ALASKA STATE LEGISLATURE  HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE  February 25, 2020 3:20 p.m.   MEMBERS PRESENT Representative Tiffany Zulkosky, Chair Representative Ivy Spohnholz, Vice Chair Representative Matt Claman Representative Harriet Drummond Representative Geran Tarr Representative Sharon Jackson Representative Lance Pruitt MEMBERS ABSENT  All members present COMMITTEE CALENDAR  PRESENTATION: ALASKA HEALTH CARE: A CHANGING LANDSCAPE - HEARD PRESENTATION: BETHEL COALITION ON HOUSING & HOMELESSNESS - HEARD PREVIOUS COMMITTEE ACTION  No previous action to record WITNESS REGISTER JARED KOSIN, President and CEO Alaska State Hospital and Nursing Home Association (ASHNHA) Juneau, Alaska POSITION STATEMENT: Presented a PowerPoint titled "Alaska Health Care: A Changing Landscape." EILEEN ARNOLD, Executive Director Tundra Women's Coalition Bethel, Alaska POSITION STATEMENT: Presented a PowerPoint titled "Bethel Coalition on Housing & Homelessness." JON COCHRANE, President Board of Directors Bethel Winter House Bethel, Alaska POSITION STATEMENT: Testified during a presentation by the Bethel Coalition on Housing & Homelessness. MICHELLE DEWITT, Executive Director Bethel Community Services Foundation Bethel, Alaska POSITION STATEMENT: Testified during a presentation by the Bethel Coalition on Housing & Homelessness. ARIEL HERMAN, Project Analyst Bethel Housing and Homelessness Coalition Wasilla, Alaska POSITION STATEMENT: Testified during a presentation by the Bethel Coalition on Housing & Homelessness. ACTION NARRATIVE 3:20:10 PM CHAIR TIFFANY ZULKOSKY called the House Health and Social Services Standing Committee meeting to order at 3:20 p.m. Representatives Zulkosky, Spohnholz, Jackson, Tarr, Claman, and Drummond were present at the call to order. Representative Pruitt arrived as the meeting was in progress. ^Presentation: Alaska Health Care: A Changing Landscape Presentation: Alaska Health Care: A Changing Landscape    3:20:48 PM CHAIR ZULKOSKY announced that the first order of business would be a presentation titled "Alaska Health Care: A Changing Landscape." 3:21:23 PM JARED KOSIN, President and CEO, Alaska State Hospital and Nursing Home Association (ASHNHA), presented a PowerPoint titled "Alaska Health Care: A Changing Landscape." To begin, he directed attention to slide 1, "A Changing Landscape," and stated that health care was constantly changing. 3:22:39 PM MR. KOSIN paraphrased slide 2, "Why Health Care?" which read: Hospitals and nursing homes contribute $4.5 billion to Alaska's economy ? 9% of Southeast's regional workforce ? 24% wage growth over past 3 years ? $569 million in economic impact to Southeast AK MR. KOSIN stated that health care was economically relevant, and he moved on to slide 3, "What is Changing?" He emphasized that cost of care was very high, and it was possible to forecast the demand by looking at the national level, the state level, and the local level. He stated that health care was moving toward an ambulatory setting whenever possible, at a lower cost, and in a way that was far more accessible. He directed attention to Medicare, stating that it was "a huge driver of health care policy in the country, as it should be." He reported that Medicare had put forward new rules for total knee replacements, which had historically been in-patient procedures for surgery and recovery but would now fundamentally shift to presume that these were out-patient procedures. He declared that all medical professional groups believed that the cost of care was too high, a challenge that needed to be solved. He reported that Medicaid funding was a constant dialogue. He pointed out that transparency laws were happening everywhere, and he acknowledged the difficulty for understanding an "explanation of benefits" and the cost of care. He reiterated that the demand was for care in an ambulatory setting, at a lower cost, and that it be made far more accessible to the consumer. 3:27:17 PM MR. KOSIN turned to slide 4, "What Does Change Look Like in AK?" He declared that there are capacity challenges in Alaska which will change the reflection of the national changes. He reported that Alaska averages two hospital beds per one thousand people, and that only eight other states have a lower ratio for acute care beds. He noted that, however, many of those other states had robust community systems in place to provide a viable alternative for hospital care, and that Alaska did not have this alternative. He added that 21 percent of the beds were not accessible from the road system, another challenge unique to Alaska. He reported that Alaska had the fewest long-term care beds, regardless of per capita or facility size, in the United States. He emphasized that this was a major problem. REPRESENTATIVE TARR asked if the 19 long-term care facilities were only taking elderly patients, and what would be the optimum number to address the unmet need. She asked if these were state- or privately-run facilities. MR. KOSIN replied that, as these were traditional skilled nursing care facilities, it was necessary to meet the criteria for this care and that age was not a factor. He acknowledged that the Alaska Psychiatric Institute (API) was not reflected on the slide. He reported that Alaska was "by far and away lower than anywhere else in the country" for acute care beds for behavioral health; the API-type beds that existed in Fairbanks, in Anchorage, in Juneau, and in the Matanuska-Susitna (Mat-Su). He described that these beds came with very specific behavioral health services, including psychiatry, within a secure environment. He declared that the lack of the API beds was "a true crisis." 3:31:23 PM MR. KOSIN shared, on slides 5 and 6, "What Does Change Look Like in AK," a graph which depicted a continuum of care. He stated that it was desired to have robust community services because that was the cheapest place to receive health care. Using behavioral health as an example, he declared that the best investment in community care was to have counselors, peer-to- peer support, supported housing, and other support services. If those services were not available, a person would go to the primary or specialty care doctor. If there was a crisis, a person would go to the emergency department. He described this as an efficient access to higher levels of care, as necessary. He asked the question, "the real story is how do you get down from that," offering as an example the discharge from a hospital to an assisted living care facility, which was a lot cheaper; however, as Alaska did not have that capacity for assisted living care facilities, a bottleneck was created and there was not an efficiency to flow within this continuum of care. He shared examples of patient difficulties for discharge from hospitals, as there was not long-term care available. He pointed out that if a patient did not meet the criteria for care in the hospital but was forced to stay in the hospital as there was not a facility to which to release them, the hospital would not be paid, or would be severely underfunded, for continuing the patient's care while waiting. System inefficiencies drive and trap patients' care at the highest cost point. He emphasized that significant capacity challenges had to be factored in when addressing the cost of health care in Alaska. 3:37:26 PM MR. KOSIN moved on to paraphrase slide 7, "What to Focus On," which read [original punctuation provided]: Understand our Situation ? Capacity is Fragile; Don't Undermine Support Innovation ? Nuka System of Care ? Crisis Intervention ? Coordinated Care Look at the Data ? 73% of Medicaid spend is from those with chronic conditions ? Approx ? of the population drives ? of spend MR. KOSIN declared that it was necessary to focus on innovation, directing attention to the tribal health care system, which he described as "years ahead in many respects of the work we see in other aspects of the health care system." He pointed to the coordination and the ability to transfer with a tertiary landing spot. He referenced the Nuka System of Care, which has received national awards for redesigning health care delivery to focus on the patient and their needs. He spoke about a program at Bartlett Hospital in Juneau which was taking its crisis intervention program out to deliver care on the street before it came into the hospital. He declared there was real progress demonstrated for major cost savings when care was coordinated, especially with avoided visits to the emergency room. He concluded, stating that patients with chronic conditions were about 25 percent of the Medicaid population, but accounted for 73 percent of the costs. He shared that ASHNA was working toward specific solutions and "trying things new" with different approaches. He declared it was necessary to focus on treating people more efficiently and effectively in the right environment. REPRESENTATIVE DRUMMOND inquired as to what the problem was with Medicare. MR. KOSIN replied that the problem was capacity. He pointed to the states with acute care bed capacity, noting they had robust health systems with greater access to care. He reported that, although Medicaid paid, on average, 26 percent higher than Medicare in Alaska, this was very nuanced; not true for all Medicaid services, as many costs had been ratcheted down. He stated that the cost of recruiting specialties, the cost of employing people, the access challenges for Rural Alaska, and the small population pockets were all challenges which did not exist in the Lower 48 and made the Medicare rate not very attractive in Alaska. REPRESENTATIVE DRUMMOND shared 65 percent of the mental health treatment and medication was provided within the prison population in Alaska, about 5,000 inmates. She asked if ASHNA was aware of that in relation to the mental health services in the state. MR. KOSIN stated that the mental health stories from hospitals indicated that, as there was no community avenue for people, they ended up in hospitals and prisons. He declared that this was not good care for the patient, not good for the providers, and very expensive. He pointed out that hospitals and nursing homes stood united with the community behavioral health providers. He stated that building in-patient beds and increasing capacity would still fail because there were not the services at the community level resulting in readmissions. He labeled this as "a crisis in the truest sense, and ... an expensive one, too." CHAIR ZULKOSKY shared a conversation regarding the mental health crisis for capacity, meeting needs for mental and behavioral health, and substance use treatment across the state. 3:47:28 PM REPRESENTATIVE CLAMAN asked about the cost factors for crisis intervention. MR. KOSIN said that he was not able to speak to this. He declared that there was support for investment from hospital systems to add in-patient behavioral health beds, even though 68 - 70 percent of patients with a primary diagnosis of behavioral health were Medicaid patients, a disproportionately high payer mix. He pointed out that, even though Medicaid cuts would have a huge affect on the project's sustainability, there was a large savings from patients not staying in the emergency room for extended periods. He added that this also decreased the return of behavioral health patients to use those resources of the emergency rooms. He stated that ideally, API would "come up to capacity and ideally we would have crisis intervention centers and they would work in tandem and take the pressure off the rest of the system." He declared that it was far cheaper to spend 23 hours in a crisis intervention center than an emergency room. REPRESENTATIVE CLAMAN noted that this seemed like the corrections problems of cost drivers, in that it was best to deal with the problem before the emergency room or upon release from the hospital with better services. MR. KOSIN offered his belief that a most profound health care project in the last five years was when the Alaska Native Medical Center, Providence Alaska Medical Center, and Alaska Regional Hospital all came together and invested in the creation of respite care at the Brother Francis Shelter. He pointed out that this was three competitors investing together for respite care for a safe place to discharge homeless patients and a chance for sustained recovery outside the hospital. He stated that this was cheaper for the hospitals, cheaper for the system, and cheaper for Medicaid, a win for everyone. 3:51:58 PM REPRESENTATIVE SPOHNHOLZ clarified that it was Southcentral Foundation along with Providence Alaska Medical Center and Alaska Regional Hospital which created that demonstration project. She offered her belief that tribal health was successful because the system was integrated, and that, as the funding structure was different, it allowed them to build out the system to meet the needs and to realize cost savings with the investments. She referenced a managed care demonstration project in Alaska that was recently pulled back and said that there had been many opportunities in health care reform. She asked what he would do to drive the system redesign without integrated care. MR. KOSIN suggested funding individual "cluster" projects before working on shared savings to make it sustainable. 3:56:06 PM REPRESENTATIVE SPOHNHOLZ shared some models that split savings between the state and the community, which were then reinvested in social determinants of health, and asked whether ASHNA was interested in exploring similar projects. MR. KOSIN stated that his success had come, not from home run projects, but from singles that have added up over time and make the difference. He allowed that an ASHNHA member who wanted to work on a project would be supported by the organization. He pointed out that it was necessary to do some modest funding up front, and that small projects could more easily demonstrate a return on investment, often in the second year. 3:58:19 PM The committee took a brief at-ease. ^Presentation: Bethel Coalition on Housing & Homelessness Presentation: Bethel Coalition on Housing & Homelessness    3:59:42 PM CHAIR ZULKOSKY announced that the final order of business would be a presentation by the Bethel Coalition on Housing & Homelessness. 4:01:05 PM EILEEN ARNOLD, Executive Director, Tundra Women's Coalition, directed attention to the PowerPoint presentation titled "Bethel Coalition on Housing & Homelessness." She shared that the Bethel Coalition on Housing & Homelessness had started in 2017, through a funding requirement from Tundra Women's Coalition under its basic homelessness assistance program. She shared that there were many partners involved with different aspects of homelessness and food security who were eager to do work in a more comprehensive, less "siloed" way. She reported that since the inception, the goals and the data collection had increased and there was "a lot of momentum right now." 4:02:31 PM JON COCHRANE, President, Board of Directors, Bethel Winter House, paraphrased from slides 2 - 3, "Common Terminology," which read: Balance-of-State: All areas of Alaska EXCEPT for Anchorage HMIS: Homeless Management Information System, a U.S. Department of Housing and Urban Development (HUD)- required database; participation is mandatory for HUD homeless funding recipients Alaska Coalition on Housing & Homelessness: the statewide Coalition for all areas of Alaska EXCEPT Anchorage (the Anchorage Coalition is known as the Anchorage Coalition to End Homelessness). The Alaska Coalition is in Juneau and staffed by one full-time and one part-time person. Project Homeless Connect: an event held to provide services to homeless individuals in a community Point-in-Time: An effort to count all people experiencing homelessness on one day in a community; typically, this count is conducted across the nation on one day in January Coordinated Entry: coordinated entry system which provides a process for conducting comprehensive entries of housing and services needs for individuals and families. Continuum of Care: HUD designed the Continuum of Care (CoC) Program to promote community-wide commitment to the goal of ending homelessness; provide funding for efforts by nonprofit providers, and State and local governments to quickly rehouse homeless individuals and families. Continuum of Care is both funding and a coordinated community or regional approach. In Alaska, Anchorage is one CoC and the rest of the state is the Balance-of-State CoC (determined by HUD). MS. ARNOLD stated that, as time was limited, much of the information was included in the PowerPoint slides. 4:03:30 PM MICHELLE DEWITT, Executive Director, Bethel Community Services Foundation, stated that when the group formed, there were three goals: the seasonal homeless shelter would be an all-year shelter; explore Housing First; and address youth homelessness. She said that the goals had grown and multiplied, as there was permanent support of Housing First which had grown into a lot of data collection in order to know who was homeless in the community and what services they utilized. She added that youth homelessness had recently grown. She reported that there was now a memorandum of understanding and a strategic plan. MS. DEWITT paraphrased slide 6, "Bethel Coalition Accomplishments, 2017 2019," which read: Project Homeless Connect and Point-In-Time Counts & Reports Data: Introduction of questions relevant to Bethel's population and service development & first-ever creation of a Bethel by-name list Housing First Research and Site Visit Trips HMIS participation- Winter House and PHC; data-sharing agreements completed with four organizations MS. DEWITT reported that the safety net for homelessness in Bethel was "extremely thin" with an insignificant investment from the State of Alaska. She declared that the incoming funds were "used extraordinarily well." She offered two examples of funding and paraphrased slide 7, "Current Homeless Funding," which read: Tundra Women's Coalition: AHFC HAP Funds: $52,609.85 Bethel Winter House Shelter: DHSS CIMG Funds $30,686 AVCP Regional Housing Authority: HUD VASH ONC: NAHASDA through IHBG. NO Continuum of Care funds are entering the YK Delta region MS. DEWITT mentioned that there was some federal funding to address homelessness, which was implemented through the Regional Housing Authority. She pointed out that there was not any CoC funding, which came through HUD with an Alaska Housing Finance Corporation (AHFC) match to address homelessness at various levels. 4:07:44 PM MS. DEWITT paraphrased slide 8, "Current HUD Continuum of Care Funding in Alaska, which read: The Last Round of HUD funding across the US for Continuum of Care was more than $2 Billion. Alaska's share, however, was only $4,688,499 across 30 projects. $3,829,763 was awarded to 15 Anchorage-based projects $858,736 was awarded to the Balance of State for 11 projects NO Continuum of Care funding is currently being awarded in the YK Delta. 4:08:41 PM REPRESENTATIVE TARR asked that the homeless situation in Bethel be placed in context. MR. COCHRANE shared that the Bethel Winter House had been started six years prior because there had been several exposure- related deaths that winter. Even though no one had thought about a shelter, a group from the community was formed to start one. He shared that there were two main types of homelessness in Bethel, about 50 percent of the guests at Bethel Winter House were chronically homeless, and the other 50 percent of guests were situationally homeless. MS. ARNOLD added that the Winter House was a seasonal homeless shelter, noting that the guests could not be prioritized. 4:10:33 PM REPRESENTATIVE JACKSON asked about the number of homeless. MS. DeWITT offered her belief that there were between 60 - 100 homeless in the hub community of Bethel at any given time. MS. ARNOLD added that agencies in Bethel were often regional providers, and, as there was not any data collected in the village communities, it could be difficult to ascertain numbers. REPRESENTATIVE JACKSON asked if the coalition was solely for Bethel or included the surrounding villages. MS. DEWITT stated that the coalition had regional impact, although they were not trying to provide a regional solution. She pointed out that the concentration of data was primarily Bethel even as there were ripple-effect impacts. She reported that they would try to share the results of the information, as there had been a lot of myths about people experiencing homelessness. She pointed out that the coalition had not fully understood the experiences of those homeless until they had asked "some very targeted questions." 4:13:19 PM ARIEL HERMAN, Project Analyst, Bethel Housing and Homelessness Coalition, presented slide 10, "Completed Data Collections," which read: Winter House 2018-2019 basic data ? January 2019 Project Homeless Connect ? Annual Point-in-Time Count ? Anonymous surveys ? October 2019 Project Homeless Connect ? New, non-anonymous surveys ? Now tracking who is homeless (not just how many) in order to better understand their needs and how this group changes ? Reports available for each collection ? Additionally, annual data available from Tundra Women's Coalition (TWC), Bethel's only year-round shelter (DV/SA) MS. HERMAN shared slide 11, "On-Going Data Collections," which read: ? Quarterly Project Homeless Connect ? Annual Point-in-Time Count done in January 2020 ? Non-anonymous surveys ? Next event April 15, 2020 (Winter House's last week for the season) Winter House 2019-2020 season ? New intake paperwork and service tracking ? Reports will be created and shared 4:15:20 PM MS. ARNOLD stated that the TWC had been in existence for more than 40 years, adding that, in 2009, a new shelter which increased capacity to 33 beds had been built, with a recent subsequent increase to 43 beds. She moved on to slide 12, "Tundra Women's Coalition Fiscal Year 2018-2019 Data," and reported that the TWC had provided shelter for 317 unduplicated people, which included 137 children. She declared that this was for almost 11,000 shelter nights, of which more than 5,000 were children's shelter nights. 4:16:11 PM MS. HERMAN declared that slide 13, "Winter House 2018-2019 Data," reflected the data from last year. She reported that Winter House was open for four months, with 216 individuals and 181 overnight guests served. She pointed out that, although Winter House could not serve children, and was not open during the day, its numbers had increased from the previous year. She moved on to slide 14, "Winter House 2018 2019 Data: Census," and reported that the average number per night was 17 guests, the highest census night was 32 guests for dinner and overnight, and 64 percent of the nights had 1 - 19 guests. She added that more than 20 guests were served on 25 percent of the nights. CHAIR ZULKOSKY asked to put these figures into context for a population sized similar to Bethel. MS. DEWITT replied that the population of Bethel was a bit more than 6,000 people. MS. HERMAN shared that 200 distinct people over the season were served at Winter House, noting that it was "pretty shocking" that there were that many people who came. She addressed slide 15, "Winter House 2018 2019 Data: Time of Year," which read: Averages are slightly higher in December, but fairly steady throughout the season, including the night with the most people (overnights and dinner-only combined) being towards the end of March. MS. HERMAN shared slide 16, "Winter House 2018-2019 Data: Weather," which read: Temperature does not explain the fluctuation in the number of guests each night. One of the warmest days was also one of the highest census days (March 24). The week in December when every night had over 20 overnight guests had an average minimum temperature of -8 degrees. This indicates there may be a need for a shelter beyond just the winter. Even though it is more dangerous to be homeless in the winter due to weather, the need for shelter/housing is demonstrated beyond nights with dangerously cold temperatures. MS. HERMAN shared slide 17, "Winter House 2018-2019 Data: Guests' Overnights," and explained that, as 35 percent of the overnight guests only stayed one night during the entire season, there was data for two major groups of people. She stated that about 70 percent of the guests stayed less than a week, while 12 percent stayed at least one month, though not necessarily consecutively. 4:19:39 PM REPRESENTATIVE TARR asked if the individuals who stayed had to pack up and move out during the day before returning that night. MR. COCHRANE, in response to Representative Tarr, acknowledged this and added that, as they only had this space in a church from 9 p.m. until 7 a.m., there was no means for storage. He directed attention to slide 18, "Winter House 2018-2019 Data: Costs," and reported that, while it cost about $80,000 to run the shelter, the state funding was only for about $36,000. He noted that they applied for various grants and appealed to various companies to raise the balance of funding. He pointed to the costs for service. He emphasized [Winter House] was a "band-aid," a mat on the floor, two hot meals, and then back on the street. He added: "We're not a solution to the problem at all, but we are keeping people alive and we're looking to take that next step." 4:21:20 PM MS. DEWITT shared that the component of data was very important because there was sort of a belief in Rural Alaska there was not homelessness and this data was "compelling;" and proved there are in fact unsheltered people who rely on Winter House and TWC. She declared that it was critical to understand length of time and the conditions experienced by the most vulnerable people, in order to design the appropriate approaches to provide services and interventions. MR. COCHRANE shared slide 19, "Winter House 2018-2019 Data: Cost Analysis, which read: 7 guests (3%) accounted for 25% of total costs and 25% of all shelter nights MR. COCHRANE added that these people needed permanent supportive housing, and, although Winter House was keeping them alive during the winter, there was nothing being done to fix the problem. He pointed out that these guests were often in the emergency room, the police station, or in the back of an ambulance, all of which cost the state far more money. 4:22:40 PM REPRESENTATIVE TARR asked if extra services would help those individuals. MS. HERMAN explained that a simple analysis revealed the cost per night to stay at Winter House, and that 3 percent of the guests accounted for 25 percent of the costs and services. REPRESENTATIVE DRUMMOND shared a comparison to the Anchorage costs and pointed out that Housing First was a much cheaper way to help with housing. She acknowledged the value of the data. MS. HERMAN pointed out there was a deeper need for what was currently available. She opined that permanent supportive housing would meet the needs of the high-utilizing guests while the need for Winter House continued for many others. REPRESENTATIVE DRUMMOND asked about the nightly capacity at Winter House. MR. COCHRANE replied, "about 45." 4:25:00 PM MS. HERMAN addressed slide 20, "January 2019 Project Homeless Connect Survey Results," which had observed that 58 adults were identified as possibly or definitely homeless. She added that more than half of those surveyed had stayed at Winter House the previous night. She pointed out that the other half may have stayed in vehicles, with friends, or in abandoned buildings. MS. HERMAN moved on to slide 21, "October 2019 Project Homeless Connect Survey Results," which asked more in-depth questions, was not anonymous, and allowed for an understanding of the needs to specific individuals over time. She pointed out that, although the number of possible homeless was lower than the January survey, it was nicer in October and Winter House had not yet opened for the season. She added that fewer women were staying at TWC in October. MS. HERMAN shared slide 22, "October 2019 Survey Results Continued: Demographics," and pointed to the wide range of ages, from 21 - 78 years, and the relatively even gender split. MS. HERMAN directed attention to slide 23, "October 2019 Survey Results Continued: Disabling Conditions," which included alcohol and drug use, physical, developmental, and mental health disabilities, as well as chronic health conditions. She reported that 69 percent of those surveyed reported having at least one disabling condition, with an average of two conditions per person. She emphasized that, for those people who reported a condition, about half stated that it prevented them from having stable housing and employment. She pointed out that these people had specific barriers that had kept them from housing and these barriers needed to be addressed in addition to supplying a roof over their heads. MS. HERMAN directed attention to slide 24, "October 2019 Survey Results Continued: Overnight Location," which included the question "where did you sleep the night before?" She pointed out that Winter House was not yet open during the survey period. About one-third of the people stayed with family or friends, and about one-quarter were staying at TWC. She declared that 17 percent stayed in a vehicle. She said 97 percent of the individuals had stayed on the streets or in a shelter at some point in their life. MS. HERMAN moved on to discuss slide 25, "October 2019 Survey Results Continued: Length of time in Current Situation," and reported that the median for time in the current situation was about 90 days, and that 51 percent of the people had been on the streets or in an emergency shelter for more than 12 months in the past 3 years, often defined as chronic homelessness. She noted that half of the group were dealing with a chronic issue, and the other half "may be dealing with something, hopefully, less chronic, which indicates we need solutions for both." She suggested a shorter-term safety net, such as Winter House, as well as a longer-term solution for those in chronic situations. REPRESENTATIVE TARR asked if there was more information on the situations regarding the one-night-or-less group. MR. COCHRANE replied that she would review the data. MS. HERMAN explained that this data did not mean that prior to this the individuals had not been without a place to live. She explained that this was a distinction for only the previous night. MS. DEWITT added that this was a HUD-required question. 4:31:26 PM MS. HERMAN introduced slide 26, "October 2019 Survey Results Continued: Housing Instability," detailing the federal definitions of homelessness, which included emergency shelter and places not meant for human habitation, such as abandoned buildings and vehicles. She pointed out that for many individuals the definition of homelessness included couch surfing and staying with friends and family, situations that were not stable and were only temporary. She declared the need for a broader understanding of homelessness in the Bethel community and pointed to housing instability as a definition to encompass other situations beyond the federal definition. She reported that the average for housing instability in the Bethel community was 5.7 years even as the range covered almost 50 years and the median was almost 2 years. She directed attention to the bar graph on the slide, which reflected that 29 percent had housing instability for less than one year, while almost half the group had housing instability for one to three years, and more than 25 percent had been in this situation for more than four years. She emphasized that it was necessary to find tailored solutions for the community based on these experiences and needs. CHAIR ZULKOSKY asked if there had been any benchmarking of this data alongside other rural communities in Alaska, larger cities, or smaller communities. 4:34:41 PM MS. DEWITT replied that some of the urban communities had done a lot of work with data, resulting in reports centered on Housing First-based solutions. She referenced a conference on housing and homelessness in municipalities and noted that most attendees were rural Alaskans. She reported that no other communities were working with data like the project in Bethel. She offered her belief that this data was "fairly unique in rural" and pointed out that she was cautious in any comparisons to urban centers as she was not certain that this would be a comparison of "apples and apples." CHAIR ZULKOSKY asked about the funding for the data collection. MS. DEWITT reported that the local community foundation funded all the data collection efforts. MR. COCHRANE explained that the data was almost ten years old and had come from the previous census. He pointed out that overcrowding was defined as more than 1.5 people per room in a house, which included bathrooms and kitchens. He reported that the lowest overcrowding in Alaska was in Southeast Alaska and it was still above the national average of 3 or 4 percent, while the Bethel region was over 40 percent in the last census. He stated that this was not even defined as homelessness. MS. DEWITT shared that the following slides dealt with myths about Rural Alaska homelessness. 4:37:06 PM MS. HERMAN shared slide 27, "October 2019 Survey Results Continued: Where people are from and where they have been for the past year." She reported that 77 percent of the people were from villages around Bethel, while 17 percent were from Bethel. She added that 86 percent of those surveyed had been in Bethel for the previous year, displacing the myth of people recently being stuck in Bethel and wanting to go back to their villages or to Anchorage. MS. HERMAN directed attention to slide 28 "October 2019 Survey Results Continued: Type of Assistance Wanted," which asked whether the participant just needed to get back to where they had a permanent place to live or if they needed a permanent place to live. She reported that 80 percent of the participants stated that they wanted a permanent place to live. MS. HERMAN moved on to slide 29, "October 2019 Survey Results Continued: Where people want to Be(thel)," pointing out that the options were for Bethel, Anchorage, or a Yukon-Kuskokwim village. She reported that 71 percent stated they wanted a permanent place to live in Bethel. When an option was offered to include both Bethel or someplace else, the number increased to almost 90 percent. She declared that it was necessary to arrive at local solutions. 4:39:37 PM MS. DEWITT moved on to slide 30, "Bethel Coalition Needs are Statewide Needs." She stressed that Bethel needs were statewide needs, including investments in the Homeless Assistance Program, the Special Needs Housing Grant program, and the Community Initiative Matching Grants programs. MS. DEWITT shared slide 31, "Bethel Coalition Needs," and reported that recent legislation, HB 206, had increased Homeless Assistance Program funding to $8.15 million, and increased the Special Needs Housing Grant program to $3.7 million. She declared support for these investments, even as there was not a guarantee that the local Bethel groups would receive any of this competitive funding. She pointed out that each of the four presenters had other full-time jobs, and that there was not any one person strategically working on homelessness in the region or the community. She stated the need for a permanent year- round emergency homeless shelter with permanent staffing, as well as an approach to permanent housing, such as Housing First. She declared that there was also a focus on youth specific homeless projects. MR. COCHRANE pointed out that although the Homeless Assistance Program funding had been restored to 2009 levels, that was flat funding for 12 years, which was a net decrease and did not address inflation or the increases in costs. 4:43:07 PM REPRESENTATIVE TARR relayed that lack of housing was always an issue and asked if additional capacity would help. MS. DEWITT declared that affordable housing, as well as housing stock, was a major issue in Alaska and that there was a population that would be substantially helped by affordable housing. She pointed out that for voucher-based services, it was necessary to have available housing stock, reporting that the Bethel area had "close to a zero percent vacancy rate." MR. COCHRANE shared that there was no affordable housing available, and he pointed out that there was a myth that all the homeless were unemployed. MS. DEWITT, in response to Representative Drummond, explained that HAP funds were the Homeless Assistance Program funds and helped with first month's rent, utilities, and deposits in private market rentals. She pointed out that one of the most affordable avenues was in the prevention of evictions. REPRESENTATIVE CLAMAN said that the data was "incredibly illuminating." 4:48:44 PM ADJOURNMENT  There being no further business before the committee, the House Health and Social Services Standing Committee meeting was adjourned at 4:48 p.m.