Legislature(2019 - 2020)CAPITOL 106
03/28/2019 03:00 PM HEALTH & SOCIAL SERVICES
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|Presentation: Alaska Children's Justice Act Task Force|
* first hearing in first committee of referral
= bill was previously heard/scheduled
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ALASKA STATE LEGISLATURE HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE March 28, 2019 3:02 p.m. DRAFT MEMBERS PRESENT Representative Ivy Spohnholz, Co-Chair Representative Matt Claman Representative Harriet Drummond Representative Geran Tarr Representative Lance Pruitt MEMBERS ABSENT Representative Tiffany Zulkosky, Co-Chair Representative Sharon Jackson OTHER LEGISLATORS PRESENT Representative Andy Josephson COMMITTEE CALENDAR PRESENTATION: ALASKA CHILDREN'S JUSTICE ACT TASK FORCE - HEARD HOUSE BILL NO. 22 "An Act extending the termination date of the Statewide Suicide Prevention Council; and providing for an effective date." - MOVED HB 22 OUT OF COMMITTEE HOUSE BILL NO. 29 "An Act relating to insurance coverage for benefits provided through telehealth; and providing for an effective date." - MOVED HB 29 OUT OF COMMITTEE HOUSE BILL NO. 97 "An Act relating to the prescription of drugs by a physician assistant without physical examination." - MOVED CSHB 97(HSS) OUT OF COMMITTEE HOUSE BILL NO. 86 "An Act relating to a state-owned inpatient mental health treatment hospital; and providing for an effective date." - HEARD & HELD PREVIOUS COMMITTEE ACTION BILL: HB 22 SHORT TITLE: EXTEND SUICIDE PREVENTION COUNCIL SPONSOR(s): REPRESENTATIVE(s) TARR 02/20/19 (H) PREFILE RELEASED 1/7/19 02/20/19 (H) READ THE FIRST TIME - REFERRALS 02/20/19 (H) HSS, FIN 03/26/19 (H) HSS AT 3:00 PM CAPITOL 106 03/26/19 (H) Heard & Held 03/26/19 (H) MINUTE(HSS) 03/28/19 (H) HSS AT 3:00 PM CAPITOL 106 BILL: HB 29 SHORT TITLE: INSURANCE COVERAGE FOR TELEHEALTH SPONSOR(s): REPRESENTATIVE(s) SPOHNHOLZ 02/20/19 (H) PREFILE RELEASED 1/11/19 02/20/19 (H) READ THE FIRST TIME - REFERRALS 02/20/19 (H) HSS, L&C 03/26/19 (H) HSS AT 3:00 PM CAPITOL 106 03/26/19 (H) Heard & Held 03/26/19 (H) MINUTE(HSS) 03/28/19 (H) HSS AT 3:00 PM CAPITOL 106 BILL: HB 97 SHORT TITLE: TELEHEALTH: PHYSICIAN ASSISTANTS; DRUGS SPONSOR(s): REPRESENTATIVE(s) KREISS-TOMKINS 03/15/19 (H) READ THE FIRST TIME - REFERRALS 03/15/19 (H) HSS, L&C 03/26/19 (H) HSS AT 3:00 PM CAPITOL 106 03/26/19 (H) Heard & Held 03/26/19 (H) MINUTE(HSS) 03/28/19 (H) HSS AT 3:00 PM CAPITOL 106 BILL: HB 86 SHORT TITLE: MENTAL HEALTH HOSPITAL: CONTRACTS/BIDS SPONSOR(s): REPRESENTATIVE(s) FIELDS 03/06/19 (H) READ THE FIRST TIME - REFERRALS 03/06/19 (H) HSS, L&C 03/26/19 (H) HSS AT 3:00 PM CAPITOL 106 03/26/19 (H) <Bill Hearing Rescheduled to 3/28/19> 03/28/19 (H) HSS AT 3:00 PM CAPITOL 106 WITNESS REGISTER CATHY BALDWIN-JOHNSON, MD Medical Director Alaska CARES The Children's Hospital at Providence Anchorage, Alaska POSITION STATEMENT: Presented a PowerPoint titled "Child Abuse in Alaska: 2019 Update." JARED PARRISH, PhD Senior Epidemiologist, MCH-Epi Division of Public Health Department of Health and Social Services Anchorage, Alaska POSITION STATEMENT: Presented a PowerPoint titled "Child Abuse in Alaska: 2019 Update." MIKE HOPPER, PhD Child & Adolescent Psychologist Fairbanks, Alaska POSITION STATEMENT: Testified during the presentation by Alaska Children's Justice Act Task Force. BERNICE NESBIT, Staff Representative Ivy Spohnholz Alaska State Legislature Juneau, Alaska POSITION STATEMENT: Reviewed HB 29 on behalf of the bill sponsor, Representative Spohnholz. REID HARRIS, Staff Representative Jonathan Kreiss-Tomkins Alaska State Legislature Juneau, Alaska POSITION STATEMENT: Reviewed HB 97 on behalf of the bill sponsor, Representative Kreiss-Tomkins. DEBORAH STOVERN, Executive Administrator State Medical Board Division of Corporations, Business, and Professional Licensing Department of Commerce, Community & Economic Development Anchorage, Alaska POSITION STATEMENT: Answered questions during discussion of HB 97. REPRESENTATIVE ZACH FIELDS Alaska State Legislature Juneau, Alaska POSITION STATEMENT: Introduced HB 86 as the sponsor of the bill. TRISTAN WALSH, Staff Representative Zach Fields Alaska State Legislature Juneau, Alaska POSITION STATEMENT: Presented the sectional analysis and the committee substitute for HB 86. ACTION NARRATIVE 3:02:25 PM CO-CHAIR IVY SPOHNHOLZ called the House Health and Social Services Standing Committee meeting to order at 3:02 p.m. Representatives Spohnholz, Drummond, Tarr, and Claman were present at the call to order. Representative Pruitt arrived as the meeting was in progress. Also in attendance was Representative Josephson. ^Presentation: Alaska Children's Justice Act Task Force Presentation: Alaska Children's Justice Act Task Force 3:03:00 PM CO-CHAIR SPOHNHOLZ announced that the first order of business would be a presentation by the Alaska Children's Justice Act Task Force. 3:03:54 PM CATHY BALDWIN-JOHNSON, MD, Medical Director, Alaska CARES, The Children's Hospital at Providence, acknowledged the Task Force members in the audience. She presented a PowerPoint titled "Child Abuse in Alaska: 2019 Update," and paraphrased slide 1, "Introduction to the Alaska CIATF," which read: Federally mandated and funded Mission: Identify areas where improvement is needed in the statewide response to child maltreatment, particularly child sexual abuse, make recommendations and take action to improve the system. Statewide, multidisciplinary membership Legislation to improve protection & justice for children (starvation, serious physical abuse, privacy) Focus on education: child abuse in Alaska, mandatory reporting, & best practices for the multidisciplinary response to child abuse DR. BALDWIN-JOHNSON moved on to paraphrase slide 2, "Key Points," which read: What's happening with child abuse and neglect in Alaska? It's COMMON What is the impact? Adverse Childhood Experiences (ACE) Studies Alaska ACEs and their costs What can we do to change the trajectory for our kids? HOPE! A real-life look at trauma 3:06:45 PM DR. BALDWIN-JOHNSON shared slide 4, "Adverse Childhood Experiences (ACE)," and explained that this was a huge collaborative study between the Centers for Disease Control and Prevention (CDC) researchers and Kaiser Permanente, a health maintenance organization in California. She reported that there were more than 17,000 participants, mostly middle-aged Caucasian with at least some college education. She reported that they were asked about events which may have happened to them prior to 18 years of age, which included physical, sexual, and emotional abuse, as well as physical and emotional neglect. She added that there were also five questions about family dysfunction, whether a parent or caregiver suffered from mental illness, if someone in the family had gone to jail or prison, did they see their mother being treated violently, was there substance abuse in the home, or was there divorce or separation. The researchers were surprised at how common it was for this history of child maltreatment, with a significant correlation between this history and the most common causes of disease and early death. She directed attention to slide 5, "34%," and noted that more than one-third of Alaskan adults reported a history of physical or sexual abuse, or physical or emotional neglect. 3:08:55 PM DR. BALDWIN-JOHNSON moved on to slide 6, "Alaska ACEs snapshot," which listed issues as reported by Alaskan adults. She stated that people who had sustained at least four or more of these categories of abuse, neglect, or family dysfunction were much more likely to be unemployed, unable to work, or to report poor health. 3:09:24 PM DR. BALDWIN-JOHNSON indicated slide 7, a graph of abuse and dysfunction with the relative percentage of co-occurrence with other exposures. She pointed out that these exposures tended to occur in clusters in families. 3:10:06 PM DR. BALDWIN-JOHNSON presented slide 8, "Adverse Childhood Experiences (ACE)," and emphasized that the more ACEs documented, the higher the risk for developing health and social problems. She reported that childhood trauma modified development and impacted genetics. She moved on to slide 9, "Impacts Start Prior to Birth," and paraphrased the slide, which read: Prenatal exposures and experiences can have an impact on both vulnerability as well as resiliency Impacts on brain development and genetics Examples: FASD ? Asthma hospitalization risk 3:11:42 PM DR. BALDWIN-JOHNSON shared slide 10, "The Developing Brain: Macro View," comparing photos which revealed the difference between infant and adult brains. She said that the baby brain was meant to grow and develop in response to the things experienced after birth. She moved on to slide 11, "Rapid Growth of Neuron Development," declaring that this was a micro view of the brain. She noted that, at birth, there were not a lot of nerve cells and connections, but that after 6 years the brain was filling with information. She reported that, in the teen years, the brain went "through a time of pruning;" when a skill was not used, it was pruned, and new connections were developed. 3:12:52 PM DR. BALDWIN-JOHNSON paraphrased slide 12 "Key Concepts," which read: Neurons are designed to change in response to external signals The undifferentiated developing brain is critically dependent on environmental cues Disruption, or lack of critical cues, can result in compromised brain function Development of brain areas occur in a certain order: "Building Blocks" DR. BALDWIN-JOHNSON shared slide 13, "Key Concepts, Continued," which read: Children learn to form relationships and respond to stress - just as they learn to see, hear, walk, talk Relationships children have with caregivers play critical roles in regulating stress hormone production during early years of life Toxic stressors in childhood create measurable changes to the brain 3:14:12 PM DR. BALDWIN-JOHNSON paraphrased slide 14, "The Brain: Targets of Stress," which read: Cerebral cortex EEG changes smaller callosum Limbic system neuronal changes decreased size Brainstem/ Cerebellum altered transmitters DR. BALDWIN-JOHNSON moved on to slide 15, "Two Roads to Travel," and stated that there were two roads for kids to travel when they were born. She paraphrased from the slide, which read: Safe and Nurturing Have a stable foundation from which to explore their world Spend more time in the upper blocks (bonding, talking, interpersonal relationships) Child feels calm and safe and can focus their energy on learning Trauma and Chaos When a child is unsafe/threatened, they spend more time in the lower blocks, focusing only on survival Fight, Flight or Freeze neural pathways become "hardwired" 3:15:23 PM DR. BALDWIN-JOHNSON concluded with slide 16, "Life course perspective," and stated that there were things that could push a child's trajectory, noting that well-educated parents who were able to meet their kids emotional needs, read to their kids, provide appropriate discipline, get the necessary health care, and have an adequate education which starts early will push the life trajectory upward for a better start. 3:16:11 PM JARED PARRISH, PhD, Senior Epidemiologist, MCH-Epi, Division of Public Health, Department of Health and Social Services, presented slide 17 "New emerging data resources" and stated that the "Alaska Longitudinal Child Abuse and Neglect Linkage Project (ALCANLink)" was a novel data source that no other state had currently. He explained that they had taken their limited resources and maximized them to turn a cross sectional study into a longitudinal study to allow them to follow people over time, and accurately estimate risk. He pointed to the Alaska Pregnancy Risk Assessment Monitoring System (Alaska PRAMS), a survey conducted in nearly all 50 states, which was offered to new mothers shortly after birth with questions related to the pre-birth, birth, and after delivery experiences. That information was integrated with administrative data sources and child welfare records to track the population in Alaska and estimate the risk. He added that a goal was to integrate with as many administrative data sources as possible. He noted that PRAMS was weighted for population, so every birth need not be linked, but instead the data from the survey response was used. 3:18:30 PM DR. PARRISH addressed slide 18 "Risk (incidence) among children" and noted that each year they were including an additional year in age. He reported that 37 percent of children born in Alaska would be reported to child welfare before the age of nine years. He declared that this was a large proportion and was an issue for the Division of Public Health to address. He continued with slide 19, "Maltreatment burden," and explained that the prevalence estimate for maltreatment was for 10 percent of the child population, ages 0 to 17 years, to have contact with child welfare in an annual year. He reported that the adult prevalence indicated that 34 percent of adults reported experiencing some form of abuse or neglect during their childhood, which he called a proxy for the risk or lifetime burden for a child. He said that as they measured the cumulative incidents, it was expected for the estimate to closely match or exceed that 34 percent as it was the measurement of actual events as they occurred. 3:20:12 PM CO-CHAIR SPOHNHOLZ asked whether a report of contact with the Office of Children's Services (OCS) was a report of harm or a substantiated report. DR. PARRISH replied that this was a report of harm. In response to Representative Drummond, he explained that BRFSS was the behavioral risk factor surveillance system. 3:20:38 PM DR. PARRISH shared slide 20, "Among children born in Alaska during 2009-2011," and reported that each was an estimate for a child under nine years of age: one out of three would have a report of harm to child welfare; one out of four would have a report of harm screened in with child welfare; one out of eight would have a report of harm substantiated with child welfare; and one out of sixteen would be removed from their home by child welfare. He moved on to slide 21, "First report by maltreatment type," which shared the reports for physical abuse, sexual abuse, mental injury, and neglect. He pointed out that these were the four classifications used by OCS. He noted that each of the estimates could be calculated because they were a cumulative measure during the developmental periods for kids over their life course trajectory. 3:22:13 PM DR. PARRISH said that the data "have a ton of information that I could be providing to you, but usually with information and data I found that I can give data overload very quickly, as he presented slide 22, "Pre-birth household dysfunction." He clarified that this was not ACEs research but was an attempt to better understand ACEs. He pointed out that abuse and neglect were suffered directly by a child and the household dysfunction was the environment in which a child developed. He stated that household dysfunction could be measured prior to birth which allowed for the ACE score of a child at birth. He pointed out that the more household dysfunctions the more likely the child would have contact with child welfare before the age of nine. He declared that an accumulation of bad things in life impacted the ability to appropriately make a safe place for a child to develop. He moved on to slide 24, "PRAMS Questions used to quantify pre-birth household dysfunction beyond ACEs only questions." He listed financial stress, arguments with partner, homelessness, partner didn't want pregnancy, and partner threatens or limits activities as additional household dysfunctions that also were strongly related, independently for contact with child welfare. He acknowledged that although dysfunction could occur in every household, if there were three of these, it was 140 percent more likely for a report to OCS before the age of 9, and if there were five or more of these dysfunctions, it was 361 percent more likely. He declared that the utilization of population-based data helped to predict the effective placement of resources for prevention, to provide services adequately to the families, and to identify those who need these services. 3:25:21 PM DR. BALDWIN-JOHNSON paraphrased slide 26, "National estimates:" which read: In the US ANNUALLY Lifetime burden Between $433.7 billion and $2 trillion (2016 USD) DR. BALDWIN-JOHNSON addressed slide 27, "Alaska estimates:" which read: Between $631 million to $10.7 billion ANNUALLY Alaska research suggests: Costs for SUBSTANTIATED reports: $82 million for childhood health care, child welfare, special education 40.6% adult Medicaid enrollment linked to Adverse Childhood Experiences (ACEs) Decreasing ACEs and improving our response to child maltreatment could save our state ~$92 million annually in costs related just to: Medicaid, smoking, diabetes, binge drinking, arthritis, obesity DR. BALDWIN-JOHNSON addressed slide 29, "What can we do?" which read: Reasons for hope: Healing is possible Our brains can always learn We can all help build resilience in children We can all help protect children DR. BALDWIN-JOHNSON moved on to slide 30, "Early & effective intervention," which read: Child Advocacy Centers Multidisciplinary response Child focused Forensic interview Medical exam Mental health services Support & advocacy Information sharing DR. BALDWIN-JOHNSON shared slide 31, "Children seen at Alaska CACs," pointing out that many hub communities had child advocacy centers, which had provided service to more than 30,000 children and their families. 3:27:58 PM DR. BALDWIN-JOHNSON presented slide 32 "How do we create the best future for our children's lives?" and slide 33 "Development influenced by both negative and positive factors." She expressed a desire for only positive factors, with the prevention of any negative experience or trauma. She pointed to slide 34 "Protective Factors: Focus on adults," which listed: Supportive, nurturing, stable family Supportive social networks Caring adults outside family Household rules, monitoring of child Parental employment Adequate housing Access to health care, other services Community safety Community involvement 3:29:11 PM DR. BALDWIN-JOHNSON addressed slide 35 "Dare to be the one" and reminded the committee that April was National Child Abuse Prevention Month and that the motto for this year was "Dare to be the one." She shared slide 36 and slide 37, "What can you do?" which read: Realize this affects ALL of us in Alaska Break the silence! Make your decisions using a trauma- informed lens "It's not what's wrong with you, it's what happened to you" Support system-wide approaches to strengthen children and families "Strengthening Families" program "Help me grow" "Alaska Resilience Initiative" Think big - "Collective Impact" Support community based initiatives Examples: ROCK MatSu (Raising our Children with Kindness) MAPP (Mobilizing for Action through Planning and Partnerships) 3:31:18 PM DR. BALDWIN-JOHNSON shared slide 38, "Our data suggests that:" which read: Many Alaskan adults bear the burden of a lifetime accumulation of family violence and dysfunction Alaskan children start accumulating these adverse events early in life Our economy and our society bear the costs DR. BALDWIN-JOHNSON concluded with slide 39 "To reduce this burden we need:" which read: Prevention Early recognition Early, effective, timely intervention Effective treatment A focus on supporting healthy, stable , safe and nurturing families and communities so our children can be healthy & successful adults 3:32:28 PM MIKE HOPPER, PhD, Child & Adolescent Psychologist, shared some of his experiences and paraphrased from a prepared statement, which read [original punctuation provided]: I have been tasked with putting a face on the statistics you just witnessed? I have been a practicing child/adolescent psychologist for the past 40 years and have been working with abused kids for that entire time but it took me most of the first decade to understand that?The faces that come most readily are the ones I failed to recognize during those early years. My first patient, Kenny, I met, sort of, as he raced sliding on stocking feet down the halls of a locked th long-term psychiatric facility on the 8 floor of LA County Medical Center. He was laughing hysterically at the staff that chased after him. I wanted him as a patient on sight. I was told he was an incorrigible delinquent who had attempted to hang himself after setting his room at an LA detention center on fire. Senior staff assured me he had only done so to escape his correctional consequences. If so, he didn't succeed. I stayed in touch with Kenny over the course of the next 20 years he spent incarcerated. He ended up in the Supermax at Pelican Bay for assaulting an inmate accused of molesting children. He would be about 56 y/o today. But he died years ago, 3 weeks after being let out on a compassionate release. I never did ask him why he tried to kill himself as a teenager. Likewise I didn't ask the crippled 15 year old prostitute I was asked to visit on an emergency unit 2 floors below Kenny's why she'd jumped off a 4-story parking structure. I was told she was just depressed. And I didn't stand up for the 14 y/o pregnant teen in that same unit who complained that one of the nursing staff had fondled her. That was quietly swept under the rug. Nobody bothered to ask her about the father of her child and so neither did I. We all just assumed she was a loose woman. I didn't know to ask these kids the hard but obvious questions. For a time I accepted the professional party line: They were disturbed and disturbing kids. But I couldn't forget them. But it wasn't until I went to work in the early 80's in the nation's first residential facility specifically for "abused and neglected children" in the dry hills near Palm Springs that I began to understand them. I came to Alaska soon after and it has been Alaska's children who have tutored me ever since. I have come to recognize that it is child abuse, and especially child sexual abuse, that is indeed "disturbed and disturbing", not the kids who survive. But survivors don't easily or typically disclose. They prefer to "tell" in behaviors that can make you feel the way many will feel their whole lives: Helplessly angry, fearful and hopeless. But I have to constantly remind myself that those feelings are not my own; they are being shared with me by the kids I work with. And so I have to tell myself that I am not helpless; I am not hopeless or fearful. But I am angry. I am angry that now that we know, now that we can recognize the survivors we can still turn away from disturbing children of all ages and not ask the hard questions or seek the real answers. It is the face of one of those more recently forgotten children that haunts my nights from time to time. You could see her clearly in numerous on-line child pornography videos the FBI confiscated. She was the 26 y/o woman cheerfully helping very young children perform horrible sex acts. Over the course of nearly 12 hours of interview in FCC this young woman patiently explained in the voice and words of a five year old, that she learned to do so as a kindergartener caught up in a sado-masochistic child sex ring in Milwaukee she called "The Play House". The only way she could help the other children not get hurt was to show them how to please a circle of sick men with unbelievably sick needs. Abused throughout her childhood even when eventually taken into the State of Alaska's custody, she remained most fearful still of the men of the Play House as a young adult. She thought she'd found sanctuary with her co- defendant, an older man who promised he would never let anyone hurt her. When he turned out be interested in very young girls and wanted her help photographing them, well that all seemed normal and she did what she could to make sure they didn't get hurt. I explained to her judge at sentencing that hers were not the acts of a criminal, but acts of a kind of heroism I have seen before only in the insanely abusive, secret world of child sexual exploitation. I will forever be angry and haunted that the judge turned away from this heroic young lady and sentenced her to 22 years in federal prison, righteously insisting "She should have known better". But in a way he was right: She should have known better. And it is responsibility of those of us who have to see that all children in AK know better. Children like the 36 y/o mother whose two young children were recently taken into foster care after she left them alone during a black out drunk. I sat across from her in a coffee shop along the way to Anchorage. She couldn't afford the trip in to Fairbanks. I wanted a little history to help her 5 y/o son. Her tired eyes were my first clue. She explained that she never sleeps and suffers from chronic panic attacks. She even offered that she had been diagnosed as bipolar and a borderline personality disorder, was on psychiatric medication and had been in counseling for 12 years with one therapist in Louisiana before coming north with her children, where she'd now found another. But nothing really seemed to help. As a rule she didn't drink her hated mother was a mean alcoholic; father, an addict but she'd found that if occasionally she drank to the point of blackout she would hit a sort of a "reset button" and could start over and keep going. This was all she knew about herself, after years of mental health support. She'd accepted that she was a broken person who was periodically under attack from her own feelings. She herself had survived a childhood with divorced parents who fought bitterly over their 3 children. Both parents partied hard, every night as the children bounced between a rock and a hard place. Our mother, the oldest, had no memory from the age of 8 to 13 y/o except for the fact that during those years she discovered her love of horses which sustained her to this day. Her two young siblings eventually both became psychiatrically disabled. For reasons she could not fathom her younger brother hated her bitterly. A loving grandmother gave her shelter growing up, paid for riding lessons and saved her life. She married young to a much older man she loved, bred and raised race horses, and had a son. She left them after 10 years for reasons she couldn't understand; she was afraid to continue caring for her son. She hadn't slept for more than a couple hours a night for as long as she can remember. This is the face of abuse you so often see with OCS parents, folks that survive things they can barely remember and yet constantly fear. This poor woman wasn't having "panic attacks": She was having repetitive "daymares" from chronic REM deprivation; nightmares from an abusive childhood that could find no safe release and maybe resolution in the privacy of her sleeping mind and so exploded into her waking life without context. Why chronic sleep problems? As a child, she and her sibs were told to remain in their room no matter what while her parents partied, every night: alone, unprotected and I am certain prey to all sorts of predators. Her adult mind could only protect her so much from the memory of that happened to her and from what she learned to do. It could not protect her from the reminders of her own children, and so her fears worsened; her vigilance remained constant; sleep unthinkable. Her tired eyes filled with tears as I assured her of the strength of her mind and goodness of her heart and explained her shattered life. She slept 5 hours that night after crying for three. She now has the difficult but I am convinced, doable task of putting together a life that won't repeat her past. She is what we call a survivor and she should have known better. So we are here to make sure you know better. Know that 1/3 of the children of Alaska come to the attention of OCS by the time they are 8 y/o. That is a large silent constituency that needs your voice and understanding in any budgetary discussion. And they need the can-do genius of Alaska's frontier if we are ever to make a dent in that startling statistic. Thank you. 3:44:23 PM REPRESENTATIVE DRUMMOND shared her support for the questioning of young mothers for their pre-natal and pre-pregnancy lives. 3:45:45 PM DR. HOPPER shared that there was a world of expertise available for help in any aspect. 3:46:13 PM CO-CHAIR SPOHNHOLZ noted that the data created an opportunity for Alaska to ensure that service and support went to the right people. She asked about the next steps to address the necessary support. 3:47:07 PM DR. PARRISH stated that the initial part about having any new data was for educating yourself and understanding the context of the situation before there can be any targeting for prevention. He emphasized that the Division of Public Health was addressing the issue because it related to all the health effects which they were attempting to prevent. He shared that he had learned that the data was not real until he could, as a member of the community, contextualize them into his life. He reported that, as many children were reported as neglected, if there were a system to help with support for the families early on, these may never require any use of resources from OCS. He reported on the use of this program with other states and the pooling of data. 3:49:17 PM DR. BALDWIN-JOHNSON acknowledged that there were several models for targeting high risk families. She added that the data would help ensure the targeting of the right intervention for the right people and to try to find targeted alternatives with less expensive interventions. 3:50:09 PM DR. HOPPER shared that there were great opportunities for information and learning from the boys in the youth centers. He pointed out that much of the chronic mental illness was really "unbelievable stories of massive abuse and neglect" and "hiding from those histories." 3:52:48 PM CO-CHAIR SPOHNHOLZ offered her belief that this underscored the need for appropriate response and support for young people that have been hurt and incarcerated. She stated that it was also necessary to look "upstream" to help prevent the incidences. She said that the child welfare system begins with a report of harm and then being drawn into the system creates more trauma, whereas creative approaches to support at-risk families could prevent this. She pointed to work being done with at-risk families in the Matanuska-Susitna area and the appropriate use of information sharing to help with the necessary supports and services. HB22-EXTEND SUICIDE PREVENTION COUNCIL 3:55:39 PM CO-CHAIR SPOHNHOLZ announced that the next order of business would be HOUSE BILL NO. 22, "An Act extending the termination date of the Statewide Suicide Prevention Council; and providing for an effective date." The committee took a brief at-ease. 3:56:39 PM REPRESENTATIVE TARR said that she did not have any additional information but that she was available for any questions. 3:57:00 PM REPRESENTATIVE DRUMMOND moved to report HB 22 out of committee with individual recommendations and the accompanying fiscal notes. There being no objection, HB 22 was moved from the House Health and Social Services Standing Committee. 3:57:33 PM The committee took an at-ease from 3:57 p.m. to 4:00 p.m. HB 29-INSURANCE COVERAGE FOR TELEHEALTH 4:00:53 PM CO-CHAIR SPOHNHOLZ announced that the next order of business would be HOUSE BILL NO. 29, "An Act relating to insurance coverage for benefits provided through telehealth; and providing for an effective date." 4:00:58 PM BERNICE NESBIT, Staff, Representative Ivy Spohnholz, Alaska State Legislature, paraphrased from the Sectional Analysis for HB 29 [Included in members' packets], which read: Section 1. AS 21.42.422 has been amended to require insurance coverage for health benefits provided through telehealth technology. Section 2. AS 21.42.422 is a new subsection that defines health care insurer as a person transacting the business of health care insurance except for a nonfederal governmental plan. It also adds the definition of telehealth under 47.05.270(e) as the practice of health care delivery, evaluation, diagnosis, consultation, or treatment, using the transfer of health care data through audio, visual, or data communications, performed over two or more locations between providers who are physically separated from the recipient or from each other or between a provider and a recipient who are physically separated from each other. Section 3 The changes to Section 1 of this bill applies to health care insurance plans that are offered, issued, delivered, or renewed on or after the effective date. Section 4 The effective date is July 1, 2020. As a preliminary matter, note that a sectional summary of a bill should not be considered an authoritative interpretation of the bill -- the bill itself is the best statement of its contents. 4:01:55 PM REPRESENTATIVE DRUMMOND moved to report HB 29 out of committee with individual recommendations and the accompanying fiscal notes. There being no objection, HB 29 was moved from the House Health and Social Services Standing Committee. 4:02:20 PM The committee took a brief at-ease. HB 97-TELEHEALTH: PHYSICIAN ASSISTANTS; DRUGS 4:03:52 PM CO-CHAIR SPOHNHOLZ announced that the next order of business would be HOUSE BILL NO. 97, "An Act relating to the prescription of drugs by a physician assistant without physical examination." 4:04:02 PM REID HARRIS, Staff, Representative Jonathan Kreiss-Tomkins, Alaska State Legislature, paraphrased from the Sponsor Statement [Included in members' packets], which read: The 2016 Medicaid Reform Bill (SB 74) provided for the use of telehealth, revising Alaska statutes to require the Alaska State Medical Board to adopt regulations and guidelines for physicians rendering a diagnosis; providing treatment; or prescribing, dispensing, or administering a prescription drug to a person without first conducting a physical examination under AS 08.64.364. However, SB 74 only addressed physicians and the Board's interpretation was that the bill's provisions should not apply to physician assistants (PA's). This effectively barred PA's from practicing telemedicine, requiring them to first conduct in-person examinations. House Bill 97 aligns statute with the intent of the Medicaid Reform Bill, clarifying that PA's can provide telemedicine in collaboration with and under the oversight of physicians. Under HB97, PA's are subject to the same statutory oversight as physicians regarding the practice of telemedicine, as well as the same disciplinary sanctions when appropriate. Alaska, with its vast geographical challenges and limited access to vital healthcare, stands to benefit from this legislation. HB 97 will increase patient access to care, extending the reach of medicine to medically underserved areas. 4:05:58 PM REPRESENTATIVE PRUITT asked for clarification that this bill was necessary because the State Medical Board had interpreted Senate Bill 74 as to not include physician assistants. He asked if Ms. Stovern believed that the intent of Senate Bill 74 was to include physician assistants. 4:06:51 PM DEBORAH STOVERN, Executive Administrator, State Medical Board, Division of Corporations, Business, and Professional Licensing, Department of Commerce, Community & Economic Development, offered her belief that the State Medical Board could not determine the legislative intent regarding physician assistants so other stakeholders asked that the proposed bill clarify that physician assistants would be covered under the statute. 4:07:58 PM REPRESENTATIVE PRUITT asked if the State Medical Board covered physicians assistants as well as physicians. MS. STOVERN replied "yes, they do." REPRESENTATIVE PRUITT shared his concern that, as more people were allowed the opportunity to prescribe up to Schedule II drugs, there may be a challenge as physicians assistants would no longer have to interact with a patient for these controlled substances. MS. STOVERN, in response, stated that part of the statute required the board to adopt the nationally published American Medical Association guidelines for practicing telehealth by physician assistants. She added that the collaborative plan with the supervising physician determined the scope of practice by the physician assistant and included the type of prescriptive authority. 4:11:49 PM CO-CHAIR SPOHNHOLZ asked for confirmation that physician assistants had to utilize the Prescription Drug Monitoring Database (PDMP). MS. STOVERN said that anyone prescribing controlled substances was required to use the PDMP and this would include physician assistants engaging in prescriptions through telehealth. 4:12:45 PM CO-CHAIR SPOHNHOLZ closed public testimony. 4:12:58 PM REPRESENTATIVE DRUMMOND moved to report CSHB 97, Version 31- LS0695\M, Marx, 3/21/19, from committee with individual recommendations and the accompanying fiscal notes. There being no objection, CSHB97(HSS) was moved from the House Health and Social Services Standing Committee. 4:13:23 PM The committee took an at-ease from 4:13 p.m. to 4:16 p.m. HB 86-MENTAL HEALTH HOSPITAL: CONTRACTS/BIDS 4:16:17 PM CO-CHAIR SPOHNHOLZ announced that the final order of business would be HOUSE BILL NO. 86, "An Act relating to a state-owned inpatient mental health treatment hospital; and providing for an effective date." 4:16:45 PM REPRESENTATIVE DRUMMOND moved to adopt the proposed committee substitute (CS) for HB 86, labeled 31-LS0623\U, Marx, 3/26/19, as the working draft. 4:17:04 PM CO-CHAIR SPOHNHOLZ objected for discussion. 4:17:06 PM REPRESENTATIVE ZACH FIELDS, Alaska State Legislature, stated that the proposed bill would prevent wholesale privatization of Alaska Psychiatric Institute (API), although it would not prevent partial privatization of individual services or components within API, some of which already existed. He noted that there was concern for "a rush to judgement in terms of contracting with a specific company whose record I'll get to in a little bit." He shared that public forums in Anchorage had made clear that workers at API were committed to the public mission of API and committed to their patients, although they had lacked the resources and managerial support to do their jobs safely and to provide for the safety of the residents. He declared that the purpose of proposed HB 86 was to provide for a safe environment for both residents and workers at API, which he opined "requires public management." He stated that the proposed bill would not undo the temporary contract with Wellpath, nor would it prevent privatization of individual components of services which was consistent with the consultant report on privatization directed by the Alaska State Legislature under Senate Bill 74. He presented a PowerPoint titled "CS House Bill 86," and paraphrased slide 3, titled "API: Background," which read in part: Opened in 1962 as part of Alaska Mental Health Enabling Act of 1956. 4:19:13 PM REPRESENTATIVE FIELDS moved on to slide 4, "Patient Population and Care," which read: It is a 24/7 safety net provider of inpatient psychiatric care Patients who need acute psychiatric care, Title 47-involuntary commitment Title 12-criminal/forensic patients awaiting court ordered examinations ADRD (Alzheimer Disease and Related Disorder) patients, often placed inappropriately because there is no community placement available Others are patients who are experiencing intellectual/developmental disabilities and where there is no community support API is key for broader health system reforms and cost savings REPRESENTATIVE FIELDS addressed slide 5, "Background Literature on Privatization," and slide 6, "2017 Legislative Study recommends against privatization," which read in part: 1999 Praat and Maahs metastudy of 33 cost effectiveness studies found that private facilities were no more cost effective than public studies 2016 the US Department of Justice cited lack of cost savings and lowered delivery of services in private prisons as reason for cessation of private prison usage. Alaska's own Legislature mandated a privatization study in SB 74, working with the Alaska Mental Health Trust and Public Consulting Group Conclusion: Continue state management to attain cost savings while preserving services Cost benefit analysis showed that full privatization carried risks of decreased quality of services, higher cost over 5 year contract period REPRESENTATIVE FIELDS emphasized that inadequacy of staffing was an important safety issue and a threat to workers safety often had a ripple effect resulting in less patient safety at API. 4:21:38 PM REPRESENTATIVE FIELDS directed attention to slide 7 "A Brief Timeline of the GEO Group, Correct Care Solutions, and Wellpath" and stated that it could get a bit confusing when attempting to ascertain the relationship between Wellpath and GEO Group and Correct Care Solutions. He stated that Correct Care Solutions and Wellpath were largely the same company, and that the GEO Group had been part of Wellpath going back in the corporate history. He pointed out that these had been the same companies at different points in their history. 4:22:14 PM REPRESENTATIVE FIELDS shared slide 8, "Death on the Wards," and declared that Wellpath had a "profoundly disturbing" record as it had been sued about 1400 times. He noted that he had a "full set of media clippings and some of them are horrifying to read through." He shared the story of an individual in a Wellpath facility who contracted a cold, which progressed into pneumonia with vomiting and bleeding, and was never provided any care beyond cough drops. The individual died without receiving any care from Wellpath. He stated that the 1400 lawsuits were direct results of "a profit model that sacrifices patient safety for profits." 4:23:11 PM REPRESENTATIVE FIELDS reviewed slides 9 - 12, "Wellpath's history of negligence, deaths," and stated that "this is the record of Wellpath. It is a very consistent, it's a very troubling record... " He offered his belief that this troubling record was the reason to pass proposed HB 86. 4:23:35 PM REPRESENTATIVE TARR asked if most of the lawsuits had been associated with the Wellpath prison facilities and not with their mental health facilities, as indicated by Wellpath testimony. 4:24:31 PM REPRESENTATIVE FIELDS replied that both facilities had lawsuits, adding the Geo Group had the prison contracts and Correct Care had the private mental health hospital contracts. He offered his belief that both groups had serious problems. 4:25:02 PM REPRESENTATIVE FIELDS added that there were "voluminous media reports from locations around the country where Wellpath has operated these facilities." He declared that it was "troubling" where there were credible detailed media reports from multiple facilities about highly specific incidents of negligence and death as a result of inadequate care. He shared his concern that there had not been any assurance from Wellpath for staffing levels or adequacy of care. He pointed to slide 13, "Wellpath has "no plan," loses key staff," and stated that the news was consistent with the company's record for not having a plan for adequate staffing. He emphasized that the history at API had shown that adequate staffing was essential for safety to both patients and workers. He declared that he did not have a fundamental objection to a different management structure at API, although he had "extreme concerns" about for-profit management through a company with a long record of negligence having a flat budget as a significant amount of money would be siphoned off for profits. He added that the ownership of Wellpath was a "highly leveraged private equity firm," explaining that private equity firms extracted profit by shortchanging care, driving down costs, and typically flipping companies. 4:27:43 PM REPRESENTATIVE FIELDS directed attention to slide 14, "Putting Alaskan's First," and he highlighted that outsourcing API to a private equity firm and Wellpath was a bad idea. He pointed to an earlier study by the Alaska State Legislature for the potential savings by privatization, which had specifically cited Wellpath as a reason not to privatize. He read from the feasibility study: "The expected margin for a for-profit contractor is eight percent. This estimate is based on reporting form South Florida State Hospital." He reiterated that there was a flat funded API budget, and that, as the Department of Health and Social Services had not put any "side boards" on the profits for Wellpath in the contract, there was no guarantee for the amount of money being spent on care versus profits for the company. 4:29:17 PM REPRESENTATIVE TARR shared that she was troubled with this cycle of change with the formation of new companies relative to the lawsuits. REPRESENTATIVE FIELDS acknowledged that it was "fairly common." He emphasized that Correct Care Solutions had a very long and very troubling history, and that Wellpath was substantially Correct Care Solutions. He pointed out that the Geo Group also had a long and troubling history, although it was not currently associated with Wellpath. 4:30:25 PM CO-CHAIR SPOHNHOLZ shared her personal concern that a "really solid company with a great reputation is gonna want to keep their name the same for a long time because you build brand equity over time." She said that the level of frequency for re- branding, acquisition, or sale over the years indicated that there was not a lot of brand value and they were not building any brand equity with a good reputation. She stated that this was a red flag for her. 4:31:07 PM REPRESENTATIVE FIELDS expressed his agreement and stated that this was actually "a toxic brand." He noted that legislative bodies in other parts of the United States had cancelled pending contracts with Correct Care because it had such toxic history and was such a toxic brand, and he offered his belief that this was the reason for the re-naming as Wellpath. 4:31:30 PM TRISTAN WALSH, Staff, Representative Zach Fields, Alaska State Legislature, paraphrased from the "Sectional Analysis for HB 86" [Included in members' packets], which read: Section 1. This section amends AS 36.30.300 to add a new subsection (f) that prohibits creation of contracts relating to the ownership or operation of an inpatient mental health treatment hospital established under AS 47.30.660 (c) (see Section 4) Section 2. This section amends AS 36.30.310, the State of Alaska's Emergency Procurement Statutes, to prohibit the use of these statutes to solicit or obtain private contracts to run an inpatient mental health treatment hospital established under AS 47.30.660 (c) (See Section 4) Section 3. This section amends AS 47.30.660 (b) to correspond with a new subsection in AS 47.30.660 (c), that is established in Section 4. Section 4. This section amends AS 47.30.660 to add an additional subsection, (c), that requires the Department of Health and Social Services operate and maintain an "inpatient mental health treatment hospital" in the State. It prohibits the state from delegating or contracting for the ownership, operation or management of such a facility. It also prohibits the state from using the single source procurement statutes in AS 36.30.310 to procure supplies or services for this facility. It also defines "inpatient mental health treatment hospital" for the purposes of this section. Section 5. This section amends the uncodified law of the State of Alaska to define the applicability of new subsections established in Section 1, Section 2, Section 3 and Section 4, to contracts entered into, extended or renewed after the effective date of this Act. Section 6. This section amends the uncodified law of the State of Alaska to state if this Act takes effect after March 1st 2019, it is retroactive to March 1st 2019. Section 7. This section provides for an effective date; it would take effect immediately on passage under AS 01.10.070 (c) 4:34:10 PM MR. WALSH paraphrased from the "Summary of Changes: CS for HB 86" [Included in members' packets], which read: Several changes were made between version M and the Committee Substitute (Version U) of House Bill 86 (introduced on 3/16/19). The administration voiced concern that it would be unable to contract out for various services handled by local vendors, such as maintenance, security, and laundry. The Committee Substitute sought to address those concerns by making the following changes: Section 1. Deleted "operation" and "maintenance" to allow the department to continue to use this limited competition procurement statute for certain aspects of the operation and maintenance of the hospital. Section 2. Deleted "operation" and "maintenance" to allow the department to continue to use this statute for emergency procurements for certain aspects of the operation and maintenance of the hospital. Section 4. Deleted "operate" and "maintain" to allow the department to continue to contract out for certain aspects of the operation and maintenance of the hospital. This meant that section 4 (c) was reduced to one subsection. Section 6. This change reflects the accurate retroactive date for Alaska Psychiatric Institute. 4:35:34 PM CO-CHAIR SPOHNHOLZ removed her objection. CO-CHAIR SPOHNHOLZ said that HB 86 would be held over. 4:36:08 PM REPRESENTATIVE PRUITT asked if Section 4 of the proposed committee substitute would prevent any outside management or ownership of API. REPRESENTATIVE FIELDS said that he would consider a friendly amendment for limited management of API to either a state or a non-profit operator. This would allow the department to retain the authority to go through a competitive procurement process for non-profit management. He offered his belief that this would address his concerns for patient and worker safety and allow for partnerships to provide better services. 4:38:19 PM ADJOURNMENT There being no further business before the committee, the House Health and Social Services Standing Committee meeting was adjourned at 4:38 p.m.