02/21/2020 01:30 PM HEALTH & SOCIAL SERVICES
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ALASKA STATE LEGISLATURE SENATE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE February 21, 2020 1:33 p.m. MEMBERS PRESENT Senator David Wilson, Chair Senator Cathy Giessel Senator Mike Shower MEMBERS ABSENT Senator Natasha von Imhof, Vice Chair Senator Tom Begich COMMITTEE CALENDAR SENATE BILL NO. 134 "An Act relating to medical assistance reimbursement for the services of licensed professional counselors; and providing for an effective date." - HEARD & HELD PREVIOUS COMMITTEE ACTION BILL: SB 134 SHORT TITLE: MEDICAID COVERAGE OF LIC. COUNSELORS SPONSOR(s): SENATOR(s) WILSON 01/21/20 (S) PREFILE RELEASED 1/10/20
01/21/20 (S) READ THE FIRST TIME - REFERRALS
01/21/20 (S) HSS, FIN 02/21/20 (S) HSS AT 1:30 PM BUTROVICH 205 WITNESS REGISTER GARY ZEPP, Staff Senator David Wilson Alaska State Legislature POSITION STATEMENT: Presented SB 134 on behalf of the sponsor. GENNIFER MOREAU, Director Division of Behavioral Health Department of Health and Social Services (DHSS) Anchorage, Alaska POSITION STATEMENT: Testified that the division stands ready to assist with SB 134. JON ZASADA, Director Policy Integration Alaska Primary Care Association (APCA) Anchorage, Alaska POSITION STATEMENT: Testified in support of SB 134. KEVIN MUNSON, Chief Executive Officer Mat-Su Behavioral Health Services Wasilla, Alaska POSITION STATEMENT: Testified in support of SB 134. PATICK ANDERSON, Chief Executive Officer RurAL CAP Anchorage, Alaska POSITION STATEMENT: Testified in support of SB 134. SEVILLA LOVE, Integration Coordinator Alaska Primary Care Association Anchorage, Alaska POSITION STATEMENT: Testified in support of SB 134. ROBIN MINARD, Chief Communications Officer Mat-Su Health Foundation Wasilla, Alaska POSITION STATEMENT: Testified in support of SB 134. DEBRA HAMILTON, Executive Director New Hope Counseling Center Soldotna, Alaska POSITION STATEMENT: Testified in support of SB 134. ERIC BOYER, Program Officer Alaska Mental Health Trust Authority Anchorage, Alaska POSITION STATEMENT: Testified in support of SB 134. DON BLACK, Board Member Bethel Family Clinic Bethel, Alaska POSITION STATEMENT: Testified in support of SB 134. JULIE THOMPSON, Licensed Professional Counselor Bethel Family Clinic Bethel, Alaska POSITION STATEMENT: Testified in support of SB 134. JEIGH STANTON GREGOR, representing self Petersburg, Alaska POSITION STATEMENT: Testified in support of SB 134. ACTION NARRATIVE 1:33:53 PM CHAIR DAVID WILSON called the Senate Health and Social Services Standing Committee meeting to order at 1:33 p.m. Present at the call to order were Senators Giessel, Shower, and Chair Wilson. SB 134-MEDICAID COVERAGE OF LIC. COUNSELORS 1:34:20 PM CHAIR WILSON announced the consideration of SENATE BILL NO. 134, "An Act relating to medical assistance reimbursement for the services of licensed professional counselors; and providing for an effective date." CHAIR WILSON, speaking as sponsor of SB 134, stated his intent to hear a sectional analysis and take invited and public testimony. 1:35:26 PM GARY ZEPP, Staff, Senator David Wilson, Alaska State Legislature, began a PowerPoint on SB 134. He read slide 2, SB134: SB 134 would add 717 Licensed Professional Counselors to the Medicaid Optional Services. The concept of the bill is to expand behavioral health capacity and utilization for Alaska's most vulnerable population, our Medicaid population. If behavioral health issues can be treated in a preventative manner within a clinical setting, rather than a crisis stage at a platinum level, the costs lesson and the quality of the healthcare services improves. This proposed legislation is a piece of the puzzle for providing behavioral health services to Alaskans. MR. ZEPP reviewed slide 3, Behavior Health: Behavioral health is the scientific study of the emotions, behaviors, and biology relating to a person's mental well-being, their ability to function in everyday life, and their concept of self. "Behavioral health" is the preferred term to "mental health." A person struggling with his or her behavioral health may face stress, depression, anxiety, relationship problems, grief, addiction, attention-deficit/hyperactivity disorder or learning disabilities, mood disorders, or other psychological concerns. Counselors, therapists, life coaches, psychologists, nurse practitioners, or physicians can help manage behavioral health concerns with treatments such as therapy counseling or medication. MR. ZEPP said licensed professional counselors (LPCs) are a valuable, cost effective part of treatment for behavioral health. This bill provides one piece of the behavioral health capacity that already includes licensed social workers, Ph.D. psychologists, prescribing nurse practitioners, and medical doctors, including psychiatrists and primary care physicians. MR. ZEPP pointed out that many people are familiar with the term mental health, which covers many of the same issues as behavioral health, but that term only encompasses the biological component of the aspect of wellness. The term behavioral health encompasses all contributions to mental wellness, including substance abuse, behavioral issues, habits, and other external forces. MR. ZEPP turned to slide 4, Why Medicaid clients and who are they? He read: Medicaid provides health coverage and long-term care services for Alaska's most vulnerable: children, seniors, people with disabilities, pregnant women, and very low income or working poor. Medicaid clients have difficulties finding access to behavioral health care and often have to wait three to six months for appointments. So you can imagine a person in crisis who cannot find behavioral healthcare access or are told it's available in three or four months, what are [their] options? Alaska's emergency room facilities are in a crisis mode treating behavioral health issues. SB 134 would directly impact the lives of our most vulnerable population of citizens, our poor, our young, and our seniors. Alaska's emergency rooms have been over-whelmed with volumes of emergency situations. The leading cause is alcohol disorders and the associated aliments of alcohol abuse. Often Medicaid clients have no where else to go due to access and then the lack of capacity causes patients to stay much longer in the emergency room than they should. Patients who have serious behavioral health issues. MR. ZEPP reviewed the statistics on slide 5, Adult Untreated Behavior Health Statistics. He reported that approximately 70 percent of Americans who need behavioral health services do not receive treatment, and 92 percent of those with substance abuse disorders and 66 percent of adults with serious mental health issues go untreated. Untreated behavioral health issues can increase the risk of cardiovascular disease, diabetes, stroke, Alzheimer's disease, osteoporosis, pancreatic disease, and hypertension. When people who need treatment do not receive it, it often leads to interaction with the police, the court system, and correctional facilities. Approximately 42 percent of state prisoners have a mental illness and 20 percent are considered severely and persistently mentally ill. MR. ZEPP reviewed the bar charts on slide 6, Children's Untreated Behavioral Health Statistics. It indicates that boys are more likely to have a mental, behavioral, or developmental disorder and children living below poverty line are 22 percent more likely to have a mental, behavioral, or developmental disorder. 1:41:46 PM MR. ZEPP reviewed slide 7, Alaska assessment of behavioral health care needs, which states: Mental Health Care Needs Alaska's suicide rate is among the highest in the nation, with the prevalence among the Alaska Native population, particularly in the most remote areas of the state, surpassing that of the general Alaska population (figure 1). The 2016 Alaska Behavioral Health Systems Assessment reported that more than 145,000 adult Alaskans, 20 percent of the state's population, are in need behavioral health services. One component necessary to address mental health issues is a well-trained cadre of mental health care providers to provide preventive support and treatment. There are several reasons why individuals needing mental health services do not receive them. In some cases, the perceived stigma associated with the problem or illness prevents the individuals from seeking help. In other cases, individuals may be more comfortable seeking help from alternative providers such as faith-based, traditional/culture-based or peer-support resources within their community. Finally, particularly in remote areas, availability and access to mental health care providers are often limited. The most common issues for children are attention deficit hyperactivity disorder (AHDH), anxiety, and depression. A child diagnosed with depression has approximately a 74 [percent] chance of having a codisorder, like anxiety. If a child diagnosed with depression and an anxiety disorders, if not treated, they usually increase over time, and the child's condition worsens. MR. ZEPP said mental disorders among children can cause serious challenges to the way children typically learn, behave, and handle their emotions, which causes distress and problems throughout the day. According to the American Foundation for Suicide Prevention, suicide is the number one cause of death for ages 15-24 in Alaska. In 2017, nine times as many people died by suicide in Alaska than in alcohol-related motor vehicle accidents. Alaska's suicide rate is 52 percent higher than the national average. 1:42:57 PM How Many Behavioral Health Care Providers Are Needed? Despite the number of individuals in need of behavioral health care services, the ratio of behavioral health care providers to population is lower in Alaska than nationally. Furthermore, most providers work in urban areas, such that the state's remote areas have even lower provider/population ratios. There are many types of behavioral health providers in Alaska (e.g., psychiatrists, neurologists, psychologists, counselors, clinicians, technicians, behavioral nurse practitioners, and behavioral health aides), though as an example, here we consider only the shortage of psychiatrists. Two studies estimated a need for 25.96 and 15.37 psychiatrists per 100,000 adults nationally, with the authors of the second study noting that the behavioral health care needs of rural populations may not have been adequately captured. National estimates do not account for Alaska's unique population, geography, and need but can serve as a benchmark for estimating the number of psychiatrists needed in Alaska. Based on 2010 Census data, Alaska needs 184 or 106 psychiatrists, respectively. MR. ZEPP said understanding the magnitude, composition, and geographical scope of the mental health provider shortage in Alaska is seen as the first step in developing effective, targeted solutions to increase workforce capacity by adding licensed professional counselors. 1:43:39 PM MR. ZEPP reviewed the chart on slide 9, titled, "Alaska Emergency Room Department, Super-Utilizer Facts, and Total Medicaid Billing charges." He said this chart reflects the total the state paid to emergency rooms from 2016 through 2019 for Alaska's Medicaid clients. The costs have increased by $47.1 million, or 21.1 percent, over the last four years. The top utilizers go to the ER at least ten times a year and sometimes as many as 50 times per year. The cost of the 2.7 percent or 1,858 top utilizers is $42 million or $22,604 per person per year. The cost of 11.6 percent or 7,996 of the top utilizers is $98 million. MR. ZEPP said the state needs to improve Medicaid programs and provide increased quality and become more cost efficient. Adding more licensed professional counseling services can improve these outcomes. With the federal approval of the 1115 [Behavioral Health Medicaid Waiver, also known as 1115 waiver], adding LPCs to the mix of behavioral health professionals offers an opportunity to expand capacity, increase the quality of care, lower the cost versus the crisis level costs that the state is paying. The state has already paid these costs for Medicaid clients for their behavioral health services. 1:45:28 PM MR. ZEPP reviewed the statistics on slide 10, "Alaska Emergency Room Department, Super-Utilizer Facts, Number of Medicaid Clients." He said the chart shows that from 2016 to 2019, the number of Medicaid clients has gone down by 9.6 percent, but the costs are rising. Alcohol-related disorders were the most common diagnoses for the top 2.7 percent, or 1,609 super utilizers and the cost was $43.5 million. The four-year average for the top 10.77 percent or 7,204 users was $103.4 million or $14,332 per person. The top 2.7 percent were likely between 20 and 59 years old. Of these patients, 61 percent were female and 39 percent were male. MR. ZEPP reviewed slide 11, Preventative Behavioral Health Care. He said the estimated cost for a behavioral health assessment in Alaska's emergency rooms is $4,300 versus $150 to $250 per hour for clinical work by a licensed professional counselor. SB 134 has the ability to lower costs for Medicaid clients' behavioral health services that the state is paying to emergency rooms for those in a crisis state. MR. ZEPP displayed the list of supporters of SB 134: • Alaska State Hospital and Nursing Home Association • Providence Health and Services Alaska • Southeast Alaska Regional Health Consortium • Alaska Regional Hospital • Mat-Su Health Foundation • Alaska Primary Care Association • Mat-Su Health Services • Alaska Mental Health Trust Authority • Alaska Department of Health & Social Services • Alaska Department of Commerce, Community & Economic Development • Discovery Cove Recovery & Wellness Center MR. ZEPP respectfully asked members to support SB 134. 1:48:56 PM GENNIFER MOREAU, Director, Division of Behavioral Health, Department of Health and Social Services (DHSS), Anchorage, Alaska, said the Division of Behavioral Health stands ready to assist with this proposed legislation. She highlighted potential benefits of SB 134, which could expand access to care to eligible Alaskans statewide, especially for remote, rural communities and for individuals with mild to moderate disturbances. The bill could potentially decrease psychiatric emergency services and acute care hospital services over time. Licensed professional counselors will be able to provide SBIRT [screening, brief intervention, and referral to treatment], which is a key element to the continuum of care. By making this provider type available to eligible Alaskans, it also provides families the opportunity to interact in a smaller and more intimate setting. Families may be more comfortable receiving services in those settings. CHAIR WILSON asked how this would be integrated with the 1115 waiver. MS. MOREAU replied the 1115 waiver is a mechanism to develop a full continuum of care. The driver behind it is to reduce the reliance on the acute end of care. Expanding access, especially for Medicaid recipients who are experiencing mild to moderate disturbances, including disruptions in social determinants of health, has the potential to prevent the future need for higher, more expensive levels of care. CHAIR WILSON called Jon Zasada to the table. 1:52:16 PM JON ZASADA, Director, Policy Integration, Alaska Primary Care Association (APCA), Anchorage, Alaska, said he spent nine years at the Anchorage Neighborhood Health Center. APCA supports the operations and development of Alaska's 27 community health centers. Its members voted to support SB 134. Adding Medicaid reimbursement for LPCs has been a top priority in its efforts to expand access to behavioral health for many years. APCA serves 113,000 patients per year through 560,000 visits at 160 clinic sites around the state. APCA serves 10 percent of Alaskans. About 85 percent of its patients have incomes at under 200 percent of the federal poverty level. Around 20 percent of Alaskans enrolled in Medicaid get their primary care at a community health center. About 10 percent of APCA patients come in primarily for mild and moderate behavioral health care and 15 percent of all visits in a year are for behavioral health. APCA employs over 180 behavioral health providers of all types. MR. ZASADA said LPCs are a valuable, cost-effective component of team-paced, whole person primary care. Primary care is built around medical, dental, behavioral health, pharmacy, and support providers working to ensure patients receive care and help them manage their chronic conditions. Making LPCs billable under Medicaid will expand access to care for Alaskans in lower cost, primary care settings. MR. ZASADA said the bill is an important component of the Medicaid reforms that were outlined in the 2016 Senate Bill 74 to expand provider types to increase access to behavioral health services. LPCs are an important provider type within a behavioral health team that includes licensed clinical social workers (LCSWs), psychologists, prescribing nurse practitioners, and medical doctors. In 2017, APCA health centers reported a deficit of 12 to 18 behavioral health providers. Conservatively, they could provide care to 6,000 to 9,000 additional patients. From a clinical standpoint, LPCs are vital for one-on-one counseling in conjunction with LCSWs. 1:57:29 PM MR. ZASADA said community health centers are already using LPCs in their practice to provide school-based services, counseling services, and supporting care coordination for patients. The addition of LPCs will increase overall provider retention and satisfaction, another challenge to health care in Alaska. All medical providers are more likely to stay in place when there is a full care team of professionals working at the top of their licensure. The full medical team model will gain increased efficiency by being fully staffed and reimbursed for the first time. Community health centers have received considerable federal investments to expand behavioral health services and support substance use treatment services in the primary care setting. Health centers are required by federal law to provide behavioral health that is integrated with medical, dental, pharmacy, and other services. Adding LPCs to the roster of billable providers enables health centers to make their services more sustainable. Now the LPCs that APCA employs are funded by nonsustainable federal grants and other grants that are not sustainable funding sources. MR. ZASADA said mild and moderate anxiety and depression are co- occurring conditions with chronic conditions including diabetes and hypertension. LPCs can provide short-term counseling support to stabilize and improve the health of emergent patients and assisting them in managing their chronic conditions. LPCs provide a range of behavioral health services in schools across the state. Currently, none of that care is reimbursed. MR. ZASADA said that in an integrated clinical setting, the attending medical or dental provider of a patient with diabetes might discover the patient is showing signs of depression or anxiety that could affect the patient's ability to follow the treatment plan. At this point an LPC would be called to provide counseling support for the patient. The LPC will work with the patient around personal issues affecting overall health, teach behavioral skills, and address social issues. The goal of the provider team is to get the patient back on path with a treatment plan, improve mental health, and avoid emergency care. 2:01:03 PM MR. ZASADA said that in school-based settings, an LPC might provide individual counseling, provide behavioral health skills education, and train teachers in how to support students. MR. ZASADA said APCA supports SB 134. It addresses the need for Alaska's response to behavioral health, lends sustainability to current efforts, and offers another tool to improve care and lower its costs. 2:02:05 PM KEVIN MUNSON, Chief Executive Officer, Mat-Su Health Services, Wasilla, Alaska, said Mat-Su Behavioral is a federally-qualified community health center. It operates a community behavioral health program funded by the state. He serves as the chair of the Alaska Primary Care Association and sits on the executive committee for the Alaska Behavioral Health Association. He said he is trained as a marriage and family therapist, but he works as a licensed professional counselor (LPC). He has practiced for 32 years in Alaska in behavioral health and primary care. It has been a long-standing desire of his to see LPCs, licensed marriage and family therapists and other licensed mental health professionals added to the list. MR. MUNSON said [SB 134] provides an opportunity to step back and do some transformational thinking about how to redesign the system. Many citizens use the emergency rooms to meet their behavioral health needs because of lack of access to behavioral health services in traditional settings. MR. MUNSON said that in terms of Medicaid, LPCs are only allowed to practice in narrow areas limited to grant-funded entities. Appropriate professionals need to be in places where citizens will most likely use them. The suicide rates provide chilling statistics, such that 54 percent of people who commit suicide have had a primary care visit in the previous 30 days. MR. MUNSON said the primary care provider may have asked about suicidal thought and may have referred the patient to a local mental health center or counseling agency. Ninety percent of those referrals do not result in a visit to a counselor and the patient drops out of the system. Federal qualified community health centers have integrated care for individuals to receive a hand off to an existing counselor within the context of primary care. Several private practices in the state have counselors who do so. The Mat-Su Behavioral Health Services pays those counselors but is not reimbursed for Medicaid clients because LPCs are not eligible providers. It is not an expandable, replicable model, he said. MR. MUNSON said he employs six licensed clinical social workers. Last year it took nine months to find a replacement when the agency lost a social work. In one month, he had five opportunities to hire LPCs to fill the slot, which he could have done if the state had a reimbursable model. His program does not have grant money to fund the licensed social workers who are funded by the reimbursable work performed. He offered his view that since much of his business is Medicaid, if he had a funding stream for LPCs, he could have replaced that licensed social worker in 30 to 60 days. MR. MUNSON highlighted the need to provide citizens with access to counselors. Usually an acute crisis drives someone to see a counselor, such as trouble at school, a divorce, a lost job, or driving while under the influence. Those are the circumstances in which someone is ready but not necessarily able to get help. Sometimes that is because the helpers are siloed in places someone does not think of using or the person cannot get access because the behavioral health system is designed to take care of the most impaired, the most at risk, and the most in need. That leaves individuals who fall in mild to moderate need without viable resources. 2:10:32 PM MR. MUNSON said a business model for federally qualified health centers for counseling programs for primary care and group practices could take care of the Medicaid population. Removing the statutory barrier for LPCs [to bill for Medicaid] will create a path to provide access for citizens who need care. When people have access to behavioral health care during that initial crisis, it is possible to salvage marriages and children no longer face disruptions and can avoid other risks, such as Adverse Childhood Experiences scores due to intervention. It could also avoid interventions by the Office of Children Services, Juvenile Justice, and the courts. MR. MUNSON said the research shows that the best way to take care of people is with a primary care team of individuals who provide wraparound services, one of which is behavioral health. His center has seen enormous success with individuals by addressing behavioral health problems, such as anxiety, parenting issues, lifestyle choices and providing management for chronic medical conditions. MR. MUNSON noted that people with diabetes find it hard to make lifestyle changes. The primary care physician has limited time and skills to help them, but the behavioral health specialist can talk to the person about small, incremental changes that eventually become large, lifestyle changes that will change the trajectory of that person's diabetic care. Patients get their A1Cs under control, lose weight, and develop an exercise program. Since 2013, his center has been operating the depression management care IMPACT model that involves the collaboration of the primary care provider, a licensed clinical social worker, and a consulting psychiatrist. His center has seen enormous improvements in treatment and has seen people ease their depression, go back to work, and put relationships back together because the center was able to provide that level of intervention. MR. MUNSON said finally, there is the notion of equity. People cannot differentiate between the services of a licensed clinical social worker, a marriage and family therapist, and a counselor. These professionals are all well trained, experienced, competent behavioral health professionals. The system recognizes some of the credentials only because these professions existed at the time the regulations were drafted. Subsequent professionals have been excluded from the process. 2:17:08 PM CHAIR WILSON opened public testimony on SB 134. PATICK ANDERSON, Chief Executive Officer, RurAL CAP, Anchorage, Alaska, said RurAL CAP serves the hard to serve individuals in Anchorage and rural Alaska. RurAL CAP has a grant to provide behavioral health services and operates 24 Head Start programs. These children go without basic services because RurAL CAP lacks licensed professionals in rural Alaska. MR. ANDERSON said the residents of Karluk Manor and Sitka Place are hard to serve communities. He supported opening the roles to add additional counselors. He spent eight years on the American Indian/Alaska Native task force on suicide prevention. It is disheartening to see the needs go unserved every day in rural Alaska. The RurAL CAP board has initiated whole community healing. RurAL CAP will need professionals and community engagement to do so. He expressed concern that learned helplessness will become the norm. He urged the committee to support the expansion of the ranks with licensed professional counselors. 2:20:59 PM SEVILLA LOVE, Integration Coordinator, Alaska Primary Care Association, Anchorage, Alaska, said she is a licensed clinical social worker. She has spent her 20-year clinical career in in primary care clinics in urban and rural Alaska, developing cutting-edge intervention programs throughout Alaska. She worked exclusively with suicidal rural patients at Alaska Psychiatric Institute. Eighty percent of the people she worked with could have been avoidable with preventative primary care. She has been the provider capturing the unseen behavioral health patients who would not otherwise have been seen or been willing to be seen. MS. LOVE said she currently works as the integration coordinator for the Alaska Primary Care Association. She provides training to health centers across Alaska on how to implement a team-based integrated care model by incorporating behavioral health into the daily health care services. She said she observes the struggles health centers have to provide quality care. The number one problem is lack of access to billable, financially sustainable behavioral health providers. The clinics she works with tell her their clinics have sought licensed clinical social workers throughout the Lower 48. These clinics pay a starting salary of over $80,000 a year plus loan repayment options, but still cannot find a licensed clinical social worker or psychologist to fill the primary care role. Their patients are desperate for care. However, many LPCs would be willing to fill the vacancies, but the centers cannot hire them. Further, medical staff face burnout so the turnover rates kill the continuity of care. Chronic-care patients also need behavioral health support to make lifestyle changes to improve their health. MS. LOVE said health centers have massive tasks but limited options to build an integrated behavioral health program. She said health centers must be allowed to meet behavioral health needs using LPCs as billable providers in primary care clinics. 2:24:44 PM ROBIN MINARD, Chief Communications Officer, Mat-Su Health Foundation, Wasilla, Alaska, said the Mat-Su Health Foundation's mission is to improve the health and wellness of Alaskans living in the Mat-Su. SB 134 is crucial because it helps to address an important health issue facing Mat-Su residents every day: mental health, and substance abuse problems. Licensed professional counselors are key behavioral health providers who can help with these problems. She reported that in 2013, residents and professionals said the top five health challenges were alcohol and substance abuse, children experiencing trauma and violence, depression and suicide, domestic violence and sexual assault, and lack of access to behavioral health care. During that same assessment, the foundation met with school nurses throughout the borough who said there was a four to eight month waiting list for children and families on Medicaid to see a counselor. Unfortunately, not much has changed since then. People need help when problems arise, not eight months later. She said there are not enough mental health providers in Mat-Su or Alaska, that there is one provider for every 860 residents, but in the U.S., the ratio is one for every 330 residents. Residents need access to behavioral health providers to obtain care before problems escalate into the crisis stage. MS. MINARD said Mat-Su Regional Hospital is inundated with people in crisis related to behavioral health. In 2016, there were almost 1,200 residents seen in the emergency department with a primary behavioral health diagnosis. These patients comprised 3,000 visits, 46 percent of which were paid by Medicaid. The top diagnoses were suicidal ideation and self- harm, alcohol-related disorders, delirium, dementia, and cognitive disorders. The cost for those visits was $14 million in facility charges alone. If residents could get immediate access to care, pain, suffering, and costs would be diminished. An individual counseling session may average $75 for Medicaid patients, but an average charge for a behavioral health emergency room visit is $4,370. The prevalence of substance abuse and mental health problems in crisis is increasing in Mat- Su and statewide. SB 134 could bring the appropriate level of care to people when a problem first presents. 2:29:15 PM DEBRA HAMILTON, Executive Director, New Hope Counseling Center, Soldotna, Alaska, said she has been a professional counselor since 2013. Her counseling center is on the campus of Alaska Christian College, which serves predominantly young adult Alaska Natives. It is also open to the community. She has served on the Board of Professional Counselors since 2013 and is the current chair. Professional counselors could provide services of great quality. Licensed professional counselors are master's level counselors who have extensive training and required coursework. Currently, there are 732 active licensed professional counselors in the state with 447 approved supervisors actively training and supervising the next generation of LPCs. There is a vacuum of accessible services. She offered her support for SB 134. 2:31:39 PM ERIC BOYER, Program Officer, Alaska Mental Health Trust Authority, Anchorage, Alaska, said he serves as the chair of Alaska Health Care Workforce Coalition. Expanding the number of health care practitioners who can bill Medicaid will increase that responsiveness to people experiencing behavioral health disorders. The Alaska Mental Health Trust Authority beneficiaries include Alaskans with mental illness, substance use disorder, developmental disabilities, Alzheimer's and related dementia, and traumatic brain injury. In partnership with Department of Health and Social Services (DHSS), the authority ensures that Alaska has a comprehensive, integrated system of care to provide the necessary services and support for beneficiaries as close to home as possible. 2:33:37 PM DON BLACK, Board Member, Bethel Family Clinic, Bethel, Alaska, said the clinic employs one licensed clinical social worker and one licensed professional counselor and has an employee working toward becoming an LPC in the behavioral health department. The clinic provides services to teens at the Bethel Youth Facility. The substance abuse programs are embedded in the community as well as in the Yukon-Kuskokwim Correctional Facility, where staff provides individual and group guidance. Youth services are also delivered to court- and medically-referred patients. The clinic receives patients from the local community and surrounding village. As a safety net medical facility, some services are provided without pay in the clinic's efforts to maintain the health of the community. Such is the case with services provided by the clinic's LPC for Medicaid patients, many of whom are youth from villages where suicide rates are high, even by Alaskan standards. The clinic's greater mission is to provide for the health of the community, so sometimes the clinic does that without pay, but the LPC provides the same level of care as the licensed clinical social worker. The work of the LPC is recognized as equivalent to the work of the licensed clinical social worker and is payable by private insurers, but this same work is not recognized and payable by the state's Medicaid policies. In a time of addressing the opioid crisis, the clinic has one hand tied behind its back. Its delivery of services is restricted simply because of how the history of the licensing process for licensed practical counselor and licensed clinical social worker developed in the state. SB 134 unties that hand. 2:35:52 PM JULIE THOMPSON, Licensed Professional Counselor, Bethel Family Clinic, Bethel, Alaska, said she is a licensed professional counselor. She graduated with a master's degree in mental health counseling in 2007. She has 13 years of experience specializing in trauma-informed interventions for people with a diagnosis of post-traumatic stress disorder (PTSD) and substance abuse disorder. She previously worked two years as a clinician at Yukon Kuskokwim Ayagnirvik Healing Center. She supported individuals in their efforts toward recovery from a substance use disorder. Over 90 percent of these clients suffered from coexisting disorders, usually PTSD, often secondary to trauma experienced as children growing up in severely dysfunctional homes due to their parents' unresolved and untreated traumatic histories. She now works for Bethel Family Clinic as a mental health clinician. However, since she is not under the Indian Health Service umbrella, she is not recognized as a clinical provider by Medicaid. She characterized this as tragic as her agency is a primary partner with the Child Advocacy Center whose primary mission is to provide timely interventions to children who have been identified as victims of sexual abuse and trauma. The center currently employs two clinicians, herself and a colleague who is a licensed clinical social worker. The clinic has been trying to recruit another social worker for over a year. It is not uncommon for the clinic to have seven referrals in a week from the Advocacy Center. At this time, the clinic can respond to none of them. Allowing LPCs access to Medicaid reimbursement will not only save millions of dollars, money that is now spent on emergency room visits, medevacked services, or legal interventions, but will ultimately save lives. "Please support SB 134 and help us help these children, help us save their lives," she said. 2:38:15 PM JEIGH STANTON GREGOR, representing self, Petersburg, Alaska, said he is an LPC in private practice. He and his wife have owned True North Counseling and Consultation for seven years. SB 134 will allow the most vulnerable patients the same access to high-quality mental health services as people with private insurance or the ability to pay out of pocket. He offered his belief that a private practice could thrive if its patients were Medicaid clients. The passage of SB 134 will lead to reductions in costly emergency room visits and acute mental health crises. Preventative care is highly effective in mitigating mental health emergencies. He characterized SB 134 as a win-win. He wants to help people be well and improve the quality of their lives. 2:40:21 PM CHAIR WILSON closed public testimony on SB 134 and held the bill in committee. 2:41:05 PM There being no further business to come before the committee, Chair Wilson adjourned the Senate Health and Social Services Standing Committee at 2:41 p.m.