Legislature(2001 - 2002)
04/23/2001 01:38 PM Senate HES
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* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
ALASKA STATE LEGISLATURE
SENATE HEALTH, EDUCATION & SOCIAL SERVICES COMMITTEE
April 23, 2001
1:38 p.m.
MEMBERS PRESENT
Senator Lyda Green, Chair
Senator Loren Leman, Vice Chair
Senator Gary Wilken
Senator Jerry Ward
Senator Bettye Davis
MEMBERS ABSENT
All Members Present
COMMITTEE CALENDAR
SENATE BILL NO. 198
"An Act establishing the Statewide Suicide Prevention Council; and
providing for an effective date."
MOVED CSSB 198(HES) OUT OF COMMITTEE
CS FOR HOUSE BILL NO. 115(HES)
"An Act relating to the definition of 'mental health professional'
for certain mental health proceedings and treatments; relating to
the services of certain medical professionals in civil proceedings
for the commitment of certain intoxicated persons; allowing a
physician assistant or advanced nurse practitioner to certify the
need for emergency treatment as a result of intoxication; and
providing for an effective date."
SCHEDULED BUT NOT HEARD
SENATE BILL NO. 38
"An Act relating to a new optional group of persons eligible for
medical assistance who require treatment for breast or cervical
cancer; and providing for an effective date."
HEARD AS PART OF THE MEDICAID DISCUSSION AND HELD IN COMMITTEE
CONTINUATION OF PRESENTATION ON MEDICAID DIRECTIONS BY THE
DEPARTMENT OF HEALTH AND SOCIAL SERVICES - CANCELLED
PREVIOUS COMMITTEE ACTION
SB 198 - No previous Senate committee action.
SB 38 - See Labor and Commerce minutes date 2/01/01 and 2/15/01.
WITNESS REGISTER
Ms. Kelly Huber
Staff to Senator Halford
Alaska State Capitol
Juneau, AK 99801-1182
POSITION STATEMENT: Testified for the sponsor of SB 198
Senator Rick Halford
Alaska State Capitol
Juneau, AK 99801-1182
POSITION STATEMENT: Sponsor of SB 198
Commissioner Karen Perdue
Department of Health &
Social Services
PO Box 110601
Juneau, AK 99801-0601
POSITION STATEMENT: Supports SB 198 and discussed the Medicaid
option to cover breast and cervical cancer treatment.
Vernon Marshall
Executive Director, NEA-Alaska
114 2nd Street
Juneau, AK 99801
POSITION STATEMENT: Supports SB 198.
Ms. Mary Diven
Division of Medical Assistance
Department of Health &
Social Services
PO Box 110601
Juneau, AK 99801-0601
POSITION STATEMENT: Provided information about the Medicaid option
to cover breast and cervical cancer treatment.
Ms. Nancy Weller
Division of Medical Assistance
Department of Health &
Social Services
PO Box 110601
Juneau, AK 99801-0601
POSITION STATEMENT: Provided information about the Medicaid option
to cover breast and cervical cancer treatment.
Ms. Carol Edwards
Alaska Nurses Association
No address provided
Juneau, AK 99801
POSITION STATEMENT: Supports legislation that provides Medicaid
coverage of breast and cervical cancer treatment.
ACTION NARRATIVE
TAPE 01-37, SIDE A
Number 001
CHAIRWOMAN LYDA GREEN called the Senate Health, Education & Social
Services Committee meeting to order at 1:38 p.m. All members were
present. Chairwoman Green asked committee members to review the
list of the Governor's appointments to various boards and
commissions and to notify her of any candidates that committee
members would like to interview. She plans to hold a hearing on
the appointments on Wednesday. Chairwoman Green also announced
that, due to time constraints, the committee will not be taking
public testimony on SB 38 today. The Department of Health and
Social Services (DHSS) will give its presentation today but
teleconference testimony will be delayed until next Wednesday.
SENATOR DAVIS asked Chairwoman Green if anyone notified people
earlier that no public testimony will be taken on SB 38 today.
CHAIRWOMAN GREEN said that people who had shown interest in
testifying today were notified earlier.
SB 198-STATEWIDE SUICIDE PREVENTION COUNCIL
MS. KELLY HUBER, legislative aide to Senator Halford, sponsor of SB
198 explained the measure as follows. SB 198 was designed to help
solve the increasing problem of suicide in Alaska. It is tragic to
lose a loved one of any age to suicide, but it is especially tragic
to lose a young person with so much to live for. Suicide is an
ongoing epidemic in Alaska; especially in rural Alaska and the Mat-
Su Valley. Suicide in preventable. SB 198 will establish a
Statewide Suicide Prevention Council made up of 14 private and
public members, representing both rural and urban Alaska. The
council will focus on finding ways to reduce suicide rates, broaden
public awareness of suicide warning signs, and enhance suicide
prevention services and programs throughout the state. Each March
the council will bring findings and recommendations to the
legislature for consideration. This bill has bipartisan support in
the Senate and Senator Halford asks the committee to act favorably
on the legislation.
Number 376
SENATOR LEMAN asked if any thought was given to appointing members
of the clergy to serve on the council.
MS. HUBER told Senator Leman that Senator Halford looked at placing
a faith-based representative on the council. He felt that it is
important to have representation from rural and urban Alaska and
that instead of placing a faith-based representative on the
council, their advice can be sought through testimony to the
council.
SENATOR LEMAN asked if it is the sponsor's intent to have advisors
to the council.
MS. HUBER said she did not think the sponsor would have any problem
with that approach and that the more advisors, the better. She
pointed out that Senator Halford was concerned that if the council
became too big, it would be difficult to get consensus and move
forward. For that reason, he kept the number of council members to
14.
SENATOR LEMAN said he believes that some of the best qualified
people to provide counsel in the area of suicide are not included
in the bill. He hopes those people can be accessed somehow. He
suggested amending the bill to allow the council to appoint an
advisory panel of an unlimited number of people.
SENATOR WARD said he agrees that people from faith-based
organizations should participate with this council, as well as
people who have had personal experience with suicide, but he
believes the amendment will overcomplicate the bill. He noted the
bill was structured to create principal executive officers, which
brings into the network 14 statewide organizations.
SENATOR LEMAN said it is his intent to broaden the reach of the
council to include people who could be good resources. He moved
the following amendment (Amendment 1).
Add to Sec. 44.29.330 on page 4, line 26:
(c) The council may appoint advisors to serve in an
advisory capacity to the council. The advisors would serve
without compensation.
He pointed out Amendment 1 is conceptual to allow the legal drafter
room to do some wordsmithing.
SENATOR WARD objected and said he believes Amendment 1 is
unnecessary. He asked Senator Leman to restate Amendment 1 for
Senator Halford.
SENATOR LEMAN explained to Senator Halford that his amendment would
specifically state that the council may appoint an advisory panel
to help it conduct its business and that the panel would serve
without compensation.
SENATOR HALFORD pointed out that the council can do that whether or
not it is specifically stated in the legislation, but he did not
believe adding it to the legislation harms it in any way. He added
that if all groups that are interested in participating had a seat
on the council, the council would have a membership of about 30,
and panels of that size do not work well.
CHAIRWOMAN GREEN asked Senator Leman to restate his motion.
SENATOR LEMAN said a new subparagraph (c) would be added to Sec.
44.29.330 that would allow the appointment of an advisory panel to
serve at the pleasure of and advise the council.
SENATOR WARD again objected and asked Senator Leman how much money
he anticipates will have to be spent on the advisory panel.
SENATOR LEMAN said none by the state.
SENATOR WARD asked if the advisory panel spent money on office
supplies or travel, whether the money would come out of the total
effort.
SENATOR LEMAN said it is not his intention to provide for travel.
SENATOR WARD said he would prefer the bill specify that the
advisory panel be at no cost. He said he is aware that four of the
groups who will have a representative on the panel have subgroups
that specifically deal with suicide prevention. He said he does
not want this effort to supplant money into these other groups. He
expressed caution that this council should be created to help, not
to become a bureaucracy.
SENATOR LEMAN said he would be happy to identify in Amendment 1
that the advisory panel serves at the pleasure of the council and
is not entitled to travel and per diem expenses.
SENATOR WARD removed his objection to Amendment 1, therefore it was
adopted.
CHAIRWOMAN GREEN commented that she finds the absence of any
reference to faith-based organizations throughout SB 198 to be
regrettable.
SENATOR HALFORD noted that a reference to faith-based organizations
was included in the bill when it was being crafted but the bill
kept getting larger and larger so he assumed faith-based
representatives would come forward to testify and participate. He
hopes they will be very involved and he has no objection to adding
further reference.
CHAIRWOMAN GREEN said her concern is that the bill should expect
the council to look to faith-based organizations.
SENATOR HALFORD felt many of the appointees to the council could
also be from faith-based organizations. He repeated that he has no
problem with adding such a member except for the size of the group.
CHAIRWOMAN GREEN said she appreciates that but she would like to
add some language to the duties section.
Number 1250
SENATOR LEMAN moved to amend (Amendment 2) Sec. 44.29.350 (4) on
page 5, line to read:
(4) develop healthy communities through comprehensive,
collaborative, community and faith based approaches;
There being no objection, CHAIRWOMAN GREEN announced that Amendment
2 was adopted.
CHAIRWOMAN GREEN said one of the things she has noticed when these
groups are formed is that the council employs the coordinator.
However, it is often the coordinator who drives the agenda of the
organization, because of the rules of longevity. She asked if SB
198 contains the typical language for the hire of the coordinator.
SENATOR HALFORD said he believes it does and that he shares Senator
Green's concern, except that he thinks the people who are committed
to suicide prevention will be committed for a long term because of
their personal experiences. He doesn't think they will be managed
by staff to the extent that some of the other boards and
commissions are. He felt the people involved in this issue will be
well directed and have a strong sense of where the council should
be going.
CHAIRWOMAN GREEN suggested revisiting this question five years from
now.
SENATOR HALFORD pointed out that Sec. 44.29.330 could contain a
provision so that the coordinator must be elected by the board
members biannually. He cautioned that the committee might want to
get another opinion on this matter. He thought that question could
be posed to the Commissioner of DHSS or someone who deals with this
sort of scenario often.
Number 1566
CHAIRWOMAN GREEN noted her concern is based on the fact that she
has seen great frustration on the part of council members who can
easily be "flim-flammed" by a coordinator. She thought some type
of mandatory assessment would put a coordinator on notice that the
position is not a career for a lifetime and that they do have to
work with councils that may change directions.
COMMISSIONER KAREN PERDUE, DHSS, told the committee that the
council can hire the individual, who would be partially exempt,
meaning that person serves at the pleasure of the council. It is
important that the individual be accountable to state procedures,
such as procurement, so the individual needs to be attached to a
department. She suggested adding language to Sec. 44.29.330(b)
that says the council shall annually review the performance of the
director.
CHAIRWOMAN GREEN asked if that is what DHSS uses for other
positions and whether the council has to take action whether the
employee is to be retained or not.
COMMISSIONER PERDUE said it is and that the model used now for
partially exempt coordinators is that the council does an annual
review and if the council indicates that the coordinator is not
performing up to certain standards, something will be done.
CHAIRWOMAN GREEN asked if there is any language in statute that
covers this situation for other directors.
COMMISSIONER PERDUE said she is sure there is but she could not
cite it at this time.
CHAIRWOMAN GREEN asked committee members for their opinions of
inserting such language.
SENATOR LEMAN said he is in agreement with Commissioner Perdue's
suggestion and although Senator Halford is concerned that the
better applicants will most likely want a long term contract, he
believes there is nothing wrong with an annual review.
CHAIRWOMAN GREEN noted that without objection, language would be
inserted requiring an annual review of the coordinator's position
(Amendment 3).
SENATOR LEMAN moved to adopt Amendment 4, which reads as follows:
on page 3, line 29, delete "2" and insert "1" and
on page 4, line 13, add subsection (J) one person who is
a member of the clergy, meaning a minister, a rabbi, a
pastor, or youth minister.
SENATOR LEMAN said the purpose of the first part is to reduce the
number of people employed in the executive branch from two to one.
He also noted the second part of Amendment 4 is conceptual so that
whatever definition that exists in state law can be used.
SENATOR HALFORD said that as much as he would like to see the
number of council members remain as low as possible, he suggested
that a new member be added and none be removed from the executive
branch. He believes that the council will want more than one
person from the executive branch to look to.
SENATOR LEMAN suggested that the second person from the executive
branch serve on the advisory panel.
SENATOR HALFORD thought the executive branch people are those who
will put the most time in because it is part of their job
description.
CHAIRWOMAN GREEN suggested just adding a new subsection (J) and
adjusting the total number of council members appointed by the
Governor to 11 on page 3, line 28.
SENATOR LEMAN said he will consider that as an amendment to his
motion.
CHAIRWOMAN GREEN noted that with no objection to increasing the
council membership from 14 to 15, 11 of which will be appointed by
the governor, and adding a new member who is affiliated with a
faith-based organization, Amendment 4 was adopted.
SENATOR LEMAN moved to adopt Amendment 5, which would place a four
year sunset date in the bill based on a four year cycle.
SENATOR HALFORD maintained that 1988 or 1989 was the last time a
working group was formed to look at this issue and that Alaska's
suicide rate is much higher than many other states. He said he
does not have a problem with the sunset review but he does not want
it to suggest that the legislature is only making a temporary
commitment to this council. He feels this council should be
ongoing.
SENATOR LEMAN said he hopes the council will succeed in preventing
suicide altogether but, in reality, that is not likely. His intent
is not to suggest that the council is temporary.
CHAIRWOMAN GREEN noted the first sunset date would be 2005.
SENATOR HALFORD suggested asking the Legislative Budget and Audit
Division what its schedule of sunset reviews is as that will be a
factor in the date.
CHAIRWOMAN GREEN suggested reviewing the sunset date in the Finance
Committee.
SENATOR LEMAN agreed.
COMMISSIONER PERDUE stated DHSS is very grateful that this issue is
getting attention and she thanked Senator Halford for his
leadership on this issue. She noted the last comprehensive look at
suicide was the result of a Senate bill that passed in 1988.
Innovative work was done, but since then, that program has not been
emphasized. The problem is complex, therefore the make-up of the
council is important.
Number 2070
SENATOR WILKEN asked if the 13 other councils listed on page 2 have
missions and measures attached to them and, if so, whether it would
be appropriate to include in the bill a requirement that the
Statewide Suicide Prevention Council develop and present its
missions and measures to the legislature.
SENATOR HALFORD said he does not know about the other councils, but
it would be appropriate to put such a requirement in the bill.
SENATOR WILKEN suggested discussing that in the Senate Finance
Committee.
Number 2170
MR. VERN MARSHALL, Executive Director of NEA-Alaska, commended the
sponsor for introducing SB 198. He noted the feeling of
shallowness that people experience when someone they know commits
suicide. This bill will hopefully engage communities and suicide
prevention efforts to help young people choose to live. He offered
to assist the committee and council in any way.
SENATOR LEMAN said that Amendment 5 was not formally adopted.
CHAIRWOMAN GREEN announced that without objection, Amendment 5 was
adopted.
SENATOR DAVIS noted the bill was amended five times by this
committee, and that several of those amendments were conceptual.
SENATOR LEMAN moved CSSB 198(HES) with its attached fiscal notes
from committee with individual recommendations.
CHAIRWOMAN GREEN said she would distribute copies of the revised
bill to committee members as soon as it is drafted.
SB 38-MEDICAL ASSISTANCE:BREAST/CERVICAL CANCER
SENATOR DAVIS informed the committee that she is very disappointed
that no public hearing on SB 38 will occur today. She contacted
many people about this hearing and was not told until she arrived
at the meeting that the public hearing will not occur for another
week. She expressed frustration that she has been working very
hard to get this bill before the committee, only to find that DHSS
will be giving a presentation on it instead, which it has already
done.
CHAIRWOMAN GREEN said the previous input from DHSS was about the
general Medicaid program, not specifically on medical assistance
for breast and cervical cancer. She felt it was important to go
back and get an update on this specific program. Her intent was not
to prevent anyone from testifying on this bill. She asked DHSS to
proceed.
TAPE 01-37, SIDE B
MS. MARY DIVEN, Division of Public Health, DHSS, gave the following
overview of the early detection for breast and cervical cancer
program.
The Center for Disease Control (CDC) funds a screening program that
provides screening for breast and cervical cancer. To be eligible,
a woman's income must be less than 250 percent of the poverty
level, or she must be uninsured or underinsured, or her insurance
deductible must be too high to make the costs of screening
affordable. The intent of this program is to detect cancers early
to reduce death and illness from the cancers.
CHAIRWOMAN GREEN asked Ms. Diven to review the original thought
behind providing free screening.
MS. DIVEN explained the federal government determined that lower
income women were dying from breast and cervical cancer at higher
rates than the rest of the population. Therefore, the government
created this program to provide free screening for early detection.
The program included outreach to attract women who were not getting
an annual screening. She noted all states have signed onto this
program.
CHAIRWOMAN GREEN asked what choices the state was given regarding
the poverty level when it signed onto that program.
MS. DIVEN said the eligibility cap was recommended at 250 percent
of the poverty level, which is what the state chose. The CDC did
not propose a lower range or a floor. She noted that there is a
range of eligibility rates that other states have selected. The
lowest is 185 percent with one state at that range, while the high
end is 250 percent with 35 states at that range.
CHAIRWOMAN GREEN asked what would have happened had Alaska chosen
133 percent.
MS. DIVEN said DHSS would have screened fewer women and would have
detected fewer women with cancer.
CHAIRWOMAN GREEN asked if the state could have set the limit at 133
percent.
MS. DIVEN said she believes that the CDC told DHSS that it was to
use the 250 percent level because Alaska's screening numbers were
not high.
COMMISSIONER PERDUE said she would get the answer to that question
for the committee.
CHAIRWOMAN GREEN said she read that the CDC had a range, which is
what she is trying to establish.
Number 2160
SENATOR DAVIS asked if people whose income is at 133 percent of the
poverty level would already be covered. She said she thought the
purpose of SB 38 was to pick up women whose income was above that
level.
MS. NANCY WELLER, Division of Medical Assistance, explained that
not everyone who is low income is eligible for Medicaid. A single
adult without children who is not elderly or disabled is not likely
to be eligible for Medicaid.
SENATOR DAVIS asked if that would be the case if that person's
income was at 133 percent of the poverty level.
MS. WELLER said that person would not be eligible even if their
income was at 20 percent of the poverty level.
SENATOR WILKEN noted that on pages 12 through 16 (Notice of
Availability of Funds) of the federal law, the floor for
eligibility is set out at 100 percent of the poverty level.
MS. DIVEN pointed out those numbers do not pertain to
qualifications for the program; those numbers apply if a fee is
charged so that no fee can be charged to a woman who is at 100
percent of the poverty level.
COMMISSIONER PERDUE clarified that, regarding Senator Davis's
question about eligibility for Medicaid, eligibility depends on
whether a woman is covered under the Temporary Aid for Needy
Families (TANF) program or whether she is covered under a
disability program or in general. She asked Ms. Weller to
elaborate on the criteria.
MS. WELLER explained that Medicaid is a categorical program so that
clients generally have to fit within one of the following groups:
families with children, pregnant women, elderly, or disabled.
Therefore a woman whose children are grown, but who is not 65 or
older or permanently disabled, will not be eligible for Medicaid,
regardless of her income or how sick she might be.
COMMISSIONER PERDUE added that women in those groups would be
covered at a different income level. Women eligible for the TANF
program are covered at 72 percent of the poverty level; disabled
women are covered at up to 250 percent of the poverty level. She
noted the purpose of SB 38 is to fill in the hole of income
eligibility for women who are not yet 65 but whose children may be
grown. Those women comprise a very important target population for
risk of breast and cervical cancer.
Number 1974
SENATOR WILKEN asked Commissioner Perdue to let the committee know
what the floor is regarding income eligibility.
COMMISSIONER PERDUE agreed.
SENATOR LEMAN asked Commissioner Perdue to provide the committee
with a chart of the eligibility level in all states that
participate in this program.
SENATOR DAVIS asked if a woman is determined to be eligible for
screening at the 185 percent level, her treatment eligibility would
be at the same level.
COMMISSIONER PERDUE said that is correct.
MS. WELLER told the committee that Congress enacted legislation to
provide this Medicaid option last December (2000). This new option
is for women who have been screened through the CDC breast and
cervical cancer detection program. The Medicaid option is more
limited than the CDC program because women with any creditable
coverage are not eligible. The CDC program screens women who are
underinsured or have high deductibles or have an insurance policy
that excludes these services. She noted Alaska Native women were
precluded from this option because of Indian Health Service (IHS)
coverage, which has led to some confusion about the Governor's
letter. In that letter, the Governor noted that 70 women were
potentially eligible for the screening program but the fiscal note
covers 42 women because Alaska Native women were excluded.
CHAIRWOMAN GREEN asked if this program is being developed in Alaska
for 42 women in the first year.
MS. WELLER said that is correct. She added that the fiscal note
estimates were taken from actual Medicaid expenditures for clients
with breast and cervical cancer who were qualified for services
under another category.
Number 1862
CHAIRWOMAN GREEN asked if the majority of women in need in Alaska
already receive coverage through other Medicaid programs.
MS. WELLER said a much larger number are already receiving
treatment under Medicaid than are potentially eligible under the
new option.
COMMISSIONER PERDUE clarified that question really applies to all
women in Alaska who have cancer, many of whom would not qualify for
this program and who do not have insurance. She said one of the
reasons this bill is important is that early detection and
treatment of these diseases improves the outcome remarkably.
CHAIRWOMAN GREEN asked if early detection and treatment has the
same result for other diseases.
COMMISSIONER PERDUE replied there are many diseases for which early
detection is equally important, such as glaucoma and heart disease.
Some of those screenings are available at the Alaska Health Fairs.
CHAIRWOMAN GREEN said she believes it is important to review what
is not covered in Alaska because there is no enabling legislation.
She asked if the optional groups, under Medicaid, can be added by
DHSS through regulation.
MS. WELLER answered that the document entitled Medicaid Services
and Groups not in Current State Law contains a list of other
Medicaid services or groups that have budgetary implications but
may not require legislation.
CHAIRWOMAN GREEN asked what the services for 12 month continuous
eligibility for children entails.
MS. WELLER explained that the 12 month continuous eligibility for
children was an option that was added to the Medicaid statute when
the Denali Kid Care program was created. It is allowed under
federal law, the idea being to get children into the program and
keep them on it for continuity of health care so that once they
apply they are eligible for an entire year. Right now, DHSS has
the authority under state law to provide coverage under Medicaid
for 12 months but it is covering those clients for six months.
CHAIRWOMAN GREEN asked what the non-emergency transportation within
communities of residence service is about.
MS. WELLER said that Medicaid now pays for transportation services
between communities but it does not pay for transportation services
within a community, so that transportation to and from a doctor or
dentist within Anchorage is not covered for an Anchorage client.
Number 1610
CHAIRWOMAN GREEN asked what is covered under school based services.
MS. WELLER explained that category would cover actual health care
services provided in schools, such as therapy.
CHAIRWOMAN GREEN asked if the services for tobacco cessation and
offering more liberal financial eligibility and coverage of
policies are categories that could be enhanced.
MS. WELLER said DHSS is allowed, under federal rules, to disregard
additional income or assets in order to make more people eligible
for the Medicaid program.
CHAIRWOMAN GREEN noted the list contains a whole raft of options
that requires legislative approval. The one she hears the most
about is adult dental services.
COMMISSIONER PERDUE acknowledged that current Medicaid services in
that area are lacking.
CHAIRWOMAN GREEN said the committee has to look at, whenever a new
program is considered, how these other services that could be
provided but have never been adopted compare. She said it is
especially difficult when the committee is faced with a bill that
will treat 42 people this year and will provide services for more
people in the future.
Number 1518
SENATOR DAVIS asserted that the screening program for breast and
cervical cancer already exists and it is provided for women whose
income is up to 250 percent of the poverty level. She asked if the
state does not participate in the Medicaid option for treatment of
those cancers, whether it will lose the screening program.
COMMISSIONER PERDUE said DHSS does have some flexibility on where
to set the screening, but if it tightens the eligibility criteria
for screening, it will be returning federal money.
CHAIRWOMAN GREEN asked what continuation of the CDC program for
screening has to do with whether or not Alaska decides to
participate in the Medicaid option for breast and cervical cancer
treatment.
COMMISSIONER PERDUE said she believes Senator Davis was asking what
would happen if the state lowered the screening eligibility.
SENATOR WILKEN asked if the change in federal funding is shown in
any of the documentation provided.
MS. DIVEN said it is not because Alaska's screening level was set
at 250 percent of the poverty level in the grant application to the
CDC.
SENATOR WILKEN asked if the eligibility limit was set at 185
percent, for example, what DHSS would trade.
MS. DIVEN answered, "Federal funds and the number of women whose
cancers are detected early."
SENATOR WILKEN asked if that is shown in the documentation.
MS. DIVEN said it is not because the current agreement with CDC was
set at 250 percent.
SENATOR LEMAN asked if DHSS has a chart of the income eligibility
guidelines used by other states for treatment under Medicaid for
breast and cervical cancer.
MS. DIVEN explained the treatment is set at the screening level.
They must be the same.
SENATOR LEMAN asked if the eligibility criteria for treatment is
changed, the criteria for screening must be changed.
MS. DIVEN said that is correct.
SENATOR LEMAN asked why the CDC would care if Alaska wanted to
screen at a higher income level, if the state pays for it.
MS. DIVEN asked if Senator Leman was asking whether the state could
set the eligibility criteria at 200 percent for screening but use
state general funds for the other 50 percent.
SENATOR LEMAN said yes, or use some other source of money to make
up the 50 percent.
MS. DIVEN said, to her understanding, that would not conflict with
the rules of the program but it would increase the amount of state
general funds needed, rather than using the federal funds
available.
SENATOR DAVIS asked why Senator Leman would want to change that
even if the state portion was from a stream of money other than
general funds. That other stream of money could be used for
something else while the federal funds are already available for
the same purpose. She also asked if 250 percent of the poverty
level equals about $52,200 net for a family of four.
MS. DIVEN said that is the gross income.
COMMISSIONER PERDUE indicated that the profile of the typical
client who will be helped by SB 38 is a middle-aged or older woman.
If a woman has raised several children but they are no longer
dependents, her income, to be eligible would have to be about
$26,000 per year. The TANF population is made up, primarily,
younger women who are raising children.
CHAIRWOMAN GREEN referred to a letter she received about a young
woman who repeatedly presented herself to doctors with symptoms of
cancer and was never referred for prescreening. She died within a
year of cervical cancer. She asked if that woman would never have
been covered under this program because she was 23 or 24.
COMMISSIONER PERDUE said the woman may have, but she was pointing
out that the profile of most women who would helped by SB 38 is
older.
CHAIRWOMAN GREEN expressed concern about some of the descriptions
she has seen about this bill as a program for older women over 65,
if it does apply to women of all ages who qualify. She noted the
program was supposedly established to eliminate disparity. She
asked what that disparity refers to.
MS. DIVEN answered the disparity is in the number of women who die
from breast and cervical cancer who did not receive screening.
Number 1064
CHAIRWOMAN GREEN said she knows no one in the legislature who does
not desire to help people but she feels it is ironic that men with
prostate or other cancers are not offered a similar option. SB 38
makes a small portion of the population more special than others
who are suffering from other diseases. She asked Ms. Diven to
discuss the criteria for the priority populations.
MS. DIVEN read [from page 2 of the Notice of Availability of
Funds]:
Criteria for priority populations are uninsured or under-
insured older women who are racial, ethnic and cultural
minorities, such as American Indians, Alaska Natives,
African-Americans, Hispanic, Asian/Pacific Islanders,
lesbians, women with disabilities, and for women who live
in hard to reach communities in urban and rural areas.
She pointed out that those are the women who die more frequently
from breast and cervical cancer.
CHAIRWOMAN GREEN asked how DHSS refers to that criteria.
MS. DIVEN explained that the criteria refers to providing outreach
to make sure that an attempt is made to reach those women. A
variety of methods for outreach have been used, including the
ministerial association affiliated with the YWCA in Anchorage,
door-to-door outreach in low income zip code areas, coupons in
newsletters to certain groups, etc. That language says DHSS needs
to put a little more effort into reaching those populations who are
dying at a disproportionately higher rate.
CHAIRWOMAN GREEN asked if because of the IHS participation, Alaska
Native and American Indian women are not provided treatment under
Medicaid.
MS. DIVEN said that is correct.
CHAIRWOMAN GREEN asked if uninsured and underinsured women are
eligible for the screening while only uninsured women are eligible
for the treatment if they are within 250 percent of the poverty
level.
MS. DIVEN said that is correct with co-pays.
CHAIRWOMAN GREEN asked for a review of the co-pay aspect.
Number 760
MS. WELLER explained that the co-payments and co-insurance for
adults on Medicaid are $50 per day to a maximum of $200 for each
inpatient hospital admission; 5 percent of outpatient hospital
expenses, such as chemotherapy or radiation; $3 per physician
service; and $2 for each prescription drug.
CHAIRWOMAN GREEN asked if Medicaid can charge a premium.
MS. WELLER said Medicaid cannot charge premiums.
COMMISSIONER PERDUE stated that DHSS supports SB 38 and she noted
that, regarding why this population is being separated out,
Congress has given the states an opportunity to enter into a cost
agreement to make a significant difference in a limited number of
women's lives. It is a modest proposal: it will not solve the
problem of access of care for all women who need breast or cervical
cancer treatment. DHSS is faced everyday with dealing with people
who fall outside of the line for government help, therefore they
are familiar with the arbitrary nature of this type of coverage.
It is a sad fact of life. She understands that the committee is
struggling with that issue, but that is the world we live in. She
felt the question before the committee is whether a state
investment of $175,000 for this population is money well spent to
save lives. She asked the committee to support the bill.
Number 607
SENATOR LEMAN expressed concern about DHSS's collection of data
regarding its ability to provide the legislature with information
regarding the link of certain behaviors to breast and cervical
cancer. He noted that DHSS acknowledged a link between tobacco use
but he has read a fair amount of research that demonstrates a high
correlation with other behaviors. He asked if government puts
money into fixing a problem when it occurs, whether it shouldn't be
putting money into preventing the problems. He said he recognizes
that cancer strikes at random sometimes and there are no apparent
linkages but there are some behaviors that can be changed. He asked
if DHSS is committed to identifying those correlations and
investing effort into changing those behaviors to minimize problems
later on.
COMMISSIONER PERDUE replied that she feels Senator Leman has a very
good point in that the approach to public health should be to look
at ways to minimize the risk for the next generation. She pointed
out the screening program entails taking medical histories of
women, looking at lifestyles, providing counseling, and collecting
forensic data on the family to let women know if they are high
risk. That approach is being taken on a one-to-one basis in
doctors' offices.
SENATOR LEMAN said he does not expect to see individual data but he
would hope that DHSS could start looking at data so that it can
come to some conclusions and suggest changes. He said he would
want to know all of the risk factors for cervical or breast cancer.
CHAIRWOMAN GREEN asked Ms. Carol Edwards to testify as she will not
be available to testify next week.
Number 388
MS. CAROL EDWARDS, an oncology nurse and a member of the Alaska
Nurses Association, and current health policy liaison and a former
director on the board of the Oncology Nursing Society, said during
her 20 years as an oncology nurse she has cared for many women with
cancer, particularly breast cancer. It is a devastating experience
for any individual to receive a diagnosis of cancer. She has long
advocated early screening and detection of cancer as it is the most
important way to improve the quality of life and it saves dollars.
If cancer is found early, it is often treatable and cured. However,
that can only occur if the cancer is treated. She believes it is
inhumane and cruel to offer testing and diagnosis of cancer but not
treatment. Our national government has provided funds to screen
and diagnose breast and cervical cancer and it has provided 70
percent of the dollars needed to treat those cancers. Our state
must provide only 30 percent of the cost. Women diagnosed with
cancer worry not only about their future but the future of their
families. She asked the committee to not ask her to tell them there
is no hope of life because the government will not provide the
money for treatment.
SENATOR LEMAN pointed out that a previous testifier told the
committee that anyone in Alaska who has cancer is able to get
treatment as hospitals do not turn people away. The question
instead is who will pay for it. He said the committee is debating
the issue of cost shifting, not whether treatment should be
provided.
SENATOR DAVIS thanked Ms. Edwards for her testimony and said Ms.
Edwards was saying the federal government will pay for 70 percent
of the treatment. She believes the state should support that
program, otherwise women who are diagnosed will have to figure out
who will provide services and will force them to ask for a handout
when they are in pain and agony.
TAPE 01-38, SIDE A
SENATOR DAVIS stated support for SB 38.
MS. EDWARDS said, regarding Senator Leman's question about the
behavioral risks for cancer and education, there is a link between
cervical cancer and sexually transmitted diseases, therefore
education for young people regarding protection and abstinence
would have an impact. She said she strongly agrees with Senator
Leman regarding the need for education. She has advocated for the
use of tobacco money for tobacco cessation programs and education
for youth. She suggested using that same source of money for an
education program about cervical cancer.
CHAIRWOMAN GREEN repeated her concern is that SB 38 raises a public
policy issue in which the government has chosen two particular
diagnoses for which it raises the income limit, while it ignores
all other diagnoses. She suggested that maybe the government
should be looking at cancer treatment coverage for everyone in the
state. She noted all cancers are special, which is why this issue
is so troublesome for the committee. She pointed out that none of
the other optional programs on the Medicaid list are being
considered at this time and some of those programs have a far
greater constituency. She referred to a document from the Health
Care Financing Administration (HCFA) that contained frequently
asked questions and answers about the Breast and Cervical Cancer
Prevention and Treatment Act of 2000 and asked how a woman would
access the CDC Title XV funds program.
MS. DIVEN said the CDC Title XV funds program is the screening
program.
CHAIRWOMAN GREEN asked how she would find out where services are
provided under that program.
MS. DIVEN said that she would go to one of the screening providers
or she could call the 800 number on the coupon or advertisement for
information about the location of screening providers.
CHAIRWOMAN GREEN asked if she would be referred to a physician's
office.
MS. DIVEN said she would be referred to a physician who is enrolled
in the CDC program.
CHAIRWOMAN GREEN asked how many physicians are enrolled in Alaska,
in general.
MS. DIVEN said there are 38 screening providers and 59 diagnostic
providers in the state.
CHAIRWOMAN GREEN asked if they differ.
MS. DIVEN said they do but a mammogram could be considered to be
screening or diagnostic, depending on the type. A woman might go
to a nurse practitioner for cervical cancer screening and a
gynecologist for the colposcopy for the diagnosis. A woman might go
to a physician for a screening who finds a lump and then be
referred to a surgeon for a fine needle aspiration to find out if
the lump is malignant.
CHAIRWOMAN GREEN asked if that is in the referral after the
screening.
MS. DIVEN said the CDC program covers the screening and diagnostic
phase.
CHAIRWOMAN GREEN asked Ms. Diven to describe the first option under
which CDC allows grantees the flexibility to extend the definition
of "screened."
MS. DIVEN said the first option applies to providers enrolled in
the CDC-funded program.
CHAIRWOMAN GREEN asked for an example of someone who is funded in
part by Title XV funds.
MS. DIVEN said that might apply to a practice with five physicians
who are enrolled providers. In Alaska, DHSS enrolls them as
providers in the program.
CHAIRWOMAN GREEN asked Ms. Diven to explain the grant or contract
options for providers.
MS. DIVEN said some states provide grants; Alaska has provider
agreements in which it pays on a fee-for-service basis.
CHAIRWOMAN GREEN asked if the provider agreements are made in
advance of services.
MS. DIVEN said they are. She also explained that women would also
be eligible for Medicaid treatment if they have been screened by
health centers that do not receive Title XV funds but provide
services to low income women.
CHAIRWOMAN GREEN asked if a woman could get screened and then get
retroactive approval for that provider.
MS. DIVEN said no, and that Chairwoman Green has the list of
enrolled providers.
CHAIRWOMAN GREEN asked for an explanation of whether there is any
income test under Medicaid for women under this new eligibility
criteria.
MS. WELLER explained that women who are already found to be income
eligible for the CDC program cannot be required to undergo another
income eligibility test by the state.
CHAIRWOMAN GREEN asked if an eligible woman could have assets.
MS. WELLER said she could.
MS. DIVEN said that question is not part of the eligibility
criteria so that question is not asked.
CHAIRWOMAN GREEN said that the state cannot impose the typical
Medicaid asset or eligibility standards for treatment on women
whose eligibility is based on CDC screening which sets up a
distinct standard for this one group of Medicaid recipients.
MS. DIVEN said there are multiple standards for Medicaid clients.
CHAIRWOMAN GREEN asked if those other standards can be applied to
this group of women.
MS. WELLER said the 250 percent income standard is the only income
related standard.
CHAIRWOMAN GREEN noted that the Health Care Financing
Administration (HCFA) has found that asset related questions would
be appropriate as part of the Medicaid application process only to
the extent necessary to determine if the individual is otherwise
eligible for Medicaid. She asked whether DHSS determines when
women are being screened whether they are otherwise eligible for
Medicaid.
MS. WELLER said it does and would put them into a regular Medicaid-
eligibility category.
MS. DIVEN said that would be done during the screening process
because that would cover the screening costs also.
CHAIRWOMAN GREEN asked what questions can be asked for the
screening.
MS. DIVEN said women are asked whether they have insurance to cover
the screening but there is no asset test.
SENATOR WILKEN asked for clarification of question 10.
MS. WELLER said these women are already eligible for the CDC
program. The document says that Medicaid cannot require an
additional income test of the CDC clients. She reads the document
to say no, these women have already been found to be income
eligible for the CDC screening program so Medicaid would not do
another income test for the treatment program.
SENATOR LEMAN asked if passive income or capital gains are
considered in the income test.
MS. WELLER said the income test is based on gross income.
CHAIRWOMAN GREEN asked if that includes the permanent fund
dividend.
MS. WELLER said it depends on when a person applies because the
Medicaid application is prospective and is based on the month when
the application is submitted.
CHAIRWOMAN GREEN said she thought it was based on annual income.
MS. DIVEN said there is an annual and monthly schedule. The annual
schedule is divided by 12.
CHAIRWOMAN GREEN asked which schedule DHSS uses regularly.
MS. DIVEN said for the screening program, either can be used.
CHAIRWOMAN GREEN asked if there were any further questions. [There
were none.]
SENATOR DAVIS commented that she appreciates all of the information
that has been provided on the Medicaid program and she thanks
Chairwoman Green for bringing a lot of information to the
committee's attention. She believes a lot of work needs to be done
and that she can see the need for further work on this issue by the
committee. However, she believes the problems with the Medicaid
system should not be tied to SB 38 because SB 38 is a way to start
helping people.
CHAIRWOMAN GREEN thanked all participants. She expressed concern
that there is no incentive in federal guidelines to decrease the
number of Medicaid recipients. The programs have been designed
with an emphasis on increasing the number of recipients. She said
the committee would be remiss to overlook what these programs will
cost the state. She then adjourned the meeting at 3:34 p.m.
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