Legislature(2001 - 2002)
04/02/2002 03:02 PM House HES
| Audio | Topic |
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* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
ALASKA STATE LEGISLATURE
HOUSE HEALTH, EDUCATION AND SOCIAL SERVICES
STANDING COMMITTEE
April 2, 2002
3:02 p.m.
MEMBERS PRESENT
Representative Fred Dyson, Chair
Representative Peggy Wilson, Vice Chair
Representative John Coghill
Representative Vic Kohring
Representative Sharon Cissna
MEMBERS ABSENT
Representative Gary Stevens
Representative Reggie Joule
COMMITTEE CALENDAR
CONFIRMATION HEARINGS
Professional Teaching Practices Commission
Donna Peterson, Ed.D. - Kenai
Vickie McCubbin - Anchorage
- CONFIRMATIONS ADVANCED
State Board Of Education and Early Development
Sally Rue - Juneau
- CONFIRMATION ADVANCED
HOUSE BILL NO. 407
"An Act relating to the certificate of need program."
- HEARD AND HELD
HOUSE BILL NO. 464
"An Act relating to statewide school district correspondence
study programs."
- BILL HEARING CANCELED
PREVIOUS ACTION
BILL: HB 407
SHORT TITLE:CERTIFICATE OF NEED PROGRAM
SPONSOR(S): REPRESENTATIVE(S)COGHILL
Jrn-Date Jrn-Page Action
02/13/02 2232 (H) READ THE FIRST TIME -
REFERRALS
02/13/02 2232 (H) CRA, HES
03/04/02 2469 (H) COSPONSOR(S): JAMES
03/13/02 2530 (H) COSPONSOR(S): SCALZI
03/14/02 (H) CRA AT 8:00 AM CAPITOL 124
03/14/02 (H) Scheduled But Not Heard
03/18/02 2593 (H) COSPONSOR(S): DYSON
03/19/02 (H) CRA AT 8:00 AM CAPITOL 124
03/19/02 (H) Heard & Held
03/19/02 (H) MINUTE(CRA)
03/21/02 (H) CRA AT 8:00 AM CAPITOL 124
03/21/02 (H) Moved Out of Committee
03/21/02 (H) MINUTE(CRA)
03/22/02 2638 (H) CRA RPT 2DP 2NR 3AM
03/22/02 2638 (H) DP: SCALZI, MEYER; NR: GUESS,
HALCRO;
03/22/02 2638 (H) AM: KERTTULA, MURKOWSKI,
MORGAN
03/22/02 2638 (H) FN1: (HSS)
03/26/02 (H) HES AT 3:00 PM CAPITOL 106
03/26/02 (H) Heard & Held
03/26/02 (H) MINUTE(HES)
03/28/02 (H) HES AT 3:00 PM CAPITOL 106
03/28/02 (H) Heard & Held
MINUTE(HES)
04/02/02 (H) HES AT 3:00 PM CAPITOL 106
WITNESS REGISTER
DONNA PETERSON, Ed.D., Appointee
to the Professional Teaching Practices Commission
52856 Tenakee Loop
Kenai, Alaska 99611
POSITION STATEMENT: Testified as appointee to the Professional
Teaching Practices Commission.
VICKIE McCUBBIN, Appointee
to the Professional Teaching Practices Commission
4272 Birch Run Drive
Anchorage, Alaska 99507
POSITION STATEMENT: Testified as appointee to the Professional
Teaching Practices Commission.
SALLY RUE, Appointee
to the State Board of Education and Early Development
7083 Hendrickson Road
Juneau, Alaska 99801
POSITION STATEMENT: Testified as appointee to the State Board
of Education and Early Development.
KATHY CRONIN, Chief Executive Officer
North Star Behavioral Health System
4500 Business Park Boulevard, Building C, Suite 10
Anchorage, Alaska 99503
POSITION STATEMENT: During hearing on HB 407, explained
Amendments 1 and 2.
ELMER LINDSTROM, Deputy Commissioner
Department of Health and Social Services
P.O. Box 110601
Juneau, Alaska 99811-0601
POSITION STATEMENT: During hearing on HB 407, concurred with
the need for more residential psychiatric treatment beds in the
state, but expressed concern that Amendment 1 fails to include
conversion of all types of beds.
JIM HOLM, Member
Board of Directors
Fairbanks Memorial Hospital Association
1041 Gilmore Street
Fairbanks, Alaska 99701
POSITION STATEMENT: During hearing on HB 407, explained the
foundation of the Fairbanks Memorial Hospital and expressed
concern regarding impacts of the proposed removal of the
certificate of need (CON).
DENNIS MURRAY, Administrator
Heritage Place Nursing Facility
232 Rockwell Avenue
Soldotna, Alaska 99669
POSITION STATEMENT: Testified in opposition to HB 407;
suggested that eliminating the CON would significantly increase
the state's general fund obligation.
CATHY DIMON
(No address provided)
North Pole, Alaska 99705
POSITION STATEMENT: Testified in support of HB 407 and building
of a new surgery center in the Fairbanks area.
MIKE POWERS, Administrator
Fairbanks Memorial Hospital
(No address provide)
POSITION STATEMENT: During hearing on HB 407, offered anecdotes
about the negative impact of removing the CON in other states
and said its removal would have dire consequences for Alaska's
larger communities.
JANICE WILKINSON
P.O. Box 75231
Fairbanks, Alaska 99707
POSITION STATEMENT: Testified in support of HB 407 and SB 256,
its companion bill.
BARBARA FLEMING, Member
Board of Directors
Providence Health System
737 West Fifth Avenue, Number G
Anchorage, Alaska 99501-2129
POSITION STATEMENT: Testified in opposition to HB 407;
explained that many services would be impossible to provide
without revenue sharing from the more profitable services that
Providence provides.
CAROLYN WATTS, Ph.D.
19920 174th Avenue Northeast
Woodinville, Washington 98072
POSITION STATEMENT: Testified in opposition to HB 407 on behalf
of Fairbanks Memorial Hospital.
RICK SOLIE, Trustee
Greater Fairbanks Community Hospital Foundation Board
4437 Stanford Drive
Fairbanks, Alaska 99709
POSITION STATEMENT: Testified in opposition to HB 407;
suggested a task force to study the CON would be appropriate.
ACTION NARRATIVE
TAPE 02-27, SIDE A
Number 0001
CHAIR FRED DYSON called the House Health, Education and Social
Services Standing Committee meeting to order at 3:02 p.m.
Representatives Dyson, Wilson, Coghill, Kohring, and Cissna were
present at the call to order.
CONFIRMATION HEARINGS
CHAIR DYSON announced the first order of business, the
confirmation hearings for the Professional Teaching Practices
Commission and the State Board of Education and Early
Development.
Professional Teaching Practices Commission
Number 0153
DONNA PETERSON, Ed.D., Appointee to the Professional Teaching
Practices Commission (PTPC), testified via teleconference,
noting that she has been superintendent in the Kenai Peninsula
Borough School District since 1999, before which she served in
various teaching and leadership positions in the district. She
said the one superintendent seat on the PTPC affords the
opportunity to bring this perspective when reviewing the fitness
of professionals in education, including teachers.
Number 0250
CHAIR DYSON remarked that Dr. Peterson has an impressive resume.
He asked if the education profession in Alaska is doing a good
job of policing its own ranks and "getting rid of the bad
apples."
DR. PETERSON replied that in positions she has held in various
states, the issues of competence and the value of teaching have
been discussed at all levels. She offered that some teachers
need coaching, assistance, and mentoring. She mentioned having
a licensing and oversight body such as the PTPC to determine
whether actions are appropriate. Hiring and evaluating are
district and site decisions, she said; the evaluative process is
in place, and most districts are fairly strong in the ability to
"take care of people that shouldn't be with our children."
Number 0356
REPRESENTATIVE KOHRING asked how Dr. Peterson's would address a
[tenured] person who lacked the proper attitude or competence.
DR. PETERSON answered that once a person is licensed in the
state, that person is considered competent. Next, it must be
considered whether this person matches his/her position and has
been given the opportunity to change. She recounted that one of
the best lessons she learned, as a principal of 25 staff members
who used different methods, was that if the end is appropriate
and [the teacher] is showing progress in student achievement and
appropriate interactions with children, then the method is less
important than the end itself. As to the ability to terminate a
teacher who isn't doing what he/she should, Dr. Peterson offered
her opinion that the evaluative processes are strong enough and,
when used appropriately, can be powerful tools in "taking care
of those people who aren't doing their job."
Number 0480
VICKIE McCUBBIN, Appointee to the Professional Teaching
Practices Commission, testified via teleconference. She
explained that she grew up in the Anchorage schools and in a
family of eight, always wanting to be a teacher. Because her
brothers and sisters had difficulty in school, she wanted to be
a teacher who was a leader. She explained that she'd worked
with the National Education Association (NEA) to be a leader in
her building; this is an interest of hers. She has worked
through NEA as part of [Excellence in Education] and a mentoring
program, thereby adding to the profession. This would be her
second term on the PTPC; she reported that she views her role as
continuing to address the moral and ethical leadership of
teachers and others who come before the PTPC.
Number 0590
CHAIR DYSON inquired whether, during her service on the PTPC,
the commission had recommended that someone not stay in his/her
teaching position. He also asked how frequently that happens.
MS. McCUBBIN responded that during her time on the commission -
almost three years - there have been two hearings when that
occurred. In addition, the commission has had stipulated
agreements before them and has recommended a sanction through a
revocation or suspension of the person's license. She added,
"There have been several times per year when I have voted my
conscience and known that I would not want to have a child of
mine in that classroom, and that they were not appropriate for
the job."
CHAIR DYSON asked how often during that time the commission has
voted to have someone excluded from the profession.
MS. McCUBBIN estimated it occurred about 25 times.
CHAIR DYSON thanked Ms. McCubbin for her willingness to serve
the children of Alaska by "looking over the shoulders of the
teachers."
[Although no formal motion was made, the confirmations of Dr.
Peterson and Ms. McCubbin were treated as advanced from the
House Health, Education and Social Services Standing Committee.]
State Board of Education and Early Development
Number 0710
SALLY RUE, Appointee to the State Board of Education and Early
Development, noted that she has been on the board for two years.
A parent of two children who have gone through the Anchorage and
Juneau public school systems, she said she feels privileged to
have seen the best the system has to offer, and wants to make
certain that "we spread that around so that all kids have that
opportunity." Active in education ever since her nearly grown
children were in preschool, she said her involvement has
included working in classrooms, on school district committees,
and on school site councils, followed by two terms on the City
and Borough of Juneau Board of Education. She reported that she
took a break from board service while maintaining her
involvement in schools; she was then appointed to the state
board two years ago.
REPRESENTATIVE KOHRING inquired about the length of the [state
school board] term.
MS. RUE replied that it is for five years and would be effective
immediately; she indicated her term expired in January.
Number 0870
REPRESENTATIVE KOHRING requested Ms. Rue to outline her thoughts
about tenure: First, is it appropriate? And second, can a
teacher be removed who is tenured in the system, short of
criminal [action] or gross negligence?
MS. RUE replied that tenure has both some good points and some
drawbacks. She remarked, "But I think you can remove teachers -
it's not to say it's easy."
REPRESENTATIVE KOHRING added, "So you're not necessarily locked
in and guaranteed a position, regardless of your competence or
your ability to be able to teach in class, just because you're
tenured?" He noted that he has heard this to be true.
MS. RUE disagreed that this is the case. She offered that if
teachers aren't competent, they shouldn't be teaching in the
classroom.
REPRESENTATIVE KOHRING asked, "Just by virtue of being tenured
doesn't guarantee them a job?"
MS. RUE replied, "Well, if they're doing their job, it does; but
if they're not doing their job, I don't believe it does."
REPRESENTATIVE KOHRING asked how it is determined whether a
teacher is doing the job.
MS. RUE offered her belief that there should be good systems for
professional evaluation so that every school or district is
responsible for having those tools in place, implementing them
all along. This would allow districts to keep track of
teachers' performance and work with them when they aren't
performing up to a high standard.
REPRESENTATIVE KOHRING asked Ms. Rue why tenure is needed if an
evaluation system is already in place.
MS. RUE noted that one argument for tenure is that it allows
teachers to teach without fear of harassment or "being chased
out of a system" for inappropriate reasons.
Number 0978
CHAIR DYSON thanked Ms. Rue for her service.
[Although no formal motion was made, the confirmation of Ms. Rue
was treated as advanced from the House Health, Education and
Social Services Standing Committee.]
CHAIR DYSON called an at-ease at 3:16 p.m. He reconvened the
meeting at 3:19 p.m.
HB 407-CERTIFICATE OF NEED PROGRAM
[Contains testimony relating to SB 256, the companion bill]
CHAIR DYSON announced the next order of business, HOUSE BILL NO.
407, "An Act relating to the certificate of need program."
[Before the committee was Version F, 22-LS1389\F, Lauterbach,
3/21/02, adopted as a work draft on 3/26/02.]
Number 1142
CHAIR DYSON called an at-ease at 3:22 p.m. He reconvened the
meeting at 3:24 p.m.
Number 1246
CHAIR DYSON moved to adopt Amendment 1, which read [original
punctuation and line numbering provided]:
1 Page 2, following line 19:
2 Insert new bill section to read:
3 "*Sec. 3 AS 18.07.031 is amended by adding a new
subsection to read:
4 (d) Notwithstanding the expenditure
thresholds, population thresholds, and
5 other provisions of this section, a person may
not convert the use of a bed in a health
6 care facility to another bed, including
converting adult psychiatric beds to psychiatric
7 beds designated for adolescents and children,
unless authorized under the terms of a
8 certificate of need issued by the department."
9
10 Renumber Sections as appropriate.
11 Page 6, line 3:
12 Delete "secs. 1 - 12"
13 Insert "secs. 1 - 13"
REPRESENTATIVE WILSON objected for purposes of discussion.
Number 1281
KATHY CRONIN, Chief Executive Officer, North Star Behavioral
Health System ("North Star"), explained that Amendment 1
requires a facility to stay within the provisions of its
original certificate of need (CON). If the facility wants to
convert those beds to another type of bed, it would need to go
through the CON process. She said North Star believes this to
be important because of the large Medicaid impact on mental
health beds.
MS. CRONIN explained that in 1996 the legislature recognized the
need to control expansion of nursing home beds because of the
large Medicaid impact. She said psychiatric beds are similar in
that 85 percent of all psychiatric beds are paid for through the
Medicaid system. As funds become increasingly tighter, she
said, North Star feels it is important to look at the best use
of state dollars for treatment and to provide those dollars
where treatment is most necessary. Her experience at North Star
has shown her that the greatest need for services is for
residential treatment, which is different from hospitalization.
Currently, Alaska has 400 children in residential treatment
centers outside the state.
MS. CRONIN told members, "I think it's really incumbent upon all
of us as citizens that these kids come home and receive
treatment in their home community." She suggested that the only
way these children will be able to return is for the number of
these beds to be expanded in the state, which requires funds.
If [Alaska] continues to provide funding for acute, intensive
beds, however, she doesn't believe money will be left for
residential beds. Therefore, Amendment 1 protects the number of
acute-care psychiatric beds currently in the system, and it
requires that new beds must go through the CON process.
Number 1409
CHAIR DYSON expressed his understanding that Amendment 1 calls
for [providers] seeking to change the designation of beds to go
before the [Department of Health and Social Services] with an
amendment, in essence, to the original CON.
MS. CRONIN replied, "Essentially, I believe it would be a new
application that would explain or would prove the need for
additional psychiatric beds."
CHAIR DYSON inquired about a hypothetical facility [should HB
407 pass with Amendment 1] that hadn't gone through the CON
process originally and that changed the use of a bed.
MS. CRONIN answered, "I believe under this amendment, in order
to change that level of service, it would require a certificate
of need."
Number 1480
CHAIR DYSON asked, "If Representative Coghill's bill [HB 407]
passes and becomes law, and a facility can be built without a
certificate of need, why would you want them to have to have a
certificate of need to change ... what they were doing?"
MS. CRONIN replied that she was limiting the scope of her
testimony to psychiatric care; it is [North Star's] contention
that because of the great impact on the state budget and because
of the need to expand services, those services should be
required to go through the CON. In further response, she
expressed her understanding that under HB 407, areas not
requiring a CON would not need one [to change the designation of
beds].
Number 1540
REPRESENTATIVE WILSON inquired about lines 6 and 7 [of
Amendment 1], which read in part, "including converting adult
psychiatric beds to psychiatric beds designated for adolescents
and children".
MS. CRONIN replied that the majority of Medicaid funds for
mental health treatment are for services for children and
adolescents, rather than adults. Thus there would be a large
fiscal impact if adult beds were changed to beds for children
and adolescents, for two reasons: first, there are more
admissions for children and adolescents, and, second, the length
of stay for children and adolescents is much greater when they
are hospitalized.
Number 1586
MS. CRONIN, in further response to Representative Wilson, said
her basic concern is simple: the cost of acute-care services
for mental health can range from $1,500 to $562 a day, whereas
the cost for residential treatment is $325 a day. She said:
If we truly believe, as a state, that it's important
to bring the 400 children who are Outside in treatment
centers home for treatment, we need to stretch our
Medicaid dollars as far as we can. If we continue to
build and support or convert acute-care beds at that
1,500- or 500-dollar-a-day rate, I don't believe
there'll be enough money left for the service that is
really needed, which is residential treatment, which
is reimbursed at $325 a day. So, in a nutshell, what
we are trying to educate the legislature about is the
huge difference in payment for acute care versus
residential treatment, and being able to preserve
dollars so that we can expand residential treatment
services, so we can bring these kids home.
Number 1651
REPRESENTATIVE WILSON asked, "Instead of taking care of one
patient, you want to take care of three patients?"
MS. CRONIN said that was correct. She added that [North Star]
believes it is a more appropriate placement for these children.
She explained that on any given day at North Star Hospital, 9 to
15 children are hospitalized at that higher acute-care rate,
waiting for a residential treatment bed outside of Alaska. She
said, "They shouldn't be there. They should be in a residential
program, which is a different method of treatment than acute
care." Adding that she has observed that [acute care] is not a
healthy placement, she remarked, "We hope that people will
understand this and will fund those kids' going to this lower
level of care." She likened it to keeping a patient in
intensive care instead of a more appropriate assisted-living
facility. "We think it's better for the kids, and we know it's
more cost-effective for the state, and that's what's we're
trying to do," she concluded.
Number 1708
CHAIR DYSON noted that in an earlier conversation with Ms.
Cronin, he'd struggled with understanding why, if the need is
for residential beds, facilities aren't being built; why the
marketplace demand isn't making it work; and why the government
needs to be involved. He asked, "By forcing people to go
through some kind of an approval process, what good is it going
to do?"
MS. CRONIN responded from a business perspective, noting that
the state is the primary payer, since 85 percent of all bills
are paid by the state. The Medicaid system in Alaska has a
priority ranking for how bills are paid. Acute care gets paid
first, which is appropriate because these patients are the most
ill. The levels of payment decrease; once the monies are gone,
the other items on the list are not funded at all. For many
years, items on the list such as psychological and social work
services never get funded because there isn't enough money to
reach that [lower] priority ranking. She added, "My concern is,
if we continue to build and support that highest level of care,
that most expensive level of service, as you go down that list,
there's less and less money available." Therefore, an
institution would have to seek a loan and build a facility
without knowing whether there will be [Medicaid] funds left to
pay for the lower level of care.
CHAIR DYSON asked whether all the acute-care beds are filled.
MS. CRONIN replied yes. She mentioned, however, that if there
were more residential beds, she doesn't believe all of [North
Star's] acute-care beds would be filled. "No kids stand in line
waiting to go Outside for acute-care treatment, but there are
kids every day in our state waiting in line to go Outside for
residential," she added.
Number 1825
CHAIR DYSON offered his understanding that if [North Star] had
the residential beds, Ms. Cronin, as a professional, would put
children in these placements that are two to five times cheaper
because it's more appropriate, even though the reimbursement for
acute-care beds is far higher.
MS. CRONIN concurred and added, "In fact, that's what we've
done." She explained that [North Star] had two facilities
licensed as acute-care facilities. Recognizing that [Alaska]
was sending a high number of children Outside, however, [North
Star] decided to convert one to a residential treatment center,
which has had 100-percent occupancy since the conversion.
CHAIR DYSON asked if a CON was required to do that conversion.
MS. CRONIN replied, "No. But we had to give up our acute-care
license to do [it]."
CHAIR DYSON inquired, "If [Amendment 1] to this bill passes,
would you have had to do a CON to convert those?"
MS. CRONIN replied yes.
Number 1878
ELMER LINDSTROM, Deputy Commissioner, Department of Health and
Social Services (DHSS), concurred with Ms. Cronin's statement
about the need for additional residential capacity in the state.
He referred to SCR 21, previously heard by the committee, and
said this resolution makes the statement that [Alaska] needs
additional non-acute beds; the department supported that and
believes it needs to be done, he said.
MR. LINDSTROM stated that [DHSS] could accept [Amendment 1], but
that it's only half of the equation. He expressed his
understanding that the sponsor [Representative Coghill] might
offer an amendment related to AS 18.07.031(b) that reads:
(b) Notwithstanding the expenditure threshold in (a)
of this section, a person may not convert a building
or part of a building to a nursing home that requires
licensure under AS 18.20.020 unless authorized under
the terms of a certificate of need issued by the
department.
MR. LINDSTROM explained that this provision in existing law
precludes the creation of any additional nursing home beds in
Alaska by converting from another type of bed. Those are beds
that [the state] pays for at 85 percent of the market. He
offered that the department also agrees with Ms. Cronin's
statement that psychiatric beds are similar. Medicaid "pays the
freight" on those beds; therefore, it might make good sense to
control costs by precluding the conversion of any beds to acute
psychiatric beds, because the [state] will pay the bulk of those
costs.
MR. LINDSTROM noted that [Amendment 1] does this in part. He
suggested that the committee consider amending the foregoing
statute to simply include acute psychiatric beds. The
deficiency in [Amendment 1] is that, for example, some existing
residential beds of any type could be converted to psychiatric
beds without a CON. [Amendment 1] precludes conversion of bed
licensed as an acute bed or other health care facility for which
statute has a definition; however, it would not preclude
conversion of other types of beds. He stated that [DHSS]
believes that if this step is taken, it ought to include all
conversions.
Number 2010
CHAIR DYSON asked why additional acute psychiatric beds would be
created if there aren't enough patients to fill them.
MR. LINDSTROM replied that he believes those acute-care beds are
full, as are all the existing [residential treatment psychiatric
care] beds. He said he also believes, based on numbers from
[the Division of Family and Youth Services (DFYS)] he has
reviewed, that the occupancy rate has been approaching 90
percent of other types of residential beds. He said, "I think
the real answer, Mr. Chairman, is perhaps we need capacity
across the entire spectrum of care here." He added that since
acute-care beds are the most expensive, it is wise to proceed
with care. "All the beds are full, is the short answer," he
concluded.
CHAIR DYSON remarked that he still didn't see why [Alaska] would
want to put any restriction on building all the beds people
want; then the people who need those beds would fill them.
Number 2085
MR. LINDSTROM answered that [the state], as the payer, needs to
be careful about those most expensive type of beds; those are
the beds controllable by the certificate-of-need process.
CHAIR DYSON asked whether Mr. Lindstrom is concerned that if the
acute beds are filled, people will end up in these beds who
shouldn't be there.
MR. LINDSTROM responded, "I think that's a concern."
CHAIR DYSON offered that instead of working on the medical-
ethics portion wherein only people needing the most expensive
beds would fill them, this is seeking to control the number of
beds available. He asked if this was correct. He said it seems
the best way to ensure that only those needing acute beds are in
them is to have careful, ethical medical professionals assigning
patients to those beds. Therefore, the payer is not paying for
patients who don't need them to be in expensive beds. He said,
"You must not have confidence that that process is working
perfectly, so you're wanting to control the number of beds."
Number 2152
MR. LINDSTROM agreed this is a good point. In fact, he said, a
couple of different ethical dilemmas come into play. In
addition to the aforementioned situation, if a DFYS social
worker needs to place a child somewhere and an acute-care bed is
the only one available, what is the ethical action for the
social worker to take?
CHAIR DYSON suggested that from a medical-placement perspective,
if doctors are doing their job ethically and are not motivated
by greed, then [the department] should not have to worry about
the number of acute-care beds. He queried, "Is what we're all
after is to have enough beds available ... every day for the
patients to go into, only the appropriate bed?"
MR. LINDSTROM replied, "Absolutely."
CHAIR DYSON asked Mr. Lindstrom if he believes the CON helps
accomplish this.
MR. LINDSTROM answered that [DHSS] believes the CON is one tool
to help control the number of those most expensive acute-care
beds, and that [Amendment 1] is only half of the piece.
Number 2230
MS. CRONIN offered an example. If a family faces the decision
of admitting a child to a residential treatment center in Salt
Lake City or keeping the child at home, many families will
choose to keep the child at home. Often what happens is that
the family keeps the child at home and the child decompensates
and winds up going to acute care.
CHAIR DYSON asked for a definition of "decompensates."
MS. CRONIN said, "Clinically, gets worse." She explained that
one challenge in [mental] health care is that it is not as
clear-cut as a broken arm, easily diagnosed with an x-ray. A
child will need a level of care - in many cases, it is not
hospitalization - but the services are unavailable in Alaska, so
the child doesn't go Outside for treatment because the family
wants to keep the child home. However, these families don't
have the ability to cope with the problem, and the child gets
worse and ends up hospitalized. She mentioned the number of
reviews, internal and external, that a patient goes through to
be hospitalized, and said it is hard to imagine that someone
would be admitted to a hospital inappropriately. The problem is
that there aren't services available to get the appropriate
treatment at the appropriate time, she concluded.
Number 2303
MR. LINDSTROM expressed his belief that [Amendment 1] was
drafted by neither [Legislative Legal and Research Services] nor
the Department of Law. He said he doesn't know what the
reference to converting adult psychiatric beds to psychiatric
beds for adolescents and children means. While he understands
the intent, he noted that there is not a separate category of
licensure for adolescent beds as opposed to adult beds.
Technically, he is not confident that this language is what is
legally necessary to accomplish [Amendment 1's] goal, he said.
He added that in order to align with Version F, lines 12 and 13
[of the amendment] should read:
Delete "secs. 1-11"
Insert "secs. 1-12"
Number 2346
REPRESENTATIVE COGHILL, sponsor of HB 407, said this is an issue
he didn't want to "wade in on." He agreed it should be
discussed, and concurred with Mr. Lindstrom that it should
[encompass all types of beds]. He indicated hesitance to
address this issue because he didn't fully understand all of it,
although he was learning as quickly as he could, he said.
[Amendment 1 was withdrawn a short time later.]
TAPE 02-27, SIDE B
Number 2360
CHAIR DYSON brought attention to Amendment 2, 22-LS1389\F.3,
Lauterbach, 3/27/02, which read:
Page 1, line 1, following "program;":
Insert "relating to children's mental health
services;"
Page 5, following line 30:
Insert a new bill section to read:
"* Sec. 11. AS 47.30.660 is amended by adding a
new subsection to read:
(c) The plan prepared, revised, and amended
under (a) of this section must include, as a distinct
component, a master plan for children's mental health
services. The master plan required under this
subsection must be developed in conjunction with the
Alaska Mental Health Trust Authority, Alaska Mental
Health Board, and Advisory Board on Alcoholism and
Drug Abuse, and must provide for involvement of
families of emotionally disturbed children and
adolescents, community mental health providers, and
providers of residential and inpatient care for
children and adolescents. After gathering information
through methods determined appropriate, the department
shall prepare the master plan, which must include the
following:
(1) recommended principles that should be
used to guide development of a comprehensive system of
care to meet the mental health needs of children and
adolescents;
(2) an estimate of the current and
projected number of children and adolescents in the
state who are suffering severe emotional, mental, and
substance disorders;
(3) a description of the current system of
care for children with emotional, mental, and
substance disorders, including the type, capacity, and
geographic availability of care;
(4) an assessment of the ability of the
existing service system to meet the identified and
projected needs, including an assessment of
utilization and factors affecting utilization;
(5) an assessment of gaps in the type or
capacity of services needed;
(6) the array and capacity of in-home,
community-based, residential, and inpatient care
needed to meet the current and projected need for
screening, diagnosis, and treatment of children and
adolescents in the state who are suffering emotional,
mental, and substance disorders;
(7) an analysis of impediments limiting or
preventing development or operation of the services
and capacities needed;
(8) recommended priorities for action to
reconfigure, expand, or enhance existing services or
to develop new service alternatives;
(9) an estimate of resources needed to
develop and support the system of services required."
Renumber the following bill sections accordingly.
Page 6, line 3:
Delete "secs. 1 - 11"
Insert "secs. 1 - 10 and 12"
Page 6, following line 5:
Insert a new bill section to read:
"* Sec. 14. The uncodified law of the State of
Alaska is amended by adding a new section to read:
MASTER PLAN FOR CHILDREN'S MENTAL HEALTH
SERVICES. The initial master plan required to be
prepared under AS 47.30.660(c), added by sec. 11 of
this Act, shall be completed and delivered to the
governor by the first day of the First Regular Session
of the Twenty-Third Alaska State Legislature, and the
Department of Health and Social Services shall notify
the legislature that the master plan is available for
review."
Renumber the following bill section accordingly.
[End of Amendment 2]
CHAIR DYSON withdrew [Amendment 1]. He asked Ms. Cronin to
explain [Amendment 2].
Number 2320
MS. CRONIN explained that Amendment 2 establishes a workgroup
charged with creating a master plan for children's mental health
services. She reiterated that 400 children are Outside for
treatment, and that there are funding issues to address. She
expressed her belief that [Alaska] needs a master plan on how to
best treat children with mental health needs within the state
and how to do it in the most economical manner.
CHAIR DYSON told Ms. Cronin that she would have to convince him
before April 4 why [Amendment 2] fits in a CON bill. He
returned to the subject of the 400 children Outside for
treatment, offering his understanding that the average cost is
over $800 a day. This is a grave concern, both economically and
as an issue of separation from families, he said. "I'm
sympathetic on the issue; I need some convincing that this is
the vehicle to accomplish what apparently we both agree on," he
concluded. [There was no motion to adopt Amendment 2.]
Number 2230
JIM HOLM, Member, Board of Directors, Fairbanks Memorial
Hospital Association, noting that he is a Fairbanks businessman,
testified to provide [the board's] assessment of what the
proposed CON change might do to [Fairbanks Memorial Hospital
(FMH)]. He reported that in 1967 there was a flood in
Fairbanks, where Saint Joseph Hospital, run by the Sisters of
Providence, was the only hospital. He elaborated:
The hospital was damaged sufficiently enough that the
Sisters of Providence decided that they could no
longer support the medical and health care needs of
the people of Fairbanks. The community itself got
together, and with the visionaries such as Dr. William
R. Wood and Harry "Red" Porter (ph) and people that
had been there for many, many years, they set up a
foundation to see what we could do about a community
creating its own hospital, providing the health care
... for the people of Fairbanks. ... I'm one, but
there's many others that gave a few dollars when we
didn't have money, to help get this thing ... on its
feet. And then, over the past 30 years, this hospital
has become a really fine institution.
Number 2164
MR. HOLM stated that FMH currently "provides the lowest
ambulatory surgery care" in the state. In addition, it provides
home care, which costs in excess of $250,000 more than is
recovered. Other services such as inebriate programs, a
neonatal facility, adult psychiatric care, and emergency room
care aren't profitable. He said 25 members of the Fairbanks
community serve on the board for no compensation. [Members]
believe that this matter needs to be looked at more carefully,
he noted,; it can adversely affect the hospital's ability to
function because the hospital is required to provide services
without compensation. Therefore, if the hospital is put in a
position in which services can be "cherry-picked" away, it will
be unable to afford the services it must provide for free.
Number 2113
DENNIS MURRAY, Administrator, Heritage Place Nursing Facility,
testified via teleconference in opposition to HB 407, conveying
particular concern about the fiscal note, which suggests that
eliminating the CON in the state's three major population
centers would significantly increase the state's general fund
obligation. He offered that in his experience, the CON statute
isn't perfect, but that the state won't be well served by
removing that process from two-thirds of the state's population.
MR. MURRAY said as a member of the Long-Term Care Task Force, he
knows the task force wrestled with the balance between community
nursing-home beds and other community options. The language in
the current [statute], coupled with legislation passed two years
ago, would be negated by [HB 407], he said. Alaska is, in many
ways, one large community: facility construction in Anchorage
affects Kenai, for example. This is why the existing CON
process allows for public oversight and scrutiny of the
construction of publicly supported services. With regard to
Amendment 1, he offered his understanding that it includes any
bed. He posed an example and suggested it could have an
unintended consequence.
Number 2022
CHAIR DYSON asked Mr. Murray to explain how the Anchorage market
affects the Kenai market.
MR. MURRAY replied, "In terms of expansion of beds or no
certificate of need, I think that ... the history of Heritage
Place Nursing Facility has been somewhat reliant on serving the
needs of persons from other parts of the state, particularly
Anchorage. Currently, that's not our circumstance." By
example, he indicated there are families in Kenai with a family
member in acute care in Anchorage. He offered his opinion that
the nursing facility is impacted, adding that acute care is
certainly impacted. "I was thinking generically there, Mr.
Chairman," he added.
Number 1991
CATHY DIMON testified via teleconference, noting that she is a
Tanana Valley Clinic employee but testifying on her own behalf.
She stated that she is in favor of HB 407 and indicated support
for a new surgery center to be built in the Fairbanks area. She
reported that her husband recently underwent cardiac surgery in
Anchorage; upon returning to Fairbanks, he needed outpatient
care for intravenous antibiotic therapy, which was only
available at the outpatient center at FMH. She said, "Let me
tell you, this was an experience in patience. Not only did the
outpatient center staff have little clue as to what was
happening or what was supposed to happen for his care, they were
repeatedly running late, [and] the majority of the staff seemed
not to care that he waited sometimes over an hour-and-a-half to
be seen." She said he was told not to make appointments, but to
just "show up and they would work him in."
MS. DIMON asked: If the only outpatient center in Fairbanks is
that busy, why is FMH worried about another facility coming into
Fairbanks? She said that although the testimony against this
bill seems to have only come from FMH staff, it seems the
hospital is trying to get a corner on the market. She asked
what has happened to consumer choice, and suggested supply and
demand should apply to medical care as well. She suggested the
benefits of a new facility would include extra jobs, more taxes
paid, and choices for patients. She requested passage of
HB 407.
Number 1896
MIKE POWERS, Administrator, Fairbanks Memorial Hospital,
apologized to Ms. Dimon for anything that might have gone wrong
and offered to discuss the situation with her. He noted that
the hospital loses $100,000 on cardiac rehabilitation, and at
the moment [FMH] is the only facility willing to provide that
service to the community. He said the CON issue is nationwide,
and that headlines in Ohio, Pennsylvania, and other states
indicate these states are experiencing similar problems. Many
of these relate to struggles between hospitals and physicians,
and problems when both ethical and financial concerns are
involved.
MR. POWERS stated that USA Today reported that hospitals
nationwide are engaging in a "medical arms" race, scrambling to
build specialized cancer and cardiac programs and other "niche
service lines." This is especially true in a few states where
the CON has been eliminated, he said; one expert notes that
supply often dictates in the health care industry; therefore,
oversupply of facilities equates to more procedures' being
performed, whether necessary or not. He said that in New York,
Rome Memorial Ambulatory Surgery Center filed suit against Rome
Memorial Hospital in January, alleging that a 120-bed facility
drove the outpatient clinic out of business by negotiating an
exclusive agreement with Blue Cross Blue Shield, the area's
largest insurer. He noted that court papers indicate that the
hospital counters that the for-profit center was cherry picking
the most lucrative cases and refusing to take high-risk and
uninsured patients, with only secondary regard to the public
health and patients' needs in the larger community.
MR. POWERS continued, indicating that a Syracuse, New York
newspaper headline read, "Hospitals Lose Patients as For-Profit
Surgery Centers Siphon Off Profits; One Hospital Files for
Bankruptcy." Last summer, he noted, a center specializing in
orthopedic surgery opened ten miles from Syracuse Community
Hospital; the hospital expected to lose 3,400 same-day surgeries
a year, more than half its annual volume. He referenced a
hospital that filed for Chapter 11 bankruptcy protection earlier
this year; he noted that the article indicated the community
must face the fact that the hospital's ability to maintain
[service] is being eroded.
CHAIR DYSON suggested that Mr. Powers make copies of that
information for committee members.
MR. POWERS said his point is that nationwide, this issue is
playing out, and that Alaska has a unique and fragile health
environment with a sparse population. He cautioned that a bill
that essentially lifts any need for scrutiny or business
planning could have dire effects on communities. In response to
Chair Dyson, Mr. Powers said he thinks the areas of particular
concern are Fairbanks, Juneau, the Kenai Peninsula, and the
Matanuska-Susitna area, and that even Anchorage is at risk.
Managed care companies are not found in Alaska, he said. He
clarified that only communities with a population of 20,000 and
above would be adversely affected.
Number 1715
JANICE WILKINSON testified via teleconference, offering support
for HB 407 and SB 256. She noted that she is a laboratory
manager for Tanana Valley Clinic, but was speaking on her own
behalf. A resident of Fairbanks for six years, she said she has
been in health care 30 years, including her high school years as
a candy-striper; her career has taken her from very small
communities to large, urban areas. She said she has witnessed
what happens in communities with a healthy competition in the
medical field, and has witnessed what happens when one medical
facility has too much control or power: it gains control over
the community, fees increase, no incentive is present to meet
the personal needs of individual [patients], and patients find
the need to go elsewhere. In this situation, she noted, both
the facility and the community are hurt.
MS. WILKINSON said Fairbanks needs more competition with regard
to its medical entities. Indicating FMH has had a massive
amount of unrestricted growth in the last few years, she said it
has developed into a monopoly, more or less. She also spoke in
favor of having alternatives such as an alternative outpatient
center in order to keep costs down and ensure that surgery
revenues remain in Alaska.
Number 1590
BARBARA FLEMING, Member, Board of Directors, Providence Health
System, read from a written statement as follows:
My name is Barbara Fleming; I serve on the Board of
Directors of Providence Hospital here in the state of
Alaska. I also sit as a trustee delegate to the
Alaska State Hospital and Nursing Home Association, as
well as the region nine American Hospital Association
board member. So, I've many hats on this issue.
During the past 100 years, the Sisters of Providence
have been in Alaska, and they have served hundreds of
thousands of Alaskans by providing health care,
education and food for the underserved, regardless of
their ability to pay.
Additionally, Providence has provided medical care
where none existed before and served those that no one
else would serve. Providence serves the expanding
population of seniors, children, and families, and has
been proactive in lowering emergency room costs by
operating a family practice clinic that allows care by
accepting patients on Medicaid and Medicare, sliding-
fee scales, insurance, and those in need of charity
care.
Providence opposes HB 407 because it will put many of
the existing programs in jeopardy. [House Bill] 407
will also allow for new competing surgery centers to
be built without any review [or] consideration of
whether or not the community can financially support
them. Statistics nationwide indicate there is a
duplication of medical services, which has contributed
to the increasing costs of health care.
MS. FLEMING continued:
Providence provides services that we know will not be
reimbursed. Five years ago the charity care
Providence provided was, roughly, $11 million. Today
it has risen to nearly $36 million. Of that, ...
approximately $10 million ... is in community benefits
for places like the Brother Francis [Shelter] and
Covenant House - daily hot meals, roughly 200 of such
to the Brother Francis Shelter and many other
charitable organizations, roughly ... 50 just ... in
the Anchorage area. Our greatest concern is in
maintaining the programs that we already have in place
and increasing those that we know are going to grow,
such as our Cancer Therapy Center. Who will offer
these medical services if Providence does not?
Eliminating the CON process in these urban areas would
allow for new surgery centers that only serve a small
number of patients who can afford ... to pay. This
could quickly erode the financial stability of our
medical center and its ability to provide the many
[un]reimbursed [services] ... for a complete medical
center for all Alaskans.
MS. FLEMING turned to concern about the 55,000-population
threshold, saying she took exception to this a bit because she
believes it does affect many of the state's small communities.
She explained:
I spent ten years in Seward. I recently moved to
Anchorage, and the medical center [in Seward] is a
Providence facility; they've supported that facility
in the past five years, to roughly $7 million in the
red. It would not be able to do that if they didn't
have a stable base, in Anchorage, to the medical
center. Outreach as far as Seward, they deserve that.
People of Anchorage deserve quality care for their
parents in Providence's long-term care facilities.
People across the region rely on home health care, and
also the ... 3,100 ... [full-time employees] at the
medical center deserve quality daycare for their kids.
... These services are in jeopardy, because they all
have red ink on their books, and those things would
not be able to happen, had the medical center not had
the stability.
Number 1441
MS. FLEMING continued:
By changing the CON and allowing independent centers
to open in the larger cities, it will affect our
ability to provide the much-needed services that
people across the state are accustomed to. Again, we
serve everyone, ... regardless of ability to pay. ...
These independents ... don't have a responsibility to
the community, as Providence does. ... If Providence
doesn't do this, who else will? The state will be
left holding the bag for even greater increases to the
Medicaid budget.
One last point: I know you've heard a lot of
conflicting information regarding the cost increases
versus savings. For FY 2003, the state's total
Medicaid budget was $830 million. Of this, $32
million was a general fund increase. Therefore, the
state's Medicaid budget [will] increase by 23 percent.
This is a dramatic jump, and with my association at
the state and national levels, the forecast is gloomy.
You can't afford to speculate on these costs.
MS. FLEMING reiterated her opposition to HB 407, noting that
Providence also opposes the bill.
Number 1388
CHAIR DYSON related his understanding from an earlier
conversation with Ms. Fleming that the excess revenues are used
to subsidize many charitable [services] such as the [center] in
Seward, the Brother Francis Shelter, [covering] nonpaying
emergency room patients, and other services. Therefore, he
noted that he understood part of the argument to be that if a
competing business comes along and takes those [excess-revenue-
generating services], Providence would not be able to subsidize
the many other services. Those costs would eventually be borne
by the state and would drive up the state's Medicaid costs, to
the detriment of all Alaskans. He asked whether this was an
accurate summation.
MS. FLEMING agreed the foregoing was accurate.
Number 1256
CAROLYN WATTS, Ph.D., testified via teleconference, noting she
is a professor of health economics and policy at the University
of Washington in Seattle. Dr. Watts said she was representing
FMH and her own research on the CON.
CHAIR DYSON noted an extensive resume from Dr. Watts.
DR. WATTS told members her testimony was in opposition to
HB 407. She has worked in the health care area for 27 years
doing teaching and research in health economics and health
policy; much of this experience focused on the organization of
the health care industry and its financing and the CON, in
particular. She agreed with the summary offered by Chair Dyson,
saying the financing of health care, both now and for the
foreseeable future, is a fragile, interdependent web of cross-
subsidies and indirect financing. If everyone were willing to
pay taxes to support public programs to provide services to
people who are unable to pay for them, cross-subsidies would be
unnecessary; competition would be fine. However, this is not
how the health-care world works, and it isn't likely to work
that way in the near future. Therefore, she said, one cannot
look at this market the way one might look at the competition in
the market for pizza, for example, because health care is too
important and is part of the essential community infrastructure,
particularly in a state like Alaska.
Number 1166
DR. WATTS offered her opinion that the CON is an important
"piece of the puzzle" for the whole state, not just the smaller
communities. She referenced other speakers' comments about
freedom and choice, control and power, and supply and demand.
Again, she noted, "This isn't pizza." She observed that
patients in Alaska, even those in Anchorage, know they will not
have many choices because the population density does not
support such choice. Other industries, including some in the
Lower 48, do not offer choice because stability is so important,
she said.
DR. WATTS, citing the recent Enron [Corporation] debacle,
pointed out that [society] understands that some pieces of
infrastructure are so important that it is necessary to ensure
access to services at all times. She drew attention to the
issue of ambulatory surgery in Fairbanks and said three CONs
were competing for the state's attention in 1999; all three were
reviewed by the state, which concluded there was no need for
them until 2017. Therefore, she suggested the issue of
inadequate capacity in Fairbanks has been addressed.
Number 1098
DR. WATTS said the real issue is whether [the state] wants to
have hospital services in Alaskan communities at all. If the
"intrusion of the entrepreneurs" is allowed, "there are plenty
of them out there" who will come in - not as community members,
but as entrepreneurs - and take the profitable services from
hospitals like Providence and FMH. That will leave the
hospitals with the legal and moral obligation to treat anyone
who comes to them. Those hospitals will have several choices,
she predicted. For example, they could shut down the services
that don't pay for themselves, thereby precluding access to
everyone; hence people would need to go Outside for services.
DR. WATTS said the CON is not about excluding a particular
facility or service; rather, it is about creating a process
whereby communities - which have in many cases funded their
hospitals - can decide where and what kind of competition they
want. So the CON doesn't prohibit competition, but provides a
mechanism to monitor it and ensure it is consistent with
community goals; it allows good stewardship of community
resources.
DR. WATTS offered her opinion that the impact on Medicaid of
HB 407 could be very large. She referenced Ms. Cronin's
comments about psychiatric beds, 85 percent of which are covered
by Medicaid. If one part of the market is restricted,
particularly in a community like Fairbanks where there is no
psychiatric hospital, where do those who cannot get into nursing
homes and psychiatric beds go? Dr. Watts offered that these
patients go to the community hospital. If the community
hospital is failing financially because the profitable services
are being provided elsewhere, there won't be the capacity to
handle these patients; consequently, everyone in the community
will suffer, and the Medicaid budget will suffer. She offered
that the impact on Medicaid expenditures is much more complex
than has been presented by Information Insights.
DR. WATTS concluded by saying the CON isn't about prohibiting
the building of a specific facility or prohibiting competition;
it is about maintaining a process. She reiterated that
competition in health care is very different from competition in
other industries. It is not about government control; rather,
it is about community stewardship.
Number 0945
REPRESENTATIVE KOHRING observed that Dr. Watts has a very
extensive background and has written some papers about national
health insurance. He asked her to give a brief summary of her
thoughts and position on that topic.
DR. WATTS stated that she is primarily a researcher and
educator, adding, "I guess I don't have a professional opinion
of whether we should or shouldn't have national health
insurance. My job is to talk about what would happen if we did,
[and] what happens now that we don't."
REPRESENTATIVE KOHRING expressed concern that without [HB 407]
Alaska would be moving towards socialized medicine, which, to
his belief, has proven to be not in a country's best interest.
DR. WATTS respectfully disagreed. In response to Chair Dyson,
she specified that she was asked to testify by FMH and was paid
for doing so.
Number 0843
RICK SOLIE, Trustee, Greater Fairbanks Community Hospital
Foundation Board, testified in opposition to HB 407, noting that
he serves on the Fairbanks North Star Borough Assembly but
wasn't representing the assembly's views. He said the CON
process, while not perfect, won't be improved by modifying it in
this fashion. Rather, he predicted it would create further
problems, allowing cherry picking of selected services and
hurting FMH's ability to pay for some services that a for-profit
venture wouldn't provide in the same manner. He recalled a
hearing several years ago on this same issue wherein the CON and
competition were discussed at length.
MR. SOLIE noted that he has a degree in economics and that his
father had a Ph.D. in the field. He said health care, including
that in Alaska, isn't simple economics. He suggested the
discussion should focus on moving in that direction, but
expressed concern about the short amount of time in the session
and at this hearing. He recalled that an interim task force was
discussed two years ago to look at the problems with the CON.
He acknowledged that the hospital foundation has some problems
with [the current CON process]; it is an uneven playing field.
Physicians are able to get services from their clinic for which
[the hospital] must obtain a CON from the state, he noted.
Number 0720
MR. SOLIE referenced an earlier amendment, saying he hadn't
understood it, and believed the committee chose wisely to not
adopt it. He conveyed concern that there is a piecemeal
approach to fix the CON due to the laudable view that [Alaska]
should move toward a competitive process. He suggested if
members truly wish to fix a process they view as flawed, they
should be willing to spend the time during an interim to study
it. Mr. Solie said people in Fairbanks have spent the better
part of 30 years creating a health care system that can provide
an array of quality services in an economical way with access to
all. He mentioned the home care program of [FMH], and pointed
out that a few years ago other providers offered home care, but
no longer do so.
MR. SOLIE emphasized that an emergency room is open to all who
cannot pay, and "will be there tomorrow for those that can't
pay, regardless of race or color or their problems." Mental
health care, neonatal care, cardiac rehabilitation, and other
services are offered. In the absence of a competitive arena, he
suggested that members look at cost, quality, and access.
MR. SOLIE noted that [FMH] has audited data from the state
showing that its inpatient prices are competitive statewide and
its outpatient prices are competitive with freestanding centers
in Anchorage. He suggested [Alaskans] are also getting quality
and access. If this needs to be fixed, a task force should [be
created], he suggested. He added that the 55,000-population
threshold doesn't have basis in fact. He said he believes
[FMH's] administrator would have concerns about a lack of a
service category when it comes to issues such as cardiac care.
He emphasized that this issue is serious, adding, "We wouldn't
have come here as volunteers to talk to you if it weren't."
Number 0566
CHAIR DYSON thanked Mr. Solie and said he could appreciate the
frustration of those involved. He noted the pile of letters
received on this matter and indicated he would read them all.
He offered his belief that members are seeking to do a
responsible job trying to understand this complex issue,
acknowledging it is unlike any other economic situation.
[HB 407 was held over.]
ADJOURNMENT
There being no further business before the committee, the House
Health, Education and Social Services Standing Committee meeting
was adjourned at 4:32 p.m.
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