Legislature(2019 - 2020)BUTROVICH 205
02/20/2019 01:30 PM HEALTH & SOCIAL SERVICES
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ALASKA STATE LEGISLATURE SENATE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE February 20, 2019 1:31 p.m. MEMBERS PRESENT Senator David Wilson, Chair Senator Gary Stevens Senator Cathy Giessel Senator Tom Begich MEMBERS ABSENT Senator John Coghill, Vice Chair COMMITTEE CALENDAR SENATE BILL NO. 7 "An Act requiring the Department of Health and Social Services to apply for a waiver to establish work requirements for certain adults who are eligible for the state medical assistance program." - HEARD & HELD PREVIOUS COMMITTEE ACTION BILL: SB 7 SHORT TITLE: MED. ASSISTANCE WORK REQUIREMENT SPONSOR(s): SENATOR(s) MICCICHE 01/16/19 (S) PREFILE RELEASED 1/7/19 01/16/19 (S) READ THE FIRST TIME - REFERRALS 01/16/19 (S) HSS, FIN 02/15/19 (S) HSS AT 1:30 PM BUTROVICH 205 02/15/19 (S) Heard & Held 02/15/19 (S) MINUTE(HSS) 02/20/19 (S) HSS AT 1:30 PM BUTROVICH 205 WITNESS REGISTER CRYSTAL BOURLAND, Executive Director NAMI Juneau Juneau, Alaska POSITION STATEMENT: Opposed SB 7. KATE FINN, representing self Homer, Alaska POSITION STATEMENT: Opposed SB 7. DIANA CHADWELL, representing self Delta Junction, Alaska POSITION STATEMENT: Opposed SB 7. SENATOR PETER MICCICHE, SB 7 Sponsor Alaska State Legislature Juneau, Alaska POSITION STATEMENT: Testified on SB 7. SHAWNDA O'BRIEN, Director Division of Public Assistance Department of Health and Social Services (DHSS) Juneau, Alaska POSITION STATEMENT: Answered questions related to SB 7. EDRA MORLEDGE, Staff Senator Peter Micciche Alaska State Legislator Juneau, Alaska POSITION STATEMENT: Testified on SB 7. ACTION NARRATIVE 1:31:05 PM CHAIR DAVID WILSON called the Senate Health and Social Services Standing Committee meeting to order at 1:31 p.m. Present at the call to order were Senators Begich, Giessel, Stevens, and Chair Wilson. SB 7-MED. ASSISTANCE WORK REQUIREMENT 1:31:20 PM CHAIR WILSON announced the consideration of SB 7 and continuation of public testimony. He noted that the Director of Public Assistance, Shawnda O'Brien, would be available to answer questions. 1:32:30 PM CRYSTAL BOURLAND, Executive Director, NAMI Juneau, Juneau, Alaska, opposed SB 7. She said NAMI, the National Alliance on Mental Illness, is a non-profit focusing on education and support for individuals affected by mental illness. Medicaid is a lifeline for eligible, low-income Alaskans, pregnant women, children, friends and family with disabilities, and the elderly. Medicaid eligibility conditional on employment does not help low-income individuals improve their circumstances. Supported employment, job training, and comprehensive health care coverage do. Access to Medicaid often supports an individual being able to engage in work and community. Work requirements may have the opposite effect and undermine an individual's employment and management of health care needs. One serious concern for her and her organization is individuals who do not meet disability criteria but live with a medical condition, mental illness, or a substance use disorder. These individuals may need to step away from work due to periodic disability or illness, a decline in mental health, or substance use treatment. While exemptions look good on paper, they cause additional stress on these individuals as they face the loss of health care coverage while navigating a work requirement exemption. The wait for social security disability is several years, so Medicaid is often a lifeline for those people as they wait for their social security disability application to go through. Residents in rural communities face challenges with limited work, job training, and volunteer opportunities. There are likely to be challenges with reporting subsistence activities in remote areas. The bill does not address concerns about unintended consequences brought forward in testimony. 1:34:52 PM KATE FINN, representing self, Homer, Alaska, opposed SB 7. She said that to do any of these things--be employed, live a subsistence lifestyle, participate in work or work equivalent-- requires a certain amount of healthiness and health care. If people need health care to work, but need work to receive health care, that is a Catch-22. She does appreciate the minutia of the exclusions. Those are excellent but not sufficient. She gave pregnancy as an example of a situation that is easy to see, but they need to pay attention to the less obvious disabilities. 1:37:27 PM DIANA CHADWELL, representing self, Delta Junction, Alaska, Opposed SB 7. She said disabled Alaskans on disability cannot work or they do not receive their social security disability. This law would discriminate against the disabled, special needs, and the poor. They do need to change Medicaid by not giving it to the lowest bidder. 1:39:50 PM CHAIR WILSON noted that written testimony from people who could not testify at the last meeting were in committee packets and then closed public testimony. CHAIR WILSON said they have heard testimony with concerns about exemptions regarding such things as age, tribal membership, children still in school at age 18 or 19, in university or trade school, an increase the age of dependents from 12 months to 60 months. He asked Senator Micciche if he had any comments and whether these were ideas that could be included in amendments. 1:41:20 PM SENATOR PETER MICCICHE, SB 7 Sponsor, Alaska State Legislature, Juneau, Alaska, responded that they all know that he has a commonsense approach and they know what is in his heart about this bill. It is about opportunities; it's not about being punitive with health care. He is open to commonsense suggestions that make the bill better. He has heard a lot of things in public testimony that are not part of the bill. That's a common thing when people are mobilized against a movement. This movement is about helping Alaskans be the best they can be. He noted that the Alaska State Hospital and Nursing Home Association (ASHNHA) letter had some good suggestions. The bill has to recognize that Alaska has a seasonal workforce. Some people work very hard for part of the year, and he doesn't want them to lose health care when they are not working. They might need to consider how to handle the first time someone doesn't meet the work requirement. He doesn't have a line in the sand that separates those people from these people. "We're all Alaskans. We want to help them to succeed," he said. 1:43:10 PM SENATOR STEVENS asked about a comment in testimony that it took years to get exemptions. CHAIR WILSON said he thought that might have been about applying for the waiver. SENATOR STEVENS answered that yes, he was referring to waivers. SENATOR MICCICHE said the timeline for an 1115 waiver is not clear. The department can only apply and look at the record for other states who have applied. They are all in various stages of execution. CHAIR WILSON added that 1115 waivers don't have a specific timeline for a federal response, unlike 1332 and 1915 waivers. SENATOR STEVENS asked for an explanation of an 1115 waiver. 1:45:26 PM SHAWNDA O'BRIEN, Director, Division of Public Assistance, Department of Health and Social Services (DHSS), Juneau, Alaska, said this bill would require DHSS to file for an 1115 waiver. This does take some time to get those approved. She testified that they would look to other states that have already applied, so they could mirror what those states have done to make their process more efficient. CHAIR WILSON asked her if she could define an 1115 waiver. MS. O'BRIEN said not accurately on record, but she would follow up with a written response to outline the different waivers and what would be required for them to apply for this one. SENATOR STEVENS clarified that a waiver is requested through the department and then it goes to the federal government. If it took years, that would be frustrating, he added. MS. O'BRIEN said that they might see some efficiencies and streamlining of the process by looking at other states that have applied for waivers. 1:46:59 PM SENATOR GIESSEL drew the committee's attention to a National Academy for State Health Policy document in their packets which she said partially summarized the waiver. "New policy allowing states to implement work and community engagement requirements. States must seek federal approval to require nonelderly, nonpregnant, and nondisabled adults to meet these requirements to qualify for a full or partial Medicaid coverage," she read. CHAIR WILSON said they would try to make sure committee members received an explanation of the waivers, which is a very complicated system. 1:48:04 PM SENATOR BEGICH said that last year Senator Kelly introduced this bill and SB 7 seems substantially the same. Senator Kelly had asked him to review the fiscal notes, which he did quite extensively, to find things that would make it more efficient. He noticed the number has changed in the fiscal notes. The original assumption was that 10.5 percent would be moved off the roles. Now it is 25 percent. He asked for explanation of the difference, which has made a substantial impact on the fiscal notes. MS. O'BRIEN responded that assumptions last year were a point in time based on what they were seeing with enrollment. The specific details of who they are looking at and the number of enrollees, excluding those who are exempted from the work requirements, change the calculations just slightly. They are basing some of their assumptions on the existing TANF (Temporary Assistance for Needy Families) work requirement programs. They are not seeing as much growth in the Medicaid program as they originally were. SENATOR BEGICH said that she said changed the numbers slightly. This is a 150 percent difference. The increase in the number is rather substantial. MS. O'BRIEN said they are using the assumptions that through success in the program, they will hopefully see more people come off the enrollment and back in the workforce. SENATOR BEGICH said the state already has an 1115 waiver in the works. He asked how many a state can have and whether they would have to amend their 1115 waiver. MS. O'BRIEN answered that they would be requesting a new waiver. SENATOR BEGICH asked for a general timeline if the bill is signed into law this year. MS. O'BRIEN replied that the fiscal notes are based on a start date of December 31 to get the waiver through the approval process and to get the regulations updated. Staffing for the program would being July 1. The staff training and the notification of the population affected by the bill would occur concurrently during the approval process and updating of regulations. SENATOR GIESSEL said states have implemented this. She noticed that 80 hours [per month] is common. She asked if Senator Micciche had any data indicating the success or outcomes of these programs. She noted the committee has materials from Arkansas. SENATOR MICCICHE said he would defer to his staff, but he wanted to point out that the program has been around for 13 months. The National Academy for State Health Policy document has a spreadsheet of what states have applied, the stage of implementation, and the work requirement hours. It does seem that 20 hours [per week] is something of a standard. He likes the idea for a monthly total instead of a weekly average, particularly for volunteer opportunities in places where employment might be limited. 1:55:16 PM EDRA MORLEDGE, Staff, Senator Peter Micciche, Alaska State Legislator, Juneau, Alaska, said that the Legislative Research Division is in the process of gathering that data. There are no definitive studies yet. Some state implementation has been held up by lawsuits. Some programs have not been around long enough to get data. SENATOR GIESSEL asked why they had a report from January 2018 about Arkansas [Work Requirements Are Working in Arkansas: How commonsense welfare reform is improving Arkansans' lives]. She noted that the report is positive. They saw incomes more than triple for folks that left welfare and found work. These are able bodied people. The report is about savings to the state. Her interest is about the impact on people--the self-esteem, the independence people gain from having their own employment, and the example for children. She has also seen data from Kansas. Their report was also quite positive. Folks significantly increased their income, far offsetting the benefits they were receiving from TANF and other aspects of Medicaid. She looked forward to receiving the Legislative Legal research document. 1:57:59 PM SENATOR MICCICHE said the Arkansas report is related to its welfare reform. The report came out before the Centers for Medicare and Medicaid (CMS) 1115 Medicaid waiver for work requirements. That is one of the reasons for his interest. They saw that able-bodied, childless adult food stamp enrollment dropped by 70 percent in Arkansas. Their incomes more than tripled within two years of leaving. New income more than offset lost food stamp benefits, and taxpayers were saving more than $28 million a year. Arkansas saw relative success in Supplemental Nutrition Assistance Program (SNAP) and TANF reductions. This bill is about Medicaid work requirements. It is about opportunity. They have provided other studies in the committee's documentation. The Economic Research Center at the Buckeye Institute study determined that women may earn an additional $212,000 or more and men an additional $323,000 over the course of a career while remaining on Medicaid work requirements. This is encouraging education or job training, social interaction and community participation, requiring accountability for those who are able bodied in a regular, structured manner, and improving social-economic conditions instead of a life of dependency. They are still providing health care benefits for those willing to work or volunteer. At some point they would be likely to get private insurance. This is in no way keeping people down. In some ways it gives them wings. Some fighting Medicaid and public assistance work requirements across the country benefit directly from those programs or are providers for those programs. He said he is trying to separate that from this discussion. This is about the individual and the opportunities and success for and of that individual. SENATOR GIESSEL noted that Alaska Housing Finance Corporation (AHFC), which has low-income housing, has seen a positive impact as people are initially given support with low-income housing and then work their way out of it. She would like to see that information. CHAIR WILSON said his office has requested information from AHFC about the Step Program, a five-year plan for housing vouchers. He will share that data with the committee when he receives it. SENATOR BEGICH asked if Senator Micciche's office provided the Arkansas report in the committee documentation. MS. MORLEDGE answered yes, for the purpose of showing that work requirements do work. SENATOR BEGICH said Arkansas did not have an 1115 waiver until last year. He clarified that Arkansas now has a lawsuit about work requirements. 2:03:08 PM MS. MORLEDGE said they do have a lawsuit, and their waiver was granted. SENATOR BEGICH said the waiver was granted in August of 2018 and three months later there was a lawsuit challenging that. He said his questions were not for or against the bill, but he wanted to point out that the data is related to other things required by Arkansas, not this waiver. He asked for clarification of that. MS. MORLEDGE said that is true. SENATOR BEGICH asked how many of these lawsuits are out there. He is concerned that Alaska would find itself in a lawsuit also if this bill passes. MS. MORLEDGE answered that Legislative Legal is researching that. SENATOR MICCICHE said they have no way of predicting whether they will be sued on any piece of legislation. He cannot stop working to improve the lives of Alaskans worrying about that. SENATOR STEVENS said the report shows the wonderful things Arkansas has done. He asked for clarification about the difference between what Arkansas has done and what SB 7 is proposing. SENATOR MICCICHE replied that the Arkansas paper has been provided as a model of what can occur when people are nudged, supported, and encouraged to take advantage of temporary support programs but move on to self-sufficiency and independence. There is a direct correlation to Medicaid. "What are we saying with this bill? We're saying we want you to retain your Medicaid benefits, but if you're able bodied, we want you to start advancing and developing your potential, and one day you will likely not require support for Medicaid," he said. The 1115 waiver is there because in other states, these practices are proven to be successful with a subset of the Medicaid and public assistance populations. The goal is not to eliminate the health care people need, but to lessen dependency on state and federal programs such as Medicaid and public assistance. This bill is about Medicaid. 2:06:51 PM SENATOR STEVENS said the Arkansas results are amazing. He is not sure how what they are proposing is exactly like that. CHAIR WILSON said Kentucky is probably the state that has progressed the furthest in terms of acquiring a waiver and implementing work requirements. He thought they prevailed in a lawsuit about the work requirements, but he is not sure if they are done with the litigation. SENATOR BEGICH said that in Kentucky, a follow-up lawsuit was initiated last month. Governor Bevin initiated the waiver process early in 2017, and it was approved in January 2018. 2:08:26 PM CHAIR WILSON held SB 7 in committee. SENATOR BEGICH asked whether anyone was working with the Alaska State Hospital and Nursing Home Association (ASHNHA) regarding their suggestions for SB 7. SENATOR MICCICHE said the ASHNHA letter is in the committee packet. He does not support all their ideas, but he wants this to work. He has no hard line in the sand. He wants it to be the best bill to help Alaskans advance. 2:09:44 PM There being no further business to come before the committee, Chair Wilson adjourned the Senate Health and Social Services Standing Committee at 2:09 p.m.