Legislature(2023 - 2024)BUTROVICH 205
03/19/2024 03:30 PM Senate HEALTH & SOCIAL SERVICES
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| Audio | Topic |
|---|---|
| Start | |
| SB233 | |
| SB241 | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| *+ | SB 233 | TELECONFERENCED | |
| += | SB 241 | TELECONFERENCED | |
| *+ | HB 344 | TELECONFERENCED | |
| + | TELECONFERENCED |
ALASKA STATE LEGISLATURE
SENATE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE
March 19, 2024
3:31 p.m.
MEMBERS PRESENT
Senator David Wilson, Chair
Senator Löki Tobin
Senator Forrest Dunbar
Senator Cathy Giessel
MEMBERS ABSENT
Senator James Kaufman, Vice Chair
COMMITTEE CALENDAR
SENATE BILL NO. 233
"An Act relating to the day care assistance program."
- HEARD & HELD
SENATE BILL NO. 241
"An Act relating to medical assistance demonstration projects
established by the Department of Health."
- HEARD & HELD
PREVIOUS COMMITTEE ACTION
BILL: SB 233
SHORT TITLE: CHILD CARE PROVIDER EDUCATION REQUIREMENT
SPONSOR(s): SENATOR(s) DUNBAR
02/15/24 (S) READ THE FIRST TIME - REFERRALS
02/15/24 (S) HSS
03/19/24 (S) HSS AT 3:30 PM BUTROVICH 205
BILL: SB 241
SHORT TITLE: MEDICAL ASSIST. DEMONSTRATION PROJECTS
SPONSOR(s): RULES BY REQUEST OF THE GOVERNOR
02/19/24 (S) READ THE FIRST TIME - REFERRALS
02/19/24 (S) HSS
03/05/24 (S) HSS AT 3:30 PM BUTROVICH 205
03/05/24 (S) <Bill Hearing Canceled>
03/19/24 (S) HSS AT 3:30 PM BUTROVICH 205
WITNESS REGISTER
RIA SMYKE, Staff
Senator Forrest Dunbar
Alaska State Legislature
Juneau, Alaska
POSITION STATEMENT: Provided the sectional analysis for SB 233.
ROBIN DEMPSEY, CEO
Catholic Social Services
Anchorage, Alaska
POSITION STATEMENT: Invited testimony for SB 233.
BRIGET REYNOLDS, Program Director
Refugee Assistance and Immigration Services
Catholic Social Services
Anchorage, Alaska
POSITION STATEMENT: Invited testimony for SB 233.
ASIA AMINI, Specialist
Refugee Education and Employment Food Services
Refugee Assistance and Immigration Services
Catholic Social Services
Anchorage, Alaska
POSITION STATEMENT: Invited testimony for SB 233.
LORI PICKETT, Executive Director
Alaska Literacy Program
Anchorage, Alaska
POSITION STATEMENT: Testified in support of SB 233.
HILARY PORTER, Deputy Director
Division of Public Assistance
Department of Health
Juneau, Alaska
POSITION STATEMENT: Answered questions on SB 233.
EMILY RICCI, Deputy Commissioner
Department of Health (DOH)
Juneau, Alaska
POSITION STATEMENT: Answered questions on SB 233; Co-presented
SB 241 and offered the sectional analysis.
HEIDI HEDBERG, Commissioner
Department of Health
Anchorage, Alaska
POSITION STATEMENT: Introduced SB 241 on behalf of the
administration.
ANNE ZINK, MD
Chief Medical Officer
Department of Health
Anchorage, Alaska
POSITION STATEMENT: Co-presented SB 241.
ACTION NARRATIVE
3:31:18 PM
CHAIR DAVID WILSON called the Senate Health and Social Services
Standing Committee meeting to order at 3:31p.m. Present at the
call to order were Senators Giessel, Tobin, Dunbar, and Chair
Wilson.
SB 233-CHILD CARE PROVIDER EDUCATION REQUIREMENT
3:32:08 PM
CHAIR WILSON announced the consideration of SENATE BILL NO. 233
"An Act relating to the day care assistance program."
3:32:36 PM
SENATOR FORREST DUNBAR, District J, speaking as the sponsor of
SB 233 stated there is a childcare affordability and access
crisis in Alaska, which is harming the state in a variety of
ways. He noted that if the department addresses the issue
through regulatory change, SB 233 will not need to go through
the legislative process. He paraphrased the following sponsor
statement:
[Original punctuation provided.]
SPONSOR STATEMENT
SB 233: CHILD CARE PROVIDER EDUCATION REQUIREMENT
Senate Bill 233 will allow childcare workers to become
licensed providers in the day care assistance program
without being required to pass a high school
equivalency test or gain a high school diploma. This
will increase childcare availability in Alaska and
provide employment opportunities, particularly for
otherwise qualified refugee and immigrant communities
who are ready to work and contribute in this vital
industry.
Alaska has a lack of childcare services and workers,
which has a profound effect on the state's economy.
New arrivals come to the U.S. with varying
backgrounds. Some must flee at a moment's notice and
don't have time to grab documents, such as diplomas.
New arrivals may have spent decades in a refugee camp
where education is not readily available; others may
be coming from countries that lack educational systems
due to political arrest. Many of these new arrivals
have children. While they may not have formally
participated in the field of childcare, they have the
experience needed to thrive in this profession.
Currently, the Childcare Assistance regulation 7 AAC
41.200 requires that Approved Relative Providers or
Approved In-Home Providers must be at least 18 years
old, have a high school diploma, general educational
development (GED) diploma, or an equivalent. This
provides a barrier to some individuals who are
attempting to become licensed childcare providers in
Alaska.
SB 233 would allow more people to enter the childcare
workforce who would still be subject to all other
regulations and requirements of the profession. This
would not only benefit immigrants and refugees, but
also longtime residents who have childcare experience
and do not have a high school diploma or GED.
Increasing childcare in Alaska will allow more parents
to return to the workforce, earn income and support
the state economy. I urge you to support SB 233.
3:34:38 PM
RIA SMYKE, Staff, Senator Forrest Dunbar, Alaska State
Legislature, Juneau, Alaska, provided the sectional analysis for
SB 233:
[Original punctuation provided.]
Sectional Analysis
SB 233: CHILD CARE PROVIDER EDUCATION REQUIREMENT
"An Act relating to the day care assistance program."
Section 1: Amends AS 47.25.001: Powers and duties.
Allows a person to provide childcare in the day
care assistance program without passing a high school
equivalency test or having a high school diploma.
3:35:05 PM
SENATOR GIESSEL mentioned hearing frequently that wages for
child care workers are very low, and there is a desire to raise
the status of child care staff. She expressed discomfort with
lowering qualifications in response to this issue. She asked
whether it would be appropriate to create a structure similar to
teachers and teaching assistants, where there could be a child
care provider and a child care assistant category, the latter
not requiring a high school diploma or equivalent.
3:36:02 PM
SENATOR DUNBAR expressed agreement with the desire to raise
wages for child care professionals but noted that the wage issue
is somewhat distinct from the current discussion. He mentioned
that testimony will be heard from representatives of Refugee
Assistance Services (RAIS) ran and the Alaska Literacy Program.
He emphasized that many individuals are qualified and trained to
be excellent child care providers but lack government-recognized
credentials. He compared this to last year's changes to
commercial driver's license (CDL) requirements, where certain
qualifications were waived to include capable individuals from
Ukraine. He suggested exploring alternative qualification
standards to allow more people to enter the child care
profession while maintaining quality through other regulatory
requirements.
3:37:46 PM
SENATOR TOBIN acknowledged that this issue has been discussed
extensively in the Child Care Task Force, where she serves. She
highlighted the challenges immigrant and refugee populations
face in providing in-home care and the concerns some families
have about caregivers from different cultural backgrounds. She
requested input from the department, noting it would likely
create regulations to address the issues that SB 233 also seeks
to resolve. She specifically inquired whether the department
would have someone on staff and what safety nets it would put in
place.
3:38:59 PM
SENATOR DUNBAR agreed and stated that in-home child care is an
important aspect of the conversation. He highlighted the
imbalance between provider compensation and family
affordability. He noted that, like other states, Alaska is
realizing that direct financial support is necessary because the
free market does not function effectively in this economy. He
emphasized that child care is essentially infrastructure.
3:40:10 PM
ROBIN DEMPSEY, CEO, Catholic Social Services, Anchorage, Alaska,
said that as an agency focused on promoting stable incomes and
permanent stability, CSS works closely with individuals from
diverse backgrounds, particularly women in the Refugee
Assistance and Immigration Service (RAIS) program. She
highlighted two main concerns from mothers seeking employment:
the difficulty in finding childcare in Anchorage and the
struggle of leaving their children with someone who does not
understand their culture or speak their language. She emphasized
the need for more culturally appropriate and multilingual
childcare providers.
MS. DEMPSEY noted that CSS works with many women who have
childcare experience but are unable to apply for positions due
to the GED requirement, which she argued does not measure
competency or experience in childcare. The removal of this
requirement, she stated, will help qualified individuals,
including RAIS clients, gain employment and expand the number of
childcare providers in the state. She also shared that the
number of new arrivals in the RAIS program has increased by 250
percent, growing from 21 in 2021 to 582 in 2023, resettling
across the state. She concluded that removing the GED
requirement will create new employment opportunities and improve
Alaska's childcare system.
3:42:56 PM
BRIGET REYNOLDS, Program Director, Refugee Assistance and
Immigration Services, Catholic Social Services, Anchorage,
Alaska, strongly expressed that the GED requirement creates
unnecessary obstacles for individuals with valuable childcare
experience. In her role working with refugees and new arrivals
in Alaska, she has witnessed hundreds of people, particularly
from Ukraine, Afghanistan, and the Democratic Republic of the
Congo, arriving in recent years. RAIS (Refugee Assistance and
Immigration Services) provides these individuals with tools for
self-sufficiency, including employment services aimed at helping
them support their families while contributing to Alaska's
economy.
3:43:52 PM
MS. REYNOLDS noted that many of these individuals, especially
mothers, have significant childcare experience but struggle to
enter the workforce due to childcare responsibilities and a
shortage of culturally appropriate daycare options. Parents are
concerned about leaving their children with providers who do not
speak their language or understand their culture. Anchorage
urgently needs more childcare providers who are culturally
sensitive and multilingual, as over 100 languages are spoken by
students in the local school district. She emphasized that many
RAIS clients, who are skilled, compassionate, and multilingual
caregivers, face barriers to employment due to the GED
requirement. Removing this requirement would allow these
qualified individuals to enter the workforce, increasing the
availability of childcare and meeting the community's need for
culturally competent providers.
3:45:27 PM
ASIA AMINI, Specialist, Refugee Education and Employment Food
Services, Refugee Assistance and Immigration Services, Catholic
Social Services, Anchorage, Alaska, from Afghanistan and a peer
leader with the Alaska Literacy Program, testified in support of
SB 233, which seeks to remove the GED requirement for child care
providers. She shared that many women in her community,
including herself, face challenges entering the workforce
because they are at home with small children. Some day care
waitlists in Alaska are one to two years long. She recounted a
friend's experience, where the lack of English proficiency made
it difficult to secure daycare for her child.
3:46:30 PM
MS. AMINI emphasized the need for more daycare workers who speak
the languages of Afghanistan but noted that the GED requirement
is a significant barrier. Many Afghan women, despite having
experience in raising their own children, cannot work in daycare
due to the time-consuming process of obtaining a GED. She
highlighted that removing this requirement would allow more
women to work in daycare, which would also free other women to
pursue employment. She concluded that eliminating the GED
requirement would help Afghan women and others from various
countries overcome this barrier.
3:47:43 PM
LORI PICKETT, Executive Director, Alaska Literacy Program,
Anchorage, Alaska, described SB 233 as a crucial step toward
removing the barrier that requires child care providers to have
a GED or high school diploma in order to participate in the
child care assistance program. She explained that the Alaska
Literacy Program provides education and job training to adult
learners, helping them acquire a GED, assist their children in
school, access health care, and navigate their new country. Last
year, the program served 892 students from 72 countries who
spoke 56 languages, with a projection to serve over 1,000
students this year. Many of these students have fled war and
unrest, which has prevented them from completing formal
education or accessing high school records.
3:48:45 PM
MS. PICKETT emphasized the statewide workforce gap caused by a
lack of childcare and stressed that removing barriers for both
workers and providers is in the public's best interest. The GED
requirement, she argued, does not reflect a person's ability to
provide child care and hinders immigrants from contributing
fully to society. Many immigrants, who come from cultures that
value family and community, bring strong work ethics and
nurturing instincts, making them ideal candidates for the child
care workforce. She urged support for SB 233, noting that
removing unnecessary barriers will allow immigrants to fill
workforce gaps and contribute to Alaska's economic growth.
3:50:31 PM
CHAIR WILSON opened public testimony on SB 233; finding none, he
closed public testimony.
3:51:32 PM
HILARY PORTER, Deputy Director, Division of Public Assistance,
Department of Health, Juneau, Alaska, introduced herself and
offered to answer questions.
3:51:42 PM
SENATOR DUNBAR stated that he had discussions with the
department and noted that a regulatory change is planned, which
will hopefully resolve the issue. He asked for a brief
description of the planned change.
MS. PORTER confirmed that the department is moving forward with
a drafted regulation change to remove the GED requirement. She
stated that the draft has been submitted and is currently under
review. This barrier was identified through the work of the Task
Force.
3:52:23 PM
CHAIR WILSON asked what task force.
MS. PORTER replied that she was referring to the Governor's Task
Force on Child Care.
SENATOR DUNBAR expressed satisfaction with the answer and
inquired about the department's efforts to improve the status of
child care and maintain its quality while removing barriers,
such as the GED requirement.
3:53:01 PM
MS. PORTER acknowledged that there have been many discussions
about wages for child care workers through the Governor's Task
Force on Child Care. She noted that the department is reviewing
those comments and considering options but could not provide
further details at this time. However, she assured that the
department is aware of the issue and is exploring ways to
improve it.
3:53:31 PM
SENATOR TOBIN asked what additional safeguards and components
the department is putting in place to reassure the public that
the child care system will remain safe and well-regulated,
ensuring providers continue to protect vulnerable Alaskans as
the GED requirement is removed.
MS. PORTER emphasized that quality remains a major focus in
child care, including the qualifications of workers. She
mentioned that there is training available through organizations
like Thread, a statewide child care resource and referral
network. Programs such as Seed and Roots recognize child care
workers for their training achievements, whether through the
university, Thread, or Learn and Grow, another organization.
Although she did not recall all the specific training levels,
she noted that there are approximately 13, and workers can
progress through these levels to become highly qualified, even
without a GED or high school diploma. She stressed that
maintaining quality remains a requirement for both providers and
workers.
SENATOR TOBIN asked for examples of other qualifications a
provider might need.
3:55:24 PM
MS. PORTER explained that health and safety are key concerns,
and background checks are a mandatory part of the department's
quality initiatives. She added that child care providers are
still required to obtain a business license and must be at least
18 years old to work in child care, ensuring that all providers
are adults.
3:56:05 PM
SENATOR GIESSEL found it helpful to learn about the available
training programs and asked whether individuals are required to
complete a training program.
MS. PORTER replied that individuals are both encouraged and
required to take training. Providers can complete basic training
or pursue advanced levels to earn a certificate. While this
certificate is not equivalent to a diploma or GED, it
acknowledges the training and qualifications of the provider or
worker.
SENATOR GIESSEL asked if individuals, despite not having a GED
or equivalent, will still be required to understand child safety
laws, such as mandatory reporting in cases of suspected abuse.
MS. PORTER confirmed that compliance is a key part of the
process. Even after someone is licensed, inspections are
conducted twice a yearone planned and one unplannedto ensure
providers maintain quality and employ qualified individuals. If
any issues arise, the department has measures to address them
and work with the provider to achieve compliance.
3:57:40 PM
SENATOR GIESSEL clarified that her question referred to in-home
child care providers rather than child care facilities. She
asked what in-home child care providers will be required to know
and understand about laws, such as mandatory reporting and child
safety regulations.
MS. PORTER replied the requirements for licensing, mandatory
reporting and safety regulations are essentially the same.
3:58:25 PM
CHAIR WILSON asked if there are other regulations that the task
force identified as a hindrance, such as outdoor play space and
infants.
3:58:58 PM
MS. PORTER replied that although there was conversation about
that specific issue, no action was taken.
3:59:15 PM
CHAIR WILSON asked if the only regulatory change the department
is currently considering for child care providers is the removal
of the high school diploma or GED requirement
3:59:39 PM
MS. PORTER replied other changes are being worked on.
CHAIR WILSON asked for a list to be provided to the committee.
MS. PORTER confirmed that the department is working on
additional changes to their licensing regulations beyond just
the high school diploma or GED requirement.
CHAIR WILSON asked that she provide the list of changes to the
committee.
MS. PORTER said she would provide more information about
licensing regulation changes to the committee.
4:00:15 PM
SENATOR GIESSEL stated that a regulatory package typically takes
about a year to complete. She then asked about the current stage
of the department's progress on GED and high school diploma
regulatory change.
MS. PORTER stated that the regulatory package is currently with
the Department of Law. The department has requested a July 1
effective date and is hopeful it will meet that timeline.
SENATOR GIESSEL asked if the public comment period has already
taken place.
MS. PORTER replied no, the department had not reached that
phase.
SENATOR GIESSEL asked when the public hearing and feedback stage
will occur.
4:01:18 PM
EMILY RICCI, Deputy Commissioner, Department of Health (DOH),
Juneau, Alaska, explained that the time required to complete the
regulatory process can vary, depending on the extent of changes
and the volume of public comments. She noted that the Division
of Public Assistance and the Commissioner's Office are working
closely with the Child Care Task Force, specifically on the
regulations related to the GED requirement, which are already
underway. The duration of the process depends on several factors
discussed, but the department may implement additional changes
aligned with the Task Force's work. She anticipated that
regulatory changes will be approved and rolled out on multiple
dates, depending on the progress of the Task Force.
4:02:25 PM
SENATOR GIESSEL pointed out that the department has not yet held
a public comment period, which will take time and require proper
notice. She questioned whether the proposed July 1 effective
date is realistic.
MS. RICCI acknowledged that July 1 is the department's goal for
the effective date.
4:03:16 PM
SENATOR TOBIN commented that there was a great presentation in
the Senate Education Committee on the progress of the Child Care
Task Force. She suggested that it would be helpful for the
current committee to hear how the Task Force's work aligns with
programs like Parents as Teachers, which is part of the
Department of Health.
CHAIR WILSON replied that he would look into scheduling a
presentation.
4:03:54 PM
SENATOR DUNBAR thanked the committee for hearing SB 233, the
Department for working with his office and presenting, and the
testifiers for their support. He emphasized that while the bill
is important, the real focus is on the change, which he believes
can and will be achieved through regulation. He reiterated his
gratitude to the department and clarified that he does not
intend to move SB 233 forward unless the regulatory changes fall
through, in which case he would bring it back next year.
4:04:31 PM
CHAIR WILSON held SB 233 in committee.
4:04:42 PM
At ease
SB 241-MEDICAL ASSIST. DEMONSTRATION PROJECTS
4:06:01 PM
CHAIR WILSON reconvened the meeting and announced the
consideration of SENATE BILL NO. 241 "An Act relating to medical
assistance demonstration projects established by the Department
of Health."
CHAIR WILSON stated SB 241 the companion bill to HB 344.
4:06:59 PM
HEIDI HEDBERG, Commissioner, Department of Health, Anchorage,
Alaska, introduced SB 241 on behalf of the administration by
explaining that it will grant the Department of Health (DOH)
permission to apply for a Medicaid demonstration waiver. The
waiver is intended to improve the health of Alaskans and reduce
healthcare costs.
4:07:36 PM
ANNE ZINK, MD, Chief Medical Officer, Department of Health,
Anchorage, Alaska, introduced herself.
4:07:43 PM
EMILY RICCI, Deputy Commissioner, Department of Health (DOH),
Juneau, Alaska, moved to slide 2, a map of the United Stated
showing total health care expenditures per capita for 2020. She
emphasized that Medicaid is a critical component of Alaska's
healthcare delivery system, covering about 38 percent of
Alaskans. She highlighted its importance as an insurer in the
state and noted that it shapes the healthcare delivery system
which responds to what is being paid for and the services
provided. She pointed out that healthcare expenditures in Alaska
and the U.S. are very high, prompting the need to assess whether
the outcomes match the investments being made at both the state
and national levels.
MS. RICCI explained that if the outcomes are not aligning with
the investments, it's important to examine the system and find
ways to leverage those investments to improve results. Given
Medicaid's role in Alaska, she stressed that the state has an
opportunity to address unmet needs and identify gaps where there
is a disconnection between investment and outcomes.
4:09:18 PM
MS. RICCI moved to slide 3, a chart of Alaska Medicaid
utilization, illustrating a key concept in health insurance,
showing how a small percentage of Medicaid beneficiaries account
for a large portion of the spending. She explained that about 5
percent of beneficiaries represent 50 percent of Medicaid
spending, which totaled approximately $1.3 billion in state
fiscal year 2023. Additionally, 10 percent of beneficiaries
account for 67 percent of the spending, or about $1.7 billion.
MS. RICCI noted that as the state looks to create a sustainable
Medicaid program, it is essential to focus on areas where
individuals with high acute needs are consistently engaging with
the system. The goal is to find ways to improve both outcomes
and the program's fiscal sustainability. She said today's
presentation would focus on those unmet needs disproportionately
affecting this high-cost portion of the Medicaid population and
explore alternatives to address them.
4:10:35 PM
MS. RICCI moved to slide 4 a graph depicting the utilization of
Alaska's emergency department. She explained that the graph
provides another perspective on individuals with acute needs who
are using the healthcare system inefficiently or
inappropriately. The graph outlines the number of patients with
more than 10 emergency department visits per year, as well as
the median number of visits for those individuals. She
highlighted that, once again, a small portion of the population
with very acute needs is utilizing the system at highly intense
levels.
4:11:10 PM
CHAIR WILSON asked whether the data had been broken down into
the types of visits, specifically whether the visits were for
medical or behavioral health issues.
MS. RICCI explained that when the data was broken down and
examined in more detail, it was found that a high percentage of
these cases involved a behavioral health diagnosis.
4:11:43 PM
DR. ZINK on slide 4, explained that the data highlights a
critical issue, particularly with patients who cycle through the
emergency department repeatedly without receiving the necessary
care. She shared that this experience initially drove her into
policy work, as she observed both the significant time and money
spent on patients, yet without addressing their real needs due
to systemic shortcomings. She noted that systems, which can be
controlled and changed, are often failing patients. Referring to
the highest utilizersthose with over 75 visits per yearshe
stated that all had a behavioral health diagnosis coded within
the last six months. She explained the complexity of
distinguishing the root cause, as physical ailments like heart
failure or autoimmune diseases can lead to conditions like
degenerative bone disease, which may require opioids, and result
in depression. She emphasized the close connection between
physical and mental health, adding that although healthcare
payment systems often separate them, both are deeply
intertwined. In the case of the highest utilizers, a high
percentage had behavioral health diagnoses.
4:13:13 PM
CHAIR TOBIN sked about the intersection of dental health and its
impact on high utilizers, specifically how plaque buildup might
lead to further health consequences. She also inquired about the
age breakdown of the high utilizers, asking if they tend to be
older, younger, or middle-aged individuals.
4:13:51 PM
DR. ZINK said the department would provide the committee with a
broader age breakdown. She noted that Alaska data can be
challenging due to small sample sizes, highlighting that there
were seven patients with over 100 visits, with one individual
having over 200 visits per year. Some high utilizers, such as a
patient with over 300 visits annually for almost a decade, have
since passed away, making generalizations difficult in small
numbers. Regarding dental health, she explained that the waiver
primarily focuses on health-related needs such as food,
transportation, and housing, and while they will discuss diet-
sensitive conditions, dental care wasn't specifically broken out
in the data. She added that, as a physician, it can be difficult
to directly attribute dental conditions like inflammation
leading to cardiovascular disease because emergency department
visits might focus on the immediate issue, such as a heart
attack. Although dental care can be a contributing factor, it's
hard to account for on an individual level.
4:15:20 PM
CHAIR WILSON humorously commented that at a healthcare
conference, teeth were referred to as "luxury bones" since many
insurance companies don't cover dental care, even though
neglecting dental health can lead to major chronic conditions.
4:15:47 PM
DR. ZINK moved to slide 5, pointed out that taking care of these
issues is important, as they have broader impacts on overall
health. She explained that the department is focused on
addressing the whole personbehavioral, mental, and physical
healthwhile recognizing that aspects like dental care also play
a role in overall health. She then noted that individuals with
multiple chronic conditions tend to be much more expensive for
the system, with costs significantly increasing for those with
eight or more chronic conditions, up to $81,000 annually. She
highlighted that some conditions are modifiable, like those
influenced by diet and lifestyle, while others are not. She
pointed out that over two-thirds of Alaskans have one or more
chronic conditions and discussed modifiable diet-related
conditions such as obesity (68 percent), hypertension (31
percent), high cholesterol (27 percent), diabetes (8 percent),
and heart disease (5 percent). These conditions contribute to
high healthcare costs and mortality. She emphasized the
importance of addressing these issues early, as the cost of
treating just one chronic condition adds approximately $7,500
per individual. She also referenced the Fresh Start program, a
public health initiative that provides free resources to help
Alaskans address chronic conditions. The department has been
listening to Alaskans across regions to better understand what's
working and what's not in addressing chronic conditions.
4:18:11 PM
DR. ZINK then moved to slide 6, discussing two specific
programs. The Produce Prescriptions program, run by the Yukon-
Kuskokwim Health Corporation (YKHC) since 2018, targets diabetes
by providing healthier food options through grant-funded
efforts. The program supports patients like elders with diabetes
and pregnant women with gestational diabetes. Another program,
the Multi-Visit Person (MVP) program at Bartlett Regional
Hospital in Juneau, coordinates care for patients frequently
cycling through the emergency department, focusing on food,
housing, and transportation. She also mentioned the High
Utilizer Mat-Su (HUMS) program, which has saved approximately $5
million through emergency department and hospitalization
avoidance for its 120 participants by addressing non-medical
needs like lodging, food, and transportation. She noted that
these programs illustrate how addressing health-related needs
can keep patients healthier and reduce hospital visits.
4:20:01 PM
DR. ZINK moved to slide 7, showing a pyramid that illustrates
the relationship between health-related needs services, with
prevention at the base and treatment at the peak. She clarified
that the 1115 waiver is not meant to replace existing food,
housing, or transportation programs, but to provide time-
limited, medically necessary support for those with high
healthcare needs. She emphasized that the Centers for Medicare &
Medicaid Services (CMS) requires that these services
specifically target patients with high healthcare costs, such as
those recently hospitalized for heart failure or acute
psychiatric conditions, to prevent costly readmissions and
emergency department visits.
4:21:27 PM
DR. ZINK moved to slide 8, providing an example from nutrition
services. She said there is a considerable amount of data from
multiple states using waivers to provide targeted support for
medical conditions. One example of target support is a pregnant
woman with gestational diabetes, who would benefit from
additional nutritional support to manage her blood sugar for
both her health and her baby's. Another example is a heart
attack patient managing heart failure, who would need a strict
low-sodium diet to avoid returning to the emergency department.
She explained that nutritional services might include education,
grocery delivery, or meal delivery, depending on the patient's
specific needs. For example, someone reliant on microwave meals
might benefit from medically tailored meals, while another
person with the ability to cook might need just nutritional
education. Studies, such as those from Massachusetts, show that
providing medically tailored meals resulted in significant cost
savingsaround 16 percent overallwith 70 percent fewer
inpatient admissions and 72 percent fewer emergency department
transports.
4:23:31 PM
SENATOR TOBIN expressed curiosity about whether the waiver could
potentially cover allergy testing or efforts to identify
autoimmune responses, such as in a patient with undiagnosed
Crohn's disease. She asked if this type of diagnostic work falls
under the waiver or if it is a different process.
4:23:57 PM
DR. ZINK explained that allergy testing can currently be covered
by Medicaid, depending on the patient's needs. She clarified
that the waiver being discussed focuses on services outside the
traditional healthcare system. CMS has approved various waivers
in the past, and the scope of Alaska's waiver application could
be broad or narrow. However, the application process has not yet
started, as legislative approval is needed to move forward. She
noted that the department would discuss the steps involved in
the process later on in the presentation.
SENATOR TOBIN clarified her question, asking if a patient who
repeatedly presents at the hospital with inflammation, undergoes
allergy testing, and is diagnosed with Crohn's disease could
receive meal services under the waiver.
4:25:11 PM
MS. RICCI responded that the department is hesitant to give a
definitive answer because the types of support offered through
the waiver are not necessarily traditional healthcare services.
What medical conditions will qualify for non-traditional
services are defined by the state through the waiver process and
its own program design. The state decided in its analysis that
time-limited prescription support is valuable for Alaskans.
While time-limited support for a patient with Crohn's disease is
something the department could consider, most states' frameworks
focus narrowly on conditions with very frequent readmissions and
high-cost utilization. Alaska can define its own framework in
this process.
4:26:18 PM
SENATOR TOBIN highlighted concerns about Alaska's Indigenous
populations, using dairy as an example. She noted that the
Western food system may not suit all Alaskans and suggested
considering these unique factors when addressing health issues
in the state.
4:26:45 PM
MS. RICCI stated that the department has met extensively with
stakeholders and will continue to do so throughout the waiver
process. This includes tribal health organizations and other
groups across the state. As ideas arise, they will be evaluated.
She noted that stakeholders have expressed a desire for clear
guidelines on what the waiver will and will not cover but
emphasized that they are still in the early stages of exploring
options. The department will need contractual and actuarial work
to determine the best fit for Alaska's Medicaid program, and
they remain open to input.
4:27:40 PM
CHAIR WILSON noted that the discussion seems to involve two
different waivers, referencing Medicaid's social determinants of
health and social drivers of health waivers, as well as a
medicine waiver. With transportation now being added, he asked
whether the department is combining these waivers to address
health-related needs in one omnibus waiver, or if they plan to
apply for multiple individual waivers.
4:28:11 PM
MS. RICCI explained that the 1115 waivers are a federal tool for
states to cover different types of services. Whether Alaska
modifies its existing 1115 waiver or applies for a new one will
depend on further analysis with consultants and the Centers for
Medicare and Medicaid Services (CMS) to determine the most
effective approach. She said she does not envision the state
applying for multiple 1115 waivers for each service; instead, it
would likely combine them into one or two waivers covering
related topics, as other states have done.
4:29:04 PM
MS. RICCI also noted that this area is evolving rapidly, with
CMS updating its approval processes every 120 to 180 days. The
proposed legislation seeks authorization to apply for a waiver
that addresses broad categories of services states are focusing
on, as outlined by CMS's streamlined 1115 process. While the
final product is still uncertain, legislative approval is needed
before the state can proceed with the time- and resource-
intensive application process.
4:30:00 PM
CHAIR WILSON expressed concern about granting blanket authority
to apply for waivers without the department returning to the
legislature to review costs and other specifics. He acknowledged
the goals and supported them but is cautious about the
legislative authority over waivers, pointing out that once a
waiver is approved, the department could modify or cancel it
without legislative input. He mentioned that this has been an
ongoing conversation with the administration regarding how
waiver authority is being used in the state. He clarified that
the department doesn't need to address this concern and could
continue its presentation.
4:31:15 PM
DR. ZINK explained that many states have 1115 waivers, with some
maintaining a single, continuously updated waiver and others
handling multiple waivers. CMS has emphasized that health-
related social needs are major drivers of healthcare costs and
has encouraged states to address them. SB 241 specifically
targets those health-related social needs as outlined by CMS.
She clarified that, while Alaska has an 1115 waiver for
behavioral health, this issue is distinct, which is why the
department consulted with legal counsel and chose to bring it
separately to the legislature. Although behavioral health
diagnoses can be linked to health-related social needs, this new
proposal focuses on improving Alaskans' health and reducing
costs, particularly in avoiding repeat hospitalizations. She
emphasized the department's intent to collaborate with the
legislature.
4:32:25 PM
MS. RICCI acknowledged that the committee is aware of the
budgetary process and noted that the budget authority for the
Medicaid program is ultimately appropriated by the legislature.
Any budgetary impact related to Medicaid will require
legislative review and approval. She also pointed out that 1115
waivers have guardrails regarding federal budget neutrality,
meaning there will likely be a financial component to consider.
She explained that many states have leveraged anticipated
federal savings early in the process to reinvest in their
systems, and Alaska could pursue a similar approach if it makes
sense. However, the department would need to return to the
legislature for budgetary approval before moving forward. She
emphasized that there will be checks and balances with the
legislature before any changes are implemented.
4:33:36 PM
CHAIR WILSON expressed concern about the reapplication process
for an approved 1115 waiver, noting that the state recently
reapplied for the current 1115 waiver without legislative
approval, oversight, or modifications, despite not fully
implementing the first waiver. He highlighted reports indicating
issues during the implementation period of the existing waiver
and raised concerns about the lack of legislative involvement in
the waiver process. While he acknowledged the value of waivers,
he questioned how they are implemented without sufficient
legislative oversight. He also suggested considering an
amendment to the current waiver to include additional authority,
such as exploring the Department of Corrections (DOC) waiver
process to allow soon to be released inmates to qualify for
Medicaid. He noted that other states have pursued this and
suggested it could be an opportunity for future consideration.
4:34:59 PM
MS. RICCI added that the department is exploring new
opportunities to support incarcerated individuals pre-release,
particularly under the existing work authorized by Senate Bill
74 and the 1115 behavioral health waiver. She noted that the
activities available through the Centers for Medicare & Medicaid
Services (CMS) reentry waiver align with the behavioral health
and substance use services already covered under Alaska's
current statutory authority. Therefore, while not explicitly
included in this bill, the department believes it already has
the statutory authority to pursue those services. She emphasized
that the department is aware of this and is considering how it
could be applied in Alaska.
4:35:52 PM
CHAIR WILSON acknowledged that these conversations have taken
place off the record but expressed his desire to have them noted
on the record.
4:35:56 PM
DR. ZINK highlighted that for nutrition services to be approved
by CMS, both a medical and a social component must be present.
In response to Senator Tobin's earlier comment about Crohn's
disease, she explained that a person would need both a medical
condition and an unmet social need, such as homelessness or lack
of access to food. She emphasized that cultural appropriateness
is also considered, referencing the success of the Yukon-
Kuskokwim Health Corporation (YKHC) program, which tailors food
options to reduce diabetes risk by addressing local needs,
transportation, and genetic factors.
4:37:01 PM
DR. ZINK API moved to slide 9 and said the waiver could address
housing for patients discharged from Alaska Psychiatric
Institute (API), noting that around 60 percent of them are
either underhoused or homeless. For example, a patient with
schizophrenia who has lost their job and housing may be doing
well after treatment at API but struggles to reintegrate without
stable housing or transportation. Temporary, medically necessary
housing could provide the support needed to help patients regain
stability, such as securing a job or renewing a driver's
license. She emphasized that transitioning from inpatient to
outpatient care can be challenging, particularly when acute
mental health issues disrupt social support networks, jobs, and
housing.
4:38:32 PM
CHAIR WILSON asked for clarification on what type of temporary
housing is being proposed. He inquired whether this would
involve something like an assisted living facility with a day
rate or if the department is referring to paying for an
apartment or housing with caregivers.
DR. ZINK explained that the type of housing support will depend
on how the waiver is scoped and the results of actuarial
analysis to determine where the greatest impact can be made. She
noted that other states are paying for temporary housing, such
as an apartment, often with a caseworker nearby. This would
apply to individuals who do not qualify for other medically
covered needs, such as a skilled nursing facility after
discharge from a hospital. She gave an example from Yukon-
Kuskokwim Health Corporation (YKHC), where a patient could be
discharged to temporary housing in Bethel, receive behavioral
health services, and stabilize on their medications before
returning to their community or village, instead of making an
immediate leap from discharge back home.
4:39:47 PM
MS. RICCI moved to slide 10 explained that the waiver is
designed to tailor Medicaid to address some of Alaska's unmet
needs, which contribute to increasing, yet potentially
avoidable, healthcare utilization. Medicaid is a state-federal
partnership, and new federal support encourages innovation in
Medicaid, particularly to address these unmet needs. The 1115
waivers are demonstration waivers that allow states to cover
services typically not included under Medicaid for a set period,
usually five years, with renewal possible if the waiver can
demonstrate that it does not cost more than what Medicaid would
have paid without the waiver. Additionally, the waiver must show
positive impacts on health outcomes.
4:40:53 PM
MS. RICCI moved to slide 11 and emphasized that when considering
changes to the Medicaid program, it's important to identify the
population being served, particularly focusing on the 5 to 10
percent of Medicaid users driving $1.7 billion in annual costs.
She stressed that the department's goal is to shift Medicaid
spending from acute services to preventive care or reducing
acute care needs, ultimately supporting the Department of
Health's mission to promote the health, well-being, and self-
sufficiency of all Alaskans.
4:41:46 PM
DR. ZINK moved to side 12 and stated that the overall goal is to
improve health outcomes and reduce downstream costs. She
emphasized that healthier people are less expensive for the
healthcare system and that a healthy population is essential for
economic growth and sustainability in Alaska. The focus is on
shifting resources away from high-risk Medicaid beneficiaries
and toward prevention, wellness, and addressing unmet needs
across the system.
4:42:11 PM
MS. RICCI moved to side 13 explained that the purpose of SB 241
is to provide the department with specific authorization to
apply for an 1115 waiver. She noted that Senate Bill 74 laid the
groundwork for the department to explore such waiver
opportunities, and recent options from the Centers for Medicare
& Medicaid Services (CMS) have led states to reassess their
Medicaid coverage. SB 241 is essential for Alaska to proceed
with its waiver application as the department determines which
services best address the state's needs.
4:42:54 PM
SENATOR TOBIN asked about the potential impact of the upcoming
election cycle on the waiver approval process, noting that a
change in administration could affect federal partnerships. She
inquired whether the department anticipates any disruptions to
the process if there is a shift in administration at the federal
level.
4:43:26 PM
MS. RICCI responded that she couldn't speculate on how a change
in administration might affect the process. However, she noted
that over 16 states, including Florida, Arkansas, Utah, and
Arizona, have already implemented, or negotiated similar waivers
with CMS. While each administration may have different
priorities, she believes that with so many states actively
pursuing these waivers, it would be difficult to change
direction quickly.
4:44:15 PM
DR. ZINK added that the department had asked this question to
their technical assistance (TA) partners. Historically, even
with changes in administrations, waivers that have been approved
tend to remain in place. These waivers become embedded in how
states operate, making it difficult to reverse specific changes
at CMS once they are implemented.
4:44:41 PM
MS. RICCI moved to side 14 and discussed some of the new
opportunities identified by CMS for 1115 waivers to address
health-related needs, including food security, transportation to
medical appointments, temporary housing, and case management.
She also mentioned workforce development, which was recently
approved in New York and is something Alaska is considering.
Moving to the financial considerations, she highlighted budget
neutrality and the possibility of pulling down federal savings
in advance to reinvest in the system, noting that providers
would need to adapt to these changes within Medicaid, which
could be challenging.
4:45:23 PM
MS. RICCI moved to slide 15 and discussed financial
considerations. She highlighted budget neutrality and the
possibility of pulling down federal savings in advance to
reinvest in the system, noting that providers would need to
adapt to these changes within Medicaid, which could be
challenging:
[Original punctuation provided.]
Financial Considerations
• Budget Neutrality: Centers for Medicare and Medicaid
Services requires budget neutrality for all 1115
waivers.
• Alaska Medicaid Spending: The legislature authorizes
Medicaid spending annually.
• Efficiencies in Care: There is strong evidence that
addressing health-related needs improves health
outcomes and reduces costs.
4:46:21 PM
MS. RICCI moved to slide 16 and said the sectional analysis for
SB 241 authorizes the department to apply for a 115 waiver to
establish one or more demonstration projects focused on
addressing health-related social needs for Alaska Medicaid
recipients in one or more specific geographic areas. It also
defines "health-related needs" as social or economic conditions
that contribute to an individual's poor health outcomes:
[Original punctuation provided.]
SECTIONAL ANALYSIS
Senate Bill 241: Medical Assistance Demonstration
Projects
Section 1. Adds a new section (h) to AS 47.07.036
authorizing the department to apply for an 1115 waiver
to establish one or more demonstration projects
focused on addressing health-related needs for Alaska
Medicaid recipients in one or more specific geographic
areas.
Defines "health-related needs" as social or economic
conditions that contribute to an individual's poor
health outcomes. Examples of health-related needs
include nutrition and food security, workforce
development, transportation, temporary housing, or
case management.
4:46:47 PM
DR. ZINK moved to slide 17, which displayed a chart outlining
Alaska's waiver process with a photograph of a river in the
background. She emphasized that SB 241 is not intended to
replace any grant-based services. Instead, it allows for the
possibility of implementing services in phases through
demonstration projects over time.
[Original punctuation provided.]
Department of Health
Preparation
Partner Engagement
Tribal Engagement
Technical Assistance
Legislative Input and Authority - WE ARE HERE
Development
Actuarial Analysis
Partner Engagement
Tribal Consultation
Waiver Proposal Drafting
Consultation
Tribal Consultation
CMS Negotiation
Public Comment
Approval
CMS Approval
Annual Budget Process
Implementation
Infrastructure and Capacity Building
Services Available to Eligible Alaskans
Review
Required Annual Reporting to CMS
Annual Budget Process
Renewal Opportunities
4:49:12 PM
CHAIR WILSON asked if there is a timeframe for each block of the
waiver process, assuming all conditions are ideal, and variables
are controlled.
4:49:32 PM
MS. RICCI replied that although she was not with the department
during the creation of the behavioral health and substance use
disorder 1115 waiver, she estimated the process could take one
to two years. The timeline depends on how quickly the department
can move internally, bring on contractors, and address key
questions. She added that the implementation timeframe would
also depend on the readiness of different regions and
communities within the state, but she did not have a clear sense
of that readiness at this time.
4:50:20 PM
DR. ZINK noted that states have found the implementation phase
challenging, as providers need to rethink their service models.
However, she emphasized that the process of discussion has been
extremely valuable. It has fostered collaboration across
different groups in the state, which is influencing and
inspiring various divisions within the Department of Health to
explore new approaches, even without needing a waiver. She
highlighted that these conversations have already led to changes
by encouraging a more holistic approach to care. The river slide
was chosen because it represents the gathering of different
ideas and information, flowing together to become a long-term
waiver.
4:51:07 PM
CHAIR WILSON expressed concern, similar to Senator Tobin's,
about potential changes in the federal administration affecting
the waiver process. He mentioned a conversation with Daniel
Tsai, Deputy Administrator at CMS, noting that waivers are often
aligned with an administration's priorities, which can shift
with a change in leadership. This could potentially disrupt the
process if there is a mid-change in administration. He
encouraged the department to ask for additional resources if
needed, especially since the legislature is in session and could
help expedite the process. He emphasized the importance of
moving quickly and offered support to ensure the department has
the resources necessary to complete the waiver process
efficiently.
4:52:21 PM
DR. ZINK moved to slide 18 and expressed gratitude for the
support and explained that the department's main limitation is
obtaining legislative approval. She mentioned that they have
technical assistance (TA) support ready, along with a team and
extensive partner and stakeholder engagement. The department has
been gathering input from community members to ensure that the
proposal aligns with their needs and interests and that partners
are ready to implement it. She highlighted the strong letters of
support the department has received and acknowledged the need
for ongoing education about what the waiver does and doesn't
cover. She also mentioned the need to do actuarial work before
moving forward. She concluded by thanking the committee for the
opportunity to discuss the SB 241.
CHAIR WILSON thanked the Department of Health (DOH) for sharing
where it is in the waiver process.
4:54:00 PM
MS. RICCI thanked the committee for offering DOH the support
needed to move forward in the waiver process by hearing SB 241.
4:54:30 PM
CHAIR WILSON opened public testimony on 241; finding none, he
closed public testimony.
CHAIR WILSON [held SB 241 in committee.]
4:55:17 PM
There being no further business to come before the committee,
Chair Wilson adjourned the Senate Health and Social Services
Standing Committee meeting at 4:55 p.m.
| Document Name | Date/Time | Subjects |
|---|---|---|
| SB 233 Version A.pdf |
SHSS 3/19/2024 3:30:00 PM |
SB 233 |
| SB 233 Sponsor Statement 2.22.2024.pdf |
SHSS 3/19/2024 3:30:00 PM |
SB 233 |
| SB 233 Sectional Analysis Version A 2.22.2024.pdf |
SHSS 3/19/2024 3:30:00 PM |
SB 233 |
| SB 233 FN DOH.pdf |
SHSS 3/19/2024 3:30:00 PM |
SB 233 |
| SB 233 Testimony.pdf |
SHSS 3/19/2024 3:30:00 PM |
SB 233 |
| SB 241 Version A.pdf |
SHSS 3/19/2024 3:30:00 PM |
SB 241 |
| SB 241 Sponsor Statement Version A.pdf |
SHSS 3/19/2024 3:30:00 PM |
SB 241 |
| SB241 Sectional Analysis.pdf |
SHSS 3/19/2024 3:30:00 PM |
SB 241 |
| SB 241 FN DOH Medicaid.pdf |
SHSS 3/19/2024 3:30:00 PM |
SB 241 |
| SB 241 DOH Presentation.pdf |
SHSS 3/19/2024 3:30:00 PM |
SB 241 |
| SB241 LOS 3.18.24.pdf |
SHSS 3/19/2024 3:30:00 PM |
SB 241 |
| SB 241 Support SFC.pdf |
SHSS 3/19/2024 3:30:00 PM |
SB 241 |