02/06/2018 03:00 PM House STATE AFFAIRS

        HCR  2-RESPOND TO ADVERSE CHILDHOOD EXPERIENCES                                                                     
                                                                                                                              
3:12:11 PM                                                                                                                    
                                                                                                                                
CHAIR KREISS-TOMKINS  announced that  the first order  of business                                                              
would be HOUSE  CONCURRENT RESOLUTION NO. 2,  Urging Governor Bill                                                              
Walker to  join with  the Alaska State  Legislature to  respond to                                                              
the public  and behavioral  health epidemic  of adverse  childhood                                                              
experiences  by  establishing  a statewide  policy  and  providing                                                              
programs to address this epidemic.                                                                                              
                                                                                                                                
3:12:28 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  GERAN TARR,  Alaska  State  Legislature, as  prime                                                              
sponsor  of HCR  2, brought  attention to  the proposed  committee                                                              
substitute  (CS)   for  HCR   2  [30-LS0277\J,  Glover,   1/17/18,                                                              
included  in the  committee packet  and hereafter  referred to  as                                                              
"Version  J"].   She  maintained  that  given the  current  fiscal                                                              
crisis,  the  need  for  long-term   planning,  and  the  need  to                                                              
understand  the  state's "cost  drivers,"  the  time is  right  to                                                              
discuss  the  issue  of  the  public   health  crisis  of  adverse                                                              
childhood  experiences  (ACEs)   in  Alaska  and  its  impacts  to                                                              
communities and the state budget.                                                                                               
                                                                                                                                
REPRESENTATIVE TARR  began a PowerPoint presentation,  entitled "A                                                              
Public  Health  Crisis:  Adverse   Childhood  Experiences."    She                                                              
referred to  slide 2, entitled "What  are ACES?" and  relayed that                                                              
two physicians  - Dr.  [Vincent] Filitti and  Dr. [Robert]  Anda -                                                              
in  doing research  on obesity,  discovered a  link between  early                                                              
childhood  experiences and  health  problems in  adulthood.   This                                                              
led to their  1998 study, in  which they gave a  ten-question quiz                                                              
to  enrollees  of  a health  insurance  program  to  assess  their                                                              
exposure to  trauma as children.   Based  on the answers  to those                                                              
questions, each  research subject was  assigned an ACE  score from                                                              
zero to ten.                                                                                                                    
                                                                                                                                
REPRESENTATIVE  TARR turned  to slide  3, entitled  "What Kind  of                                                              
Childhood Trauma?"  and relayed that  the quiz assessed  trauma in                                                              
three  categories -  abuse,  neglect, and  household  disfunction.                                                              
Two of  the categories include  behaviors that impact  the person,                                                              
such as physical  abuse, sexual abuse, neglect,  domestic violence                                                              
to an adult family member, and having a parent in jail.                                                                         
                                                                                                                                
REPRESENTATIVE TARR  moved on to  slide 4, entitled "What  is your                                                              
ACES Score?"  and encouraged  committee members  to take  the quiz                                                              
on their own to  get a better understanding of  the exposures that                                                              
are assessed  by the quiz.  She  offered that doing so  would help                                                              
the   members  appreciate   the  information   gathered  and   the                                                              
potential  of  that  information  to  influence  policy  and  save                                                              
money.                                                                                                                          
                                                                                                                                
3:16:44 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE TARR  referred to  slide 5, entitled  "ACES Studies                                                              
in Alaska," and  stated that there were two key  findings from the                                                              
ACE studies  conducted  in Alaska.   The first  is that  childhood                                                              
trauma is far  more common and far more expensive  than previously                                                              
realized.   She said  that the  finding that  childhood trauma  is                                                              
"more  common"  is something  of  great  concern.   Alaska  has  a                                                              
record  number  of children  in  foster  care  - more  than  3,000                                                              
currently -  and these  children likely  have experienced  a great                                                              
deal  of trauma  in  childhood and  are  continuing to  experience                                                              
trauma.   She  referred  to the  category  "neglect," and  offered                                                              
that  the research  demonstrates  that  prolonged  neglect can  be                                                              
more damaging  than physical  and sexual abuse.   She  stated that                                                              
the  second  key  finding  was that  the  impact  of  this  trauma                                                              
affects   individuals  over   a   lifetime   and  societies   over                                                              
generations.   She  emphasized  the  importance of  that  finding:                                                              
the ACE  study reveals  the exposures to  an individual  that lead                                                              
to  undesirable  health  outcomes  in  adulthood;  the  impact  to                                                              
societies over  generations has not  been fully understood  in the                                                              
public  policy  context.    She   mentioned  that  the  Office  of                                                              
Children's  Services  (OCS)  often  serves the  second  and  third                                                              
generations of the same families.                                                                                               
                                                                                                                                
REPRESENTATIVE  TARR   referred  to  slide  6,   entitled  "Select                                                              
Negative  Health Outcomes,"  and said  that some  of the  negative                                                              
outcomes  listed are  not  surprising.   Before  the ACE  studies,                                                              
people referred to  the "cycle of violence," in  which individuals                                                              
growing  up with  domestic  violence  in the  home  have a  higher                                                              
likelihood of  committing violence.   She said  that what  the ACE                                                              
study  discovered that  was new  was physical  health problems  as                                                              
outcomes, such  as liver disease  and heart disease, which  can be                                                              
very costly.                                                                                                                    
                                                                                                                                
REPRESENTATIVE TARR  turned to slide 7, entitled  "Select Negative                                                              
Health  Outcomes," to  point  out the  percentages  of an  outcome                                                              
linked to  high ACE scores.   She relayed that the  research shows                                                              
that  40.6  percent   of  Medicaid  spending  can   be  linked  to                                                              
childhood trauma;  Medicaid spending is prominent  in state budget                                                              
discussions;  and there has  been an  increase of 30,000  Medicaid                                                              
enrollees  this  year.    To  the  extent  that  the  increase  in                                                              
Medicaid  enrollees  is  the result  of  early  childhood  trauma,                                                              
"upstream"  prevention   activities  become  more   important  for                                                              
influencing the outcomes and eliminating spending.                                                                              
                                                                                                                                
REPRESENTATIVE  TARR  cited  from  slide 7  the  "current  smoker"                                                              
outcome  percentage  of  32  percent   and  the  "heavy  drinking"                                                              
outcome percentage  of 20.5 percent.   She referred to  a McDowell                                                              
Group  report,  entitled "The  Economic  Costs  of Drug  Abuse  in                                                              
Alaska,  2016  Update,"  prepared  for the  Alaska  Mental  Health                                                              
Trust Authority (AMHTA)  and the Advisory Board  on Alcoholism and                                                              
Drug  Abuse  (ABADA),  which  claims  that  the  cost  is  in  the                                                              
billions of  dollars.   She emphasized that  Alaska is  paying for                                                              
the   costs    through   treatment,   through    courts,   through                                                              
incarceration,   and  through   the   handling  of   dysfunctional                                                              
students in  schools.   She maintained  that considering  the cost                                                              
to Alaska, there  is great opportunity to makes  changes and spend                                                              
this money better.                                                                                                              
                                                                                                                                
3:21:01 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE TARR  referred to slide  8, entitled "The  Price of                                                              
Not Intervening  Before Trauma  Occurs," to demonstrate  potential                                                              
savings:   a 32 percent  reduction in costs  due to  smoking would                                                              
yield  a  $186 million  in  savings;  a  20 percent  reduction  in                                                              
[costs  due to]  substance abuse  would  yield a  $350 million  in                                                              
savings;  and a  40.6 percent  reduction in  Medicaid costs  would                                                              
yield a $350  million in savings.   She offered that  the proposed                                                              
resolution mentions  other statistics  and explained  that because                                                              
of  all the  research  in this  area,  costs  and percentages  are                                                              
constantly being  updated; in any case, the costs  are significant                                                              
and there are opportunities for savings.                                                                                        
                                                                                                                                
REPRESENTATIVE  TARR referred  to  slide 9,  entitled  "Overcoming                                                              
ACES in  Alaska Building a Statewide  Movement," to point  out the                                                              
many  and varied  organizations that  have been  able to  "connect                                                              
the  dots"  by  looking  at the  outcomes,  such  as  drug  abuse,                                                              
domestic violence,  and suicide, through the ACE  "lens", and thus                                                              
understand that  their issues are  all interrelated.  She  gave an                                                              
example:  individuals  with four or more ACEs are  in the hundreds                                                              
of percentiles  more likely  to commit  suicide; Alaska  leads the                                                              
nation  in  suicide  rates;  if  suicide  prevention  is  directed                                                              
toward  young  adults or  teens,  the  opportunity may  have  been                                                              
missed, because  suicide may  be the  result of childhood  trauma.                                                              
She  claimed  that  organizations  such  as  Best  Beginnings  and                                                              
Alaska Association  for Infant and  Early Childhood  Mental Health                                                              
(AK-AIMH) have  been formed  based on  the recognition  that early                                                              
childhood experiences  are integral  to lifetime experiences,  and                                                              
there is  opportunity to impact  the subsequent issues  by looking                                                              
at them through the lens of ACE.                                                                                                
                                                                                                                                
3:24:06 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  TARR  turned  to slide  10,  entitled  "Overcoming                                                              
ACES  in Alaska:  Connecting people  and policies,"  to point  out                                                              
additional work done  in the state.  She stated  that OCS receives                                                              
50 reports  of child abuse or neglect  per day.  Most  ACEs happen                                                              
to  Alaska  kids   by  age  3;  therefore,  waiting   until  early                                                              
adulthood or adulthood to address the problem is too long.                                                                      
                                                                                                                                
REPRESENTATIVE  TARR moved  on to slide  11, entitled  "Overcoming                                                              
ACES in  Alaska" to  present the three  "asks" in the  resolution.                                                              
She  maintained  that  the  resolution  does  not  request  policy                                                              
changes  at this time;  it is  more focused  on raising  awareness                                                              
and building  the knowledge  foundation around  ACE, the  research                                                              
that  has  been  performed  in Alaska,  and  the  opportunity  for                                                              
changing practices, improving health outcomes, and saving money.                                                                
                                                                                                                                
3:25:07 PM                                                                                                                    
                                                                                                                                
ALISON  KULAS, Executive  Director, Advisory  Board on  Alcoholism                                                              
and  Drug  Abuse  (ABADA),  testified that  ABADA  looks  for  the                                                              
connections that  Representative Tarr  mentioned and ways  to work                                                              
with partners  to reduce  ACEs.   She stated  that ABADA  has been                                                              
able  to  partner  with the  Department  of  Education  and  Early                                                              
Development  (DEED), which  created  eLearning  modules to  inform                                                              
teachers,  school  staff, and  community  members  about ACEs  and                                                              
offer  them a  trauma-informed approach  to  intervening early  in                                                              
life.                                                                                                                           
                                                                                                                                
3:26:50 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  KNOPP moved  to  adopt Version  J  as the  working                                                              
document.   There being  no objection,  Version  J was before  the                                                              
committee.                                                                                                                      
                                                                                                                                
3:27:17 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE LEDOUX  expressed her  belief that ACEs  cause some                                                              
real problems  in adulthood.   She referred  to page 2  of Version                                                              
J, lines  6-10, and  asked whether smoking  and obesity  were more                                                              
the  result of  parents  smoking  and the  foods  they gave  their                                                              
children, rather than abuse.                                                                                                    
                                                                                                                                
REPRESENTATIVE TARR  maintained that ACE research  is changing the                                                              
understanding  on  those issues.    She  gave  an example:    many                                                              
schools  are  incorporating "mindfulness"  activities  to  address                                                              
trauma   by  helping   children   self-regulate  their   emotions;                                                              
activities   often   include   meditative   and   deep   breathing                                                              
exercises.  She  maintained that some counselors  believe that the                                                              
link  between smoking  and a  high  ACE score  is because  smoking                                                              
replicates  a mindfulness  activity; it  involves deep  breathing,                                                              
but in the form  of smoking.  She claimed that  the original [ACE]                                                              
study is  recent, and the information  is new, therefore,  has not                                                              
been  broadly  applied  in  the medical  community  or  in  public                                                              
policy  yet.   She  emphasized  the  importance  of the  quiz  and                                                              
maintained that  doctors are beginning  to ask their  patients the                                                              
same  questions [as  on the  ACE  quiz] to  better understand  the                                                              
origin of behaviors.                                                                                                            
                                                                                                                                
REPRESENTATIVE TARR  offered the term "epigenetics"  and explained                                                              
that  everyone starts  out with  a  genetic blueprint,  but it  is                                                              
subject to change  due to environmental exposures.   She said that                                                              
there are  modifications  and mutations to  the genetic  blueprint                                                              
that may be related to later health effects.                                                                                    
                                                                                                                                
3:30:00 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  LEDOUX  asked if  the  quiz  is in  the  committee                                                              
packet.                                                                                                                         
                                                                                                                                
REPRESENTATIVE  TARR replied,  it  is not.   She  stated that  she                                                              
would  provide the  link  to committee  members.   She  maintained                                                              
that  the collective  ACE score  of  all 60  legislators would  be                                                              
interesting information.                                                                                                        
                                                                                                                                
3:30:38 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  WOOL expressed  his  appreciation  with the  study                                                              
and  his support  of early  intervention.   He  commented that  he                                                              
believes  that there  are some  "leaps  of faith"  in the  numbers                                                              
provided  by Representative  Tarr:   for  example,  20 percent  of                                                              
people who  smoke do so  because of ACEs  or 20 percent  of people                                                              
who  drink  heavily do  so  because  of ACEs;  therefore,  without                                                              
ACEs, 20 percent of the costs would be eliminated.                                                                              
                                                                                                                                
REPRESENTATIVE WOOL  relayed that he recently asked  the principal                                                              
at his children's  school what she needed most.   He said that she                                                              
replied, "I  need a social worker."   He offered that  children in                                                              
elementary school  today have more  social problems  than children                                                              
a generation  ago; dealing with  those problems earlier  [in life]                                                              
would be advantageous.                                                                                                          
                                                                                                                                
REPRESENTATIVE  TARR referred to  page 8  of the report,  entitled                                                              
"The Economic  Costs of Adverse  Childhood Experiences  in Alaska"                                                              
[prepared  by  Patrick Sidmore,  MSW,  for  ABADA and  the  Alaska                                                              
Mental  Health   Board  (AMHB)  and  included  in   the  committee                                                              
packet],  which read,  "Population  attributable risk  is a  well-                                                              
established method  in epidemiology of determining  the percentage                                                              
of an  outcome which  is linked  back to a  precursor".   She said                                                              
that  this  section  of  the  report   explains  the  science  and                                                              
methodology of determining  the percentages.  She  maintained that                                                              
often health data  is difficult to obtain, and it  is important to                                                              
continue the research.                                                                                                          
                                                                                                                                
REPRESENTATIVE  TARR  mentioned  that  the  All  Alaska  Pediatric                                                              
Partnership  (A2P2)  has  been   encouraging  physicians  to  have                                                              
conversations  [about ACEs]  with  their patients;  Alaska  Native                                                              
Tribal   Health   Consortium  (ANTHC)   has   incorporated   these                                                              
discussions  into  their standard  communications  with  patients.                                                              
She  emphasized  the  importance  of  this  in  dealing  with  the                                                              
intergenerational trauma aspect of ACE.                                                                                         
                                                                                                                                
REPRESENTATIVE  TARR stated that  when one  hears stories  about a                                                              
person getting into  trouble, he/she rarely hears  that the person                                                              
came from  a stable, loving home  with an upbringing  that offered                                                              
opportunity; more often  the person had a great  deal of childhood                                                              
trauma.    She  maintained  that  when  looking  at  these  issues                                                              
through the ACE  lens, instead of asking, Why did  you do that? or                                                              
placing  the  blame  for  the behavior  entirely  on  the  person,                                                              
whether  a  child or  adult,  ask,  What  happened  to you?    She                                                              
maintained that  many of  these behaviors are  the result  of "bad                                                              
things  that have  happened  to  people" and  people  are only  so                                                              
resilient.    Resiliency   comes  from  protective   factors,  and                                                              
protective  factors  include  a  stable, loving  home.    Children                                                              
growing  up  without  protective  factors are  hindered  in  their                                                              
abilities to overcome trauma experiences.                                                                                       
                                                                                                                                
3:34:53 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE JOHNSON  offered that  [ACE] exists to  some degree                                                              
but opined that  the proposed resolution feels  like "big brother"                                                              
intrusion and "social  engineering."  She cited page  3 of Version                                                              
J, lines 23-26,  which read, "take into account  the principles of                                                              
early  childhood   and  youth  brain  development   and,  whenever                                                              
possible,  consider   the  concepts  of  early   adversity,  toxic                                                              
stress,  childhood   trauma,  and  the  promotion   of  resilience                                                              
through protective  relationships, supports,  self-regulation, and                                                              
services".                                                                                                                      
                                                                                                                                
REPRESENTATIVE  TARR answered  that  she disagrees.   She  relayed                                                              
that she grew up  in an abusive household and  watched her brother                                                              
struggle  his  whole  life  until   he  committed  suicide.    She                                                              
expressed  her belief that  what is  proposed under  HCR 2  is not                                                              
social  engineering; children  should  not have  to  be beaten  or                                                              
sexually  abused; children  are  innocent and  have  no choice  or                                                              
power in  the situations into which  they are brought;  and caring                                                              
for  children  is  a  moral  responsibility.    She  reminded  the                                                              
committee  of the 50  reports of  child abuse  or neglect  per day                                                              
coming into  OCS; over 10,000 reports  per year; and in  the month                                                              
of December  there were  several hundred  reports of child  sexual                                                              
abuse.     She  asserted   that  there   are  children   suffering                                                              
unnecessarily,  and  the state  has  a role  to  play  to end  the                                                              
suffering and give these children more opportunities in life.                                                                   
                                                                                                                                
REPRESENTATIVE  JOHNSON  responded  that  she  did  not  say  that                                                              
children should  be abused.   She emphasized that  the legislature                                                              
is not  for abusing  children.   She maintained  that not  passing                                                              
the resolution does  not mean that the legislature  is for abusing                                                              
children.                                                                                                                       
                                                                                                                                
3:38:30 PM                                                                                                                    
                                                                                                                                
CHAIR KREISS-TOMKINS announced that HCR 2 would be held over.