Legislature(1995 - 1996)
02/26/1996 01:08 PM JUD
* first hearing in first committee of referral
= bill was previously heard/scheduled
= bill was previously heard/scheduled
HB 493 - INVOLUNTARY COMMITMENT:ALCOHOL/DRUG ABUSE Number 1830 TOM WRIGHT, staff to Ivan Ivan, read the sponsor statement regarding HB 493 into the record. "Representative Ivan introduced HB 493 as one of the solutions to assist with the public inebriate problem faced by many communities throughout the state. "Under current statute, AS 47.37.190, provisions allow for the involuntary commitment of alcoholics. These provisions allow for 30 day commitments with recommitment for 90 days. This current law has been found to be unwieldy, expensive and treatment options are not readily available. According to a community survey report by the City/Borough of Juneau, in March 1993, communities use the commitment policy sparingly, if they use it at all. This report also stated that the current commitment process simply is not working. "Under HB 493, the involuntary commitment process is similar to those found in the involuntary mental health commitments. "It is not Representative Ivan's intent to impose unlawful restrictions on an individual. However, by using the involuntary commitment process, he hopes that lives may be saved. He also hopes that the financial impacts on different agencies may be lessened if the revolving door process many inebriates find themselves when the protective custody statues are applied." MR. WRIGHT also added that work was done on this legislation with the Department of Law and the Division of Alcohol and Drug Abuse. He noted the CS as well with explanations about the changes to it. Number 1930 ART SNOWDEN, II, Administrative Director, Alaska Court System stated that they had a lot of small questions which they have no answers to and some suggestions about this bill. He did give these questions and suggestions to the sponsor's aid. MR. SNOWDEN referred to page 1, line 7 - 15. The courts want to know if there is a reason why this new commitment standard and the addition of drug abusers was included in the involuntary commitment statute, section 190 and was not included in the emergency commitment statutes section 180. If the current standard is inappropriate for regular commitments, why does it remain appropriate for emergency commitments. These are the types of issues they are most concerned with and felt confident that staff could work these out. He noted their next comment regarded page 1, line 11, and noted that the following words appear to be missing, between the words health and despite, which are "and who continue to use alcohol or drugs." He pointed out as a comparison on page 5, lines 23 and 24 where these words are spelled out. There are additional technical sections such as this which could be cleaned up as necessary. MR. SNOWDEN stated that the fiscal note attached to this legislation is just under $80,000. Their fiscal note could be cut more than in half if some small changes were made. On the original bill and also in the present draft, on page 2, line 26, it is suggested that the court would appoint a guardian ad litem. The courts would have to do this privately and it has a cost. If it was stated rather that the court could appoint the Office of Public Advocacy (OPA), who has guardian ad litem services, then it wouldn't have a cost for the court system. OPA presently has some of the best trained guardian ad litem representatives in the nation. MR. SNOWDEN stated that if the court has to pay for appointed counsel, perhaps it should be in OPA, for example, now the public defender does represent people who have been committed based on mental illness. The only significant comment Mr. Snowden wished to make other than the technical, was that the courts think there is an unworkable provision in the bill, which requires the respondent's next-of-kin be notified of the commitment petition and be given notice of a hearing. It is often the case that respondents in this type of hearing are very transient and uncooperative, or might have mental illness and don't know who their next-of-kin is. It is very hard to make these notifications, if not impossible. The courts believe that this legislation should allow a provision for a waiver of this requirement. If not a waiver, at least a notice in the newspaper. Number 2182 REPRESENTATIVE TOOHEY asked in his long history of handling these involuntary commitments, did Mr. Snowden feel that these ever worked. MR. SNOWDEN pointed out that his job is to administer the court and keep it efficient. He felt as though judge's opinions on this subject would vary. A lot of people might say that it's good to get these individuals off the street since they pose a danger to themselves or others, but there are some people who say that this commitment process would not make a difference one way or another. REPRESENTATIVE TOOHEY said she feared that this type of commitment would be very expensive. She also questioned this procedure being applied in small villages which might not have incarceration facilities. Would these individuals be shipped to Anchorage or Nome? CHAIRMAN PORTER asked if there was a requirement for appointed counsel under the current commitment procedure. MR. SNOWDEN responded that they have done this, but it's very rare. However, the court felt that under the terms of this bill that the appointment of an attorney for indigent people, which would cost over $45,000 of this bill's fiscal note which would go to the private bar. He thought a guardian ad litem provision would cut the cost in half. Number 2300 DON DAPCEVICH, Executive Director, Governor's Advisory Board on Alcoholism & Drug Abuse, testified in support of HB 493. In preparation for this hearing his staff prepared a cost benefit analysis related to commitments, based on commitments executed in the community of Juneau. Juneau is the only community which uses the commitment law presently in place. Mr. Dapcevich was the treatment director for this program in a previous life and he's had the opportunity to bring 35 commitments, a first hand exposure to the process. MR. DAPCEVICH felt as though this commitment process was a humane way to treat people who are not willing or unable to recognize their needs for intervention. The board recognizes that the treatment success rate is fairly low with this population, but the successes which do take place are best measured in a legal sense and a legislative sense, in terms of dollars and cents in relieving human suffering. In the cost analysis, people who undergo treatment under an involuntary commitment have less need for services, such as dependency treatment, medical care and the police services after commitment, much less than before. The cost analysis tracked those people six months prior to their commitment and six months after their commitment to see if there was a difference in their use of a 12 hour hold in community corrections, in emergency room use, transportation of community service patrol and the police transportation associated with administering to them. Mr. Dapcevich noted his staff person, Steve Hamill, was available to answer any questions about the cost benefit analysis. Number 2414 REPRESENTATIVE TOOHEY asked if they had tracked individuals for more than one year and were the summer months considered when natives go back to their villages. Are these people employed. She felt as though one year for a program which costs over a half a million dollars was not a fair way to spend this type of money. Representative Toohey said she was opposed to this because if she wanted to be a size 12, with a 24 inch waist, that's her problem, not his. Nobody is feeding her the food that she eats, nobody is feeding her the alcohol that she drinks. Until she is able to recognize it is her problem then she is the only one who can do anything about this. She felt as though the state, municipalities, and the cities have all tried to take care of this problem. It can't be taken care of by committing someone and forcing them to rehabilitate. It has to come from inside. MR. DAPCEVICH agreed that she should have this choice as long as she can make this rational decision. This program does not deal with people who can make wise choices. They're dealing with people who don't make these choices and if it's not made for them, they create enormous costs to their fellow citizens. He noted an example of one patient who ended up costing over $100,000, someone who could not make a rational choice regarding treatment. He also mentioned the first person he ever committed six years ago who is celebrating his 5th year of sobriety right now. He is a productive member of this community. This program does work to produce permanent sobriety for a long period of time, if not a lifetime, for a very few. For nearly all, it produces some sobriety, some lessening of the burden that their placing on their fellow taxpayers and that's what the board is really concerned about. TAPE 96-24, SIDE B Number 033 REPRESENTATIVE TOOHEY felt as though they were missing the boat and if he thought this is a mental illness problem, then maybe they should be put into a different slot. They should be put in Alaska Psychiatric Institute (API) or somewhere where they are committed mentally. If this is a disease which can only be cured by someone else, rather than the patient, then it might be a whole different ball game. She felt as though they were going about it the wrong way. REPRESENTATIVE DAVID FINKELSTEIN stated that it seemed from the presented analysis that these people are being treated regardless. One way or another they are being treated and the recommendation the committee is receiving is that it's more cost effective to treat under a commitment program. The decision to be made here is what's the best program to run these individuals through, what's best for society and this individual. CHAIRMAN PORTER asked Mr. Dapcevich if it was their intent to track these individuals further than six months after a commitment. MR. DAPCEVICH said absolutely and they wanted to be more comprehensive in the way they track these individuals. They've only been able to track the community of Juneau. Also, they were only able to, in the short time they had to prepare for this hearing, look at the costs in only a few other communities as a comparison. CHAIRMAN PORTER noted an Alcoholic Task Force study and an Ombudsman inquiry regarding Alaska's alcohol problem sometime ago which indicated that the programs tasked to mission to and address these problems really didn't have an evaluation component which was reliable. These studies measured more the amount of people the programs touched, rather than those people's behaviors the programs were able to change. He felt Mr. Dapcevich's analysis is on target in terms of meaningfulness, rather than how many individuals cycle through the system. The longer this evaluation can be extended, the more valuable this information will be. Number 154 REPRESENTATIVE BUNDE asked how this legislation would affect Anchorage's repealed law against public drunkenness. CHAIRMAN PORTER stated that the public drunkenness ordinances around the state were criminal statutes and that this was a civil involuntary commitment procedure. Within the structure that statutorily exists now, this civil procedure has been found not to raise constitutional problems, which criminal statutes do. Generally, he noted a Supreme Court case which found that alcoholism, as opposed to a crime which encompasses intent, is a condition which takes away the ability for a person to make cogent decisions for themselves. Consequently this nullifies the requisite intent requirement for criminal violations. REPRESENTATIVE GREEN pointed out that Mr. Dapcevich had indicated that before commitment there is a $9,000 cost as versus $6,800 after, which is a savings of better than 25 percent. He asked if this included all kinds of inebriants. Does this comparison include some of those who are habitual, as opposed to some of those picked up once or twice. Representative Green also asked if the response of the committed person wanes after a few days or weeks of drying out. MR. DAPCEVICH noted that these individuals are chronic, they don't have the hills and valleys which would normally be seen in a problem drinker. If these people don't have their drink, they go into withdrawal. The detox facilities are taxed around the state, but their taxed by a very small number of people who go through over and over again. The wide majority go through detox once or twice, enter complete treatment and lead productive lives for a period of years, if not a lifetime afterwards. MR. DAPCEVICH pointed out that in regards to evaluation, the legislators should have received the new independent, standards study done regarding the quality and outcomes in treatment throughout the state which was recently published. The assessment regarding these programs was extremely positive and very comparable with the best treatment programs available in other states. The Advisory Board on Alcohol has recently taken the lead in quantifying and qualifying the treatment outcomes in the state. People from their board, treatment providers and state government people have come together to hammer out some standardized outcome measures that will be used for all programs in the state. STEVE HAMILTON, Research Analyst, Advisory Board on Alcoholism and Drug Abuse responded to Representative Green's question about the numbers Representative Green previously cited about what group of people are these, treatable or chronic, or a mix of both which the cost analysis addresses. The numbers for all the commitments were a core of people that were the repeat offenders, people who accessed all of the services, both police, ambulance, hospital, etc. repeatedly. He cited numbers related to one year's worth of consecutive admissions to detox recovery in Juneau. Out of 897 admissions for that year there were 17 individuals who accounted for 231 admissions. This is 4 percent of the people accounted for, 25.4 percent of all of admissions. When this core of 17 individuals are identified, they become the committed population. Other communities have these same core situations. REPRESENTATIVE GREEN asked if they measurably see as an improvement in this hard core, habitual population. If these people, for example, have been in the program for an extended period of time and they go through a commitment program. If it's decided that they're not as bad as they were before, what relatively do they look at to make this determination. MR. HAMILTON stated that they look at the number of times these individuals are subjected to either a Title 47 hold or a detox admission as surrogate markers for impacting the system. In Juneau, when these people start drinking again and it gets out of control they invariably go into detox or a Title 47 hold with the police department. These are the surrogate markers which they use to determine whether they are impacting the system again. Rarely do they show up at the jail or the hospital on their own. REPRESENTATIVE GREEN asked if these individuals do or don't come back as often in the six month period. MR. HAMILTON said they do not come back as often. MR. DAPCEVICH added that they did not look at admissions to detox, but those individuals who went through a 30 or more day commitment It was those people after the commitment who did not come back to detox, did not use the ambulance, etc. CHAIRMAN PORTER stated that detox is where individuals go after the community service patrol finds that person incapacitated. MR. DAPCEVICH added that these individuals, as soon as they're sobered up, they're back on the street. Four or five years ago the board tracked people with 100 detoxes, which were targeted for commitment. Now they target people with far fewer detoxes. In Fairbanks, Dillingham, and Bethel the 12 hour, Title 47 holds are very high and would be impacted dramatically if these communities intervened, even in very small numbers. The board doesn't anticipate a large number of commitments to done once the statute is changed. Mr. Dapcevich said that they're not changing the basic tenants of the statute, but making it more user friendly. The fiscal note for the first year would be zero. Number 667 LOREN JONES, Director, Division of Alcoholism and Drug Abuse, Department of Health and Social Services, testified in support of HB 493 and thought that the issues raised by Mr. Snowden could be worked out. He then outlined the history behind this legislation. The original statute was written back in the 1970's and has not been changed significantly since. The commitment concept has been used on an off-again and on-again basis, often times at the initiative of a particular person who's committed to making this concept work in their community. When this person moves on and changes jobs, the program falls off. The Attorney's Office in the City and Borough of Juneau, supports this program to help alleviate the hospital and police department costs, etc. As noted by the cost analysis, Mr. Jones said that this legislation has some good financial benefits on other parts of the system and have provided individuals with a needed break. MR. JONES said the division would like to take this Juneau example and over the next year work with their providers to identify those high risk persons who are impacting the system in extreme fashions, teach them how build the history required to go to court to undertake a commitment and he pointed out that this is not something they do lightly. In essence, this procedure takes away the individual's liberty and the court system wants to know if other alternatives have been tried before taking these steps of commitment. He said they want to train these people to work with the programs and get them ready. In the second year he hopes there are enough providers interested in trying this program, in order that money gets put aside to off-set the legal costs. MR. JONES stressed that unlike the mental health commitment, the alcohol and drug use commitment is a private one. A spouse, guardian, private physician, and the program director of a private or publicly funded treatment program can do these commitments. In the circumstances of a private facility, they usually don't have an attorney on staff who is familiar with commitments that include clinical diagnosis, medical records, and dealing with the court. There has to be some support for these programs to get the attorneys to represent them. MR. JONES noted that it's obvious from the statements made today there still is an inebriate problem on the streets and because of this most people might think that treatment must not work. Unless the division can reduce the numbers of these people, they will have a hard time convincing people otherwise. This commitment tool will keep these inebriates in a program long enough that their treatment be more effective. He noted the severe cases of people who have done neurological damage to themselves, so extensively that they don't understand the concept of intensive treatments or are unable to hold down a job. They need a place for these individuals. MR. JONES mentioned the issue of a jury trial in the first 30 days if a person requests it. At a recommitment a person can ask for a jury trial and they kept this clause in the new legislation, although not in the first 30 days. This is an impediment, because the time it takes to impanel a jury. The CS goes a long way to fix some of the problems that the Department of Law had with it. Number 1023 REPRESENTATIVE BETTYE DAVIS agreed that this process would make it easier for them to commit people, but she doesn't understand when Mr. Jones says this would decrease costs. She thought it would increase because the money needs to loaded on the front end. There are not enough programs to solve this problem. She asked who would treat these people and where will the beds come from. Number 1070 MR. JONES noted that for them it's a matter of priorities. They realize that the division could put in a large fiscal note, since they have hugh waiting lists, some 500 people. The division has considered putting certain priorities on certain populations for treatment. Pregnant women, for instance, get treatment right away and they anticipate doing these same types of things with persons who they were committed to serve. They're not about to commit someone they don't feel they can bring into treatment. Some individuals may need to wait longer, but these people probably won't have an impact on police, emergency rooms, etc. REPRESENTATIVE DAVIS made the argument that as they begin to put these people at the top of the list, they leave the people on the waiting list even longer. These kinds of people might not be going to hospitals or jails on a regular basis, etc., but their children might be in custody or the children are at home in marginal situations. There has to be some money put in this legislation or the home system will be upset. Number 1188 REPRESENTATIVE FINKELSTEIN assumed that this involuntary commitment is tried where there are beds available in a particular community, at a particular time. The issue of bed availability might affect this legislation, but he noted this involuntary commitment does not get used very much and if it does get used more it will be when beds are available. MR. JONES said that the main reason this commitment process is not used more is because programs feel as though it's a cumbersome process. Attorney's have to be hired. Given even existing beds, if this process was made easier, programs would use it more. Juneau serves a lot of southeast for outpatient and residential treatment. Juneau has been very successful finding places for these people without significantly impacting others. REPRESENTATIVE TOOHEY noted the breakdown of the survey group studied as indicated by race. She pointed out that this is largely a problem that deals with the native community. It's a major problem and something Alaska has been dealing with for years. Number 1379 MR. JONES said that the numbers which Representative Toohey referenced came from the Department of Corrections and deals with those individuals by race who have been put into jail on existing 12 hour protective custody (indisc.). In a five year period, 85 percent of the admissions were individuals committed once, twice or three times. Over five years, this is not a large impact. One person in the study had 170 admissions to a jail in a five year period. This type of person they would like to get into an involuntary program. CHAIRMAN PORTER noted that two things were happening at the same time. He felt as though this legislation was a good idea. A person can't be helped unless they can be held for a certain amount of time based on individual need. Also, the sobriety movement has been embraced by the native population which exemplifies and gives real validity to the movement. It is the best hope this state has ever had, but it has to have the support of this program to help people who need to get to a level where they can recognize the value of sobriety. This legislation will target many of these people, to get them into this position and then many of the communities which have these problems now, along with this sobriety movement, can help these people. REPRESENTATIVE TOOHEY absolutely agreed with these statements and agrees that the sobriety movement has impacts. It's a shining light, but committing over half a million dollars of state money which will be used up anyway... what happens to Indian Health monies, where does their money come in with any kind of mental health. Is there any commitment by the INS to commit to mental health. She questioned what involuntary commitment would come under, whether under mental health, as a physical illness, etc. MR. JONES stated that Indian Health Service currently funds significant portions of the alcohol and drug abuse prevention and treatment effort throughout Alaska. Through their existing contract mechanisms many of the programs use the state's money, Indian Health Service money and local money. This doesn't change under the commitment process. The commitment process is unique by statute to an approved alcohol and drug abuse treatment program. The division approves programs, even those they don't fund. Under existing legislation, an individual can be committed to a private treatment agency, one that receives absolutely no funds. Alcoholism is a complex, physical and psychological disease. It can be successfully treated very well. Alcoholism is not just a mental health problem, a physical problem, or an addiction problem, they all work together. The physical toxicity has to get out of the system before the individual can address the rest of the problem. The division, through the process of commitment is trying to get the body less toxic enough for a person to handle their remaining issues. Number 1697 REPRESENTATIVE BUNDE asked if Mr. Jones could project three to five years down the road how this legislation would impact the programs and does he anticipate what kind of an increased need would exist. MR. JONES noted that this was a long way down the road. If the division instigates a significant amount of commitments, the division may want to do some unique treatment for these individuals in order to move them out of the existing treatment system. This is reflected in the fiscal note. He felt as though the way in which individuals in the substance abuse field are being treated is under a lot of scrutiny and change. Issues around managed care, patient placement, matching a client to appropriate treatments are really making changes in how the division delivers services. He noted a move from less residential into more intensive out patient for those individuals who are able to move into less restrictive kinds of care and treated more cost effectively. MR. JONES added that three years from now Alaska will be further along in this process and new ways of treatment for people of different cultures, or from rural or urban settings across the state will be taken into effect. They will never have enough available to treat everybody on a treatment demand basis. He noted that the division has a strong prevention and education message. Given the resources the division does have and the new state-of- the-art treatment available, he felt as though they could keep their heads above water. Number 1886 REPRESENTATIVE BUNDE asked about these revolving clients helping to pay for their own treatment through private contributions. MR. JONES noted that the department currently requires all of their programs to charge on a sliding fee scale and to look at how a client can contribute to a program. He mentioned clients working off some of their treatment through volunteer work. They also look at the permanent fund as a source of money too. Some of the voluntary commitments may be able to tap veteran's benefits or native corporation benefits, as well as social security monies. The department looks at all of these sources. It is in their statute, that the inability to pay, is not a determinate as to whether or not they receive treatment or whether these individuals stay in treatment. MR. JONES noted that in a lot of ways the permanent fund is untouchable, if a person is on social security and they're medicaid eligible, they can tap these resources, but if they're in an ineligible service status, the programs aren't allowed to bill the patient under federal law. Some of their treatment is not covered under medicaid because of federal rules. In some cases the individual is billed, but they might refuse to pay. There are some limitations. In regards to the permanent fund, a person may not have applied for one, or it might already be seized because of taxes, or child support enforcement, it might be taken by the Department of Corrections for the person's incarceration costs. If an individual has been convicted on felony charges and incarcerated, they are not eligible for the permanent fund. Number 2317 REPRESENTATIVE BUNDE made a motion to adopt CS HB 493 (C/2/26/96) for the committee's consideration. Hearing no objection it was so moved. Number 2395 MR. JONES responded to a question by Representative Toohey regarding situations where an involuntary client might sue the state and what the state is fiscally responsible for in such an instance. He outlined that under a commitment proceeding, the state of Alaska is not involved in the commitment process at all on the legal end. They might be the funder of the treatment program and they do the approval of commitment. Under the commitment act, as it currently stands, the persons who have standing to bring a commitment proceeding are a legal guardian, spouse, etc. TAPE 96-25, SIDE A Number 001 MR. JONES said of the person requests an attorney appointed by the court, then the court would appoint that attorney. Under current law, the state would pay for this service if the person was unable to. REPRESENTATIVE DAVIS requested that when the Department of Law and the Division of Alcoholism and Drug Abuse work the language changes to the legislation, as well as, the numbers regarding the fiscal note, could they also talk to other agencies to see what their impacts will be as they shift this procedure from the court to these other agencies. She would like to know what the costs will be.