Legislature(2017 - 2018)BUTROVICH 205
03/12/2018 01:30 PM Senate HEALTH & SOCIAL SERVICES
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| Audio | Topic |
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| Start | |
| SB193 | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| + | TELECONFERENCED | ||
| *+ | SB 193 | TELECONFERENCED | |
| + | TELECONFERENCED | ||
ALASKA STATE LEGISLATURE
SENATE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE
March 12, 2018
1:30 p.m.
MEMBERS PRESENT
Senator David Wilson, Chair
Senator Natasha von Imhof, Vice Chair
Senator Cathy Giessel
Senator Peter Micciche
Senator Tom Begich
MEMBERS ABSENT
All members present
COMMITTEE CALENDAR
SENATE BILL NO. 193
"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 193
SHORT TITLE: MED. ASSISTANCE WORK REQUIREMENT
SPONSOR(s): SENATOR(s) KELLY
02/19/18 (S) READ THE FIRST TIME - REFERRALS
02/19/18 (S) HSS, FIN
03/12/18 (S) HSS AT 1:30 PM BUTROVICH 205
WITNESS REGISTER
SENATOR PETE KELLY
Alaska State Legislature
Juneau, Alaska
POSITION STATEMENT: Sponsor of SB 193.
HEATHER CARPENTER, Staff
Senator Pete Kelly
Alaska State Legislature
Juneau, Alaska
POSITION STATEMENT: Presented the sectional for SB 193.
JON SHERWOOD, Deputy Commissioner
Medicaid & Health Care Policy
Department of Health and Social Services (DHSS)
Juneau, Alaska
POSITION STATEMENT: Answered questions on SB 193.
MONICA WINDOM, Director
Division of Public Assistance
Department of Health and Social Services (DHSS)
Juneau, Alaska
POSITION STATEMENT: Answered questions on SB 193.
MIKE COONS, President
Alaska Chapter of Mature American Citizens (AMAC)
Palmer, Alaska
POSITION STATEMENT: Supported SB 193.
JESSICA CLER, Alaska Public Affairs Manager
Planned Parenthood Votes Northwest and Hawaii
Anchorage, Alaska
POSITION STATEMENT: Opposed SB 193.
JEREMY PRICE, Alaska State Director
Americans for Prosperity
Anchorage, Alaska
POSITION STATEMENT: Supported SB 193.
ACTION NARRATIVE
1:30:12 PM
CHAIR DAVID WILSON called the Senate Health and Social Services
Standing Committee meeting to order at 1:30 p.m. Present at the
call to order were Senators Giessel, von Imhof, Begich, and
Chair Wilson. Senator Micciche joined shortly thereafter. He
advised that the presentation regarding the "Behavioral Health
Continuum of Care and the Alaska Psychiatric Institution" had
been removed from the agenda.
SB 193-MED. ASSISTANCE WORK REQUIREMENT
1:30:38 PM
CHAIR WILSON announced the consideration of SB 193.
1:31:16 PM
SENATOR PETE KELLY, Alaska State Legislature, sponsor of SB 193
said the bill answers the question of whether Alaskans who
receive Medicaid should be required to work or volunteer as a
condition of their benefits. He said I believe the answer is yes
and SB 193 is a simple and direct path to achieving that end. He
clarified that SB 193 does not require the elderly, disabled, or
new mothers to work. The exemptions are spelled out on page 2,
lines 6-19. People who are not employed, volunteering, or
otherwise exempt can receive exemptions if they are in an
education or training program that will lead to work. The
genesis for the bill was an announcement by CMS [Centers for
Medicare & Medicaid Services] allowing work requirements through
the structure of the Medicaid Section 1115 waivers. He explained
that SB 193 applies to a narrow band of Medicaid users, those
who can work but do not. It's not so much about saving money as
encouraging people to get out and build their skills and
reputation and work their way out of the welfare or Medicaid
system. He described the bill as philosophical in that it should
be the default position of Americans that those who can work
should work. He opined that depending on government funds has
frozen people in place and denied them the dignity of work and
joining their fellow Alaskans who have a reason to get up in the
morning and make this state a better place.
1:35:55 PM
HEATHER CARPENTER, Staff, Senator Pete Kelly, Alaska State
Legislature, paraphrased the following sectional analysis for SB
193:
Section 1:
Amends AS 47.07.036 to direct the DHSS to apply for a
section 1 115 waiver of the Social Security Act to
establish a work requirement for adults in the Medicaid
program who not meet the criteria to be exempted.
The waiver must include the following:
(l) Requires an able-bodied Medicaid recipient to
participate in work activities for a minimum of
20 hours each week. Actively seeking employment,
participating in an education or training
program, volunteering, or engaging in subsistence
activities also are counted towards the 20-hour
requirement.
(2) If a Medicaid recipient is also receiving
benefits under Alaska Temporary Assistance
Program and in compliance with the work
requirements listed under AS 47.27.035, then they
automatically meet the work requirement for
Medicaid.
(3) Exempt Medicaid recipients who are:
a. Children or elderly (Under 18 years old and
over 65 years old)
b. The parent or caretaker of a dependent child
of up to 12 months of age and the parent or
caretaker is providing home care for the
child
c. The parent or caretaker of a child
experiencing a disability and the parent or
caretaker is providing home care for the
children
d. The caretaker of a relative who is
experiencing a disability and requires 24-
hour care
e. The parent or caretaker of a child under six
years of age and the parent or caretaker
demonstrated that appropriate child care is
not available
f. Unable to work for medical reasons, as
determined by a licensed medical
professional
(4) Ensure that the work requirement does not impact
a Medicaid recipient from obtaining substance
abuse treatment
(5) A notification to all Medicaid receipts once the
waiver is approved, and a 90 day notice of non-
compliance with the work requirement before
benefits are terminated.
MS. CARPENTER noted that pregnant women would need to be
specifically added to the list in paragraph (3). The sponsor
thought that referencing the Temporary Assistance for Needy
Families (TANF) statutes was sufficient, but the deputy
commissioner pointed out that not all pregnant women receive
TANF.
1:39:58 PM
SENATOR GIESSEL asked why the sponsor chose to do this through
the Section 1115 Medicaid waiver.
SENATOR KELLY said the CMS guidance letter directed doing it
through that process.
SENATOR GIESSEL, noting that at least one state received
approval, asked how that could happened so quickly through an
1115 waiver process.
MS. CARPENTER said she did not know, but the CMS guidance letter
said that applying through the waiver was the only avenue. She
added that the bill tests the theory that work requirements will
improve health outcomes of people on the Medicaid program.
SENATOR KELLY said it is an interesting point that the CMS
requirement has nothing to do with the dignity of work, but the
idea that people who work will be healthier.
SENATOR GIESSEL shared that her concern about using the Section
1115 Medicaid waiver was that it is a very ponderous process.
For example, the regulations for the 2015 Medicaid reform for
behavioral health were finally filed in January 2018 and will
take two more years to implement.
1:42:30 PM
SENATOR BEGICH said the provision on page 2, line 20, "ensure
that the work requirement does not prevent a recipient with a
substance abuse disorder from obtaining appropriate treatment
for the substance abuse disorder," was insightful. He asked
whether there was a standard to determine whether someone is
able-bodied.
MS. CARPENTER said the department is used to these terms and CMS
puts out guidance on them. Someone able-bodied would not be
enrolled in Medicaid through disability. They might have a
disability, but it will not be the Social Security level of
disability.
SENATOR BEGICH said he likes that the bill mirrors TANF
requirements. He asked whether the sponsor would consider an
amendment to allow a caseworker to suggest a modified work
requirement of less than 20 hours a week.
SENATOR KELLY said he assumes it would be appropriate under the
waiver. He would not object to giving the department the
flexibility it needs. He added that volunteering is always an
option when work is difficult to find.
MS. CARPENTER said the CMS letter lays out guidance for the
department on how to work with people who will be affected by
this requirement. The guidance addresses the Americans with
Disabilities Act and Section 504 of the Rehabilitation Act. The
letter says, "States should include, in their proposals,
information regarding their plans for compliance with these
requirements, including provision of reasonable modifications in
work or community engagement requirements."
1:46:20 PM
SENATOR BEGICH said the bill might require a minor amendment to
add that option.
MS. CARPENTER said she wanted to hear from the department
because the allowance for medical exemptions might address that.
SENATOR BEGICH asked how many people the bill would affect and
how many might be removed.
SENATOR KELLY said he has heard that as many as 25,000 might be
affected, but that seems high since many of the people on
Medicaid under the expansion do work.
CHAIR WILSON said the DHSS fiscal note provides answer.
SENATOR MICCICHE said he is a cosponsor who believes the bill
has peripheral values that are more significant than the bill
itself. Social programs have changed from something to relieve
dire need to something of convenience. The 20 hours are
extremely important because it shows people they have so much
more potential to excel. People are afraid to succeed because
they fear losing their benefits. He is sure they will hear about
how many people now are working. The definitions used for
working are generous. The expansion population has to be
working, so he's not sure it includes them at all. He would like
to see a table of all the costs, which are interesting and
somewhat creative.
CHAIR WILSON said he also was going to ask the department for a
memo to summarize all the expenditures and fiscal notes and how
they interact.
SENATOR KELLY said the department representatives in the room
are professional and hard-working people, but the large fiscal
note reflects a philosophical difference. The discussion about
the fiscal note is yet to come.
1:50:32 PM
SENATOR MICCICHE reiterated support for the bill and deferred
discussion about the appropriateness of the fiscal note to
Finance.
SENATOR VON IMHOF said the fiscal notes will be discussed in
Finance, but it is the crux of the bill. She pointed out that
Kentucky cited administrative burdens as one reason why they
downgraded their work requirements. The tracking system and
paperwork needed to demonstrate 20 hours of paid or volunteer
work made the cost almost a wash. Philosophically there are many
reasons to support the bill, but the question is whether an
already over-taxed department can take this on.
SENATOR MICCICHE asked if the committee's only responsibility
was a workload and money-saving question or if part of their
responsibility was to put policies in place to break the cycle
and help Alaskans succeed in this generation and in the future.
He said he cannot isolate his consideration to today's cost and
administrative burden. He has to look at the people who are not
reaching their ultimate potential and the systems that have been
set up to actually compromise success and potential.
CHAIR WILSON asked if the department could put together a memo
to summarize all the costs and savings and how they interact.
1:54:11 PM
JON SHERWOOD, Deputy Commissioner, Department of Health and
Social Services (DHSS), said they'd be happy to put together a
table to summarize all the fiscal notes, both theirs and other
departments, to explain the different pieces.
CHAIR WILSON said that would be helpful for the general public.
SENATOR BEGICH asked how many people DHSS determined might be
affected by SB 193 and how they arrived at that number.
1:55:24 PM
MONICA WINDOM, Director, Division of Public Assistance,
Department of Health and Social Services (DHSS), said they
looked at the entire Medicaid caseload and removed children, the
elderly, the disabled, and people receiving ATAP [Alaska
Temporary Assistance Program] because it has a work requirement.
That left about 25,000 people.
SENATOR BEGICH asked if the exemptions on page 2 of the bill
were included.
MS. WINDOM said yes.
SENATOR MICCICHE noted that individuals on any DHSS program go
through an eligibility analysis so the extra effort would likely
amount to simply adding another column.
MS. WINDOM said the guidance from CMS is to follow ATAP rules
and those case managers spend about 9.5 hours and $5,500 per
person per year. The fiscal note for SB 193 reflects their
assumption that most of these people do not have children and
will be easier to serve than someone on temporary assistance.
They estimated case managers would spend between three and five
hours a year per person.
SENATOR MICCICHE said it won't require an entirely new
bureaucracy to account for work requirements. It is applying it
to more people and more recipients of other programs.
MS. WINDOM said the basic concepts are the same, but DHSS does
not have the staff to work with this large group of people. The
ATAP caseload is 3,000 and the work services line for that is
$11 million. The estimate for this is for 25,000 people.
SENATOR MICCICHE said when he recently asked how many people of
the Medicaid population were working, he got a very quick
answer. He said he assumes the answer came quickly because the
department understands the proportion of people who are already
working.
1:58:45 PM
MR. SHERWOOD explained that an eligibility determination
includes whether someone is working and has an earned income.
The people that are covered by the fiscal notes do not have an
earned income. They assumed that initially about 25,000 people
would be on Medicaid and not covered by one of the exemptions.
Over time some people will drop out of the program for
noncompliance so the number will drop. Over three years, that
number will probably stabilize at 18,000. He agreed with
Director Windom's point that it would take a lot more people to
do the work services for 18,000 than for the 3,000 people on
ATAP. The CMS letter is clear that providing some level of
supported services is expected if the loss of Medicaid is
imposed as a result of noncompliance.
CHAIR WILSON asked whether the state could add this requirement
to the work services it already contracts out.
MR. SHERWOOD confirmed that DHSS does a substantial amount of
contracting. They do some in-house work with ATAP with their
employment services. Something unusual about the State Medicaid
Director Letter is that it states that work supports are not a
Medicaid eligible expense. While states must make them
available, there are no federal funds for that. DHSS thinks the
argument can be made that if they keep the work in-house, they
can claim it is part of the eligibility and program
administration and they will claim the federal share for that
staff. If DHSS puts it out for a contract, they would have to
treat it all as work services and not claim any federal match.
They would negotiate with the federal government about where to
claim the federal match as appropriate. Their expectation is
that work services itself is not eligible for a federal match.
Over time, the total savings are substantial but mostly in areas
of federal funds and the expenditures are in general funds.
2:02:55 PM
SENATOR VON IMHOF said it is important to fully understand the
impact of this. She read an article that other states have
discovered that when people are asked to go to work, the federal
government does not cover job training, childcare assistance,
transportation, and other services. The estimate is that the
state will pay $1,000 per enrollee, which is $21 million each
year. The fiscal note estimates 49 new DHSS employees to track
this, plus the price of computers and cubicles. She expressed
interest in leverage existing programs like TANF versus creating
a new department.
CHAIR WILSON said the 2015 DHSS audit pointed out inefficiencies
in the Division of Public Assistance that have been not
addressed to date. Working on two systems instead of one, for
example. He asked if the fiscal note reflects some of the same
issues highlighted in the 2015 audit.
MS. WINDOM said the majority of staff request is for the work
services piece, not the eligibility piece. They did ask for a
few more eligibility technicians to implement penalties for
noncompliance. DHSS is working to improve its system and hopes
to be in one system within 3 years. Part of the fiscal note is
to reprogram the system to put the work requirement in and
provide a penalty for noncompliance.
2:06:50 PM
SENATOR MICCICHE said the CMS guide talks about their commitment
to support state demonstrations that require eligible adult
beneficiaries to work or engage in community activities. He
asked if they have published any other document to describe
their commitment and what that support may look like.
MR. SHERWOOD said he is not aware of any other published
guidance from CMS.
SENATOR MICCICHE said he would welcome any evidence of CMS's
ability to support training programs.
2:08:34 PM
CHAIR WILSON opened public testimony.
2:08:56 PM
MIKE COONS, President, Alaska Chapter of Mature American
Citizens (AMAC), supported SB 193. He said AMAC, which is a
conservative organization for senior citizens in Alaska, has an
Alaskan membership of 4,500. Those able-bodied people added to
Medicaid in the Obama era and by the governor against the wishes
of the majority in the House and Senate, as well as against the
wishes of a large part of the population of Alaska, are part of
the failed great society of the LBJ administration. Nationally
the country has lost more than $2 trillion since then and has
generations of families that do not work yet eat better than
most working Alaskans. He opined that Medicaid puts able-bodied
people over those working or retired citizens who have Medicare.
He has heard that adding able-bodied to Medicaid hurts those
whom Medicaid was intended for, those with true needs. The
American with Disabilities Act was passed to enable disabled
people to work, but Medicaid removes the incentive to work. The
value of work for self-esteem for anyone with a physical
challenge is more helpful both physically and mentally than not
working and living on government handouts. He said those who can
work to work should be encouraged to do so. He said DHSS is
trying to help people by spending more money, which he is not
too happy about, but the minimum wage of $9.86 per hour for 20
hours for 25,000 people is $236,160,000 a year of increased
income into people's wallets and into the economy.
2:12:37 PM
SENATOR BEGICH asked if he supports the exemptions.
MR. COONS said they are reasonable.
2:13:52 PM
JESSICA CLER, Alaska Public Affairs Manager, Planned Parenthood
Votes Northwest and Hawaii, opposed SB 193. She said Planned
Parenthood is the nation's leading provider of sexual and
reproductive health. In 2015, 26 percent of their patients were
Medicaid beneficiaries. Planned Parenthood is committed to
everyone in the state having access to the health care they
need, regardless of their income or where they live. Enrollment
restrictions like those proposed in SB 193 will decrease access
to health care in Alaska and disproportionately impact women.
Medicaid covers one of five women of reproductive age and is the
source of coverage for nearly half of women giving birth. Many
women face barriers to work such as transportation, housing,
education, and abusive relationships. Research shows work
requirements do not decrease poverty and, in some cases, push
families deeper into poverty.
She said SB 193 would cut Alaskans off from the care they depend
on without improving their economic stability. Burdensome work
requirements are not the best way to improve the health and
well-being of Alaskan women and families. To support the dignity
and economic well-being of Alaskans, the state must preserve and
expand access to Medicaid. Medicaid coverage makes it easier for
women to secure and maintain employment, it provides treatment
for conditions that may keep them from working, and its coverage
of family planning allows women to pursue their educational and
career goals. She urged the committee to focus on proven
policies to improve women's health and economic security.
2:16:14 PM
JEREMY PRICE, Alaska State Director, Americans for Prosperity,
supported SB 193. He said this is a fabulous step forward for
Alaskans. The United Kingdom Department for Work and Pensions
commissioned a study ten years ago entitled, "Is Work Good for
Your Health and Well-being?" Doctors Gordon Waddell and Kim
Burton concluded, "There is a strong evidence base showing that
work is generally good for physical and mental health and well-
being. Worklessness is associated with poorer physical and
mental health. Work can be therapeutic and reverse the adverse
health effect of unemployment. That is true for healthy people
of working age, many disabled people, most people with common
health problems, and social security beneficiaries." This
legislation only impacts Medicaid recipients who are working age
and able-bodied who can work but choose not to. In February
Americans for Prosperity made the following statement:
Beginning with former Mayor Rudy Giuliani and
continuing with Mayor Michael Bloomberg, New York City
became a model for how work requirements for welfare
applicants and recipients could contribute to a steep
drop in a city's welfare caseload. From 1995 to 2013,
the number of welfare recipients in New York City
shrank from almost 1.1 million to less than 347,000
a drop of more than 700,000 men, women and children.
But while New York City may have undergone the most
visible transformation, other states and localities
across the country were seeing similar success.
Among the most promising examples of work requirements
empowering able-bodied adults were the results of 2013
Kansas reforms to the food stamp program. Prior to
instituting new food stamp work requirements, Kansas
was spending nearly $5.5 million per month on
government assistance programs, while 93 percent of
food stamp recipients were living in poverty. Few of
the recipients claimed any income, with only 21
percent working at all, and 40 percent working fewer
than 20 hours per week.
Soon after work requirements were implemented,
thousands of food stamp recipients in Kansas moved
into the workforce, resulting in a decrease in
poverty, with 40 percent of former food stamp
recipients finding a job within the first three
months, and nearly 60 percent within a year. The
people who moved off of food stamps and found a job
weren't "punished," they lifted themselves out of
poverty and improved their lives.
MR. PRICE said this bill is about improving the lives of
Alaskans by providing incentives for them to be more self-
sustaining and provide benefits for themselves instead of the
government. This reform helps people, helps Alaskans better
themselves, their situation, and their health outcomes will
improve. Since his testimony is long, he will submit written
testimony.
SENATOR MICCICHE asked Mr. Price to forward his data sources to
the chair for distribution to the committee.
2:20:02 PM
CHAIR WILSON closed public testimony.
2:20:14 PM
SENATOR GIESSEL referenced a longitudinal study of Alaska's
remote Arctic communities and the life expectancy since the
development of oil resources on the North Slope. The life
expectancy of people living in the rural Arctic now exceeds that
of major cities in the lower 48, attributable to the ability to
have an income and work. She offered to provide a copy of the
study to the committee.
CHAIR WILSON held SB 193 in committee.
2:21:10 PM
There being no further business to come before the committee,
Chair Wilson adjourned the Senate Health and Social Services
Committee at 2:21.
| Document Name | Date/Time | Subjects |
|---|---|---|
| SB 193 Version D Sponsor Statement.pdf |
SHSS 3/12/2018 1:30:00 PM SHSS 3/26/2018 1:30:00 PM |
SB 193 |
| SB 193 Version D Sectional.pdf |
SHSS 3/12/2018 1:30:00 PM SHSS 3/26/2018 1:30:00 PM |
SB 193 |
| SB 193 Version D CMS Letter 1.11.18.pdf |
SHSS 3/12/2018 1:30:00 PM SHSS 3/26/2018 1:30:00 PM |
SB 193 |
| SB 193 Version D.pdf |
SHSS 3/12/2018 1:30:00 PM |
SB 193 |
| SB 193 Fiscal Note DHSS DPA Field Svcs.pdf |
SHSS 3/12/2018 1:30:00 PM SHSS 3/26/2018 1:30:00 PM |
SB 193 |
| SB 193 Fiscal Note Dept Admin - Cent Admin Svcs.pdf |
SHSS 3/12/2018 1:30:00 PM SHSS 3/26/2018 1:30:00 PM |
SB 193 |
| SB 193 Fiscal Note DHSS DPA QC.pdf |
SHSS 3/12/2018 1:30:00 PM SHSS 3/26/2018 1:30:00 PM |
SB 193 |
| SB 193 Fiscal Note DHSS DPA Work Svcs.pdf |
SHSS 3/12/2018 1:30:00 PM SHSS 3/26/2018 1:30:00 PM |
SB 193 |
| SB 193 Fiscal Note DHSS Med Svcs Adult Dental.pdf |
SHSS 3/12/2018 1:30:00 PM SHSS 3/26/2018 1:30:00 PM |
SB 193 |
| SB 193 Fiscal Note DHSS Medicaid Services.pdf |
SHSS 3/12/2018 1:30:00 PM SHSS 3/26/2018 1:30:00 PM |
SB 193 |
| SB 193 Fiscal Note DHSS Medicaid Svcs BH.pdf |
SHSS 3/12/2018 1:30:00 PM SHSS 3/26/2018 1:30:00 PM |
SB 193 |
| SB 193 Fiscal Note DLWD E&TS.pdf |
SHSS 3/12/2018 1:30:00 PM SHSS 3/26/2018 1:30:00 PM |
SB 193 |
| Support Letter for SB 193.pdf |
SHSS 3/12/2018 1:30:00 PM SHSS 3/26/2018 1:30:00 PM |
SB 193 |
| SB 193 Support M Coons.pdf |
SHSS 3/12/2018 1:30:00 PM SHSS 3/26/2018 1:30:00 PM |
SB 193 |
| SB 193 Medicaid Work Requirement Testimony - Americans for Prosperity.docx |
SHSS 3/12/2018 1:30:00 PM |
SB 193 |