Legislature(2019 - 2020)BUTROVICH 205

02/20/2019 01:30 PM HEALTH & SOCIAL SERVICES

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Audio Topic
01:31:05 PM Start
01:31:20 PM SB7
02:09:44 PM Adjourn
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
Heard & Held
-- Public Testimony --
+ Bills Previously Heard/Scheduled TELECONFERENCED
                    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                                                               
     - 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                                                               
             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                                                               
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                                                               
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                                                               
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                                                               
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                                                               
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                                                               
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                                                               
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                                                               
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                                                               
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.                                                                                                 

Document Name Date/Time Subjects
SB 7 Chart of Requirements and Exemptions.pdf SHSS 2/20/2019 1:30:00 PM
SB 7
SB 7 Buckeye Institute Report 12.3.18.pdf SHSS 2/20/2019 1:30:00 PM
SB 7
SB 7 Modern Healthcare Article.pdf SHSS 2/20/2019 1:30:00 PM
SB 7
SB 7 Fiscal Note Summary 2.11.19.pdf SHSS 2/20/2019 1:30:00 PM
SB 7
SB 7 Public Input 2.20.19.pdf SHSS 2/20/2019 1:30:00 PM
SB 7
SB7 Chadwell.pdf SHSS 2/20/2019 1:30:00 PM
SB 7
SB 7 League of Women Voters of AK.pdf SHSS 2/20/2019 1:30:00 PM
SB 7
SB 7 FGA Letter to Chair Wilson 2018.pdf SHSS 2/20/2019 1:30:00 PM
SB 7
SB 7 FGA Work Requirement Paper 1.9.2019.pdf SHSS 2/20/2019 1:30:00 PM
SB 7
ASHNHA comments on medicaid work requirements 2-13-19.pdf SHSS 2/20/2019 1:30:00 PM
SB 7
SB 7 A Snapshot of Exempted Groups Nationwide - NASHP.pdf SHSS 2/20/2019 1:30:00 PM
SB 7
SB 7 A Snapshot of Age Requirements Nationwide - NASHP.pdf SHSS 2/20/2019 1:30:00 PM
SB 7
SB 7 A Snapshot of Qualifying Activites Nationwide - NASHP.pdf SHSS 2/20/2019 1:30:00 PM
SB 7
SB 7 A Snapshot of ACA Implementation Nationwide - NASHP.pdf SHSS 2/20/2019 1:30:00 PM
SB 7
SB 7 A Snapshot of Hour Requirements Nationwide - NASHP.pdf SHSS 2/20/2019 1:30:00 PM
SB 7
SB 7 A Snapshot of Work Requirements Nationwide - NASHP.pdf SHSS 2/20/2019 1:30:00 PM
SB 7