Legislature(2023 - 2024)ADAMS 519
04/12/2023 01:30 PM House FINANCE
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| Audio | Topic |
|---|---|
| Start | |
| HB58 | |
| HB59 | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| + | HB 58 | TELECONFERENCED | |
| + | HB 59 | TELECONFERENCED | |
| + | TELECONFERENCED |
HOUSE BILL NO. 59
"An Act relating to Medicaid eligibility; expanding
eligibility for postpartum mothers; conditioning the
expansion of eligibility on approval by the United
States Department of Health and Human Services; and
providing for an effective date."
2:09:32 PM
EMILY RICCI, DEPUTY COMMISSIONER, DEPARTMENT OF HEALTH,
introduced herself and appreciated the committee hearing
the bill.
DR. ANNE ZINK, CHIEF MEDICAL OFFICER, DEPARTMENT OF HEALTH
(via teleconference), introduced herself and provided a
PowerPoint presentation titled "State of Alaska Department
of Health: HB 59: Postpartum Medicaid Extension," dated
April 4, 2023 (copy on file). She began on slide 3 titled
What is Postpartum Medicaid Extension?
HB 59 extends postpartum Medicaid coverage for new
mothers from 60 days to 12 months as postpartum health
issues occur far beyond 60 days.
HB 59 supports growing families and will improve
Alaskan maternal and child health, setting the stage
for a healthier future.
Simplified Medicaid pregnancy coverage reduces
bureaucracy and stress to a young families' life.
Saves health care dollars in the long run because
early interventions have the best return on investment
and focuses on prevention.
2:12:13 PM
Dr. Zink elaborated that the coverage period was increased
through the American Rescue Plan Act (ARPA) and
subsequently the 12 month extension was offered to states
that chose to continue with the program. She noted that 10
states had completely implemented the program and 31 states
plus the District of Columbia had begun the extension
process.
2:12:40 PM
Dr. Zink turned to slides 4 and 5 titled "What are the
Stakes?" She informed the committee that the United States
(US) was the only developed country where maternal
mortality rates were worsening. She pointed to the bar
chart on slide 4 that depicted Maternal Mortality Ratios
per 100,000 live births in selected countries that showed
the US rated significantly higher than other countries. She
highlighted slide 5:
What Are the Stakes?
Pregnancy-related deaths occur well beyond the
60-day postpartum period.
29% of pregnancy-related deaths in the U.S. not
including those caused by accidents, homicides,
and suicides occur 43 to 365 days postpartum.
For every pregnancy-related death, there are 70
to 80 cases of severe maternal illness and
morbidity in the postpartum period.
Medicaid-enrolled women are especially vulnerable
to pregnancy-related death as they are more
likely to experience chronic conditions, pre-term
or low-weight births, and severe maternal
morbidity.
2:13:38 PM
Dr. Zink elucidated that postpartum could not be diagnosed
for at least 6-weeks after birth. She addressed slide 6
titled "Pregnancy-Associated Deaths in Alaska:"
In 2021, Alaska's overall pregnancy-associated death
rate exceeded the previous 5-year average by 109
percent.
Among deaths in 2015-2019: 73% occurred >6 weeks post-
delivery.
Among deaths reviewed by Alaska's Maternal and Child
Death Review (MCDR) committee during 2016-2022, 88%
were potentially preventable, and 44%were associated
with barriers to health care access.
Dr. Zink pointed to the bar graph on the left of the slide
and furthered that there was a significantly faster
increase in morbidity and mortality rates in rural areas
(233 deaths per 100,000 live births) compared to urban
areas (110 deaths per 100,000 live births).
Ms. Ricci addressed slide 7 titled What Can Alaska Do
About It?
Section 9812 of the American Rescue Plan Act (ARPA)
added the time-limited option for allowing states to
extend postpartum coverage from the required 60 days
to 12 months for eligible beneficiaries through March
1, 2027.
The Consolidated Appropriations Act of 2023 (CAA-2023)
revised ARPA to make the optional coverage extension
permanent.
Ms. Ricci discussed that typically there was nothing easy
or simple about the Medicaid program or about making
changes to the program. However, the federal government
devised the easiest method to allow states to participate
in this type of extension, which was a new approach for
Medicaid. Ms. Ricci turned to slide 8 titled "Why a Bill?"
The Legislature must approve all optional groups for
Medicaid coverage in statute AS 47.07.020.
Women who are eligible for Medicaid in Alaska based on
their pregnancy currently only receive coverage for 60
days postpartum.
In Alaska, 51% of births are covered by Medicaid.
Ms. Ricci indicated that at 51 percent of Medicaid coverage
for births it was critically important to scrutinize the
states postpartum coverage.
2:16:27 PM
Dr. Zink turned to slide 9 titled Benefits to Alaskans:
Improves maternal health outcomes:
Prevents gaps in health care coverage and improves
health care access.
Improves maternal mental health:
Mental health conditions contributed to 31% of
pregnancy-associated deaths in Alaska between 2014 and
2018.
14% of Alaskan mothers who had a baby in 2020 had
symptoms of postpartum depression.
Addresses disparities in maternal health outcomes:
Medicaid plays a vital role in addressing disparities
in maternal mortality and morbidity rates.
Postpartum period is an especially vulnerable time for
parents recovering from substance use disorders.
Extending postpartum coverage increases access to
screening and education about chronic diseases such as
diabetes and high blood pressure.
Dr. Zink provided a real life example. She recounted that a
patient had struggled with severe depression and while
pregnant she was treated for depression and alcoholism,
which she had medicated herself with but with help was
doing well. Subsequently, she lost her Medicaid coverage
60-day postpartum. She lost access to treatment and started
to drink again during that time. She appeared at the
Emergency Room (ER), and they had been able to reenroll her
in the Medicaid program. She returned to the ER sometime
later for her son and she was doing well and not drinking
and her son also benefited. She stated that the benefits to
Alaskans were multifactorial.
Dr. Zink moved to slide 10 titled Benefits to Alaskans:
Improves child health outcomes:
Parental enrollment in Medicaid is associated with a
29% higher probability that a child will receive
an annual well-child visit.
Maternal mental health matters not only because of
maternal mortality; it is intimately tied to the
health and development of the child.
Maternal depression can lead to negative outcomes in
children including delayed cognition and social-
emotional/behavioral development.
2:19:09 PM
Dr. Zink addressed slide 11titled Cost Savings:
The Congressional Budget Office (CBO) estimates that
by 2024, about a quarter of postpartum beneficiaries
will live in states that elect the new option and that
extended Medicaid coverage will result in almost $6.1
billion in federal spending over the first ten years
and expected to grow over time.
The CBO estimates that not only are their federal and
state cost savings, but this will decrease ACA subsidy
cost for private insurance.
Savings from averted severe maternal morbidity:
Medicaid-enrolled pregnant women with severe maternal
morbidity cost an average of $10,134 annually compared
to $6,894 for those without.
Savings from prevention: Preventing gaps in coverage
ensures access to primary and preventive care,
including management of chronic conditions and
screening for mental health conditions, substance use,
and intimate partner violence.
Dr. Zink indicated that the CBO estimated how much
potential savings could result through the extension versus
how much it cost. The fiscal notes did not take
preventative costs into account and only estimated the cost
of 10 months of additional coverage. The slide listed some
of the savings that were identified. She noted that good
prenatal and postpartum care decreased costs in all sectors
of healthcare.
2:20:49 PM
Dr. Zink discussed slide 12 titled "Mental Health:"
Drug/alcohol use or substance use disorders were
documented in 72% of Alaskan pregnancy-associated
deaths reviewed by the MCDR Committee during 2016-
2022.
Increasing access to screening and treatment for
substance misuse during and after a pregnancy may
reduce costs for the index child as well as subsequent
pregnancies and births.
Alaska Medicaid paid 3.9 times as much per infant for
those affected by Neonatal withdrawal compared to
nonaffected infants.
Dr. Zink pointed to the graphics on top of the slide that
depicted data regarding Perinatal Mood and Anxiety Disorder
(PMAD). She indicated that 1 in 7 pregnant women were
affected by PMAD and roughly half of perinatal women with
depression did not receive needed treatment. An estimated
$14.2 billion was spent for all births in 2017.
2:21:37 PM
Dr. Zink advanced to slide 13 titled "Alaska Supports HB
59." She reported that the slide listed the many
organizations that supported the extension. She moved to 15
titled Healthy Families Initiative:
Strong families are the foundation of a healthy
society and a vibrant economy.
4-year statewide investments in the health and well-
being of Alaskan families.
Governor Dunleavy proposed $9.5M (UGF) in FY 24
operating budget for Healthy Families activities
within DOH:
Postpartum Medicaid extension
Office of Health Savings
TB and congenital syphilis mitigation
Healthy Beginnings
Health Care Access
Healthy Communities
Dr. Zink emphasized that the extension was part of the
governor's Health Families Initiative. She communicated
that there were three strong pillars to the initiative:
Healthy Beginnings, Health Care Access, and Healthy
Communities.
2:22:41 PM
Ms. Ricci provided a sectional analysis (copy on file)
which was also included on slides 17 through 20:
Section 1
Adds a new section (o) to AS 47.07.020, authorizing
the department to implement an extension of postpartum
Medicaid coverage up to the maximum period authorized
under federal law.
Section 2
Amends the uncodified law to add the requirement for
submission of a Medicaid state plan amendment to allow
Medicaid beneficiaries to receive postpartum coverage
for up to 12 months.
Section 3
Amends the uncodified law to establish the requirement
that the commissioner of health notifies the revisor
of statutes within 30 days of federal approval of the
state plan amendment.
Section 4
Establishes that the postpartum extension takes effect
on the day after the date the commissioner notifies
the revisor of statutes as described above.
Co-Chair Foster looked at slide 15 showing the governor
proposed $9.5 million in Undesignated General Funds (UGF)
in the FY 24 budget. He looked at the fiscal note showing
$9 million made up of three items: Postpartum Medicaid
Extension, Office of Health Savings, and Tuberculosis (TB)
and Congenital Syphilis Mitigation. He noted that $6.4
million was comprised of federal funds. He asked if the
postpartum extension actually cost $2.6 million and the
remainder of the $9.5 million was for the other two items.
Ms. Ricci answered that the $9.5 million UGF would be for
the three areas: postpartum extension, congenital syphilis
mitigation, and the Office of Health Savings. She relayed
that the slide was outdated. She detailed that initially
the department hoped to get the work done sooner but the
earliest the initiative could take effect was July 1 of the
following year (2024). The amount had been backed out of
the FY 24 budget and would be included in the FY 25 budget,
which was reflected in the fiscal note, but not on the
slide.
Co-Chair Foster asked for verification the UGF amount was
only for the postpartum extension in FY 2025. Ms. Ricci
answered in the affirmative.
2:26:15 PM
Representative Ortiz cited slide 4 and found the mortality
rates alarming. He wondered why the US was the only
developed country where maternal mortality rates were
worsening. Dr. Zink agreed that the data was very alarming.
She replied that the reasons were multifactorial, but a lot
of the reason had to do with early diagnosis and
prevention, in connection with additional systems of care
compounded with things like drug abuse, mental health
issues, and violence. She shared Alaska data related to
maternal mortality between 2015 and 2019: 7 deaths were due
to suicide, 7 from drug and alcohol overdose, 8 deaths were
related to homicide and assault, 8 were from unintentional
injuries, 9 were pregnancy related medical causes, and 9
were other natural causes. She pointed out that there was a
disproportionate share of injury deaths versus non-injury
deaths. Representative Ortiz understood that the U.S. had
one of the highest infant mortality rates. He asked if his
statement was accurate. Dr. Zink stated it was her
understanding as well, but she deferred to a colleague.
2:28:18 PM
REBEKAH MORISSE, ACTING DIRECTOR, DIVISION OF PUBLIC
HEALTH, DEPARTMENT OF HEALTH (via teleconference), answered
in the affirmative and added that there were higher rates
of infant mortality and pre-term birth. In addition, the US
had higher rates of chronic disease e.g., diabetes's and
obesity, which contributed to poor outcomes.
Co-Chair Johnson referenced slide 4 and wondered if the
statistics were consistent across the country and how they
were generated. She asked if there was a consistency among
mortality. Dr. Zink replied that Alaska had a maternal
mortality review committee to try to understand the causes.
She added that the reasons were both physical as well as
mental conditions, violence, unintentional injury, as well
as suicide and homicide, including pregnancy related and
other medical causes; all were counted. She indicated that
the committee broke the data down on a yearly review and
noted that drug and alcohol and substance use disorder was
documented for 72 percent of the deaths, 71 percent a
history of domestic violence, 44 percent experienced
barriers to health care access, and 88 percent were deemed
to be potentially preventable. She reiterated that the data
was from the Alaska Maternal and Child Death Review
Committee that examined the mortality cases. She detailed
that slide 4 reflected national data comparing US national
statistics versus international statistics based on the
number of deaths per 100,000.
Ms. Morisse did not have anything else to add to Dr. Zincs
answer.
Co-Chair Johnson looked at slide 6 and asked if the chart
showed the maternal mortality rate. Dr. Zink responded in
the affirmative. Co-Chair Johnson was trying to determine
whether there was something hiding in the statistics. She
noted the significant changes between rural and urban
mortality. She asked if it was because of access to
healthcare in rural areas. She believed that the statistics
were startling. She asked for someone to speak to the
statistics. She wanted to determine the causes.
2:33:39 PM
Dr. Zink replied that the statistics were incredibly
alarming, which was one of the reasons there was a review
committee. She delineated that part of the reason for the
legislation, besides the logistically simpler new option,
was that it was a critical time for the state to extend
its postpartum coverage and it ensured women had access to
healthcare the entire first year after birth. Both mother
and child would be covered for the first year. She affirmed
the disproportionate burden in rural Alaska versus urban
Alaska. Physical and mental health services were harder to
access in rural Alaska. There was also a disproportionate
burden on races and ethnicities, therefore maternal
mortality was higher for Alaska Native women. She concluded
that access to healthcare was a major component to the
issue. Co-Chair Johnson asked whether infant mortality
tracked in a similar line with maternal mortality. Ms. Zink
deferred the answer to Ms. Morisse.
Ms. Morisse replied that she did not have the infant
mortality data on hand and would follow up with the
information. She was aware that the pre-term and infant
mortality rates had risen but could not recall specific
data.
Representative Stapp favored the bill and did not believe
it went far enough. He cited AS 07.020 as the statute the
department was amending. He referenced that the Federal
Poverty Limit (FPL) was 175 percent of the poverty line
adjusted for Alaska. He surmised that equated to $15.38 per
hour wage for a single mom. He thought the numbers should
be higher. He had heard it already was higher and he
wondered how that was possible.
Ms. Ricci responded that currently pregnant women were
eligible at 200 percent of the federal poverty level. She
explained that when the 175 percent threshold was
established in statute it was prior to changes that
occurred under the Affordable Care Act (ACA) that took
effect in 2014. The ACA used a different method to
establish income called Modified Adjusted Gross Income
(MAGI) and when translated it became 200 percent of the
federal poverty level supplanting the 175 percent
designated in state statute.
2:38:48 PM
Representative Stapp asked whether Ms. Ricci did not
believe the state needed to amend the state statute to
conform with the federal guidelines. Ms. Ricci answered in
the affirmative. Representative Stapp asked what steps it
would require the department taking if he wanted to amend
the bill to 225 percent of FPL. Ms. Ricci answered it would
require a state plan amendment, regulatory change, and a
CMS 1115 waiver. She added that other states pursued
changes to postpartum coverage outside of the CMS 12-month
extension, which required waivers.
Representative Galvin wondered about the magnitude of the
problem. She referenced Dr. Zink's statistic that 88
percent were deemed to be potentially preventable. She
recounted that 44 percent of deaths was associated with
barriers to healthcare access. She was concerned it would
not be implemented in FY 24. She wondered if the department
had thought about a workaround to address some of the dire
concerns before the FY 25 implementation date. Ms. Ricci
answered that the department was looking at how to initiate
the change earlier in 2024. She was hopeful that it could
be implemented earlier, but the state plan and regulatory
processes could be very time consuming and typically took
from 6 to 9 months. The department was ready to start the
regulatory process immediately after passage of the bill.
2:42:45 PM
Representative Galvin understood that because of
bureaucratic hurdles they would be delaying the opportunity
for a pathway to healthcare access. She wondered how the
legislature could help. She referred to slide 11 that
related to cost savings and pointed to preventing the
deaths and outcomes in children that were critical to
mitigate. She asked the department to let the legislature
know if there were ways it could help overcome the
bureaucratic barriers to helping families.
Representative Hannan cited the data on slides 4 and 6 and
noted there was much more detail from the one-page document
in the bill backup titled "Pregnancy-Associated Mortality
in Alaska" (copy on file). She believed that the fact that
the state had a review committee underscored the need for
mitigation efforts. She applauded the effort to do as much
as possible when faced with the loss of life and impact to
families. She recounted earlier testimony that 41 states
were already taking advantage of the extension and wondered
why it took so long in Alaska. Ms. Ricci replied that
Alaska valued legislative input in many aspects of the
Medicaid program. However, it created bureaucratic
challenges that resulted in a longer process. The positive
part of the involvement was engaging with Alaskans, but it
could go both ways. When an issue was highly complex more
participation was good but was challenging when the changes
should be made quickly. There was a saying that every
state's Medicaid program was unique and structured
differently. She restated that Alaska had a higher level of
involvement that was overall good for the program. She
added that the regulatory time period was one of the longer
aspects to implementing any changes in Medicaid. A robust
review process was at times necessary but challenging when
faced with a non-controversial issue that warranted quick
action. She commented that everyone in the department was
passionate about the bill and shared a sense of urgency
to make positive changes.
Representative Josephson referenced needing legislative
authority to expand an optional program. He understood that
the governor could remove a program without legislative
approval. He asked whether he was correct. Ms. Ricci was
unsure of the answer.
Representative Josephson referred to Representative Stapps
question regarding increasing the FPL and wondered why a
waiver was necessary. Ms. Ricci replied that it was because
it was different than what was offered and asking for
something outside of the new streamlined approach would
need a longer regulatory process and potentially a waiver.
Representative Josephson deduced that there must be an
upper limit to qualifying.
2:50:03 PM
Ms. Ricci answered that she was aware of some states that
had a higher limit for coverage up to 300 percent of the
FPL. She was uncertain what the process with CMS was.
Representative Josephson favored the bill but cited a
statistic regarding intimate partner violence and wondered
how the bill would work regarding prevention. He guessed
that would be a topic for a different bill. Ms. Ricci
replied that one aspect to consider was when an individual
had independence in different ways, they might leave a
violent situation. She believed that having heath coverage
may provide that additional support. She deferred to Dr.
Zink for additional comments.
Dr. Zink replied that the bill was necessary but not
sufficient to address many of the challenges associated
with the postpartum period. She added that there was a lot
of other work happening with DOHs partners to address the
issues. She shared that the research showed that women with
increased access to resources including healthcare were
less likely to remain in an abusive relationship and more
likely to seek help with other issues.
Representative Coulombe had heard that currently women had
the option to renew after 60 days. She asked if she was
correct. Ms. Ricci answered in the affirmative. She
furthered that they had the option to be redetermined to
find out if they were eligible for other types of Medicaid
coverage. The Medicaid could potentially continue through
other categories such as parents with children or Medicaid
expansion, depending on the circumstances but not on the
postpartum care program. However, some women may not
qualify at all. She offered that even aside from whether
the women were eligible for Medicaid or other types of
coverage, dealing with the transition and the level of
paperwork two months after birth could be overwhelming. The
data showed gaps in coverage between the 60 day mark and
continued Medicaid or other types of health insurance
coverage. The legislation helped reduce the gaps in
coverage. She delineated that there had been an association
with children having more well check visits when the mother
had health insurance because she was not always aware that
her child had continued coverage. The extension benefitted
both the mother and child.
2:55:30 PM
Representative Coulombe asked if the baby's coverage
stopped at 60 days. Ms. Ricci answered that the infant's
coverage typically lasted one year and after the time there
was a standard review process for continued eligibility.
Representative Coulombe ascertained that the children were
covered for an entire year and if the mother was also, it
would make the difference in outcomes. Ms. Ricci responded
in the affirmative. She added that aligning the childs and
mothers coverage made it more likely for both parties to
get the coverage they needed. Representative Coulombe
requested references to the data included in the slides.
Ms. Ricci agreed to provide the information.
2:57:15 PM
Representative Tomaszewski thanked the governor for
bringing the information to the legislature's attention. He
asked if there was a location in the department's budget
that the $2.6 million could be decremented to make the
proposal cost neutral. Ms. Ricci replied that the Medicaid
budget was very large, and the department was constantly
seeking ways to save money. However, there was an increased
need due to impacts of inflation, increased costs across
the board, and increased utilization by Medicaid enrollees.
Some people had deferred care during the pandemic and
currently needed more acute care and chronic diseases had
increased. The department believed the fiscal note
associated with the bill would ensure that the department
had sufficient funds to provide the extended coverage.
Representative Tomaszewski remarked that at the same time
they would be reconsidering Medicaid eligibility and he
thought that would result in decreased costs. He suggested
that there was a location in the budget to keep the
proposal cost neutral.
2:59:40 PM
Representative Galvin looked at slide 4 and the 17.4
percent mortality rate in the US. She asked if it was per
100,000 population. Ms. Morisse answered affirmatively.
Representative Galvin cited the data on slide 6 and asked
if the was based on per 100,000 population as well. Ms.
Morisse answered in the affirmative. Representative Galvin
asked her to confirm some of the data on the slide. Ms.
Morisse wanted to reexamine the national data and would
follow up.
Dr. Zink offered to follow up with the information in
writing.
Representative Galvin referenced slide 11 that included
data on cost savings. She guessed that beyond the first
year of the program that would likely increase costs, in
the long run the upstream measures would ultimately save
money. Ms. Ricci agreed with Representative Galvins
statement. She elaborated that savings were anticipated in
the long term but immediately after the expansion
implementation claims would begin to come in and need
payment.
3:03:42 PM
Representative Galvin asked if the department had done any
other research on savings related to children and fewer
costs in future years. Ms. Ricci deferred to Dr. Zink.
Dr. Zink answered she would provide additional information.
Co-Chair Foster thanked the department for the
introduction.
HB 59 was HEARD and HELD in committee for further
consideration.
Co-Chair Foster reviewed the schedule for the following
day.
| Document Name | Date/Time | Subjects |
|---|---|---|
| HB 58 LFD Response to Q Out Year FN Costs 041323.pdf |
HFIN 4/12/2023 1:30:00 PM |
HB 58 |