Legislature(1997 - 1998)
03/27/1997 03:11 PM HES
* first hearing in first committee of referral
= bill was previously heard/scheduled
= bill was previously heard/scheduled
HOUSE HEALTH, EDUCATION AND SOCIAL SERVICES STANDING COMMITTEE March 27, 1997 3:11 p.m. MEMBERS PRESENT Representative Con Bunde, Chairman Representative Joe Green, Vice Chairman Representative Al Vezey Representative Fred Dyson Representative J. Allen Kemplen MEMBERS ABSENT Representative Brian Porter Representative Tom Brice COMMITTEE CALENDAR *HOUSE BILL NO. 193 "An Act relating to financial assistance for students attending certain graduate education programs; and providing for an effective date." - HEARD AND HELD HOUSE BILL NO. 152 "An Act regulating hospice care." - MOVED CSHB 152(HES) FROM COMMITTEE *HOUSE BILL NO. 127 "An Act relating to the citizen review board and panels for permanency planning for certain children in state custody; renaming the Citizens' Review Panel For Permanency Planning as the Citizens' Foster Care Review Board; extending the termination date of the Citizens' Foster Care Review Board; and providing for an effective date." - HEARD AND HELD (* First public hearing) PREVIOUS ACTION BILL: HB 193 SHORT TITLE: REPAY GRADUATE EDUCATION AID SPONSOR(S): HEALTH, EDUCATION & SOCIAL SERVICES JRN-DATE JRN-DATE ACTION 03/14/97 665 (H) READ THE FIRST TIME - REFERRAL(S) 03/14/97 665 (H) HES, FINANCE BILL: HB 152 SHORT TITLE: REGULATION OF HOSPICE CARE SPONSOR(S): REPRESENTATIVE(S) RYAN JRN-DATE JRN-DATE ACTION 02/24/97 441 (H) READ THE FIRST TIME - REFERRAL(S) 02/24/97 441 (H) HES, FINANCE 03/20/97 (H) HES AT 3:00 PM CAPITOL 106 BILL: HB 127 SHORT TITLE: FOSTER CARE REVIEW BOARD SPONSOR(S): HEALTH, EDUCATION & SOCIAL SERVICES JRN-DATE JRN-DATE ACTION 02/12/97 318 (H) READ THE FIRST TIME - REFERRAL(S) 02/12/97 318 (H) HES, FINANCE WITNESS REGISTER REPRESENTATIVE JOE RYAN Alaska State Legislature Capitol Building, Room 420 Juneau, Alaska 99801 Telephone: (907) 465-3875 POSITION STATEMENT: Sponsor of HB 152 SHELBY LARSEN, Administrator Health Facilities Licensing and Certification Division of Medical Assistance Department of Health and Social Services 4730 Business Park Boulevard, Suite 18 Anchorage, Alaska 99503-7117 Telephone: (907) 561-8081 POSITION STATEMENT: Testified on CSHB 152(HES) PAULA McCARON Hospice of Anchorage 205 East Dimond, Number 187 Anchorage, Alaska 99515 Telephone: (907) 248-6317 POSITION STATEMENT: Testified on CSHB 152(HES) CONNIE J. SIPE, Director Division of Senior Services Department of Administration 3601 C Street, Suite 310 Anchorage, Alaska 99503-5984 Telephone: (907) 563-5654 POSITION STATEMENT: Testified on CSHB 152(HES) RUPERT E. ANDREWS, Lobbyist American Association of Retired People (AARP) 9416 Long Run Drive Juneau, Alaska 99801 Telephone: (907) 789-7422 POSITION STATEMENT: Testified in support of CSHB 152(HES) DIANE BARRANS, Executive Director Postsecondary Education Commission Department of Education 3030 Vintage Boulevard Juneau, Alaska 99801-7109 Telephone: (907) 465-6740 POSITION STATEMENT: Testified on HB 193 MIKE MAHER, Director of Student Financial Aid Postsecondary Education Commission Department of Education 3030 Vintage Boulevard Juneau, Alaska 99801-7109 Telephone: (907) 465-6740 POSITION STATEMENT: Testified on HB 193 LAURA BURLESON, Student 4758 Glasgow Street, Number 1 Fairbanks, Alaska 99709 Telephone: (907) 479-7348 POSITION STATEMENT: Testified in support of HB 193 JEAN RICHARDSON, Student 2045 Jack Street, Apartment A Fairbanks, Alaska 99709 Telephone: (907) 451-9598 POSITION STATEMENT: Testified in support of HB 193 PATRICIA SWENSON, Legislative Assistant to Representative Bunde Alaska State Legislature Capitol Building, Room 104 Juneau, Alaska 99801 Telephone: (907) 465-4843 POSITION STATEMENT: Provided sponsor statement for HB 127 NANCY MILLER, Administrative Director Citizens' Foster Care Review Board 1163 State Street Salem, Oregon 97310 Telephone: (503) 378-2244 POSITION STATEMENT: Testified on HB 127 CANDICE WHEELER 2758 Upper Breckenridge Street Salem, Oregon 97304-3434 Telephone: (503) 540-0263 POSITION STATEMENT: Testified on HB 127 BARBARA MALCHICK, Deputy Public Advocate Office of Public Advocacy 900 West Fifth Avenue, Number 529 Anchorage, Alaska 99501 Telephone: (907) 269-3500 POSITION STATEMENT: Testified in support of HB 127 SCOTT CALDER P.O. Box 75011 Fairbanks, Alaska 99707 Telephone: (907) 474-0174 POSITION STATEMENT: Testified on HB 127 ACTION NARRATIVE TAPE 97-24, SIDE A Number 0000 CHAIRMAN CON BUNDE called the House Health, Education and Social Services Standing Committee meeting to order at 3:11 p.m. Members present at the call to order were Representatives Bunde, Vezey and Kemplen. Representative Dyson arrived at 3:12 p.m. and Representative Green arrived at 3:13 p.m. Representatives Brice and Porter were absent. This meeting was teleconferenced to Anchorage, Fairbanks, Ketchikan, and offnet sites. HB 193 - REPAY GRADUATE EDUCATION AID Number 0030 CHAIRMAN BUNDE announced the first item on the agenda was HB 193, "An Act relating to financial assistance for students attending certain graduate education programs; and providing for an effective date." A quorum was not present, but the chair explained that this was the first time the bill was being heard and he would not ask the committee to take any action on it today. Number 0066 CHAIRMAN BUNDE explained that HB 193 addresses the WAMI program (Washington, Alaska, Montana and Idaho Medical Education Program). Representative Dyson joined the committee meeting and so HB 193 would be addressed later in the meeting. HB 152 - REGULATION OF HOSPICE CARE Number 0135 CHAIRMAN BUNDE announced the next item on the agenda as HB 152, "An Act regulating hospice care." Number 0167 REPRESENTATIVE AL VEZEY made a motion to move the committee substitute for HB 152, Lauterbach, dated March 26, 1997. Hearing no objections CSHB 152(HES) was now before the committee. Number 0203 REPRESENTATIVE JOE RYAN, Sponsor of HB 152, said CSHB 152(HES) addresses some of the problems that were voiced by people employed by volunteer hospices. Those people were afraid that the fees might be such that they couldn't comply with the regulations and they would go out of business. Commissioner Perdue indicated that the Department of Health and Social Services (DHSS) had no intention of issuing burdensome regulations and\or fees that would cause volunteer hospices any problems. He referred to page 7, line 6, Article 2, which creates a different set of licensing requirements for volunteer hospice programs. REPRESENTATIVE RYAN said CSHB 152(HES) tries to ensure a level of competence, based on national standards, so that people who are entering the hospice program, either volunteer and\or for profit, receive the kind of treatment they desire. This level of service is critical for people with a terminal illness and prevents mistreatment or abuse. The concept of hospice care is that someone has a terminal illness and receives services to end their life as peaceably as possible, surrounded by family and friends. Number 0343 REPRESENTATIVE VEZEY questioned why we want to or need to license hospices. Number 0356 REPRESENTATIVE RYAN answered that there have been instances where people have found inadequate conditions, people were not receiving the level of care for which they were paying. This bill would ensure compliance within a national standard so that people receive proper care, retain their dignity and are not taken advantage of in this situation. There are people who would abuse the system. With the increase in hospice services and the increase in the older adult population, we want to make sure there is a standard of care and treatment for these people. Number 0423 REPRESENTATIVE VEZEY asked how a hospice could take advantage of people. He assumed people could discontinue hospice services. He was aware of fraud against senior citizens, but wondered how it entered into this issue. Number 0467 REPRESENTATIVE RYAN explained that a person entering a hospice program is entering with a terminal illness, they might not necessarily be able to get up and discontinue the service. The family support might not be as available, especially in Alaska, because the person lacks an extended family. People might have some monies to pay for services and yet not receive basic services. There have been instances where a person who was incontinent was left for periods of time. This bill ensures that there is someone to provide oversight to inspect the hospice from time to time, check the records, to make sure services are provided as promised, the level of care is at the acceptable national standard and that people are not being abused. Some older people with serious terminal illnesses are not in a position to take care of themselves. Number 0646 SHELBY LARSEN, Administrator, Health Facilities Licensing and Certification, Division of Medical Assistance, Department of Health and Social Services, testified next via teleconference from an offnet site in Anchorage. It would be his agency's responsibility to develop regulations and (Indisc--paper shuffling) and to provide the oversight to the hospice organizations. His division has been trying to work with hospice organizations since they were notified about CSHB 152(HES). They believed the bill, the way it is currently written, is readable to both the certified and volunteer organizations. They do support the bill. MR. LARSEN explained that some of the problems which occurred are that certain organizations have offered hospice services, but many times they were not providing all the services which are considered essential hospice services or they were offering some services somewhat related to what a hospice organization provides. His division is expecting that HMOs (Health Maintenance Organizations) will begin entering Alaska. The HMOs and other managed care organizations are set up in a way that services are often fragmented. This bill would protect the public. Any entity which claims to provide hospice services would in fact have to adhere to certain standards. MR. LARSEN commented that this bill also provides for oversight, not currently available. In the certified facilities, Medicare requires 10 percent of the hospice organizations be evaluated each year. Currently there are three certified hospice organizations which are only being looked at once every three years. Hospice is a growing provider and there is the expectation that there will be more hospice organizations in the future. If this was to happen, the length of time between certification reviews would grow. The division sees this as a problem. Number 0862 PAULA McCARON, Hospice of Anchorage, testified next via teleconference from Anchorage. She was pleased to see that CSHB 152(HES) included the provisions requested by the volunteer hospices. Specifically, the delineation of requirements for volunteer hospices regarding administration and the assurance that licensing fees would not be assessed. In talking to some of those programs around the state, they indicated that they are much more comfortable with those new provisions. MS. McCARON commented that, basically, hospice provides volunteer and bereavement support to families after the death of a loved one, spiritual care and focus on supporting families and patients. Other health care systems only work with patients and do not provide the other services because they are not within the scope or mission of that particular health care program. There have been situations where people are being offered nursing care, while it may be high quality nursing care, it is being promoted as hospice care. People are not receiving the full range of services that entail the hospice philosophy. This was the reason for promoting legislation. When people are in a vulnerable and stressful place in their lives and are relying on the words of others and referrals by health care providers, not knowing fully what to expect, that they could be ensured that they would receive the full level of hospice services. Number 0965 CHAIRMAN BUNDE said that, typically, he imagined that hospice care was arranged by a family member. He asked if individuals checked themselves into a hospice program without family involvement. Number 0981 MS. McCARON answered that, in her Anchorage program, most often the referrals are a result of a family member. The family member has initiated a phone call and typically knows very little about the services that a hospice provides. The topic of dealing with a loved one's impending death is so emotionally charged that often people are doing all they can do to pick up the phone and make that first call. These people tend not to ask a lot of questions, in terms of making sure they receive quality services. They do express concern about the cost of care. Referrals are usually done by a family member, not the individual themselves. Number 1044 REPRESENTATIVE JOE GREEN said the definition of a hospice covers physical, emotional, theological and other areas of service. He expressed concern that if there were rigid guidelines, would it have an adverse affect on the volunteers, spiritually and emotionally. He also asked if volunteers receive training. Number 1089 REPRESENTATIVE RYAN said CSHB 152(HES) would require that a volunteer receive 18 hours of training. He felt that the people who run volunteer hospice organizations, especially the volunteer programs who adhere to the national standards, would request a volunteer to receive training on the philosophy of a hospice and what it is that a volunteer is expected to do. REPRESENTATIVE RYAN commented on the concept of hospice. Kegler Ross (Ph.) was the person who came up with the idea of death with dignity, that you shouldn't be stuck alone in a hospital bed someplace with family visiting once in awhile. He said we are just going back to what used to happen, his grandmother died at home. He explained that hospice aids the family. Number 1171 CHAIRMAN BUNDE explained that there was initial testimony from volunteer hospice organizations where people were concerned about being subjected to regulations. The committee has adopted CSHB 152(HES) which alleviates some of those concerns. Number 1246 REPRESENTATIVE VEZEY felt this was an important area. Although CSHB 152(HES) talks about protecting terminally ill people from fraud, he did not feel it was being addressed in this bill. He did not feel that CSHB 152(HES) addressed the issue of fraud as there are not any gates in which do that. He asked how fraud was perpetrated on a senior citizen or a terminally ill person. He felt that normally a family would request the service. If there isn't a family, he did not feel that a terminally ill person would typically check themselves into a hospice. He said a medical facility would go through some sort of process to transfer a person to hospice care. He asked what mechanisms would allow fraud to be perpetrated and what could the legislature do to put some side- boards up to make it difficult for fraud to occur. Number 1254 REPRESENTATIVE RYAN referred to the HMO concept on a nationwide scale. These are profit making organizations. He discussed a myriad of concerns regarding these organizations; not being able to get an appointment in a timely manner and not getting services outside the HMO. This bill is a first step to ensure that everybody plays by the same rules, the national standards for hospice care. It gives some oversight where there isn't any now. In the future, there might be some other things that need to be done. He did not try to address all the possibilities which might occur, it is just a basic framework to see that there is some oversight to ensure a standard level of hospice service. Number 1349 CONNIE J. SIPE, Director, Division of Senior Services, Department of Administration, said her division provides Medicare counseling. Medicare is a federal program which seniors qualify for by reason of their own social security eligibility. Hospice is a Medicare benefit, something that the state of Alaska does not regulate. As a condition of receiving Medicare funding in the state, the state has to agree to certify, to the federal Medicare agency, those agencies which are qualified to be paid directly by Medicare. The federal government pays directly to an agency for the benefit, known as the hospice benefit. Alaska, for years, has had certified hospice agencies, certified according to federal standards, which qualifies them for federal payment. MS. SIPE explained that the Division of Senior Services and the DHSS are very supportive of getting this licensure in place as a first step to make sure that we have some protection for the consumers of this service. If someone holds themselves out as a hospice agency, but doesn't care to receive Medicare money, then the state has no ability to say that the organization should not represent themselves as a hospice agency to consumers in their town or area. This is why licensure and federal Medicare payment certification allows certain standards. The state does the licensure and the federal government has the state complete payment certification, but the two are not the same. If the state's certification agency in the state, located in the Division of Medical Assistance, said a certain hospice entity may not receive Medicare payments because of a failure to meet the standards, then that agency could provide services for their private pay clients. The state would then not have any grounds to prevent them from representing themselves as a hospice organization. MS. SIPE suggested that it is difficult, in this time when we are not looking for more government regulation, to realize that if we are interested in providing protection for the vulnerable elderly it is important that, at the state level, we do the basic regulation of setting up licensure. This bill would have more detailed regulations. The state's intent is to have the regulations parallel the federal certification standards. Even if some person or group held themselves out to be a hospice organization and decided not to be a federally certified Medicare hospice agency, the state could enforce some basic standards. MS. SIPE said the same is true for us for home health care agencies, hospice agencies and certified nurse's aides. The state has leaned on federal certification payment standards, but the state has not had their own enforcement mechanism in place. The state can go after organizations for criminal acts, but can't regulate how they enter the business, train staff, represent themselves, whether they get bonding, or other things which seem necessary to have in place before an organization provides services or calls themselves something to the public. Licensure is a basic beginning for the state of Alaska. The high interest which was shown last year, regarding protection for the vulnerable elderly, is promoting legislation which would put in place some long overdue regulations. Alaska is one of the few states which doesn't have basic licensure in place. She referred to this bill, a certified nurse's aid bill, as well as a possible home health agency licensing bill which would provide this basic licensure. MS. SIPE explained that under federal Medicare, a doctor prescribes hospice. Whether it is the family who suggests hospice to the doctor, it is still the doctor who prescribes it under the federal social security hospice benefit. This benefit defines who is eligible, for how long a benefit period and what it covers. It is a valuable benefit under social security. The majority of people, who use hospice, receive it under this benefit. MS. SIPE said her father died 18 months ago in Florida under hospice care. Once her father was signed up for Medicare hospice care, by his doctor who certified in the normal course of his disease he would not be likely to live more than six months, the hospice agencies and their nurses became a link. Every time her mother was worried, she did not have to take her husband to the doctor. The nurse would make an extra stop and check his vital signs, check with the doctor to change his nausea medication. Medicare would have had to pay if her father had to run to the doctor every time. MS. SIPE explained that the federal Medicare benefit includes extra things such as paying for all of the prescription drugs relating to pain relief and management of disease. Normally Medicare does not pay for any prescription drugs for our senior citizens. The prescription drugs, which can be useful around death and dying, are often expensive. The other benefits include helping to pay for the hospital bed, oxygen and other equipment. Hospice is a wonderful service and citizens will be using it whether or not the state provides licensure. Senior citizens, who use this benefit under Medicare, will have some protection because of payment and certification linkage to the federal standards. Younger citizens who use hospice, under private pay or a private insurance, will not have any way to ensure those standards. Number 1655 RUPERT E. ANDREWS, Lobbyist, American Association of Retired People (AARP), said his organization is in full support of CSHB 152(HES). There was a concern that small communities would not be able to meet the original regulations, but this has been addressed in the current language of CSHB 152(HES). Number 1678 REPRESENTATIVE FRED DYSON asked about the senior citizen ombudsman in the state. Number 1691 MS. SIPE answered that there was a long term care ombudsman, but the official jurisdiction only has powers for long term care out of home care or out of home care facilities only. They can do intervention and health advocacy, but they don't have the same powers as they have with nursing homes and assisted living homes. Hospice would be an area that a long term care ombudsman is concerned about, but it wouldn't be within their strongest federal jurisdiction nor are they authorized to serve people under age 60. There are many users of hospice under age 60. Number 1720 REPRESENTATIVE DYSON asked if AARP did not believe that most of the consumers or family members, utilizing hospice care, are in the position to make inspections and ensure quality services. Number 1738 MR. ANDREWS suggested that the main concern is that there should be a standard of services. As new units and services are added, they should meet some standard for the consumer public. Number 1753 REPRESENTATIVE GREEN asked, under the current law, if he started a hospice organization would there would be any standards under which he would have to perform. He also asked if he could receive Medicare payments for the services his organization provides. Number 1781 MS. SIPE explained that if his organization found families who would privately pay him, he could do that and the state would not have the ability to set standards for him or his employees. If his organization wished to be paid by Medicare or Medicaid for some of the clients, then his organization would have to come to the state and receive certification under the federal standards. If his organization operated in that area outside Medicare and Medicaid, then the organization would not have to be licensed, they could operate on a business license. If the organization took people in, then the state could come in and say that he was operating a nursing home without a license. If he went into people's homes and provided hospice care, then the state would not have a way to protect the consumers. The consumers, at the very time that they want the service, are dealing with the imminence of death. Family members do not have the energy to go out and investigate these agencies. Number 1830 REPRESENTATIVE GREEN clarified that there is no control over what his proposed organization might charge these bereaved people. He asked if there were standards if his organization received Medicare payments. Number 1845 MS. SIPE explained that if his organization wanted to bill Medicare a rate is set for each visit, the benefit period and for certain other services. The same would also apply if he wanted to bill Medicaid, the state would set a rate. At this point, the licensure law does not contemplate setting rates for private pay clients. This would still be in the private market sector. If his organization dealt with someone who had AETNA insurance which covered hospice care, the provider would either have to agree what AETNA paid or get a deductible from the consumer. If his organization just took private pay clients, no one could say anything about what he did until a criminal fraud was committed. Number 1878 REPRESENTATIVE GREEN verified that CSHB 152(HES) would rectify this situation. Number 1883 REPRESENTATIVE VEZEY clarified that there is no evidence of any unscrupulous characters in this business right now. He has not heard anything about how fraud would be perpetrated and what the state could do to prevent it. Another concern is that we are talking about an inspection every three, four or five years. Inspections are not a very good policing force. There is some sort of policing force out there now because he has not heard anything ill about hospice programs in Alaska. Number 1922 MS. SIPE clarified that she didn't speak for the DHSS, but she would try to answer his questions. Doctors, real estate agents, nurses and other professions are licensed. There isn't always an inspection every year, but a complaint can be made about services, quality, or a possible overreach of services to medical certification licensing. This licensing agency has civil type of investigators who can look into the matter. They can use licensing laws and take disciplinary action or write a letter. It isn't just those inspections which provide the oversight. Without this licensure, a person would have to file a private lawsuit against this person or organization. MS. SIPE explained that the lucky thing about this bill is that since the federal government already pays the state for the cost of certifying these agencies and investigating complaints, it shouldn't cost the state anything more. She referred to the zero fiscal note from DHSS. It will only be an incremental amount above that, it won't require a big new project to handle this licensure. Number 1991 REPRESENTATIVE VEZEY asked how fraud was perpetrated against seniors and how it been adequately addressed in our laws. He cited the classic case where people are talked into signing over all their worldly possessions in turn for being cared for the rest of their life. Number 2011 MR. ANDREWS expressed concern that the people who are administering care to the public have a minimum amount of training, qualifying them to do whatever duties they need to do, particularly in the small, rural communities. These communities do not always have the opportunity to have registered nurses. This bill would mandate a minimum amount of training, so that no matter where a hospice unit was created, there would be that standard of care available. Hospice provides follow-up counseling and work with the survivors. Number 2049 CHAIRMAN BUNDE asked if it was fair to say that CSHB 152(HES) was a consumer protection and equal protection issue, those who don't pay for hospice currently have some consumer protection and those who do pay out of their own pocket will be provided protection. Number 2067 REPRESENTATIVE RYAN said this was a fair assessment. Number 2071 REPRESENTATIVE VEZEY made a motion to move CSHB 152(HES) out of committee with individual recommendations and attached fiscal note. Hearing no objection CSHB 152(HES) was moved from the Health, Education and Social Services Standing Committee. HB 193 - REPAY GRADUATE EDUCATION AID Number 2138 CHAIRMAN BUNDE announced the next item on the agenda was HB 193, "An Act relating to financial assistance for students attending certain graduate education programs; and providing for an effective date." TAPE 97-24, SIDE B Number 0000 CHAIRMAN BUNDE explained that HB 193 addresses a forgiveness provision for those who take advantage of the state subsidy to attend medical school. If those graduates return to the state of Alaska and practice medicine for five years, they would be forgiven a portion of their indebtedness. If they choose not to return, then they would reimburse the state. There are ten students a year who go into this program, historically a little less than half return to the state and practice medicine. The program costs $1.6 million a year for a total of 40 students. A hefty investment is being made for these students and the state has a right to expect that they will return. The people at the university, who supervise this program, are quick to note that another five physicians do come to Alaska and practice medicine. He suggested that Alaska should receive the credit, rather than giving the program credit. CHAIRMAN BUNDE noted that Ms. Barrans was hear to testify. He referred to her written comments and said he would work with her to address those questions in the bill. If needed, they would be addressed in a committee substitute. Number 0151 DIANE BARRANS, Executive Director, Postsecondary Education Commission, Department of Education, apologized for the lateness of getting the written testimony to the committee. The commission has not taken a position on HB 193, it has not been reviewed, so at this time they would be considered neutral. Number 0189 CHAIRMAN BUNDE clarified that the postsecondary education commission would be the vehicle in which to collect the repayment. Number 0203 REPRESENTATIVE GREEN said that some of the postsecondary education loans have met with less than a desirable response in terms of repayment. He asked what sort of repayment occurs for those medical people who don't come back to Alaska. Number 0227 MS. BARRANS explained that she did not have information about the repayment plan for those medical students who are currently training and borrowing from the regular Alaska student loan program and do not come back to the state. A sophisticated system research would have to be done to come up with that data. The older loans did not have the field of study, which is currently being done, so it would be difficult to get meaningful information about how well these people behave in terms of repayment. She suspected that the repayment behavior is quite good because some examinations for students who graduate from four year colleges have occurred and it has shown a high repayment rate. Number 0285 CHAIRMAN BUNDE asked if any research had been done on if there is a difference in repayment for those people who graduate from four year institutions and remain non-residents of Alaska as opposed to those who remain residents of Alaska. Number 0307 MS. BARRANS answered that this is perhaps the case, but she would have to review the information and get back to the committee. Number 0313 REPRESENTATIVE GREEN expressed concern that the state is paying a significant amount for these students and we don't know whether they are repaying the state. Number 0335 MS. BARRANS explained that global default rate calculations have been done, but there is not a research staff to determine how many psychiatrists or medical doctors repay the state. Number 0354 REPRESENTATIVE GREEN clarified that he was asking about loan tracking. Number 0362 MS. BARRANS stated that approximately 18 percent of borrowers default. Of that amount, the state continues to collect on an additional 8 percent. As far as the money given out, money to be repaid, the state fails to collect between 11 and 12 percent of that money due to default or death. Number 0392 REPRESENTATIVE GREEN said this was pretty specific. He asked whether the commission knew whether this was equal between those who are in the state or those who are not in the state. Number 0396 MS. BARRANS explained that the statistical analysis shows that the repayment behavior of those who remain outside the state is somewhat better than those who remain in the state. Number 0421 MIKE MAHER, Director of Student Financial Aid, Postsecondary Education Commission, Department of Education, stated that of the plus $1.3 million which is funneled through the commission for this program, it is a direct grant. None of the money is paid back into the program. Ms. Barrens talked about how these students can also borrow through the regular student loan program, approximately $10,000 a year. This is an area which is being tracked, they are just like any other general fund money which the legislature appropriates every year. This is the $1.6 million direct grant which is not returned. This bill attempts to turn this portion into a loan program. Number 0476 CHAIRMAN BUNDE clarified that many of the students eligible for the grant program also receive student loans. Number 0513 LAURA BURLESON, Student, testified next via teleconference from Fairbanks. She voiced her support for the proposed format of this program. As a pre-medical student, she is aware of the importance of this program. Getting into medical school is more difficult than it ever was in the past. She received a medical school rejection letter with an explanation that the school had received 10,096 applications for 113 positions. This is true throughout most of the country. The WAMI program gives students from Alaska, who don't have an in-state medical school, a medical school preference and a chance at getting admitted. She was in favor of keeping the program. She realized, in these financial times, the state needs to find ways to generate revenue and felt this bill was fair. If the state is going to pay something for a person's education, then something should be required in return whether it is by serving the state or paying money back if a student decides to practice medicine elsewhere. MS. BURLESON expressed concern about the repayment conditions. The bill says does not require repayment while the student is in medical residency. Above this, the bill states that repayment is not required until six months after termination of the graduate program. If she chose to move out of state, she questioned whether repayment would begin right after residency or within that six months after medical school. Aside from that concern, she is in support of this bill as it is fair to the students, the state and the taxpayers. It is an equitable solution and a compromise. Number 0647 JEAN RICHARDSON, Student, testified next via teleconference from Fairbanks. She thought HB 193 was a good bill, it focused the intent of the lending program. This program is supposed to be there for students who need it, it asks that they not move out of state and assists them in getting preference to an out of state medical school as Alaska does not have a state medical school. It takes those people, who are committed to staying in Alaska, gives them a chance to go to school and then come back to Alaska. They wouldn't be competing against people who plan to move out of Alaska. Those people are not providing a benefit back to the state. Number 0688 CHAIRMAN BUNDE stated that their testimony was refreshing as compared with other students, in years past, who had told him no, that if they had to repay the money they would go somewhere else on a scholarship. Those students were only participating in this program because Alaska was giving them 100 percent. Number 0712 REPRESENTATIVE VEZEY asked the status of the WAMI program. Number 0721 CHAIRMAN BUNDE said the legislature had looked at changing the program a year or two ago. Number 0729 MS. BARRANS suggested that they might be thinking of the Western Interstate Commission on Higher Education (WICHE) student exchange program which was also health education; veterinary medicine, optometry, allied health, occupational therapy, et cetera. That program has been effectively phased out. The WAMI program is the sole program through which Alaskans have preferential access to medical education at the University of Washington. Number 0744 CHAIRMAN BUNDE commented that last year the legislature passed a bill affecting the whole student loan program, which allowed a floating interest rate and diligence in repayment. He said as this is the first time the bill has been heard, no action will be taken on it today. HB 127 - FOSTER CARE REVIEW BOARD Number 0801 CHAIRMAN BUNDE announced the next item on the agenda was HB 127, "An Act relating to the citizen review board and panels for permanency planning for certain children in state custody; renaming the Citizens' Review Panel For Permanency Planning as the Citizens' Foster Care Review Board; extending the termination date of the Citizens' Foster Care Review Board; and providing for an effective date." Number 0827 PATRICIA SWENSON, Legislative Assistant to Representative Bunde, referred to the committee substitute. The goal of the committee substitute for HB 127 and of foster care review in general is to assure that children do not linger unnecessarily in out-of-home care. To that end, this legislation strengthens the independence of both the citizens' foster care review board and the local review panels. Additionally the sunset date for the board is extended to June 30, 2000. MS. SWENSON stated that independent foster care review panels are not a new concept. South Carolina enacted the first legislation in 1974. Since that time, 26 other states have followed their example. Foster care review panels, in all the states, have been successful at decreasing the amount of time children linger in out- of-home care as well as in decreasing the number of times a child needs to be moved from one out-of-home placement to another. The accomplishment of these goals saves both staff time and state dollars for the involved agencies, but more importantly it creates a more stable environment for children in out-of-home placements. She said all of these are things that the committee substitute for HB 127 hopes to accomplish. MS. SWENSON listed the highlights of the committee substitute for HB 127. The citizens' foster care review board is reestablished, the members will be appointed by the Governor, the board will also appoint local panel members in each judicial district throughout the state. It will create an executive director position. The executive director will be empowered to write grants and\or contracts to local agencies, help expand existing local panels and help create new panels in all areas of the state. The executive director will keep statistics which will indicate whether or not the board is achieving the goal of decreasing the amount of time children spend in out-of-home placements. If this is accomplished, the board will be able to show a cost savings to the state. MS. SWENSON stated that the ability to keep accurate statistics depends on the cooperation of the Division of Family and Youth Services (DFYS). The state board must be able to get the necessary information from the DFYS, which has not been possible most of the time. However, the DFYS is creating a new data system which will allow a link to the state board office. The division has indicated a willingness to allow existing employees of the panel to have input into the creation of the data system which will ensure proper data collection by the state board. MS. SWENSON explained that another part of this bill is that the state board will be responsible for training all local panel members. Local panel members will be appointed by the state board in each judicial district of the state. More than one panel can also be allowed in each district. The panels will consist of three or more volunteers. The duties of the review panel are stated clearly. The state board or local panels are granted access to any state agencies records for the purpose of locating interested parties for hearing notification. Number 1006 MS. SWENSON said, finally, the bill contains a provision that will allow the recommendations and findings of the panel to be placed into the court's records for consideration in the disposition of a case. Input about the provisions of this committee substitute was obtained from Office of Public Advocacy, public defender's office, private lawyers within the system, DFYS and the Department of Administration. There are some concerns that have been consistent throughout the discussions. Three of the largest concerns regard placing language in the bill stating that the panels will comply with Title 4-E review requirements. Another concern is the broadness in the language used to grant the state board and the local panels access to other agency's records for the purpose of locating and notifying interested parties of hearings. The existing panel is very willing and anxious to work with the departments towards a solution to meet the needs of everyone concerned. The panel wishes to retain the ability to function as an independent oversight entity and will have its findings and recommendations weighed equally with the concerns of others who are interested in each case. The intention of the state board and the local review panel is to have a fair process with as much participation as possible from interested parties. Number 1284 CHAIRMAN BUNDE stated that the basis of HB 127 is a citizen oversight review of work done by DFYS. It would try to make sure that parents or grandparents are involved in hearings regarding a child's disposition. MS. SWENSON said the panel independently hears cases and asks questions about whether reasonable efforts have been made to prevent an initial placement in foster care. The panel finds out whether the child's current placement is appropriate and if progress has been made to alleviate the cause of the out-of-home placement. They also check on the compliance level of the parents or anyone involved in the case plan. CHAIRMAN BUNDE stated that they would be considered a gentle watchdog group. Number 1284 NANCY MILLER, Director, Citizen Review Board Program, State of Oregon, testified next via teleconference from an offnet site. In Oregon they are housed in the judicial branch, but the functions are very much the same as the functions that are being proposed in HB 127. The review board system maintains a comprehensive data base that collects about 25 data points on every reviewed child in foster care. Reviews are started, in Oregon, at six months, so they are tracking the long term population. One of the criticisms of the program is that they start too late. She supported the 90 day start time which is in HB 127. The data, located in the committee file, shows a decreasing length of time for children in long term foster care. In 1992, children were spending an average of 36.5 months in foster care and in 1996, that number was down to 27.9 months. This data is only on the long term population. The Oregon child welfare agency's data looks very different, in terms of the overall length of stay which is down 22 months because they are also counting the children who go in and out of the system up at the front end. The review board does not see these children. Number 1237 MS. MILLER explained that the review board also tracks the number of moves of children in care. In 1992, for the long term population, there was 4.1 moves per child and for 1996 that number is down to 3.1 moves. When you look at both of these statistics, you are measuring the fiscal savings to the state, in terms of having the boards review these cases, and the emotional savings for children, in terms of reducing the trauma of moving them from placement to placement. In their monthly care report, they talk about the Citizen Review Board (CRB), which is the abbreviation for their program in Oregon. The CRB is meant to be an active player and partner in the system to access those outcomes for children. She would not say that the reason for the reduction in the length of stay is due to the CRB, but she would say that the overall length of stay for all the kids in care is increasing and the only difference, for the long term population is that the CRB is involved. This says, to her, that the CRB has a significant impact. MS. MILLER stated that when this program started in Oregon, they were called an adversarial watchdog group. It was clear in their legislation that there is a dual mission and the mission of HB 127 looks the same to her. The job is not only to review the cases of individual children, to make sure that they are moving through the system, but to make recommendations on policies, procedures and laws relating to substitute care. They are providing both the oversight role and one of advocacy. There are about 350 volunteers serving on 70 boards around Oregon. Those folks are highly educated about the child welfare system and how it works. They are active in advocating for resources for the children in their community. They have been instrumental in providing information to the agency to ensure that the agency is dealing with programs which work. Two group homes closed down as a result of the intervention of the board, those homes were not adequately providing for the children. Number 1342 MS. MILLER cautioned the committee about saying that HB 127 has only a watchdog role. This is certainly a part of the goal, but the advocacy role is equally as important. Number 1350 CHAIRMAN BUNDE stated that he viewed it as a very protective watchdog role. Number 1375 CANDICE WHEELER testified next via teleconference from an offnet site. She worked with the foster care and home program in Anchorage since its inception in late 1993 to the fall of 1996 when (Indisc.) She had been a social worker for almost 30 years and substitute care has been her area of expertise. (Indisc.) mommy and daddy. She has seen first-hand the kind of incredible emotional trauma which occurs to children in the substitute care system. Having worked as a social worker, it was exciting for her to come to the foster care review program. In her three years there, she became a real believer in this effort. Calling this type of program a watchdog does seem to have a negative implication, but we need, as citizens, to be watchdogs for our children. These children belong to Alaska. MS. WHEELER said that one of the great strengths of citizen reviews is in dealing with the crises of individual children. There are 20 to 25 individual citizens who give their time to really sit and listen, day after day, to what is happening in the foster care system. These people are empowered to go out and advocate as Ms. Miller talked about in her testimony. It is critical, from that standpoint, to have someone outside the system serve those children and provide oversight to the programs. Number 1465 MS. WHEELER referred to an editorial in the Anchorage newspaper a few years ago after a 14-year-old boy shot his father in central Alaska. The article said that the way the system is set up, there is no way for anyone in the state to know the truth, what is happening to kids in the foster care and child protection system. The article said that if DFYS does its job, the public needs to know that and if the agency isn't doing its job, the public needs to know that too. This is the kind of thing that citizen reviews and independent reviews bring to the table for kids who are in out- of-home care. MS. WHEELER stated that she is supportive of this legislation which strengthens what has been done in Anchorage and allows it to move to the rest of the state. Many times outlying areas have asked the program in Anchorage why they can't have a citizen review. Her organization works with Native groups, non-profit groups and areas throughout the state because kids often gravitate to Anchorage. This kind of program needs time to work, it has only been in existence for three and a half years. Funding has been short so it has been difficult to demonstrate the kind of statistics that Ms. Miller used. It is worthwhile to look at similar programs around the United States to see their results and what results can be expected in Alaska when the program expands. MS. WHEELER stated full support of these changes, they are critical and they will be the kind of things which will make a real difference for individual children and for all of Alaska's children. Better services for them, when they've had the horrible trauma of being separated from their original parents. Number 1561 BARBARA MALCHICK, Deputy Public Advocate, Office of Public Advocacy, testified next via teleconference from Anchorage. Among her duties, she is a guardian ad litem and supervises all the guardian ad litems. It is her job to represent the best interest for children who are in the foster care system. On behalf of the guardian ad litems and the children that they represent, she strongly supported the continuation and the strengthening, through expansion, of the citizens' foster care review board. With adequate funding, staffing and training the review board is a valuable tool to make the system more responsive to the needs of the children in foster care, both on the individual small picture and on the big picture level. The process holds people responsible and gets the correct services for the child; either through getting the child back at home, preferably, or finding another alternative permanent placement for the child. On the bigger picture, the foster care review board can be an advocate for overall changes within our system. Number 1621 MS. MALCHICK suggested that some provisions need to be changed in HB 127. The bill proposes to move the initial review from 180 days to 90 days and she said there might be some problems with moving this date up. It is also important to look at the provision regarding submitting the panel's report to the court. She felt solutions could be reached and added that the state needs this sort of a bill. Number 1657 SCOTT CALDER testified next via teleconference from Fairbanks. Generally speaking, he was against HB 127. A bill similar to HB 92 or SB 15 from the 19th Legislature would be appropriate. Merely extending the sunset termination date of the program, as it currently exists in law, effective since July 1, 1990. The important thing to remember here is that when we are talking about citizen oversight, essentially it is agency personnel who comply to some appropriate legal, moral or other standard. The legislature was elected to do these things for us. He suggested the reason for this review process is to periodically document the work of state government in statute. He did not feel it was a good idea to create a new and improved, high dollar level of bureaucracy to save children and all of those other things. Many other speakers do not talk about the problems of saving children from state government, this is the heart of the matter when it comes to citizen review. Subjecting children, parents and families to an inquisitorial process is already in place. We need an irresistible oversight effort directed specifically at state agencies by the people of the state of Alaska. This has already been done by the Citizens' Review Panel for Permanency Planning Act of 1990. Historically, the problem has been the implementation of the program which requires the Governor of this state to make appointments to local panels. It has been six and a half years where there has not been full compliance with the requirement by law to make appointments to the local and state panel. Number 1742 MR. CALDER briefly wanted to run through a memorandum from Legal Services. In general the bill renames all of this. He did not think it needed to be renamed, we need to remember it as it has existed and ask the question of why it has not been allowed to occur. Many of the sections referred to the changing of the name and the constitution of the panel. Section 2 states that the DHSS would notify the state board, rather than the local panel. This is not a very good way to have local oversight. It avoids people at the local level who are doing the overseeing. The word, "citizen" has been removed in Section 3. There have been excellent reasons for supporting the Citizen Review Panel for Permanency Planning Act of 1990, however these reasons, which are good reasons, have been wrongly supported by a series of misleading claims about false assertions and implications of facts, that are not facts about the law, but about the desire to evade existing laws. Number 1812 REPRESENTATIVE GREEN clarified that Ms. Wheeler was responding to the committee substitute, version F. He verified that the policy would be that board members would be limited to two consecutive terms. He asked if that was consistent with what was in place in Oregon. He made a motion to move that the committee adopt the committee substitute for HB 127, version F, Lauterbach, as the working document. Hearing no objections CSHB 127(HES) was before the committee. Number 1870 MS. MILLER responded to a concern that panels have to meet the requirements of 42 U.S. C. 671-675 (PL 96-272). In Oregon, their citizens' review board meets all those requirements. Their child welfare agency does no review. In terms of submitting the reports to the court, this is done directly after each review. This is sometimes difficult if the court hearing occurs right after their review, but most of the time the board is able to get it there in time. Their child welfare agency had been nervous about whether or not they could meet all the federal requirements. However if the committee wished to talk with Oregon's shared regional representative, Carol Overbeck (Ph.) in Region 10, she would assure you that the citizen review could do that. If the committee wanted any further information, she would be happy to send it by mail or fax. ADJOURNMENT There being no further business to conduct, CHAIRMAN BUNDE adjourned the meeting of the House Health, Education and Social Services Standing Committee at 4:35 p.m.