Legislature(2009 - 2010)CAPITOL 106

04/09/2009 03:00 PM HEALTH & SOCIAL SERVICES


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* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+= HB 188 TAX ON MOIST SNUFF TELECONFERENCED
Heard & Held
*+ HB 168 TRAUMA CARE CENTERS/FUND TELECONFERENCED
Heard & Held
*+ HB 223 TRAINING FOR PSYCHIATRIC TREATMENT STAFF TELECONFERENCED
Heard & Held
<Bill Hearing Rescheduled from 04/07/09>
                    ALASKA STATE LEGISLATURE                                                                                  
      HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE                                                                     
                         April 9, 2009                                                                                          
                           3:05 p.m.                                                                                            
                                                                                                                                
MEMBERS PRESENT                                                                                                               
                                                                                                                                
Representative Bob Herron, Co-Chair                                                                                             
Representative Wes Keller, Co-Chair                                                                                             
Representative John Coghill                                                                                                     
Representative Bob Lynn                                                                                                         
Representative Paul Seaton                                                                                                      
Representative Sharon Cissna                                                                                                    
Representative Lindsey Holmes                                                                                                   
                                                                                                                                
MEMBERS ABSENT                                                                                                                
                                                                                                                                
All members present                                                                                                             
                                                                                                                                
COMMITTEE CALENDAR                                                                                                            
                                                                                                                                
HOUSE BILL NO. 188                                                                                                              
"An  Act relating  to the  taxation  of moist  snuff tobacco,  and                                                              
amending  the  definition  of  'tobacco   product'  in  provisions                                                              
levying an excise tax on those products."                                                                                       
                                                                                                                                
     - HEARD AND HELD                                                                                                           
                                                                                                                                
HOUSE BILL NO. 168                                                                                                              
"An  Act  relating  to  state  certification  and  designation  of                                                              
trauma centers;  creating  the uncompensated  trauma care  fund to                                                              
offset  uncompensated  trauma  care   provided  at  certified  and                                                              
designated trauma centers; and providing for an effective date."                                                                
                                                                                                                                
     - HEARD AND HELD                                                                                                           
                                                                                                                                
HOUSE BILL NO. 223                                                                                                              
"An   Act  relating   to   the  qualifications   for   residential                                                              
psychiatric treatment  center caregiver  staff; and  providing for                                                              
an effective date."                                                                                                             
                                                                                                                                
     - HEARD AND HELD                                                                                                           
                                                                                                                                
PREVIOUS COMMITTEE ACTION                                                                                                     
                                                                                                                                
BILL: HB 188                                                                                                                  
SHORT TITLE: TAX ON MOIST SNUFF                                                                                                 
SPONSOR(s): REPRESENTATIVE(s) HERRON                                                                                            
                                                                                                                                
03/12/09       (H)       READ THE FIRST TIME - REFERRALS                                                                        
03/12/09       (H)       HSS, L&C, FIN                                                                                          
03/24/09       (H)       HSS AT 3:00 PM CAPITOL 106                                                                             
03/24/09       (H)       <Bill Hearing Rescheduled to 03/26/09>                                                                 
03/26/09       (H)       HSS AT 3:00 PM CAPITOL 106                                                                             
03/26/09       (H)       Heard & Held                                                                                           
03/26/09       (H)       MINUTE(HSS)                                                                                            
04/09/09       (H)       HSS AT 3:00 PM CAPITOL 106                                                                             
                                                                                                                                
BILL: HB 168                                                                                                                  
SHORT TITLE: TRAUMA CARE CENTERS/FUND                                                                                           
SPONSOR(s): REPRESENTATIVE(s) COGHILL                                                                                           
                                                                                                                                
03/09/09       (H)       READ THE FIRST TIME - REFERRALS                                                                        
03/09/09       (H)       HSS, FIN                                                                                               
04/09/09       (H)       HSS AT 3:00 PM CAPITOL 106                                                                             
                                                                                                                                
BILL: HB 223                                                                                                                  
SHORT TITLE: TRAINING FOR PSYCHIATRIC TREATMENT STAFF                                                                           
SPONSOR(s): HEALTH & SOCIAL SERVICES                                                                                            
                                                                                                                                
04/08/09       (H)       READ THE FIRST TIME - REFERRALS                                                                        
04/08/09       (H)       HSS                                                                                                    
04/09/09       (H)       HSS AT 3:00 PM CAPITOL 106                                                                             
                                                                                                                                
WITNESS REGISTER                                                                                                              
                                                                                                                                
ROB EARL, Staff                                                                                                                 
to Representative Bob Herron                                                                                                    
Alaska State Legislature                                                                                                        
Juneau, Alaska                                                                                                                  
POSITION STATEMENT:  Introduced the proposed CSHB 188, Version                                                                
N, for the prime sponsor, Representative Herron.                                                                                
                                                                                                                                
DR. FRANK SACCO, Chair                                                                                                          
Alaska Trauma Systems Review Committee                                                                                          
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  Presented a Power Point titled "Trauma Care                                                              
in Alaska 2009" and answered questions about the Alaska trauma                                                                  
system.                                                                                                                         
                                                                                                                                
DR. REGINA CHENNAULT, Chair                                                                                                     
Alaska Committee on Trauma;                                                                                                     
American College of Surgeons                                                                                                    
Alaska Native Medical Center                                                                                                    
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  Spoke in support of HB 168.                                                                              
                                                                                                                                
DR. DANNY ROBINETTE                                                                                                             
Northern Alaska Medical Surgical                                                                                                
Fairbanks, Alaska                                                                                                               
POSITION STATEMENT:  Spoke in support of HB 168.                                                                              
                                                                                                                                
GERAD GODFREY, Chair                                                                                                            
Alaska Violent Crimes Compensation Board                                                                                        
Juneau, Alaska                                                                                                                  
POSITION STATEMENT:  Spoke about HB 168.                                                                                      
                                                                                                                                
DAVID HULL, Chairman                                                                                                            
Alaska Council on Emergency Medical Services                                                                                    
Ketchikan, Alaska                                                                                                               
POSITION STATEMENT:  Testified in support of HB 168.                                                                          
                                                                                                                                
ROD BETIT, President & CEO                                                                                                      
Alaska State Hospital and Nursing Home Association (ASHNHA)                                                                     
Juneau, Alaska                                                                                                                  
POSITION STATEMENT:  Testified about HB 168.                                                                                  
                                                                                                                                
MARK JOHNSON, Chief (ret.)                                                                                                      
Community Health and Emergency Medical Services                                                                                 
Department of Health and Social Services (DHSS)                                                                                 
POSITION STATEMENT:  Testified about HB 168.                                                                                  
                                                                                                                                
DR. JAY BUTLER, Chief Medical Officer                                                                                           
Office of the Commissioner                                                                                                      
Department of Health and Social Services (DHSS)                                                                                 
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  Testified about HB 168.                                                                                  
                                                                                                                                
MYRA MUNSON, Attorney                                                                                                           
The Boys and Girls Home of Alaska                                                                                               
Fairbanks, Alaska                                                                                                               
POSITION STATEMENT:  Testified about HB 223.                                                                                  
                                                                                                                                
PAT HEFLEY, Deputy Commissioner                                                                                                 
Office of the Commissioner                                                                                                      
Department of Health and Social Services (DHSS)                                                                                 
Juneau, Alaska                                                                                                                  
POSITION STATEMENT:  Testified about HB 223.                                                                                  
                                                                                                                                
STACIE KRALY, Chief Assistant Attorney General;                                                                                 
Statewide Section Supervisor                                                                                                    
Human Services Section                                                                                                          
Civil Division (Juneau)                                                                                                         
Department of Law (DOL)                                                                                                         
Juneau, Alaska                                                                                                                  
POSITION STATEMENT:  Answered questions about HB 223.                                                                         
                                                                                                                                
STACY TONER, Deputy Director                                                                                                    
Division of Behavioral Health                                                                                                   
Department of Health and Social Services (DHSS)                                                                                 
Juneau, Alaska                                                                                                                  
POSITION STATEMENT:  Answered questions about HB 223.                                                                         
                                                                                                                                
BEVERLY WOOLEY, Director                                                                                                        
Division of Public Health                                                                                                       
Department of Health and Social Services (DHSS)                                                                                 
Juneau, Alaska                                                                                                                  
POSITION STATEMENT:  Answered questions about HB 223.                                                                         
                                                                                                                                
JIM MALEY, President & CEO                                                                                                      
Alaska Children's Services (ACS)                                                                                                
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  Testified about HB 223.                                                                                  
                                                                                                                                
JEFF JESSEE, Chief Executive Officer                                                                                            
Alaska Mental Health Trust Authority (AMHTA)                                                                                    
Department of Revenue (DOR)                                                                                                     
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  Testified about HB 223.                                                                                  
                                                                                                                                
KATE BURKHART, Executive Director                                                                                               
Alaska Mental Health Board (AMHB)                                                                                               
Office of the Commissioner                                                                                                      
Department of Health and Social Services (DHSS)                                                                                 
Juneau, Alaska                                                                                                                  
POSITION STATEMENT:  Answered questions about HB 223.                                                                         
                                                                                                                                
FRAN PURDY, Executive Director                                                                                                  
Alaska Youth & Family Network (AYFN)                                                                                            
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  Testified about HB 223.                                                                                  
                                                                                                                                
ACTION NARRATIVE                                                                                                              
                                                                                                                                
3:05:45 PM                                                                                                                    
                                                                                                                                
CO-CHAIR WES KELLER called the House Health and Social Services                                                               
Standing    Committee   meeting    to   order    at   3:05    p.m.                                                              
Representatives   Keller,  Herron,   Cissna,  Seaton,   Lynn,  and                                                              
Coghill  were  present  at  the call  to  order.    Representative                                                              
Holmes arrived as the meeting was in progress.                                                                                  
                                                                                                                                
HB 188-TAX ON MOIST SNUFF                                                                                                     
                                                                                                                                
3:06:01 PM                                                                                                                    
                                                                                                                                
CO-CHAIR KELLER announced  that the first order  of business would                                                              
be HOUSE BILL NO.  188, "An Act relating to the  taxation of moist                                                              
snuff tobacco,  and amending the  definition of 'tobacco  product'                                                              
in provisions levying an excise tax on those products."                                                                         
                                                                                                                                
3:07:08 PM                                                                                                                    
                                                                                                                                
CO-CHAIR HERRON  moved to adopt the proposed  Committee Substitute                                                              
(CS)  for HB  188, Version  26-LS0714\N, Bullock,  4/9/09, as  the                                                              
working document.                                                                                                               
                                                                                                                                
CO-CHAIR KELLER objected for the purpose of discussion.                                                                         
                                                                                                                                
CO-CHAIR  HERRON said that  his intent  was to  reduce the  use of                                                              
snus and moist  snuff tobacco, especially by young  people, and to                                                              
increase  the revenue  for cessation  grants.   He said that  this                                                              
Committee Substitute,  Version N, changed  the tax on  moist snuff                                                              
tobacco to a weight  based tax, and changed the tax  on snus to an                                                              
ad  valorem  tax  of  100%.    He   shared  his  desire  to  craft                                                              
legislation  that  impacted  the   smokeless  products,  which  he                                                              
opined was a crisis in his district.                                                                                            
                                                                                                                                
3:09:28 PM                                                                                                                    
                                                                                                                                
ROB  EARL,  Staff  to  Representative  Bob  Herron,  Alaska  State                                                              
Legislature, read from a prepared statement:                                                                                    
                                                                                                                                
     Currently  in  state law,  cigarettes  are taxed  at  10                                                                   
     cents per  cigarette ($2 a  pack) and all other  tobacco                                                                   
     products  (OTP) are  taxed ad  valorem at  75% of  their                                                                   
     wholesale  price.   Moist snuff  tobacco (more  commonly                                                                 
     called  "dipping  tobacco")  presently falls  under  the                                                                   
     OTP tax regime.                                                                                                            
                                                                                                                                
     HB 188  distinguishes between  two types of  moist snuff                                                                   
     tobacco   (MST):  spitless  MST   and  all  other   MST.                                                                   
     Spitless  MST are these  new light-weight products  that                                                                   
     come  in teabag-like  pouches and obviate  the need  for                                                                   
     spitting.   (Like  the Camel  Snus tin we  saw a  couple                                                                   
     weeks  ago when  this bill  was  first heard.)   HB  188                                                                   
     taxes this spitless  MST at 100% ad valorem.   All other                                                                   
     MST  (mostly  the circular  tins)  will  be taxed  on  a                                                                   
     weight-based  system  of $1.88  per  ounce.   All  other                                                                   
     OTPs (everything  besides cigarettes  and both  types of                                                                   
     MST) will remain taxed at an ad valorem rate of 75%.                                                                       
                                                                                                                                
     Taxing  MST  (excluding spitless  MST)  at a  $1.88  per                                                                   
     ounce  is   designed  to  reduce  the   price  disparity                                                                   
     between discount  and premium  MST products.   $1.88 per                                                                   
     ounce  is currently  roughly equal to  what the  premium                                                                   
     brands  currently  pay  under  the  ad  valorem  system.                                                                   
     With HB  188, the tax  on discount brands will  increase                                                                   
     dramatically  and   the  tax  on  premium   brands  will                                                                   
     initially be  about the same.   The bill does  include a                                                                   
     sunset  provision, whereby  the $1.88  per ounce tax  on                                                                   
     non-spitless MST  products, barring further  legislative                                                                   
     action,  would revert  back  to a  75%  ad valorem  rate                                                                   
     after 3 years.                                                                                                             
                                                                                                                                
     This new  taxation system will produce  additional state                                                                   
     revenue, mostly  by raising  the taxes paid  by discount                                                                   
     MST  brands.   The Dept.  of Revenue  has estimated  tax                                                                   
     revenue  would   increase  by  $1.1  million,   although                                                                   
     that's   assuming  the   same  amount   of  product   is                                                                   
     purchased  as  before  the  tax increase.    Also,  some                                                                   
     popular  MST companies lowered  prices recently,  having                                                                   
     the net  effect that this bill  might result in  as much                                                                   
     as $1.8 million in additional revenue.                                                                                     
                                                                                                                                
     This  bill  also  increases   funding  for  the  tobacco                                                                   
     education  and  cessation fund  by  sending 25%  of  the                                                                   
     annual  tax revenue  collected  on all  MST products  to                                                                   
     this fund, which  may be used for tobacco  education and                                                                   
     cessation programs.                                                                                                        
                                                                                                                                
     Currently,  if you  order  cigarettes  for personal  use                                                                   
     over the  Internet, you  must pay  state taxes on  those                                                                   
     purchases.   But in current  state law, you do  not have                                                                   
     to pay taxes  on any OTP products imported  for personal                                                                   
     use.  HB 188 closes that loophole.                                                                                         
                                                                                                                                
     The bill also  requires that cigars be sold  in packages                                                                   
     of  at  least  five;  that  loose  tobacco  be  sold  in                                                                   
     packages weighing  at least  one ounce; and  that single                                                                   
     dose   units   be  sold   in   original   manufacturer's                                                                   
     packaging.                                                                                                                 
                                                                                                                                
                                                                                                                                
3:13:34 PM                                                                                                                    
                                                                                                                                
CO-CHAIR  HERRON said  that snus  was only  available on  military                                                              
bases in Alaska.   He said that it was outlawed  everywhere in the                                                              
European Union, except Sweden.                                                                                                  
                                                                                                                                
3:14:55 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE    SEATON   introduced    three   amendments    for                                                              
discussion.   He began  discussion of  the first amendment,  which                                                              
read [original punctuation provided]:                                                                                           
                                                                                                                                
     Page  3, line  19 following  "sold only  in" insert  "no                                                               
     less than units of 10"                                                                                                 
                                                                                                                                
He  said  that  this  would  eliminate   very  small  packages  of                                                              
smokeless  tobacco.   He  discussed  the second  amendment,  which                                                              
read [original punctuation provided]:                                                                                           
                                                                                                                                
     Page  3, line 1  following "subsection  is" delete  "75"                                                                   
     insert "100"                                                                                                           
                                                                                                                                
     Page 3,  line 10 following  "subsection is"  delete "75"                                                                   
     insert "100"                                                                                                           
                                                                                                                                
He referred to  this second amendment and explained  that this was                                                              
an  increase to  the tax  rate from  75 percent  of the  wholesale                                                              
price  of the  tobacco product  to  100 percent  of the  wholesale                                                              
price.   He brought attention to  the third amendment,  which read                                                              
[original punctuation provided]:                                                                                                
                                                                                                                                
     Page 1 line, 10 insert:                                                                                                    
                                                                                                                                
     Sec. 11.76.100. Selling or giving tobacco to a minor.                                                                      
               (a) A person commits the offense of selling                                                                      
     or giving tobacco to a minor if the person                                                                                 
               (1) negligently sells a cigarette, a cigar,                                                                      
     tobacco,  or a  product containing  tobacco or  nicotine                                                               
     to a person under 19 years of age;                                                                                         
               (2) is 19 years of age or older and                                                                              
     negligently  exchanges or  gives a  cigarette, a  cigar,                                                                   
     tobacco,  or a  product containing  tobacco or  nicotine                                                               
     to a person under 19 years of age;                                                                                         
              (3) maintains a vending machine that                                                                              
       dispenses cigarettes, cigars, tobacco, or products                                                                       
     containing tobacco or nicotine ; or                                                                                    
               (4) holds a business license endorsement                                                                         
     under AS  43.70.075 and allows  a person under  19 years                                                                   
     of  age to  sell  a cigarette,  a  cigar,  tobacco or  a                                                                   
     product containing tobacco or nicotine.                                                                                
                                                                                                                                
He  explained that  this would  regulate  products that  contained                                                              
either  tobacco or  nicotine.   He  said that  the issue  revolved                                                              
around  two  methods  for  taxes  on tobacco,  and  he  asked  the                                                              
sponsor  to  formulate  a  per nicotine  dose  tax,  so  that  the                                                              
committee  could   achieve  a  balanced  discouragement   to  each                                                              
nicotine delivery system.                                                                                                       
                                                                                                                                
3:19:21 PM                                                                                                                    
                                                                                                                                
CO-CHAIR KELLER closed testimony.                                                                                               
                                                                                                                                
[HB  188  was held  over.    Co-Chair Keller's  objection  to  the                                                              
motion  to  adopt  the  committee  substitute  (CS)  for  HB  188,                                                              
Version  26-LS0714\N, Bullock,  4/9/09, as  the working  document,                                                              
was left pending.]                                                                                                              
                                                                                                                                
HB 168-TRAUMA CARE CENTERS/FUND                                                                                               
                                                                                                                                
3:19:35 PM                                                                                                                    
                                                                                                                                
CO-CHAIR KELLER  announced that the  next order of  business would                                                              
be HOUSE  BILL NO.  168, "An Act  relating to state  certification                                                              
and  designation of  trauma  centers; creating  the  uncompensated                                                              
trauma care fund  to offset uncompensated trauma  care provided at                                                              
certified  and designated  trauma  centers; and  providing for  an                                                              
effective date."                                                                                                                
                                                                                                                                
3:20:19 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE COGHILL  stressed that it  was a high  priority for                                                              
Alaska  to  have   an  emergency  trauma  delivery   system.    He                                                              
explained that  he would like  to incentivize hospitals  to attain                                                              
trauma  center  designation,  and  to direct  funding  for  trauma                                                              
uses.    He noted  that  two  central issues  were  for  uninsured                                                              
patients, and for  payment to the hospitals for  the new programs.                                                              
He  suggested   that  hospitals   which  increased   their  trauma                                                              
designation  would  receive  repayment   for  the  expenses.    He                                                              
referred  to the  "Trauma  System  Consultation"  report from  its                                                              
November 2-5,  2008, meeting in  Anchorage, Alaska.   [Included in                                                              
the  members'  packets]    He  noted  that  the  report  contained                                                              
suggestions of ways  for Alaska to improve its trauma  system.  He                                                              
opined that hospitals  would be reluctant, but  would support this                                                              
program.  He summarized  that there was an important  need to take                                                              
care of  Alaskans who were  hurt, and that  there should not  be a                                                              
question of where the payment would come from.                                                                                  
                                                                                                                                
3:27:48 PM                                                                                                                    
                                                                                                                                
DR. FRANK  SACCO, Chair, Alaska  Trauma Systems Review  Committee,                                                              
said that  his report  would demonstrate  why this was  important,                                                              
what had been done  so far, and what was still  needed.  He quoted                                                              
the former  U.S. Surgeon General,  C. Everett Koop, "If  a disease                                                              
were  killing our  children  at  the rate  unintentional  injuries                                                              
are, the public  would be outraged and demand that  this killer be                                                              
stopped."   He opined  that a  public health  system approach  was                                                              
the  only proven  way  to make  an  impact.   He  stated that  the                                                              
leading cause of  death for individuals up to 44  years of age was                                                              
trauma, and yet it was still not recognized.                                                                                    
                                                                                                                                
3:31:15 PM                                                                                                                    
                                                                                                                                
DR. SACCO  referred to slide 5,  "Trauma in Alaska,"  and detailed                                                              
the annual impact to Alaskans.                                                                                                  
                                                                                                                                
3:31:45 PM                                                                                                                    
                                                                                                                                
DR. SACCO directed  attention to the comparative  deaths by trauma                                                              
in  the  U.S.  and  Alaska  on slide  6,  "Death  from  Trauma  in                                                              
Alaska."  He pointed  out the high rate for Alaskans  and the much                                                              
higher  rate for  Alaska natives,  and  he noted  that the  Alaska                                                              
trauma death rate was second only to New Mexico.                                                                                
                                                                                                                                
3:32:21 PM                                                                                                                    
                                                                                                                                
DR. SACCO  explained that  the leading  causes of traumatic  death                                                              
in Alaska  were motor vehicles and  firearms, slide 7,  "Trauma in                                                              
Alaska."   He disclosed that  25 percent  of the $73  million cost                                                              
for trauma care in Alaska was not compensated.                                                                                  
                                                                                                                                
3:32:53 PM                                                                                                                    
                                                                                                                                
DR.  SACCO compared  the time  from injury  to death  on slide  8,                                                              
"Death  from Trauma."   He  pointed out  that intervention  during                                                              
the golden hours would improve survival.                                                                                        
                                                                                                                                
3:33:27 PM                                                                                                                    
                                                                                                                                
DR.  SACCO  indicated  slide  9, "Trauma  Systems,"  and  read  "A                                                              
trauma  system  consists  of  hospitals,   personnel,  and  public                                                              
service  agencies with  a preplanned  response to  caring for  the                                                              
injured patient."                                                                                                               
                                                                                                                                
3:33:51 PM                                                                                                                    
                                                                                                                                
DR. SACCO  considered slide  10, "Trauma  Systems," and  described                                                              
the  facilities, the  personnel training,  the patient  transport,                                                              
the  triage.   He said  "a  trauma system  was  getting the  right                                                              
patient to the right place in the right amount of time."                                                                        
                                                                                                                                
3:34:20 PM                                                                                                                    
                                                                                                                                
DR. SACCO  looked at  slide 11,  "Facilities-Trauma Centers,"  and                                                              
reviewed the definitions for Levels I-IV of trauma centers.                                                                     
                                                                                                                                
3:35:28 PM                                                                                                                    
                                                                                                                                
DR. SACCO  spoke about the  various trauma related  courses, which                                                              
included ATLC, TNCC, RTTDC, and ETT, on slide 12, "Personnel."                                                                  
                                                                                                                                
3:36:07 PM                                                                                                                    
                                                                                                                                
DR.  SACCO  directed   attention  to  slide  13,   "Transport  and                                                              
triage," and  spoke about  the guidelines  that take into  account                                                              
local resources and capabilities.                                                                                               
                                                                                                                                
3:36:35 PM                                                                                                                    
                                                                                                                                
DR. SACCO referred  to "Trauma Systems" on slide  14, and declared                                                              
that trauma  systems improved  survival of  the seriously  injured                                                              
by 15  -25 percent,  increased the  productive working  years, and                                                              
enhanced the statewide disaster preparedness.                                                                                   
                                                                                                                                
3:37:25 PM                                                                                                                    
                                                                                                                                
DR. SACCO  spoke to  slide 15 "Preventable  Deaths: the  impact of                                                              
trauma systems,"  and he compared  the decrease to  percentages of                                                              
preventable deaths for three major metropolitan areas.                                                                          
                                                                                                                                
3:37:47 PM                                                                                                                    
                                                                                                                                
DR.  SACCO continued  on  to slide  16,  "Trauma  Systems &  crash                                                              
mortality," which  depicted a state to state  comparison for crash                                                              
mortality before and after the introduction of trauma systems.                                                                  
                                                                                                                                
3:37:59 PM                                                                                                                    
                                                                                                                                
DR.  SACCO  explained  that  slide 17,  "Trauma  systems  &  crash                                                              
mortality"  revealed the  impact  on mortality  rates with  trauma                                                              
systems,  seat belt restraint  laws, lower  allowable blood  level                                                              
alcohol, and increases to the speed limit.                                                                                      
                                                                                                                                
3:38:21 PM                                                                                                                    
                                                                                                                                
DR. SACCO  spoke about slide  18, "Anchorage Mortality  Rate 2005-                                                              
2007" which depicted  the lower mortality rate  for designated, as                                                              
opposed  to  non-designated,  trauma  centers in  Anchorage.    He                                                              
explained   that  the   next  slide   reflected  the   significant                                                              
differences for  age group mortality rates between  the designated                                                              
and non-designated  trauma centers.   He reviewed the  next slide,                                                              
"Trauma  Center  and  Disaster Preparedness,"  and  noted  that  a                                                              
trauma  center  maintained  its  readiness, was  staffed  for  all                                                              
types of  injuries, had  a broad  communications network,  and had                                                              
the resources to facilitate the patient's recovery.                                                                             
                                                                                                                                
3:39:21 PM                                                                                                                    
                                                                                                                                
DR. SACCO  stated that slide 21  "Trauma Systems and  the Public,"                                                              
showed that  83 percent of  the people  wanted a trauma  system in                                                              
their area.                                                                                                                     
                                                                                                                                
3:39:47 PM                                                                                                                    
                                                                                                                                
DR. SACCO  said that  slide 22,  also titled  "Trauma Systems  and                                                              
the  Public,"  affirmed  that 75  percent  of  people  interviewed                                                              
thought there  was a trauma center  system in their state,  but in                                                              
actuality only  15 percent of the  people lived in a state  with a                                                              
comprehensive system.                                                                                                           
                                                                                                                                
3:40:17 PM                                                                                                                    
                                                                                                                                
DR. SACCO  explained slide 23,  "Alaska Trauma System,"  and noted                                                              
that  a  1993  Alaska  statute   created  the  EMS  authority  for                                                              
designating  trauma centers,  set  national  standards for  trauma                                                              
centers,  and made  hospital participation  in  the trauma  system                                                              
voluntary.   He said that  in the 15  years since, there  was only                                                              
one Level  II trauma center and  four Level IV centers  in Alaska,                                                              
which were all listed on slide 25, "Current Status."                                                                            
                                                                                                                                
3:41:54 PM                                                                                                                    
                                                                                                                                
DR.  SACCO introduced  the Site  Visit Team  on slide  26, and  he                                                              
described the  "Objective," slide 27,  which was "To  help promote                                                              
a  sustainable   effort  in  the   graduated  development   of  an                                                              
inclusive trauma system for Alaska."                                                                                            
                                                                                                                                
3:42:20 PM                                                                                                                    
                                                                                                                                
DR. SACCO  continued on  to slide 28,  "Advantages &  Assets," and                                                              
emphasized that  Alaska had very committed individuals  who served                                                              
Alaska,  that  there  was an  extensive  transport  network,  that                                                              
there were  three large medical  centers with extensive  expertise                                                              
in the  state, and that  there was a  very good relationship  with                                                              
Harborview   Medical  Center   in  Seattle   for  sending   trauma                                                              
patients.   He  also  listed the  Level  II facility,  with  other                                                              
small  hospitals working  toward  verification of  Level  IV.   He                                                              
said the  Alaska Trauma Registry  received data from all  24 acute                                                              
care hospitals.                                                                                                                 
                                                                                                                                
3:43:27 PM                                                                                                                    
                                                                                                                                
DR.   SACCO    moved   on   to    slide   30,   "Challenges    and                                                              
Vulnerabilities."   He declared that Alaska did not  have a trauma                                                              
system plan,  there were no  trauma standards, there  were limited                                                              
human   resources,  there   were  few   incentives  for   hospital                                                              
participation,   and  there  was   not  a  statewide   performance                                                              
evaluation.                                                                                                                     
                                                                                                                                
3:44:24 PM                                                                                                                    
                                                                                                                                
DR. SACCO directed  attention to slide 31, "Trauma  Care in Alaska                                                              
2009,"  and  concluded:  "There  are two  healthcare  systems  for                                                              
injured  patients.    One  for  Alaska  natives  that  adheres  to                                                              
national   standards  and   another  for   the  majority   of  the                                                              
population." [original punctuation provided]                                                                                    
                                                                                                                                
3:44:32 PM                                                                                                                    
                                                                                                                                
DR.  SACCO   referred  to   the  recommendations   on  slide   32,                                                              
"Definitive  Care Facilities,"  and said  that a  second Level  II                                                              
Trauma  Center  had  to be  established  in  Anchorage,  and  that                                                              
participation  by  all acute  care  hospitals should  be  mandated                                                              
within  two years  for trauma  center  designation appropriate  to                                                              
their  capabilities.   He continued  with slide  33, and  declared                                                              
that there  was a need for  pediatric trauma care capability.   He                                                              
concluded  that  it  was  necessary   to  determine  a  method  of                                                              
financial support to trauma centers for uncompensated care.                                                                     
                                                                                                                                
3:45:30 PM                                                                                                                    
                                                                                                                                
DR.  SACCO noted  that  slide 36,  "Alaska  Trauma Systems  Review                                                              
Committee,"  reflected that  the committee  met twice  a year  and                                                              
that  its role  was  to  review the  Level  IV hospitals  and  the                                                              
interfacility  transfer  guidelines,   and  make  suggestions  for                                                              
trauma system improvement.                                                                                                      
                                                                                                                                
3:45:57 PM                                                                                                                    
                                                                                                                                
DR. SACCO  explained that  "Head Injury  Guidelines for  Rural and                                                              
Remote Alaska,"  were implemented  primarily by the  tribal health                                                              
system and it  decreased unnecessary medevacs by  75 percent, with                                                              
no adverse consequences.                                                                                                        
                                                                                                                                
3:47:10 PM                                                                                                                    
                                                                                                                                
DR.  SACCO  commented on  slide  38,  "Current Activity  US,"  and                                                              
compared that  both Georgia and  Arkansas put millions  of dollars                                                              
into  the  trauma  system,  whereas  Alaska  was  the  only  state                                                              
without  a designated  Level 1  or  Level 2  trauma center,  other                                                              
than the  Native Health Service  facility.  He added  that federal                                                              
legislation  was currently  being  considered for  help to  trauma                                                              
centers.                                                                                                                        
                                                                                                                                
3:48:24 PM                                                                                                                    
                                                                                                                                
DR. SACCO concluded  with slide 39, "Alaska Trauma  System: "Where                                                              
do  we  go now?"  and  said  that  it was  necessary  to  increase                                                              
facility participation for development of an inclusive system.                                                                  
                                                                                                                                
3:49:08 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  CISSNA asked  about  community emergency  response                                                              
training.                                                                                                                       
                                                                                                                                
DR. SACCO,  in response to  Representative Cissna,  explained that                                                              
the  difference between  designated  and non-designated  hospitals                                                              
was determined  by the ability to  maintain a minimum  care level.                                                              
He  endorsed the  need  to organize  providers  and facilities  to                                                              
ensure that this care level was always available.                                                                               
                                                                                                                                
DR. SACCO,  in response to  Representative Cissna,  explained that                                                              
the mortality  rates were  adjusted per  100,000 people,  and that                                                              
Alaskans had the second highest rate.                                                                                           
                                                                                                                                
3:52:30 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  CISSNA  referred  to  the need  for  funding,  and                                                              
asked what could be done that was not funding related.                                                                          
                                                                                                                                
DR. SACCO  said that  there were  over 70  recommendations  in the                                                              
American  College of  Surgeons report  [Included  in the  members'                                                              
packets],  many of which  did not  require any  funding.   He gave                                                              
two  examples:  mal-practice  caps  on  damages  at  a  designated                                                              
trauma  center and  Medicare  and  Medicaid allowable  billing  by                                                              
designated trauma  centers for the Emergency Room  activation of a                                                              
trauma team.                                                                                                                    
                                                                                                                                
3:55:37 PM                                                                                                                    
                                                                                                                                
CO-CHAIR KELLER opened public testimony.                                                                                        
                                                                                                                                
3:55:55 PM                                                                                                                    
                                                                                                                                
DR.  REGINA   CHENNAULT,  Chair,   Alaska  Committee   on  Trauma,                                                              
American College  of Surgeons, Alaska Native Medical  Center, said                                                              
that  she agreed  with Dr.  Sacco, and  that a  trauma system  was                                                              
also the best design  for handling any disaster.   She stated that                                                              
appropriate trauma care did reduce mortality.                                                                                   
                                                                                                                                
3:58:26 PM                                                                                                                    
                                                                                                                                
DR. DANNY  ROBINETTE, Northern  Alaska Medical Surgical,  observed                                                              
that  there  was  an  increasing  manpower  shortage  for  general                                                              
surgery.  He  noted that trauma patients were  often under insured                                                              
and he suggested  that there be  incentives for doctors.   He said                                                              
that it  became necessary  to medevac  a patient  to Seattle  when                                                              
the Anchorage medical system did not have the availability.                                                                     
                                                                                                                                
4:01:45 PM                                                                                                                    
                                                                                                                                
GERAD GODFREY,  Chair, Alaska  Violent Crimes Compensation  Board,                                                              
related a personal  story which reflected the flaws  in the trauma                                                              
response time.   He said  that the ad  hoc committee  had realized                                                              
that  there  was   not  a  standardized  procedure   for  all  the                                                              
potential  variables.   He  opined  that there  was  unwillingness                                                              
from the hospitals  to go along with the training,  the protocols,                                                              
and the start  up cost.  He  supported the pro active  approach of                                                              
the American College of Surgeons.                                                                                               
                                                                                                                                
4:08:00 PM                                                                                                                    
                                                                                                                                
DAVID  HULL,   Chairman,  Alaska  Council  on   Emergency  Medical                                                              
Services,  said that  trauma  care  needed to  be  addressed.   He                                                              
offered examples  of emergency  medical systems  that had  treated                                                              
trauma  patients,  and he  advocated  for  an entire  trauma  care                                                              
system.                                                                                                                         
                                                                                                                                
4:12:30 PM                                                                                                                    
                                                                                                                                
ROD  BETIT, President  & CEO,  Alaska State  Hospital and  Nursing                                                              
Home  Association  (ASHNHA), said  that  ASHNHA agreed  that  work                                                              
needed  to be  done on  the  trauma care  system,  and that  there                                                              
should be  incentives for initiating  the system.  He  opined that                                                              
DHSS needed to agree  on its importance before any  talks would be                                                              
effective.   He observed  that that there  was a significant  cost                                                              
to guarantee  the availability  of physicians  and nurses  for the                                                              
required time  response.   He remarked that  it was  different for                                                              
staff  model  hospitals,   as  the  physicians  worked   for  that                                                              
hospital,  than for private  hospitals, where  the physicians  did                                                              
not work  for the  hospital.   He agreed  that HB  168 was  a good                                                              
idea.                                                                                                                           
                                                                                                                                
4:16:45 PM                                                                                                                    
                                                                                                                                
MR. BETIT,  in response to  Representative Coghill, said  that the                                                              
Medicaid  disproportionate share  funds were  available, as  these                                                              
were often left unused.                                                                                                         
                                                                                                                                
4:17:22 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  COGHILL  agreed that  having  an already  existing                                                              
funding stream was optimal.                                                                                                     
                                                                                                                                
4:17:27 PM                                                                                                                    
                                                                                                                                
MARK  JOHNSON,  Chief  (ret.),   Community  Health  and  Emergency                                                              
Medical Services,  referred to the  initial legislation  passed in                                                              
1993, which  had set up the  aforementioned voluntary system.   He                                                              
explained  that  DHSS had  co-sponsored  the American  College  of                                                              
Surgeons review of  eight different hospitals in Alaska.   He said                                                              
that  he participated  in the  reviews, and  that many  facilities                                                              
were  close  to  designation.   He  opined  that  incentives  were                                                              
necessary  for  enthusiasm  for   the  designation  process.    He                                                              
stressed that the trauma system would save lives.                                                                               
                                                                                                                                
4:19:38 PM                                                                                                                    
                                                                                                                                
DR.   JAY  BUTLER,   Chief   Medical   Officer,   Office  of   the                                                              
Commissioner,  Department of  Health and  Social Services  (DHSS),                                                              
said that  injury deaths could not  be controlled like  a disease.                                                              
He  reported that  a systematic  approach to  improve trauma  care                                                              
had become  a DHSS priority.   He shared that an  American College                                                              
of Surgeons  recommendation was  for each  acute care  hospital to                                                              
seek  trauma  center designation,  appropriate  to  its  capacity,                                                              
within  the next  two years.   He affirmed  that  the goal was  to                                                              
improve the  quality of care for  trauma victims.  He  stated that                                                              
HB  168 provided  an  incentive to  become  a trauma  center.   He                                                              
cited  potential funding  sources for  reimbursement to  hospitals                                                              
for underinsured  trauma patients.  He noted  that DHSS recognized                                                              
the  importance of  trauma care,  but that  there was  uncertainty                                                              
for  fiscal support.    He observed  that  the administration  had                                                              
taken a neutral stance.                                                                                                         
                                                                                                                                
4:22:37 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE SEATON  asked how  many trauma deaths  were alcohol                                                              
related, and  if it  was necessary to  address the larger  problem                                                              
of alcoholism.                                                                                                                  
                                                                                                                                
DR.  BUTLER, in  response to  Representative  Seaton, agreed  that                                                              
alcohol  was a  component  and that  the  reduction  to the  legal                                                              
limit for blood alcohol was a part of the larger solution.                                                                      
                                                                                                                                
REPRESENTATIVE  COGHILL,  in response  to  Representative  Seaton,                                                              
said  that he  was open  to  the inclusion  of  other aspects  for                                                              
prevention, as these also had an impact on the system.                                                                          
                                                                                                                                
4:25:53 PM                                                                                                                    
                                                                                                                                
DR.  BUTLER spoke  about  teachable moments,  and  he shared  that                                                              
non-fatal  incidences  of  trauma,  specifically  alcohol  related                                                              
events, were excellent teachable moments.                                                                                       
                                                                                                                                
4:26:42 PM                                                                                                                    
                                                                                                                                
DR. SACCO  agreed with the use  of teachable moments, and  he gave                                                              
examples to the  success with alcohol intervention  and education.                                                              
He suggested  that a requirement  for trauma centers was  to teach                                                              
injury prevention to high risk populations.                                                                                     
                                                                                                                                
4:29:17 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE COGHILL,  in reference to the bill,  reflected that                                                              
it was  important to  "be quick  but don't  get in  a hurry."   He                                                              
agreed  that  there were  complexities  to  the issues,  but  that                                                              
people's lives were involved.                                                                                                   
                                                                                                                                
4:30:34 PM                                                                                                                    
                                                                                                                                
CO-CHAIR KELLER closed public testimony.                                                                                        
                                                                                                                                
[HB 168 was held over.]                                                                                                         
                                                                                                                                
HB 223-TRAINING FOR PSYCHIATRIC TREATMENT STAFF                                                                               
                                                                                                                                
4:31:00 PM                                                                                                                    
                                                                                                                                
CO-CHAIR KELLER announced  that the final order  of business would                                                              
be HOUSE  BILL NO.  223, "An  Act relating  to the  qualifications                                                              
for  residential  psychiatric treatment  center  caregiver  staff;                                                              
and providing for an effective date."                                                                                           
                                                                                                                                
The committee took an at-ease from 4:31 p.m. to 4:36 p.m.                                                                       
                                                                                                                                
4:36:57 PM                                                                                                                    
                                                                                                                                
CO-CHAIR  KELLER   acknowledged  that   there  had   been  ongoing                                                              
discussion  and  negotiation  about  HB  223.   He  opened  public                                                              
testimony.                                                                                                                      
                                                                                                                                
4:39:12 PM                                                                                                                    
                                                                                                                                
CO-CHAIR HERRON  moved to adopt the proposed  Committee Substitute                                                              
(CS)  for HB  223, Version  26-LS0842\C, Mischel,  4/8/09, as  the                                                              
working document.                                                                                                               
                                                                                                                                
REPRESENTATIVE HOLMES objected for the purpose of discussion.                                                                   
                                                                                                                                
MYRA MUNSON,  Attorney, The  Boys and Girls  Home of  Alaska, said                                                              
that the  Committee Substitute (CS)  set a new level  of caregiver                                                              
qualification  for   residential  psychiatric   treatment  centers                                                              
(RPTC).   She  noted  that there  were currently  three  caregiver                                                              
standards,  and she explained  the requirements  for each  option.                                                              
She  reported  that HB  223  allowed  for a  fourth  qualification                                                              
option.                                                                                                                         
                                                                                                                                
4:45:47 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  HOLMES  asked  for  a clarification  for  the  new                                                              
qualification.                                                                                                                  
                                                                                                                                
4:45:52 PM                                                                                                                    
                                                                                                                                
MS.  MUNSON explained  that page  2,  line 26  should not  contain                                                              
(1),  and that  this would  allow  someone without  the four  year                                                              
combination of education  and experience to work  during the hours                                                              
that another qualified  caregiver with that four  year combination                                                              
was at work.                                                                                                                    
                                                                                                                                
4:46:54 PM                                                                                                                    
                                                                                                                                
MS. MUNSON referred  to Section 1 (c) and noted  that an amendment                                                              
would  mirror  the  regulation  except  to  also  allow  that  the                                                              
training  be approved  by  the  department, not  merely  provided.                                                              
She  pointed  to  Section  1(d) which  provided  a  definition  of                                                              
caregiver.                                                                                                                      
                                                                                                                                
4:48:34 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  HOLMES  removed her  objection.    There being  no                                                              
further  objection,   Version  C   was  adopted  as   the  working                                                              
document.                                                                                                                       
                                                                                                                                
4:49:08 PM                                                                                                                    
                                                                                                                                
PAT  HEFLEY,  Deputy Commissioner,  Office  of  the  Commissioner,                                                              
Department  of Health  and Social  Services (DHSS),  said that  he                                                              
recognized that the  health care workforce had one  of the highest                                                              
vacancy rates in  Alaska.  He emphasized that this  bill was for a                                                              
residential  psychiatric facility  for kids,  and that these  were                                                              
very tough  kids.  He  acknowledged that  the Bring the  Kids Home                                                              
program was  working very well, and  that about 66 percent  of the                                                              
kids were  home in Alaska.   He said  that many of  the facilities                                                              
had problems recruiting  employees to be in frequent  contact with                                                              
the  kids.   He said  that  DHSS had  a concern  with  the use  of                                                              
statute for  changes in  qualification standards.   He  noted that                                                              
the facilities  had the ability  to ask  for a variance,  and that                                                              
there was not a  need to drop the standard.   He expressed concern                                                              
that  incident  reports  would   increase.    He  said  that  only                                                              
recently  had he  been apprised  of  this urgency,  though he  was                                                              
aware  of a shortage  of staff.   He  said that  DHSS agreed  that                                                              
there was a  problem, but did not  agree with a change  in statute                                                              
as a solution.                                                                                                                  
                                                                                                                                
4:57:09 PM                                                                                                                    
                                                                                                                                
STACIE  KRALY, Chief  Assistant Attorney  General, Human  Services                                                              
Section, Civil  Division (Juneau),  Department of Law  (DOL), said                                                              
that she  had not seen  the CS, but  that the primary  concern for                                                              
DOL was that  there were already  processes in place to  solve the                                                              
issues.   She opined that  there were quite  a few  legal problems                                                              
with the original  bill.  She reserved any further  comments until                                                              
she had an opportunity to review the CS.                                                                                        
                                                                                                                                
4:59:01 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  SEATON asked  what the optimal  limitation  to the                                                              
number of applicants was qualified within Section 1(b)(4).                                                                      
                                                                                                                                
MR. HEFLEY said  that it was important to have  experienced staff,                                                              
and he  acknowledged that  experience was  learned.  He  expressed                                                              
his concern  for having  too many inexperienced  staff at  any one                                                              
given time.                                                                                                                     
                                                                                                                                
5:01:46 PM                                                                                                                    
                                                                                                                                
STACY  TONER,  Deputy Director,  Division  of  Behavioral  Health,                                                              
Department of  Health and Social  Services (DHSS), in  response to                                                              
Representative  Seaton, opined  that no  more than  10 percent  of                                                              
the staff should be this inexperienced.                                                                                         
                                                                                                                                
5:02:09 PM                                                                                                                    
                                                                                                                                
BEVERLY WOOLEY,  Director, Division  of Public Health,  Department                                                              
of   Health  and   Social   Services   (DHSS),  in   response   to                                                              
Representative Seaton,  said that  it was difficult  to determine,                                                              
and  this allowed  for the  variance process  to work  well.   She                                                              
explained that the  variance request came through  her office, and                                                              
it allowed review for the specific needs and situations.                                                                        
                                                                                                                                
5:03:44 PM                                                                                                                    
                                                                                                                                
CO-CHAIR KELLER  asked if there  was a comparable standard  in the                                                              
other states where Alaska had sent the youth.                                                                                   
                                                                                                                                
MS. TONER,  in response to Co-Chair  Keller, said that  the Alaska                                                              
standard was comparable  to other states, but that  this was a big                                                              
change to  the existing  requirements.  She  noted that  there was                                                              
no reference to supervision in HB 223.                                                                                          
                                                                                                                                
5:05:39 PM                                                                                                                    
                                                                                                                                
CO-CHAIR   KELLER  offered   his  belief   that  supervision   was                                                              
addressed in Section 1(b)(4)(C).                                                                                                
                                                                                                                                
MS. TONER  noted that  the wording,  "to work  at the  center only                                                              
during hours  in which an  individual is  on duty at  the center,"                                                              
did not address supervision.                                                                                                    
                                                                                                                                
5:06:24 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  CISSNA said  that it  was her  desire to make  the                                                              
atmosphere  at  the   RPTCs  more  homelike.     She  related  her                                                              
experiences working  at Alaska Psychiatric  Institute (API).   She                                                              
described  the RPTC  current  atmosphere  as "much  more  severe,"                                                              
with  a  higher level  of  violence,  and  an increased  sense  of                                                              
hopelessness,  all  of  which  required  a much  higher  level  of                                                              
supervision.   She  stated that  she wanted  HB 223  to result  in                                                              
shorter, safer, healthier patient residential placements.                                                                       
                                                                                                                                
5:10:05 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  LYNN  remarked  that his  year  teaching  severely                                                              
emotionally disturbed  kids was good  preparation for his  work at                                                              
the legislature.                                                                                                                
                                                                                                                                
5:10:41 PM                                                                                                                    
                                                                                                                                
CO-CHAIR KELLER asked  how many kids were in  RPTCs outside Alaska                                                              
and ready to come back to Alaska if beds were available.                                                                        
                                                                                                                                
MS. TONER,  in response to Co-Chair  Keller, said that  there were                                                              
164 kids still outside Alaska.                                                                                                  
                                                                                                                                
5:11:05 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  COGHILL referred  to Section  1(c), and asked  the                                                              
cost for the department to provide "training for caregivers."                                                                   
                                                                                                                                
MS. TONER pointed out that the fiscal note was $400,000.                                                                        
                                                                                                                                
5:11:59 PM                                                                                                                    
                                                                                                                                
CO-CHAIR KELLER  asked if it was  a given that DHSS  provided this                                                              
training for RPTC staff.                                                                                                        
                                                                                                                                
MS.  TONER  replied  that  there  was  a  residential  care  child                                                              
certification  training for  behavioral  rehab service  facilities                                                              
through the  Office of  Children's Services.   She explained  that                                                              
this  training  brought  staff   to  the  Medicaid  standards  and                                                              
Medicaid treatment  requirements.   She allowed that  the proposed                                                              
HB 223 would  also use this same  "Bring the Kids Home"  venue for                                                              
training.                                                                                                                       
                                                                                                                                
5:13:36 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  SEATON  referred  to  Section 1(b)  and  asked  if                                                              
paragraphs (1), (2), and (3) were each a separate requirement.                                                                  
                                                                                                                                
MS. WOOLEY  said that four  different tiers of qualification  were                                                              
created.                                                                                                                        
                                                                                                                                
5:15:39 PM                                                                                                                    
                                                                                                                                
MS. WOOLEY reiterated  that the variance process  was currently in                                                              
place  for   any  immediate  needs.     She  explained   that  the                                                              
regulatory  process allowed full  public process  and input.   She                                                              
expressed her concern with HB 223 as "a quick fix."                                                                             
                                                                                                                                
5:16:47 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE COGHILL  agreed that he was "no big  fan of pulling                                                              
regulation  out  and  putting  in   statutes,"  but  that  he  was                                                              
troubled  by  the difficulties  for  navigating  the system.    He                                                              
asked for suggestions to a remedy for hiring qualified care.                                                                    
                                                                                                                                
MS. WOOLEY,  in response  to Representative  Coghill, agreed  that                                                              
the regulations  were overdue  for a revision.   She  offered that                                                              
the front line providers  should be involved in the  process.  She                                                              
also  suggested that  the university  system  could offer  classes                                                              
for  qualification.   She noted  the difficulty  in balancing  the                                                              
staff qualifications,  the safety and protection of  the kids, and                                                              
the priority to bringing the kids back to Alaska.                                                                               
                                                                                                                                
5:20:47 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  SEATON  asked  how many  current  variances  there                                                              
were throughout the state.                                                                                                      
                                                                                                                                
MS. WOOLEY  said that about 37-38  were granted over the  last few                                                              
years.                                                                                                                          
                                                                                                                                
5:21:48 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE SEATON  commented that  only one variance  had been                                                              
allowed for a RPTC.                                                                                                             
                                                                                                                                
MS. WOOLEY  said that there  had only been  one request,  and this                                                              
was a reason for the DHSS surprise to this recent crisis.                                                                       
                                                                                                                                
5:22:12 PM                                                                                                                    
                                                                                                                                
JIM  MALEY, President  & CEO,  Alaska  Children's Services  (ACS),                                                              
reported that ACS  employed 250 staff, with 96  direct care staff,                                                              
who would be  included under these regulations.   He expressed his                                                              
disagreement with the  statement from DHSS, and he  said that this                                                              
had  been a  long standing  challenge.   He  observed that  hiring                                                              
direct care  staff was always a  problem, and he gave  examples of                                                              
staff shortages and  the resulting problems.  He said  that he had                                                              
asked DHSS for a  variance, but that he was told  that it would be                                                              
denied.   He reported  that ACS had  developed a competency  based                                                              
training model  for residential  child care  workers.   He offered                                                              
the use  of this  model at  no cost  to the  state.  He  expressed                                                              
discomfort  at  this venue  for  discussion,  but he  offered  his                                                              
belief that  DHSS had not  viewed this  as a high enough  priority                                                              
to  make  changes to  the  regulation.    He reported  that  staff                                                              
shortages diminished  the opportunity to  bring more kids  back to                                                              
Alaska.                                                                                                                         
                                                                                                                                
5:26:48 PM                                                                                                                    
                                                                                                                                
MR. MALEY,  in response to Co-Chair  Keller, repeated that  he had                                                              
approached DHSS about  a variance, and was told that  it would not                                                              
be granted.                                                                                                                     
                                                                                                                                
5:27:04 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE CISSNA  asked about  the difficulty for  hiring and                                                              
retaining staff.                                                                                                                
                                                                                                                                
MR.  MALEY replied  that there  were  a number  of factors,  which                                                              
included staff  pay.  He said  that an intensive  training program                                                              
could develop the  competency for staff to work with  kids, and he                                                              
opined  that there  was  a difference  between  this training  and                                                              
getting an education.                                                                                                           
                                                                                                                                
5:30:27 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  SEATON  asked  what   the  most  common  Bachelors                                                              
degree was for applicants.                                                                                                      
                                                                                                                                
MR. MALEY responded  that it would be either  psychology or social                                                              
work,   although    there   were   occasional    applicants   with                                                              
environmental and therapeutic recreation degrees.                                                                               
                                                                                                                                
5:31:15 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  SEATON  asked  if  a  required  degree  in  social                                                              
services would be more restrictive for hiring.                                                                                  
                                                                                                                                
MR.   MALEY  replied   that  it   would  not   be  a   significant                                                              
restriction.      He  commented   that   he  was   supportive   of                                                              
regulations, but  that he had  been frustrated with  the responses                                                              
he had received.                                                                                                                
                                                                                                                                
5:32:27 PM                                                                                                                    
                                                                                                                                
JEFF JESSEE, Chief  Executive Officer, Alaska Mental  Health Trust                                                              
Authority   (AMHTA),  Department   of  Revenue  (DOR),   expressed                                                              
concern  with the legislation.    He stated that  the points  were                                                              
well taken,  and that there was  agreement that the  licensing and                                                              
staff qualification  for RPTCs  needed to be  reviewed.   He noted                                                              
that  the  Fairbanks  RPTC had  not  asked  for  a variance.    He                                                              
suggested  that it  was  better to  work  through the  regulations                                                              
than to change through  statute.  He said that  the full assurance                                                              
from  DHSS to  quickly address  these issues  was most  important.                                                              
He expressed  concern with the minimum  level for staffing  in the                                                              
current CS.   He pledged  his support to  the Bring the  Kids Home                                                              
work group.                                                                                                                     
                                                                                                                                
5:38:23 PM                                                                                                                    
                                                                                                                                
KATE  BURKHART, Executive  Director,  Alaska  Mental Health  Board                                                              
(AMHB), explained the  background of the AMHB, and  noted that the                                                              
AMHB was  also an advocacy  group which solicited  public comments                                                              
on mental health  issues.  She stated that AMHB  could not support                                                              
the current  version of HB  223.  She  said AMHB had  not received                                                              
any  comments  from   parents  that  they  would   support  lesser                                                              
qualified  caregivers  at  the  RPTC.    She  suggested  that  the                                                              
committee  solicit  consumer  discussion.    She  said  that  AMHB                                                              
recognized the  necessity to balance  the provider  staffing needs                                                              
with the need for quality treatment.                                                                                            
                                                                                                                                
5:40:42 PM                                                                                                                    
                                                                                                                                
MS.  BURKHART   declared  that   AMHB  supported  the   regulation                                                              
process,  which  involved  the  public.   She  allowed  that  this                                                              
staffing  problem  was  pervasive  throughout  the  mental  health                                                              
arena.  She stated  that all the variables involved  in work force                                                              
shortages,  including wages,  benefits, and  stress, needed  to be                                                              
addressed.                                                                                                                      
                                                                                                                                
5:43:22 PM                                                                                                                    
                                                                                                                                
MR.  HEFLEY  acknowledged  that   there  was  a  problem,  but  he                                                              
suggested that  resolution not be  through statute.  He  said that                                                              
there was not resistance  from DHSS.  He reiterated  that DHSS was                                                              
not aware that there was an issue.                                                                                              
                                                                                                                                
5:44:20 PM                                                                                                                    
                                                                                                                                
FRANCES PURDY, Executive  Director, Alaska Youth  & Family Network                                                              
(AYFN),  said  that  she  had  solicited   comments  from  parents                                                              
involved  with RPTCs.   She  reported that  parents had  commented                                                              
that the  turnover issue was  related to pay, not  qualifications.                                                              
She urged the  committee to continue with the  regulation process.                                                              
She stated that  this was not an issue of education,  but an issue                                                              
of competencies.   She shared  that the university  was developing                                                              
"best  practice  standards."    She  declared  that  many  issues,                                                              
including cultural  competency, the  stigma of mental  health, and                                                              
de-escalation  of confrontations,  were new  and required  ongoing                                                              
training.                                                                                                                       
                                                                                                                                
5:47:53 PM                                                                                                                    
                                                                                                                                
MS. MUNSON  said that she  was sympathetic  to the DHSS  and AMHTA                                                              
concerns.    She  stated  that   this  problem  deserved  a  quick                                                              
solution.  She allowed  that DHSS had set very  high standards for                                                              
care providers,  which could  make it  difficult to find  adequate                                                              
caregivers.   She questioned  whether the  high standards  created                                                              
the best  protection for children,  as the issues were  most often                                                              
about: how  much protection, how much  money to spend,  and how to                                                              
find workers  willing to  do this difficult  work.   She explained                                                              
that, prior  to drafting  this legislation,  she had reviewed  the                                                              
states with Alaskan  children enrolled in RPTCs.   She stated that                                                              
the Alaska  standards were  higher than any  of the  other states,                                                              
and she offered  some comparisons.  She declared that  she was not                                                              
trying  to  minimize  the  important and  essential  role  of  the                                                              
direct care  providers.   She stated that  the original  intent of                                                              
the  bill was  to exactly  replicate the  existing regulation,  so                                                              
that there  would not be any  service disruption, and then  to add                                                              
an additional  standard.  She  referred to the amendment  [labeled                                                              
C.3] [Included  in the  members' packets.]  and explained  that it                                                              
included on-site  supervision, or  mentorship, by someone  who met                                                              
the  specifically listed  requirements.   She  reiterated that  it                                                              
was the experience  of residential child care in  the setting, not                                                              
the  education, which  was most  critical.   She  said that  these                                                              
entry  level  jobs  often  led   to  an  increased  interest,  and                                                              
continued education.   She noted that the ratio  of supervisors to                                                              
caregivers was one to six.                                                                                                      
                                                                                                                                
5:59:15 PM                                                                                                                    
                                                                                                                                
MS.  MUNSON  said   that  variances  were  on   an  individual  by                                                              
individual basis.   She said that  any RPTC which was  planning to                                                              
open could  not ask for  a variance until  they were hiring.   She                                                              
explained  the importance  for any  new RPTC  to be  aware of  the                                                              
qualification guidelines  in advance.  She acknowledge  the desire                                                              
of the  DHSS to make  the regulatory process  a priority,  but she                                                              
noted  that the regulations  had  been in effect  since 1998,  and                                                              
that all  the testifiers  to the  process had  suggested that  all                                                              
the  levels of  care needed  to be  reconsidered.   She cited  the                                                              
difficulty for  ACS to maintain  all of  their units, even  with a                                                              
large  workforce   to  draw  experienced  personnel   from.    She                                                              
expressed the  urgency for action,  and she expressed  her concern                                                              
that  Alaska  was   sending  kids  to  other  states   with  lower                                                              
standards  than  Alaska.   She  suggested  to fix  this  caregiver                                                              
problem  immediately,  and then  to  move  forward and  deal  with                                                              
other problems.   She suggested  making this a temporary  bill for                                                              
one year,  with a  provision for  DHSS to  undertake a  regulatory                                                              
process.    She noted  that  this  would allow  for  uninterrupted                                                              
care,  and  would  give  guidance   for  the  development  of  new                                                              
standards.                                                                                                                      
                                                                                                                                
6:07:19 PM                                                                                                                    
                                                                                                                                
CO-CHAIR KELLER closed public testimony.                                                                                        
                                                                                                                                
6:08:10 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE COGHILL  noted that there were amendments  still to                                                              
be proposed  which could affect the  fiscal note.  He  stated that                                                              
he wanted  to keep moving forward  with the legislation,  but that                                                              
he was hesitant about the approach.                                                                                             
                                                                                                                                
6:08:47 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  SEATON reflected  that there  were problems  which                                                              
had existed  for years.  He  said that the legislature  made laws,                                                              
not regulations.   He did not want to rush forward,  but preferred                                                              
to hear more suggestions for options within the variance system.                                                                
                                                                                                                                
6:10:42 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  CISSNA  said  that   the  serious  problems  began                                                              
decades ago.   She  explained that previously  when there  were no                                                              
services in Alaska,  the kids were sent out of state.   She opined                                                              
that, even  now, state  policy did  not give  a priority  to these                                                              
issues.    She stated  that  the  preventative  approach  achieved                                                              
great results at  a fraction of the cost.  She  counseled to "take                                                              
the time  to do this  right."  She  offered her belief  that there                                                              
was a pressure  "to fill those  beds."  She emphasized  that there                                                              
was not a rush  for quality or for safety of  kids.  She suggested                                                              
that the House  Health and Social Services Standing  Committee put                                                              
pressure on DHSS for solutions.                                                                                                 
                                                                                                                                
[HB 223 was held over.]                                                                                                         
                                                                                                                                
                                                                                                                                
6:14:13 PM                                                                                                                    
                                                                                                                                
ADJOURNMENT                                                                                                                   
                                                                                                                                
There being  no further business  before the committee,  the House                                                              
Health  and   Social  Services  Standing  Committee   meeting  was                                                              
adjourned at 6:14 p.m.                                                                                                          
                                                                                                                                

Document Name Date/Time Subjects
CSHB 188 Sponsor Summary version N.doc HHSS 4/9/2009 3:00:00 PM
HB 188
CSHB 188 Version N.PDF HHSS 4/9/2009 3:00:00 PM
HB 188
HSS188pkt.PDF HHSS 3/26/2009 3:00:00 PM
HHSS 4/9/2009 3:00:00 PM
HB223pkt.PDF HHSS 4/9/2009 3:00:00 PM
HB 223
HB168pkt.PDF HHSS 4/9/2009 3:00:00 PM
HB 168
HB 188 Sectional Version N.PDF HHSS 4/9/2009 3:00:00 PM
HB 188