies.
AHPR: Let me just reiterate that question of recruitment and retention of health care providers. Does that fit in anywhere in the schema?
Butler: It really doesn't.
AHPR: Again, I was just trying to review as best as I could the various programs within your division. I see that one of them is the Department of Community Environment and Safety, and it has within it the Center for Climate and Health. I think that's fascinating that there would be a center for climate and health. And I wonder if you could talk a little bit about the current activities and concerns of that center?
Butler: This center, which is led by Doctor Jim Burner and Mike Brubaker, is really trying to assess the impact of climate change in rural Alaska. Some of the examples of the work that has been going on, one that was actually in the paper a couple weeks ago, is looking at food spoilage in ice cellars on the North Slope. Based on some of the initial anecdotal reports of those problems, going in and doing a more objective assessment on what is the "refrigeration quality" in those ice cellars and how is that resource being impacted by climate change. It's a very big issue.
We're really on the front line of climate change in many ways, and being able to get a handle on that and having a program that's really focused on not just investigating individual outbreaks that we think may or may not be related to climate change, but rather scanning the horizon to be able to look at what scenarios could develop over the coming years, and try to help communities be ready to address the likely and low-impact scenario or the less-likely but higher-impact scenario.
I perceive it as being perhaps under the rubric of the Health Impact Assessment, although what we're focused on is not so much the health impact on a community by the project so much as the impact on a community, communities, or region by changes in the climate.
"The epi center is one of about a dozen centers nationwide that focus on
the epidemiology of health and disease among native peoples. ... We're fairly unique
because our epi center is based within the nonprofit health care
operation, the Alaska Native Tribal Health Consortium."
AHPR: The Alaska Native Epidemiological Center is also under your purview. I wonder if there are ongoing studies or recent findings of note you would like to mention?
Butler: Let me just mention a little bit about [the Epidemiological Center.] The epi center is one of about a dozen centers nationwide that focus on the epidemiology of health and disease among native peoples. I've actually been able to attend a meeting with representatives of a number of those epi centers and the tribes they serve, and they're all very different in terms of how they operate, how they partner with their state agencies, how complex or simple the partnerships are.
For example, the epi center in Nashville I think is working with 24 different states. On the other hand, the epi center in the Navajo Nation is working basically with one very large tribe; the Navajo Nation is bigger than a number of U.S. territories in terms of population. Other epi centers are working with numerous tribes. We're fairly unique because our epi center is based within the nonprofit health care operation, the Alaska Native Tribal Health Consortium.
The epi center I see very much as conducting particularly the surveillance activities that are mandated to the state, but partnering with the state to use those data to assess what are both the concerns and the areas of progress in health of native people, and I think one of the ways we're able to get that out is the Alaska Native Health Status Report. Some of that is nuts and bolts, vital statistics, cause of death, with focus on, for instance, cancer as the leading cause of death in Alaska Natives, and then looking at what types of cancer are being reported. It also provides comparison to disease rates among non-Native Alaskans as well as the U.S. as a whole. So it provides data and context to be able to assess Alaska Native health.
The epi center also has some developing prevention programs. One that I think is very exciting is the colorectal screening program, which is getting off the ground. Colorectal cancer is the second leading cause of cancer-mortality among Alaska Natives, second to lung cancer. It's also is exciting because it's really bridging that gap that oftentimes exists all over the place between clinical practice and public health. I think this is a good opportunity to, within our organization, to increase the partnerships between the clinical service side and the public health side.
AHPR: This publication that you handed me, the Alaska Native Health Status Report, is this an annual publication?
Butler: It's not annual. We do have updates that come out online. The nice, glossy publication is fairly pricy, but we're looking at ways to do it more frequently. I'm not sure what the ideal frequency is. Annual, I think, would be terrific. I'm not sure we'll be able to keep pace for that. Back to selected topics list
The Challenge of the 21st Century: Improving Health, Not Just Delivering "Health Care"
AHPR: Looking at the Division of Community Health Services as a whole, what are some of the greatest challenges, in your opinion, the division will be facing in the future that have the potential to interfere with its mission, for example?
Butler: Let's approach it in terms of SWOT analysis [a strategic planning method used to evaluate the Strengths, Weaknesses, Opportunities, and Threats to an organization], if you will. I think you're probably asking specifically about internal challenges or challenges within the health systems, and I think one of the biggest challenges is competition, the tendency towards creating turf and protecting turf, rather than focusing on the goal, which in this organization is the vision of Alaska Natives as the healthiest people on earth. That's a remarkably high goal, and one that no one person, no one group is going to be able to achieve.
I think the external challenges are addressing the problems of what I call 21st century public health. Tobacco, for instance, is an addictive substance that is a major health threat. Alcohol is also addictive and a health threat. People oftentimes use these substances as a way of self-medication. Well, why did they self-medicate? There are issues in their lives that have gone unaddressed, and oftentimes there is an overlay of mental health issues, past history of physical or sexual abuse, cultural factors.
It's not like the 20th century where we made so much progress by focusing on specific problems and developing technical fixes. Small pox eradication -- a terrific public health victory -- and we did that through focus and a technical fix. The 21st century is going to be a little more complicated, so in terms of an external challenge, being able to approach health from a more ecological standpoint I think is going to be a little different paradigm than how we've practiced public health in the past.
That said, I do think there's great opportunity right now. Everybody's trying to figure just what the impact of health care reform is going to be. It's an exciting time in terms of ... I think a lot of smart people looking at the question of how do we improve health, not just deliver so-called "health care" which is really "illness care."
One model that I think is very intriguing is the Institute of Healthcare Improvement's triple aim model, focusing on the patient experience including quality of care, the effectiveness of care, and the satisfaction of the patient, health at the population level, health systems that ideally are having perhaps more empty hospital beds and using those resources in other ways than just to make money by treating disease.
And thirdly, being able to operate in a cost-effective manner. I think sometimes we tend to think efficiency as doing more with less, whereas in fact it's operating smarter, running with greater efficiency. I think of the automobile example: through engineering we can develop cars that have better gas mileage. You get more miles on less gallons of gas. Efficiency is not just driving more and putting less gas into the tank, because the system will break down.
" ... my approach is if we have common interests, we need to work together to
achieve those. If we can agree on where we disagree, then I think we can
set those boundaries and agree that those are areas where our interests
may be at odds."
AHPR: You raised a couple of issues like tobacco, for example, and alcohol. It seems to me that there has historically been something of a tension between the Native health care systems and the state, and I wonder if there is active collaboration at a policy level for example in terms of issues like tobacco and alcohol -- obviously there's a shared interest at those levels.
Butler: That's a very broad question. Certainly in specific issues we've been able to partner, and I'm actually going to speak more from the state perspective, we've been able to partner well with the Native health system. It's always interesting to sit on the other side of the table and see how it looks from that perspective. I'm still learning that viewpoint, but certainly my approach is if we have common interests, we need to work together to achieve those. If we can agree on where we disagree, then I think we can set those boundaries and agree that those are areas where our interests may be at odds.
AHPR: Looking at the slightly larger picture, I've long been fascinated by the melding of health care delivery on the one hand, and the classic public health interests of water and sewage construction and maintenance on the other in one organization: ANTHC. I don't really know of any other organization that does this. I'm wondering to what extent does your division have regular interaction or collaboration with the Division of Environmental Health and Engineering on those kinds of issues.
Butler: We certainly have very common interests, and just in the recent past I think much of the collaboration has been through the activities of the CDC Arctic Investigations program, and looking at what is the health risk from lack of sanitation, and trying to quantify that better, and then setting up surveillance systems to assess the impact. It's not cheap to bring sanitation into these villages, and the more we can make the case for what the savings will be in the health care system, I think the stronger it will be.
The data suggests that hospitalization rates among children for respiratory tract infections and skin and soft tissue infections are higher in those villages without sanitation, and it's practically a dose response when you compare those villages with the lowest proportion of homes with plumbed water and flush toilets compared to those with higher proportions. It's very interesting data, and I think it's very important because we're talking about an intervention that, even though it seems very basic, is not cheap because of the particular engineering challenges in rural Alaska. In some ways this is 19th century public health. We've talked about 20th and 21st, but we're really talking about the things that were done in major cities in the Lower 48 or in Europe during the 1800s. Back to selected topics list
Silos Have a Place But Should Function As Part of a Larger System of Health Care Provision
AHPR: I think you addressed this a little bit but I just wanted to bring it up again to see if you have additional information. Looking at a statewide perspective, it's become increasingly clear to me and of course to many others that the coordinated delivery of health care to all the people of Alaska is in partly hampered by institutional and programmatic silos that deliver health services to targeted groups of people but fail to coordinate or collaborate in a meaningful way. Is this an issue of interest in terms of the work of the Division of Community Health Services.
Butler: Absolutely, and I was just marveling at how well you said that because I think that is one of the challenges. You answered my question earlier much better than I did in the form of your next question. The breaking down of silos, I think, is one of the critical factors. There's nothing wrong with silos. Silos were made for a specific function. We use that analogy because we think in terms of bureaucratic structures that don't communicate with one another. Those bureaucratic structures generally were created for a reason but they were not created to be completely freestanding or to be the only structure that stores grain; they were intended to be part of a system of food production. Similarly, we have to look at how each of those silos functions within the larger system for the end of providing health care across the state.
That response is a little bit "ivory tower" and ethereal. What does that mean in terms of what I'm trying to do different? One of the things I'll be doing [in] becoming more familiar with the program here and my program managers and department chiefs, is going out to the regions and meeting with the community health program directors out in the areas to understand better what can we do to support them in the work that they're doing. In some ways I'm beginning to conceive the department, community health services, as being somewhat to the region what CDC is to that states. The work is really done at the states. CDC helps to facilitate that through technical support, funding, and whatever is needed to help link those entities together. I think similarly the real "boots on the ground" prevention work is being done out in the communities. It's not being done necessarily from this shop.
AHPR: On an inter-organizational relationship level -- I'm thinking of collaboration or other kinds of relationships, for example the VA system, the community health centers, Premera Blue Cross -- are there any kinds of relationships going on there or attempting to be created?
Butler: I think it's a great idea, and certainly you're thinking along the same lines I'm thinking along. I can't point to any examples of that that we have going at this time, but I think that's the direction we need to go in.
AHPR: This again is something you touched on earlier, moving to the national perspective now, how do you anticipate that health care reform at the federal level may be impacting or influencing the work of ANTHC in general or the work of the Division of Community Health Services in particular in the coming years?
Butler: Two things come to mind. Of course the caveat is that the Patient Protection and Affordable Care Act is huge both in scope and number of pages. I think everybody is still getting their heads around what it says. But two things come to mind. One is the reauthorization of the Indian Health Care Improvement Act. That makes it possible for the funding particularly that comes through the Indian Health Service to be more in keeping with the needs. Those funds had been pretty much frozen for a number of years. Certainly, I found when I was with the state, one of the biggest misperceptions about the tribal health care system is that it was all covered by federal funds. In fact only about half of operating costs are covered by Indian Health Service funds.
The other component of that bill, which I think is going to particularly impact the Division of Community Health Services, is the wellness and prevention component. With increasing funding going each year to prevention and wellness -- the goal of $2 billion by 2014 -- part of that is specifically worded -- state, tribal and local health department support -- so tribal entities are clearly being recognized in that. Some of that money goes to community health prevention programs that are funded through the CDC.
Dr. Frieden has come into the CDC as director and has done some reorganization. The biggest part of that reorganization is within his office, and how he has set up a system of deputy directors, and there is now an office of state, tribal, local, and territorial health services. That's a fairly big paradigm shift, because now at the CDC level they're viewing tribal entities as governments that provide public health services just as states, counties, cities, and territories do.
That's a major shift from the past where tribal health was addressed from offices of minority health, which really changed the dynamic because it wasn't recognizing the tribes as necessarily government entities so much as representing a proportion of the population that may have particular risks or different health status for any variety of reasons. It also failed to recognize that there are tribally administered health systems that can be used as a tool to influence health.
The downside of that is that the tribal entities are playing with the big boys now when we compete for grants. It's going to be competing against entities like the state of California with a population base of 38 million people. It's a different playing field. I think it's an appropriate one, but it's one that we'll have to be agile to be able to compete well on.
AHPR: As you were talking I was thinking about the question of Medicaid. It seems to me Medicaid is going to be pretty dramatically affected by the changes at the national level, and it seems to me there's a lot of overlap between Native peoples and Medicaid -- Denali KidCare thrown in there, too. Do you have any comments on that, from that perspective?
Butler: I really don't at this time. The analysis is going on within our organization as well as at the state in terms of what can be done, and what will the impact of the federal legislation be.
AHPR: We have reached the end of my previously prepared questions. I wonder if there's anything else you would like to say to the readers of the Alaska Health Policy Review.
"It's a time of change, and it's a time when I think a lot of people are
concerned about change. ... I think everybody's a
little edgy."
Butler: This may be a broad closing comment. It's a time of change, and it's a time when I think a lot of people are concerned about change. Is it good change? Is it bad change? We're also in a time of economic downturn. We have issues in the state in terms of what's going to be happening with the price of oil. Our petroleum-based economy locally, how is that going to impact us? I think everybody's a little edgy.
On the other hand, there's a big question of is it best to get through challenging times by hunkering down, or is it better to look at how to adapt and best deal with these changes? I'm not sure that I know the absolute best answer to that, but I think it's a time of opportunity to address problems that are not only being raised by the economic downturn, but also to address some of our longstanding problems such as relatively skyrocketing price of health care compared to other things.
When I say "relatively," what I'm talking about is as the proportion of the gross domestic product that didn't used to go into health care. Addressing questions like whether or not we're spending those resources in ways that really deliver the best for health of the population, so everyone can enjoy wellness to the best of their ability. I think it's actually exciting times. I'm glad to be back in state again after being away for nearly a year and look forward to being back in the swim of things again.
AHPR: Thank you very much for the interview. I'm really glad to see you in this position. I think you bring a lot to it because of your history here in Alaska and also your history of working with the state and the feds. I think those connections are tremendously important.
Butler: Well thanks. I hope you're right.
Back to selected topics list
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Take Alaska Health Policy Class in Fall 2010 ... in Your Jammies! |
Early warning! In fall 2010, AHPR Editor Lawrence Weiss, will teach HS 690 Alaska Health Policy, a class offered by the Master of Public Health Program at UAA. This course is 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! Back to top |
Interview with Pat Luby of AARP Alaska
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Pat Luby  is advocacy director for AARP Alaska. In this wide-ranging interview, we discuss topics such as the governor's recent veto of the expansion of Denali KidCare, the joys and sorrows of new federal health reform, why AARP does not support a return of the Longevity Bonus, and other topics of interest. We visited Luby in his office -- with a fabulous view from the top of the Frontier Building in downtown Anchorage -- on June 28, 2010 to conduct this interview. The interview transcript has been edited for length and clarity. Note that Pat Luby is on the board of the Alaska Center for Public Policy.
Links to Selected Topics
AARP: Change Agents for Current and Future Generations
Focusing on Voluntary Long Term Care Insurance Options
The Real Life Consequences to Denali KidCare Veto
Anticorruption Initiative Brings Normally Opposing Sides Together
AARP Taking the Lead in Explaining Health Care Reform
AARP: Change Agents for Current and Future Generations
AHPR: Pat, what is your position here within AARP, and what the heck do you do?
Luby: That's a good question. I'm the advocacy director for AARP, which basically means that we work on legislation, usually at the state or the congressional level, and sometimes on municipal issues also. We have a lot of volunteers who are also interested in legislation, but we only have one paid staff person to support those volunteers.
AHPR: And that's a different person other than you?
Luby: No, that's me.
AHPR: Oh, that's you. Okay. And what is AARP's mission?
Luby: It changes. At one time, when AARP was first developed, it was before Medicare existed, and one of the things that people were interested in was how to get some health insurance after they retired, because there was no Medicare. And once you stop working, you lost your employee health coverage. So AARP started out basically [when] some retired educators were trying to figure out how to solve some of their financial problems in terms of health coverage, and they also started a nonprofit pharmacy because that was also one of the expenses that they faced. It was a mail order pharmacy.
Since then, AARP has really shifted so that now we like to call ourselves an agent of social change in that we want to make life better for people who are over 50, but also better for their family members. For the past couple years, we've actually partnered with some business organizations and some labor unions, trying to figure out how we can make sure that future generations are going to have health security, which we think we'll now have, but also financial security. People are afraid that today's children are not going to have it as well as current generations, and that when they reach retirement they may not be able to afford to retire, or it's just not going to be available to them, and they're going to have a lot of financial problems as they get older.
AHPR: And what kinds of work has AARP done in Alaska in terms of advocacy, for example? And what kind of membership base does AARP have here in Alaska?
We have about 97,000 members. That includes spouses, so it might be closer to probably about 65,000 households. In terms of our advocacy agenda, it varies each year. About 50 percent of it might be proactive; 50 percent of it "simply happens to us." Someone gets an idea -- a good idea or bad idea, and then we act on it. So, there are many issues. For example, today we're working on some of the Wall Street reform issues, trying to protect consumers. Earlier today I was working on a utility issue for an electric utility down in Juneau that wants to raise their rates 24 percent, and give a break to the cruise ships and the goldmine. Have the residential customers pay for it. So, we get involved in some of the consumer issues like that, but we are also involved in health care issues.
First meeting I had this morning was with people from the lung association, heart association, and the cancer society to talk about what we're going to be doing in terms of a clean indoor air law for the entire state of Alaska. We try to reduce tobacco consumption. The others are health organizations. They are concerned about lung health, they're concerned about heart health, they're concerned about cancer. When we come to the table, we're concerned about those issues, but we're much more concerned about the Medicaid budget, and the Medicare budget, and the VA budget, the Indian Health Services budget, and how much of that is eaten up because people smoke or chew tobacco. Anything that we can do to save health care costs by reducing tobacco consumption, it's good for everybody.
"We actually have more members under age 65 than we do over age 65.
Alaska and Florida, strangely, have the highest percentage of baby
boomers of all the states."
AHPR: You mentioned you have approaching 100,000 members, including spouses. What kinds of people are in your constituent base? And does it actually go beyond those nearly 100,000 members?
Luby: There are some people who won't join AARP because they can't afford to. Even $16 is a lot of money to them. Most of our materials are in English. We do a lot in Spanish, but we don't do much in Korean, and we don't do anything in Yup'ik, so for many people in Alaska we are simply not going to be that relevant, and we wouldn't be seen as relevant. It's very hard for us to figure out how can we be relevant to people in the Bush communities, for example. They have a different lifestyle, and many of the things that we try to offer members as a benefit simply are not appropriate for them.
But what's interesting is that the AARP membership starts at age 50. We actually have more members under age 65 than we do over age 65. Alaska and Florida, strangely, have the highest percentage of baby boomers of all the states. With Alaska, I think it's a lot of people who came here for jobs and stayed here and now are aging, and I'm not sure why Florida has so many baby boomers. It may be the same thing. People went down there for work. Those folks join AARP -- many of them join at age 50. Part of our dilemma is how do you be relevant to a 50-year-old and their 72-year-old parent and their 94-year-old grandparent because we have all three generations in AARP membership.
AHPR: I just want to revisit for a minute what you said about being relevant to the Bush. It just seems to me that the Wall Street issues, utility issues, health care issues, Medicaid, Medicare, all of those it seems to me have relevance to people in the Bush.
Luby: They do certainly, but one of the things that people perceive about AARP is, "Well, you can get a hotel discount." Well, a lot of the folks out in the villages are never going to stay in a hotel anyway. They're going to stay with some friends if they ever get to Anchorage. But, what we do try to do is look at low-income issues. There is basically no lobby for low-income people. We were talking to one of the gubernatorial candidates today, who said that he'd like to bring back the longevity bonus. People are surprised that we don't support the longevity bonus, and never did, and wouldn't support it if someone raised it again today.
We do support financial assistance for people based on income and based on need. We don't support giving property tax exemptions to people simply because they're aged 65. We think it makes a lot more sense to give property tax exemptions based on need. So we will work on the Senior Benefits Program [state of Alaska public assistance program]. If you look at Southwestern Alaska, about 50 percent of the people over age 65 in southwest Alaska are getting senior benefits. There's a lot of financial need by some of the older citizens out there and that's a program that basically we pushed through, even through a special session. Back to selected topics list
Focusing on Voluntary Long Term Care Insurance Options
AHPR: Moving more directly to health care, what has been AARP's position on health policy changes at the federal level, the recent ones? And where is AARP now on that, now that it's passed?
Luby: We've supported health care reform. The first meeting I went to on health care reform was as a graduate student intern at AARP headquarters in Washington, D.C. in 1972. We've been working on it ever since. For the first time we've actually made some progress. I have talked to AARP staffers who've been around, some of them as long as I have. And they're going to take retirement now because they feel that we've finally gotten health care reform. It's not perfect, but it certainly is a big step in the right direction.
There are some things that we worked on and that we still have to work on because one of the things that is missing in health care reform is long-term care. We have a little bit of health care reform that's paying attention to that, but it's not an adequate program by any means. What happens is when people do need long-term care, whether it's a younger person with disabilities or an older person, they have to use all their assets basically, qualify for Medicaid, and then the government will pick up the tab for their care. What we would like to do is either see -- and we do see it in this program -- where there is a voluntary long-term care insurance program that people could contribute to and then draw from. I don't think it's going to be effective enough. It's minuscule in terms of what the need may be.
We have done a good job in Alaska, and we can't take any credit for it. It's just something that happened because of the nature of the population here. We were a young state and we didn't have people who needed long-term care that much, so we didn't build nursing homes the way they did in the Lower 48. We have a lot of home and community-based services, a lot of mom and pop assisted living facilities, some very good private assisted living facilities, and people have been able to stay in those types of institutions --- because they are an institution basically -- but it's not a nursing home where you're being restrained chemically and physically in many cases. And then people are coming in and out every day to see what the care is like. Family members are usually more involved. We've got a good base of home and community-based services.
The dilemma, though, is that the baby boomers are here, they're not going anywhere, and they're going to get older. Usually, about age 85 is when people begin to need some long-term care services. As the first boomers hit age 65 in 2011, that's when we're going to begin to see some concern about this. And the boomers will not be as polite as today's generation of older people. They're going to say, "What do you mean, you're going to put me in an institution? I want to stay in my house. Figure out how to keep me here." So, there's going to be a big demand, a consumer demand for consumers to direct their own long-term care services and to do it the way they want to do it. That is not necessarily the cheapest way to deliver services. If the state and the federal government are picking up the tab, they're obviously interested in the cost. The individual is much more interested in the services that are going to keep him or her independent. Trying to match [them] is going to be a great challenge in the future.
"So one of the things we have to figure out is alternative housing,
shared housing. We've got all kinds of students ... who if they could move in with an older person ... it would be the
ideal situation."
AHPR: I've heard over the years that seniors in rural Alaska may have a particularly difficult time accessing care that's appropriate for their geographical location -- long-term care.
Luby: We used to argue that people ought to be able to age in their homes as long as possible. Dr. Thomas is a noted geriatrician and a scholar in residence with AARP. He sort of chastised us. He said that, very appropriately, people should be able to stay in their community in their home, but putting a little bit more emphasis on the community because people in the villages don't necessarily want to stay in a house by themselves, but they may want to stay in the village or as close to the village as possible. And it's the same thing in Anchorage. One of the things that we don't want to end up with is a lot of widowed older people living in big homes by themselves.
So one of the things we have to figure out is alternative housing, shared housing. We've got all kinds of students here including some of your interns who, if they could move in with an older person during the summer into a room that they already have available, it would be the ideal situation. When I worked in Dallas we had a shared housing center, and one of the things that many older people did was they would register at the shared housing center. They'd say, "What I'd really like is a young male student who could help me out with some of the chores. I've got to get somebody who could climb up on the roof and clean out the gutters and I'll cut his rent down because of that." So there are a lot of things that people can do if they'll open the door to their house. There are ways to set this up. We have examples throughout the country of shared housing. But I think it's something that's never been discussed here, I don't believe. And with all the students and all the young people and the cost of housing here, it's one of the things that we really ought to be looking at.
AHPR: You're right. I've never heard that idea before. What are some of the most significant reforms for Alaskans in the next year or two in terms of the changes at the federal level?
Luby: For the immediate situation, the health care reform is going to be phased in. One of the things that we are going to see immediately though, is people will be able to put their kids back on their employer insurance up to age 26. We're just doing that right now for AARP employees. Several of the large insurance companies are doing it. The university is beginning to do it for their employees. And a lot of the people that I've talked to, that's the most significant thing that they're seeing right away. I know one of the university employees at the geriatric education center. She has three adult children, all of them uninsured, and she is going to be able to get at least two of them back on her employee insurance. She has to pay for it -- she has a co-pay. But she's been so worried about those three kids. One auto accident would basically financially wipe out their entire family. We're going to see that as an immediate benefit.
For many of the provisions for older people one of the first things that we'll be seeing that I think is not even known by most of the Medicare beneficiaries, but Medicare is going to offer a free physical every year. One of the problems we traditionally have had with older men is that they won't go to see their primary care provider on a regular basis. Well, if it's free, I think we're going to get a better turnout from some of those people on Medicare. They will show up, they will get their annual physical, we'll be able to find out some of those problems that are just beginning to start, and we're not going to end up having to do surgery. We'll be able to take care of them just with some good advice or possibly with a purple pill. Back to selected topics list
The Real Life Consequences of Denali KidCare Veto
AHPR: Moving now to more specific legislation, recently the governor vetoed an expansion of Denali KidCare. What do you believe will be the real-life consequences of that veto?
Luby: The real-life consequences are 1,300 children and a couple hundred pregnant women are not going to have health coverage. We supported expansion of Denali KidCare. We think that every child, no matter whose child it is, should have access to good health care. We think that every pregnant woman, no matter how much money they have, should have access to good neonatal and prenatal care. That's how you have healthy older adults, is by having healthy babies. We opposed what the governor did in his veto. We understand some of his philosophical and religious reasons for doing it, but we don't support that. We think that Denali KidCare is an insurance program. Period. Now, the decision made between a physician and a woman, that's none of our business. That's something that our insurance providers as AARP employers do not ask anything about it, and we don't think the Denali KidCare program should be asking those types of questions either.
Having said that, we will try to go back and expand Denali KidCare, try and take it back up to that 200 percent. Fortunately, health care reform is going to be generous enough so that many more people will be able to qualify for the Medicaid program, and then obviously for the children's health insurance program also. I think the governor has taken some flak for what his decision was. You can make legitimate arguments obviously on both sides of the issue, but we think insurance is insurance. The Supreme Court already told us, "If you're going to ensure health care for babies, then you also have to ensure health care for people who choose not to have a child."
AHPR: And my impression is that there was very widespread support of expanding Denali KidCare.
Luby: Yeah, and you know, the faith community was in the leadership of it. The Catholic archdiocese funds and supports AFACT [Anchorage Faith & Action Congregations Together] -- it's like 15 congregations in Anchorage that are working together. This has been their top priority for the last couple years. It's not just the Catholics. The Lutherans are there. We have a lot of different religions from across the spectrum who are involved in AFACT. They have agreed insuring children is a priority for their congregations, and they're not going to get into the minutiae of what's been done. They just want to make sure that people have insurance coverage. Those folks are not going to give up either. They reacted immediately when the governor did veto it -- with a prayer session outside the governor's office.
" ... one of the things that we are going to have to see is how the
gubernatorial candidates comment on this issue because we know it's
going to come up. "
AHPR: You may have answered my next question, but I'll ask it anyway. Is there a strategy to advance this expansion of Denali KidCare beyond the veto?
Luby: Yes. One of the things that we are going to have to see is how the gubernatorial candidates comment on this issue because we know it's going to come up. Whoever survives in the primaries is going to go to the general election, and there's going to be a Democrat and a Republican sitting across from each other, and someone who is hosting that forum or the candidates themselves they're going to ask each other, "What are you going to do about insuring children? Would you support an expansion of Denali KidCare?" And then people are going to have to put their cards on the table and indicate it, and find out how the gubernatorial candidates and eventually the winner of the governor's office stands on this issue. This the first thing.
If you can get a supporter in there, it will be a lot easier to get this through than taking the risk of another governor that might veto it again. The real argument being raised by people who support Denali KidCare is legitimate, I think. If you are opposed to the use of government money for abortions, and you want to eliminate that completely, then you better get rid of the Medicaid program, you better get rid of Denali KidCare completely, if that's your belief. Don't just veto an expansion of it.
AHPR: Those sound like terrible ideas.
Luby: The government is getting flak for that. People are saying, "Are you just objecting to the expansion for another 1,200 children and two or three hundred women? Or do you object to the whole thing?" Let's eliminate Medicaid. See how far that gets you. Back to selected topics list
"Anticorruption" Initiative Unites Historically Opposing Sides
AHPR: Moving again to another piece of legislation that is around right now -- or potential legislation -- the so-called Anticorruption Initiative is scheduled to go before the voters in August. I believe AARP has been part of a broad-based coalition which opposes that initiative. Why is that?
Luby: We have about 60 organizations that are working to oppose Measure 1 on the August ballot. Except for the supporters, there are no organizations supporting measure one. When people actually understand what it does, then you find out that if you serve on the board of a nonprofit organization -- say I'm on the board of the Alaska eHealth Network -- as a board member I would not be allowed to talk to any elected official who is responsible for voting on our budget. We get some state money. It's passed on from the federal government. We also have some state money that comes in. As a board member, I would be gagged basically from trying to indicate to the governor or a legislator why electronic health records are useful.
It's AARP's policy. We support electronic health records because we think it's going to cut down on medical errors. That's the first reason. It's also going to save money. That's the second reason. But I would be gagged as a board member, and I could not make any contributions to a political candidate. What is interesting then is my uncles and aunts couldn't either. My brothers and sisters couldn't, my children couldn't, my wife can't. Even my in-laws couldn't make a contribution to a political campaign. If they did, it would be a misdemeanor.
AHPR: Because of their personal relationship to you?
Luby: Right, and the fact that I'm on the board of a nonprofit organization that receives some government funds. It's just nuts. The family implications alone are terrible. But it also goes for anyone who is representing an organization that receives some money. A mayor, whether it's the mayor of Anchorage or the mayor of a small village, could not go to the legislature to explain why they need state funds unless they were invited. The legislature is not about to invite every elected official, every assembly member, every mayor, every school district board member. Carol Comeau can't go to the legislature unless she's invited to go and talk. You know, they don't particularly want to hear from people, so we are going to have a lot of people who have the expertise who are not going to be allowed to exercise their right to communicate with their own elected officials.
It takes away our freedom of speech and it destroys democracy completely in terms of that open interchange that we want people to have with their elected officials. Anyone who receives any government money above $500 will be subject to this. If some guy has a contract to plow snow from one of the municipalities, and the contract is worth more than $500, he basically eliminates his eligibility to make a political contribution to a candidate of his choice. And everybody in his family is in the same boat, [including] the extended family.
" ... you have all these unholy bedfellows of labor
unions who normally might be fighting with the business community, and
the business community and labor unions are holding hands on this one
and saying, "No, Measure 1 is a terrible idea, and we are going to work
together to ensure it does not pass."
AHPR: I understand that even some organizations here in Alaska that we would consider conservative are also opposed to Measure 1.
Luby: Oh yeah, most of the business organizations have come out. It started with the state Chamber of Commerce. They were the first ones to come out. The Municipal League came out right away. Many of the unions also came out. So you have all these unholy bedfellows of labor unions who normally might be fighting with the business community, and the business community and labor unions are holding hands on this one and saying, "No, Measure 1 is a terrible idea, and we are going to work together to ensure it does not pass."
AHPR: Why should people interested in health policy care about Measure 1?
Luby: If Providence receives over $500 in the Medicaid program, then everyone at Providence is going to be prohibited from talking to their legislators unless they are invited. And they are also prohibited from making a contribution to any candidates of their choice. That also affects everybody in their family. Many people are concerned about corruption in government and the power of money in government, and we should be. But that doesn't mean that my in-law should be prohibited from making a contribution to a candidate of her choice simply because I'm on the board of a nonprofit organization. First of all, she probably does not know that, and she'd be violating the law unknowingly, but it would still be a crime, and she is still going to have to pay the consequences for it.
AHPR: AARP is a long-standing member of the Alaska Public Pension Coalition. Would you please tell us why that is -- sort of outline the issue -- and perhaps address what happens next?
Luby: Well, one of the problems that we have in our public policy in Alaska is that we don't participate in Social Security for our state employees and for our municipal employees and for our teachers. You cannot outlive Social Security. If you don't have Social Security, then you need a defined benefit pension plan where you are going to get a monthly check as long as you live. It's very similar to what Social Security does. In 2005, effective 2006, the legislature changed our defined benefit pension plan for our municipal and state and educational retirees, so that now all they have is basically a 401(k) -- it's called a defined contribution plan.
You can outlive those plans. And our argument, just based on economic security for older Alaskans, is that we are going to have older firefighters, older teachers, who are going to live a long time. One of the things that we keep telling people, and it's sort of our mantra now, is that 29 percent of women who make it to 65 will also make it to 90, and 18 percent of men who make it to 65 will make it to 90. Twenty-five years is a long time to have to save for your own retirement. If you're not going to get a guaranteed check from Social Security or a guaranteed check from a defined benefit pension plan, you're going to be in trouble. In addition, the health care benefits under this new program are basically a health savings account that's going to expire in just a couple years. It's not based on longevity or expected life expectancies at all.
AHPR: Does the state change from a defined benefit plan to a defined contribution plan for public employees have any specific impact on health care issues or health policy for Alaskans?
Luby: We started out with Tier 1, which was a very good health benefit plan. Once we hit 65, everybody's on Medicare anyway, but the Tier 1 benefit actually had a pharmaceutical benefit that was much better than anything that Medicare offers. And you do keep that. You also have vision and hearing in the Tier 1 program. Then we went to Tier 2, and Tier 3, now we have Tier 4, and each year we take away some of the benefits for the new hires so that basically from a health security standpoint these people are very much at risk.
They will have Medicare because they do contribute to the Medicare program. They're going to have a basis, but it's not going to be anything close to what they could have had. And if they retire before the age of eligibility for Medicare, they're on their own tab, and then they have to put into their own health savings account basically enough savings to take care of them. We have many people that still retire at 62 and 63. You can use up a lot of money if you're ill at age 63, and you're very seriously ill. You might go through your entire health savings accounts, and then where are you? You're at age 64 -- too young for Medicare, with no money saved. Then you could go out on the open market and buy something, but no you can't. You're not making enough money first of all, because your pension is not that good. Those policies are not designed to offer good, affordable coverage to people who are under age 65. They are very, very expensive. Back to selected topics list
AARP Taking the Lead in Explaining Health Care Reform
AHPR: Are there any other significant health-related policy issues that AARP is tracking in Alaska at this time, or tracking nationally that would impact Alaskans?
Luby: Yeah, pretty much daily we are worried about what Congress is doing. Right now, we're in the educational phase of trying to put out a lot of plain English, one-page pieces explaining, "What does health care reform really mean for you?" We did have an eight-page insert that we included in our national AARP bulletin, which looked at different scenarios: so you're a small businessperson and you are insuring yourself and your spouse and maybe one employee. Here's what health care reform means to you. You are a grandparent raising a grandchild. Here's what health care reform means to you. You're 72-years old and you're already on Medicare. Here's what health care reform means to you. You're 63, and you took early retirement. Here's what health care reform means to you. Here's what health care reform means to women.
We're trying to appeal to different topics of interest and be able to present good information. You have in front of you one of the samples of that. This one is on health insurance practices. Suppose you do have a pre-existing condition, or suppose you have lifetime limits. Most of us, if not all of us, have some type of lifetime limit on our health insurance. Most of us don't even know that.
When I was out making presentations about health care reform, the example I used was one that I took from the American Cancer Society. This was actually a woman that was with President Obama. She'd brought her young daughter to the speech that the president gave last week celebrating the 90 days after he had signed health care reform and what it was doing. This young girl, I believe at age 9, contracted leukemia. By the time she was 11, she was pretty close to exhausting her lifetime limits on her health insurance. Her parents were in the dilemma of trying to figure out -- she needed a hip replacement from some of the problems that she had with the leukemia, but they were afraid to spend that much money because that would pretty much exhaust everything she had for health coverage for the rest of her life. She is no longer in that situation.
That family got immediate relief under health care reform. Most of us probably have some type of a pre-existing condition. Certainly most AARP members have something. Any of those people, especially many of our people who work for small employers or who are small-business owners themselves, they have a tough time getting coverage simply because somebody had diabetes, somebody else had rheumatism or arthritis -- there's any number of different things that would eliminate you from coverage. Those days are over. Insurance companies are going to have to provide coverage for people no matter what problems they may come with.
"Certainly, as with any law, we will find there are some unintended
consequences in the health care reform law. You can't do anything in
Juneau or in Washington without screwing something up. The devil's in
the details, and there's probably some devils in there. So we will have
to go back and work to fix some of these things."
AHPR: I've reached the end of my specific questions. Do you have any last words for the readers of Alaska Health Policy Review?
Luby: It's not over. Certainly, as with any law, we will find there are some unintended consequences in the health care reform law. You can't do anything in Juneau or in Washington without screwing something up. The devil's in the details, and there's probably some devils in there. So we will have to go back and work to fix some of these things, but the main thing that we think people ought to be glad about is the fact that we no longer have to be our brother's keeper. I mean that from the standpoint of I don't have to pay your bill if you don't have any health insurance. The cost shifting that has taken place here for years and years is no longer going to be relevant. What we found was that if someone went into the ER, they had no insurance, and I came in right after them and I had an insurance card, the estimate was that I was picking up -- every Alaska family that had insurance was picking up about $1,900 a year to cover the uninsured. That's not going to take place anymore. It's going to be a much fairer ground. It's going to be level ground.
Employers are going to have to pick up their fair share instead of trying to shift it to another employer. Individuals will have to pick up their fair share. If you can't afford it, we'll give you subsidies. But everybody is going to have to make sure that we are at least providing basic insurance for ourselves. If we're employers, for our employees. Just that even playing ground is going to bring down health care costs for many people that have been picking up the tab for others in the past. And that's a good thing. Everybody should share, but share fairly.
AHPR: A lot of times the health reform is presented as mainly benefiting the uninsured. Would you say that there are benefits for the middle class in this health reform?
Luby: I think there are many benefits for the middle class. I think they're actually more benefits for employers who have traditionally been trying to do the right thing and provide health coverage for their employees and their dependents. Those folks are going to save some money on this because they're no longer going to have to pick up all the costs of the people that are shifting it to them. That includes the biggest employer we have: the state of Alaska.
AHPR: Thank you very much for a great interview. I always enjoy talking with you. Back to selected topics list
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| Guest Commentary: Who's Who, Where's Where and Why is Why ... |
 Until recently Wilson Justin was vice president of Mt. Sanford Tribal Consortium, but now he is administrator of Cheeshna Tribal Council. Generally Mr. Justin has an innovative perspective on health policy and related issues, so we keep an eye out for his writings. In this unique piece, he gives names and backgrounds to many of the key players in the May compact negotiations between the 26 Compacting Health Providers and the Indian Health Service. This commentary, reprinted here by permission of the author, originally appeared in the June/July 2010 issue of Kelt'aeni Newsletter published by Mt. Sanford Tribal Consortium. This commentary has been edited for clarity.
I have written extensively about the ATHS, (Alaska Tribal Health System) in many of its manifestations but so far have stayed out of the people side of things. So let's take a look at that in this column. With close to 8,000 workers in the ATHS, you wouldn't think that any one person is that big a part of the system, but it's always about leverage, timing and focus. Compact [Alaska Tribal Health Compact] negotiations took place last week so let's start from there. The negotiations began with a Tribal caucus on Monday, May 17, and ended Friday, May 21. There were at times up to 100 people in the room. At the table were the official negotiations teams for each of the 26 compacting health providers. For MSTC [Mt. Sanford Tribal Consortium], there was Larry Sinyon, chair of the MSTC BOD [board of directors]; Evelyn Beeter, MSTC president; Wilson Justin, [MSTC vice-president]; and Geoff Strommer, attorney of record. Mr. Strommer's firm also represents a number of other co-signers from throughout the state including Ketchikan Indian Corporation, Yakutat Tribe, Bristol Bay Health Corporation, Council of Athabascan Governments (CATG) and several other providers.
The tenor and focus of the negotiations this year changed greatly due to the passage of the health bill in February (my last column was about the passage of this bill). For the main part, Indian Health officials did not want to commit to certain wording presented by compactors, which meant regrouping for part two of the negotiations in mid-August 2010. The Indian Health Service negotiation team is large but always includes their Region 10 lead counsel, Katherine Bader; area director, Christopher Mandregan; Jim Armbrust, lead negotiator; and the ratifier, Admiral Hartz. The co-lead negotiators for the compactors are: Valerie Davidson (ANTHC) [Alaska Native Tribal Health Consortium] and Dan Winkleman (YKHC) [Yukon Kuskokwim Health Corporation. Past lead negotiator for the compact includes Lincoln Bean of Kake, Alaska. Facilitator is Evelyn Dotomain; president of ANHB [Alaska Native Health Board], and staff support is provided by ANHB and in some cases, by on-site ANTHC staff. Lead council for the compact is Myra Munson, who also represents a number of other co-signers, one of which is the Copper River Native Association.
All work is done off a series of work paper[s] prepared by Dave Mather, who has been the reigning numbers and formula guru for the compact since the beginning, in 1998. Some compactors, like Eklutna and Knik, will have only one representative present; others like ANTHC, YKHC, SEARHC [Southeast Alaska Regional Health Consortium] and SCF [Southcentral Foundation] will have entire teams there for the entire session. There is an informal network of small providers who share concerns and issues with many sidebars among small providers throughout the negotiations. In these discussions, you will find Carol Crowder of APIA, [Alaska Pribilof Islands Association]; (in the past, Chris Devlin) of Eastern Aleutian Tribe; Patrick Anderson of Chugachmuit; and Andy Teuber of KANA [Kodiak Area Native Association] (also chair of ANTHC BOD) wrestling with population user counts, encounter definitions and other formulaic items that could spell the difference between program success and failures at our level.
In just one case, KIC [Kikiktagruk Inupiat Corporation] strongly objected to a new funding breakout adopted by the caucus in pre-negotiations, which left KIC short of about $143,000 in new funding. The same action also affected several other providers in the same way. A good way to think of all this is: You have to know people in each of the other organizations and you have to understand their concerns. You have to be able to focus entirely on their issue for a little while at least -- strictly from their perspective -- even if you never spent a day in their office. You need to have a name with the issues and a face with the concern. No matter where you go in the ATHS, it's all about people and the leverage you find in sharing concerns and reaching out for common solutions.
No matter what we are looking at, it is people from the bottom up and people from the top down. Right next to us at the table was Andy Teuber of KANA; right next to him was Don Kashavaroff of Seldovia. KANA and Seldovia have common small-provider issues shared with MSTC and CATG and YAKUTAT [Yakutat Tlingit Tribe] and KIC, yet Andy is the chair of the 17-member board of directors of ANTHC and Don Kashavaroff is the president/CEO of ANTHC. Valerie Davidson is general counsel of ANTHC but is also co-lead negotiator for the 26-member compact. The bottom line is that the ATHC is complete with faces with grandkids and everyday issues or concerns just like every other village in Alaska. The Alaska Tribal Health System is the biggest village in the world, so the next time you hear us use the term ATHS, think of us like that.
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AHPR Staff and Contributors
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Lawrence D. Weiss, PhD, MS, Editor
Kelby Murphy, Senior Policy Analyst
Kalia Yeagle, Administrative Assistant
Jacqueline Yeagle, Newsletter design and editing |
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