Legislature(2015 - 2016)CAPITOL 106

03/17/2015 03:00 PM HEALTH & SOCIAL SERVICES

Audio Topic
03:02:25 PM Start
03:02:51 PM Presentation: Memory Care & Eden Philosophy
03:54:19 PM Discussion: Medicaid Expansion
05:08:14 PM Adjourn
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
"Alaska Pioneer Homes: Memory Care & the Eden
+ Continuing Medicaid Discussion TELECONFERENCED
-- Testimony <Invitation Only> --
+ Bills Previously Heard/Scheduled TELECONFERENCED
                    ALASKA STATE LEGISLATURE                                                                                  
      HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE                                                                     
                         March 17, 2015                                                                                         
                           3:02 p.m.                                                                                            
MEMBERS PRESENT                                                                                                               
Representative Paul Seaton, Chair                                                                                               
Representative Liz Vazquez, Vice Chair                                                                                          
Representative Louise Stutes                                                                                                    
Representative David Talerico                                                                                                   
Representative Geran Tarr                                                                                                       
Representative Adam Wool                                                                                                        
MEMBERS ABSENT                                                                                                                
Representative Neal Foster                                                                                                      
COMMITTEE CALENDAR                                                                                                            
PRESENTATION: MEMORY CARE & EDEN PHILOSOPHY                                                                                     
     - HEARD                                                                                                                    
DISCUSSION: MEDICAID EXPANSION                                                                                                  
     - HEARD                                                                                                                    
PREVIOUS COMMITTEE ACTION                                                                                                     
No previous action to record                                                                                                    
WITNESS REGISTER                                                                                                              
VICKIE WILSON, Acting Director                                                                                                  
Central Office                                                                                                                  
Division of Alaska Pioneer Homes                                                                                                
Department of Health and Social Services                                                                                        
Juneau, Alaska                                                                                                                  
POSITION STATEMENT:  Presented a PowerPoint titled "Memory Care                                                               
& Eden Philosophy" during a presentation by the Alaska Pioneer                                                                  
GINA DEL ROSARIO, Administrator                                                                                                 
Juneau Pioneer Home                                                                                                             
Department of Health and Social Services                                                                                        
Juneau, Alaska                                                                                                                  
POSITION STATEMENT:  Spoke during  the PowerPoint presentation by                                                             
the Alaska Pioneer Home.                                                                                                        
CAITLIN TEASTER                                                                                                                 
Social Services Program Coordinator                                                                                             
Division of Alaska Pioneer Homes                                                                                                
Department of Health and Social Services                                                                                        
Juneau, Alaska                                                                                                                  
POSITION STATEMENT:   Answered questions during  the presentation                                                             
by the Alaska Pioneer Homes.                                                                                                    
ACTION NARRATIVE                                                                                                              
3:02:25 PM                                                                                                                    
CHAIR PAUL  SEATON called  the House  Health and  Social Services                                                             
Standing   Committee    meeting   to    order   at    3:02   p.m.                                                               
Representatives Seaton, Talerico, Stutes,  Vazquez, and Wool were                                                               
present at  the call  to order.   Representative Tarr  arrived as                                                               
the meeting was in progress.                                                                                                    
^Presentation: Memory Care & Eden Philosophy                                                                                  
          Presentation: Memory Care & Eden Philosophy                                                                       
3:02:51 PM                                                                                                                    
CHAIR SEATON announced that the  first order of business would be                                                               
a presentation by the Alaska Pioneer Homes.                                                                                     
3:04:10 PM                                                                                                                    
VICKIE  WILSON,  Acting  Director, Central  Office,  Division  of                                                               
Alaska Pioneer  Homes, Department of Health  and Social Services,                                                               
reported that  she had "been  working in  the field of  aging for                                                               
the past 30 years," primarily  working with individuals with some                                                               
form  of dementia.   She  asked how  many in  the audience  had a                                                               
family member with dementia, or had been a care giver.                                                                          
MS. WILSON  explained that Alzheimer's Disease  was a progressive                                                               
disease  that destroyed  the memory  and  other important  mental                                                               
functions,  and that  it was  one of  the more  common causes  of                                                               
dementia  currently being  diagnosed.   She emphasized  that this                                                               
was a degenerative  disease that would result  in death, although                                                               
it  could go  on  for many  years.   She  stated  that almost  75                                                               
percent of  the residents  of the Alaska  Pioneer Homes  had some                                                               
form of  memory impairment, at  least 50 percent  had Alzheimer's                                                               
Disease,  and that,  as most  had  previously been  in their  own                                                               
homes receiving  community based care,  they had a  more advanced                                                               
stage  of  dementia.   She  directed  attention to  a  PowerPoint                                                               
titled "Memory Care & Eden  Philosophy," and spoke about slide 1,                                                               
"Alzheimer's  and Dementia."   She  reported that  these advanced                                                               
stages  of the  disease  were often  more  aggressive, with  more                                                               
wandering  outside  the home  without  knowing  where they  were,                                                               
hence the  transition into  the Pioneer Homes.   She  shared that                                                               
patients  often perfected  "cocktail conversations,"  superficial                                                               
conversations with no depth which masked the disease.                                                                           
3:08:45 PM                                                                                                                    
MS. WILSON moved on to slide  2, "Transition to Memory Care," and                                                               
reported that the Alaska Pioneer  Homes had begun this transition                                                               
to memory care  in 1996.  She explained that,  although there was                                                               
a  skilled nursing  level in  the facilities,  there was  not any                                                               
care for advanced  cases of dementia so that people  were sent to                                                               
facilities with  no family  or friends nearby.   The  Division of                                                               
Alaska  Pioneer Homes  changed  its course  to  include care  for                                                               
Alzheimer's  Disease, and  created  specialized neighborhoods  in                                                               
the Pioneer  Homes which  were more secure  and cozy,  creating a                                                               
sense of  home.  She  reported that, as this  specialization lead                                                               
to taking on higher risk individuals,  the outer doors in all the                                                               
homes were then  alarmed to provide protection to  all the homes.                                                               
She  detailed that  activities were  tailored to  focus on  their                                                               
abilities for  success, which allowed individuals  to more easily                                                               
reconnect with their  family members.  She said that  some of the                                                               
traditional methods of memory care  for patients had included the                                                               
use  of  anti-psychotic  drugs as  well  as  physical  restraint,                                                               
declaring that "basically they were  warehoused" with no programs                                                               
or activities for  individuals.  She directed  attention to slide                                                               
3,  "Alternative Methods  of Memory  Care,"  noting that  shortly                                                               
after the  Pioneer Homes  accepted dementia care  as part  of its                                                               
mission,  the Eden  Philosophy was  introduced  into the  Pioneer                                                               
Homes.  She  declared that, as Alaskans were  more progressive in                                                               
their thoughts and  ways in which things were  handled, the focus                                                               
had already  begun for person  centered care and getting  to know                                                               
the  people.   She relayed  that the  environments had  been made                                                               
more  stimulating  and  cozy,  animals were  moved  in,  and  the                                                               
residents became a  part of their own care.   She declared that a                                                               
key factor  was to  "know who  the person  was," noting  that the                                                               
homes had  people from all  walks of life.   She reported  that a                                                               
goal for the staff was to  understand who the person was and what                                                               
was their history.                                                                                                              
3:17:01 PM                                                                                                                    
GINA DEL ROSARIO, Administrator,  Juneau Pioneer Home, Department                                                               
of Health and  Social Services, stated that  the Eden Alternative                                                               
Philosophy  had  inspired  all  of the  staff  to  transform  the                                                               
environment for the  elders and care partners, slide  4, in order                                                               
to  promote a  truly home  like environment.   She  declared that                                                               
there were no  more nursing stations, which had  been replaced by                                                               
tables  and  chairs, dubbed  the  "hot  spot plaza"  for  reading                                                               
newspapers and  having coffee  and donuts.   She shared  that the                                                               
staff  stayed away  from wearing  uniforms to  instead promote  a                                                               
home like environment, with the  ultimate goal for elimination of                                                               
the  three  main  issues for  elders:  boredom,  loneliness,  and                                                               
MS.  WILSON interjected  that these  issues  were considered  the                                                               
plagues of any nursing care.                                                                                                    
MS.  DEL  ROSARIO  explained  that  the  transformation  included                                                               
bringing  plants,  cats,  dogs,  and children  into  the  Pioneer                                                               
Homes, as the purpose was  to promote intergenerational contacts.                                                               
She emphasized  that this also  promoted respect for  the elders,                                                               
reminding   everyone  that,   first  and   foremost,  they   were                                                               
individuals with unique  identities.  She pointed  out that, even                                                               
with dementia, many  of the patients still had  memories of those                                                               
happy days.  She  shared that the staff tried to  get to know the                                                               
likes and  dislikes of  the patients, what  were they  most proud                                                               
of, what  made them  happy or  mad, and  what was  their favorite                                                               
food,  as those  individualities  allowed for  a person  centered                                                               
approach.   She declared that the  environment promoted continued                                                               
growth.   She offered an anecdote  of a resident who  had arrived                                                               
only with thoughts of death, but  had then realized how much life                                                               
there  was  within  the  Pioneer  Home.    She  stated  that  the                                                               
residents were given autonomy for many of their decisions.                                                                      
MS.  WILSON reported  that the  residents of  all the  homes were                                                               
allowed  to be  out in  the  community, often  sharing their  own                                                               
insights  for places  to eat  or  visit.   She said  that it  was                                                               
important  to maintain  interactions to  slow the  advancement of                                                               
the disease.                                                                                                                    
3:25:05 PM                                                                                                                    
MS.  DEL  ROSARIO  emphasized  the need  for  residents  to  have                                                               
choices, so they  would feel freedom within the  Pioneer Home, as                                                               
it  was important  for each  individual to  continue to  explore.                                                               
She  directed attention  to slide  7, and  stated that  residents                                                               
needed a sense of security, to  feel safe.  She stressed that, no                                                               
matter the imparity  of memory, the basic [needs]  do not change:                                                               
respect, love, and genuine care.                                                                                                
MS. WILSON  shared that, for many  people who had been  living on                                                               
the  street, at  the  end  of their  lives,  if  they were  given                                                               
respect it could change their whole life.                                                                                       
MS. DEL ROSARIO stated that  the residents could feel whether the                                                               
care was genuine,  regardless of the stage of  dementia, as those                                                               
feelings could  transcend.   She noted that  the staff  worked to                                                               
provide opportunities for  the residents to enjoy  life, slide 8,                                                               
pointing out that  the residents freely offered  words of wisdom.                                                               
She declared that there were many  ways to make a positive impact                                                               
to  people   with  Alzheimer's   Disease  without   resorting  to                                                               
MS.  WILSON shared  a story  about a  truck stop  with incredible                                                               
pies and  milkshakes where  the residents  would visit,  slide 9,                                                               
"Enjoying a Special Treat."                                                                                                     
MS. DEL ROSARIO moved attention  to slide 10, and emphasized that                                                               
the person centered  approach had been practiced  for many years,                                                               
as  well as  relationship building  and continuing  education for                                                               
care partners and  families.  She said that  providing events and                                                               
activities to make life more  enjoyable, to make people grow, and                                                               
to inspire the elders were all very important.                                                                                  
MS. WILSON  said that each  of the homes had  different community                                                               
provided  services, which  included river  tours, cruises,  and a                                                               
variety  of  community  involvement.   She  lauded  the  core  of                                                               
thousands of volunteers that helped  provide entertainment in the                                                               
MS. DEL  ROSARIO shared slide 11,  stating that two of  the homes                                                               
had started  using music to  inspire and promote awareness.   She                                                               
said that  the staff would  learn the residents'  favorite music,                                                               
and record  these on  i-pods with headsets.   She  concluded with                                                               
slide 12,  "Pioneers' Home Mission,"  and read:   providing elder                                                               
Alaskans  a  home and  community,  celebrating  life through  its                                                               
final breath."  She said  that she could not over-emphasize their                                                               
gratefulness that  the great State  of Alaska continued  to honor                                                               
its elders  by continuing to  provide this program of  support to                                                               
the people who contributed so much to Alaska.                                                                                   
MS. WILSON said that it was a blessing.                                                                                         
MS. DEL  ROSARIO shared that  working at the Alaska  Pioneer Home                                                               
was a great way  for her to honor her dad, to  give back and make                                                               
a difference.  She added that  her sister had also worked for the                                                               
past 10 years at the Pioneer Home in Ketchikan, Alaska.                                                                         
3:35:46 PM                                                                                                                    
REPRESENTATIVE  STUTES  commented  that  she was  a  recent  past                                                               
president of the  Pioneers of Alaska of Kodiak, and  that she had                                                               
a lot  of exposure  to people  with family  in the  Pioneer Home,                                                               
declaring that  it was "a tremendous  gift to the people  of this                                                               
MS. WILSON said  that there had always been  a strong involvement                                                               
with the pioneers in Fairbanks.                                                                                                 
REPRESENTATIVE WOOL  asked how many  pioneer homes there  were in                                                               
MS. WILSON replied that there were 6 homes, with about 499 beds.                                                                
CHAIR SEATON asked if there was a waiting list.                                                                                 
MS.  WILSON replied  that the  beds varied  as to  the levels  of                                                               
care, and that  there were not enough beds to  meet the needs for                                                               
the higher  level of care.   She reported that the  Pioneer Homes                                                               
across the  state were about 90  percent full, and that  the wait                                                               
list varied  per community.  She  said that there were  more than                                                               
5,000 people on  the inactive waiting list, each of  whom were at                                                               
least 65 years of age with at  least one year of residency in the                                                               
state.   She  said that  the application  date set  each person's                                                               
time to  be added.  She  relayed an anecdote about  living in the                                                               
home you were managing.                                                                                                         
MS. DEL  ROSARIO added that collaboration  and communication with                                                               
the families, volunteers,  and staff was a  very important factor                                                               
for successful  care of the elders.   She relayed that  "it truly                                                               
takes a  community to raise  an elder."  She  encouraged everyone                                                               
to sign up for the Alaska  Pioneer Homes when they reach 65 years                                                               
of age so they have their priority date set.                                                                                    
REPRESENTATIVE  TARR reflected  on  the recent  recognition of  a                                                               
need to  the higher  level of  care for  aging populations.   She                                                               
asked  about early  intervention  services, specifically  through                                                               
Medicaid Expansion, and if these  were opportunities to assist in                                                               
a delay of the onset for the more severe symptoms.                                                                              
MS.  WILSON offered  her belief  that  community based  services,                                                               
including in-home  and respite care,  were growing.   She pointed                                                               
out  that the  Medicaid  waivers provided  those  services.   She                                                               
declared that  approximately 50 percent  of the residents  at the                                                               
Pioneer Homes  were able  to afford  the care.   She  opined that                                                               
Medicaid Expansion  would offer  a waiver  to allow  diagnosis of                                                               
the  disease,  and  then  also qualify  for  eligibility  to  the                                                               
services waiver.                                                                                                                
CHAIR SEATON asked about the active  wait list, as opposed to the                                                               
inactive wait list.                                                                                                             
MS.  WILSON estimated  that there  were about  400 people  on the                                                               
active wait  list, although  it varied  from home  to home.   She                                                               
said that  the shortest  active wait  list was  20 people  at one                                                               
home; whereas, the  longest active wait list was about  90 - 100.                                                               
She pointed  out that this was  most often for the  highest level                                                               
of care, and that  the beds at that level did  not empty out very                                                               
CHAIR  SEATON asked  for the  probable  length of  time from  the                                                               
active wait list to admission.                                                                                                  
MS.  WILSON replied  that  this  depended on  the  date a  person                                                               
signed up,  noting that  some people  needed specialized  care as                                                               
they were  at risk for leaving  the facility.  She  reported that                                                               
the current  active wait list in  Fairbanks and Juneau was  4 - 5                                                               
MS. DEL ROSARIO shared that  Sitka historically had shorter times                                                               
on  the active  wait list,  adding that  the vacancies  were also                                                               
dependent on male  or female, as opposite sexes  were not allowed                                                               
to share a room, unless they were a couple.                                                                                     
CHAIR SEATON asked if the wait list  was for a home in a specific                                                               
MS. WILSON replied that the  application included a list for home                                                               
placement by priority, as well as  the option to be placed on all                                                               
five Pioneer Home waiting lists.   She noted that many people did                                                               
not want to live that far from  their home.  She pointed out that                                                               
veterans were given a priority for  75 percent of the beds at the                                                               
Palmer Veterans Home.                                                                                                           
CHAIR SEATON asked if the  Mediset issue regarding individualized                                                               
prescription packaging had been resolved.                                                                                       
MS.  WILSON  replied that  there  had  been  a change  which  had                                                               
allowed  for individual  packaging.   She relayed  that this  was                                                               
done by a pharmacy within the system.                                                                                           
REPRESENTATIVE TARR  asked if the  Palmer Pioneer Home  model for                                                               
veteran preference was being looked at in other homes.                                                                          
MS.  WILSON  explained  that,  as  the  Veterans  Home  did  give                                                               
preference, any  changes to  the system on  a larger  scale would                                                               
require discussion for those limitations.   She relayed that this                                                               
had been discussed a long time ago.                                                                                             
3:49:05 PM                                                                                                                    
CAITLIN  TEASTER, Social  Services Program  Coordinator, Division                                                               
of  Alaska  Pioneer  Homes,  Department   of  Health  and  Social                                                               
Services,  replied  that  it would  require  75  percent  veteran                                                               
occupancy to be included as a  Veterans Home, which would cut off                                                               
a  lot of  Alaskan  pioneers.   She shared  that  there had  been                                                               
discussion for changes  to sections of each  home, weaning toward                                                               
larger  veterans  occupancy,  and   thereby  allowing  access  to                                                               
Veterans Administration funding.                                                                                                
REPRESENTATIVE  TARR acknowledged  that, as  Alaska had  an aging                                                               
population  and the  largest veterans  population per  capita, it                                                               
was good  to have discussions regarding  opportunities to provide                                                               
good care to elders.                                                                                                            
CHAIR SEATON  reiterated that,  although no  one was  exempt from                                                               
Alzheimer's Disease,  the primary focus  of the House  Health and                                                               
Social  Services   Standing  Committee  was  for   prevention  of                                                               
disease.   He directed attention  to a series of  eight different                                                               
peer  reviewed  scientific  studies  between 2013  -  2015  which                                                               
reviewed the delay  of onset and the prevention by  at least half                                                               
for  the occurrence  of  dementia and  Alzheimer's  Disease.   He                                                               
shared that  the community should  be made aware that  there were                                                               
things that could be done to slow down the onset.                                                                               
MS. WILSON replied that she was  aware of several of the studies,                                                               
and  that the  Pioneer Homes  did Vitamin  D blood  draws on  its                                                               
residents, and that supplements were offered by the providers.                                                                  
CHAIR SEATON said that there was  a new study from Sweden for the                                                               
geographic distribution  of Alzheimer's Disease, noting  that the                                                               
rate of the disease increased the  further north.  He pointed out                                                               
that Sweden  was at a similar  latitude to Alaska.   He said that                                                               
it was  not being suggested  that there was  a single cause.   He                                                               
expressed his support for nutritional  sufficiency in the Pioneer                                                               
3:53:46 PM                                                                                                                    
The committee took a brief at-ease.                                                                                             
^Discussion: Medicaid Expansion                                                                                               
                 Discussion: Medicaid Expansion                                                                             
3:54:19 PM                                                                                                                    
CHAIR SEATON announced  that the next order of  business would be                                                               
continuation of  earlier discussions  on Medicaid Expansion.   He                                                               
shared future plans for ongoing presentations and discussion.                                                                   
REPRESENTATIVE TARR  referenced a  one page memo  of suggestions,                                                               
which  included,  super utilizers  and  over  utilization of  the                                                               
emergency rooms.   She offered her belief that  this issue should                                                               
be  focused  upon  as  it  offered  the  opportunity  to  discuss                                                               
successful reforms already  started and how these  reforms can be                                                               
built upon  to bring  more efficiency to  the program  and reduce                                                               
costs.   She reported  that the issue  for super  utilizers first                                                               
came  to  light  during  a  presentation  to  the  House  Finance                                                               
Committee  early last  year, and  she  offered an  example of  an                                                               
individual  super  utilizer  who  added extra  costs  from  these                                                               
emergency room visitations.  She  reminded the committee that the                                                               
presentation  by Commissioner  Davidson had  discussed the  early                                                               
success for  this as one of  the current reform measures,  with a                                                               
goal for  expansion to address  more individuals that  were super                                                               
utilizers.  She  said that this would  accomplish several things,                                                               
citing "the right care, at the  right time, for the right price."                                                               
She  declared that  this was  a great  opportunity to  build this                                                               
component  into the  Alaska health  care system.   She  suggested                                                               
that  this could  incorporate the  patient centered  medical home                                                               
model, a  more holistic  approach to  overall health  needs which                                                               
was the  right type  of care  and less costly.   She  offered her                                                               
belief that several million dollars  had already been saved, with                                                               
a  future savings  target of  a few  million dollars  more.   She                                                               
asked  about  a  report  that Chair  Seaton  had  requested  from                                                               
Legislative Research Services.                                                                                                  
CHAIR SEATON  offered his  belief that many  minds would  need to                                                               
work together  for a  solution to super  utilizers, to  get these                                                               
super utilizers to  understand that there was  better health care                                                               
in a  more appropriate  environment.   He reminded  the committee                                                               
that  signups for  Medicaid would  be  voluntary, as  it was  not                                                               
4:01:19 PM                                                                                                                    
REPRESENTATIVE TALERICO  asked about  the potential  for Medicaid                                                               
payments to help people purchase private insurance.                                                                             
CHAIR  SEATON  suggested  that  this  question  be  submitted  to                                                               
Department  of Health  and Social  Services.   He asked  that any                                                               
articles be shared  with the other committee members.   He stated                                                               
that  they  were looking  for  a  solution  to  fill the  gap  in                                                               
Medicaid coverage created by the U. S. Supreme Court.                                                                           
REPRESENTATIVE  TARR  offered her  belief  that  this was  taking                                                               
place in  some other states,  possibly Arkansas, and that  it was                                                               
possible to apply  for a waiver.  She mused  that some states had                                                               
not negotiated  the correct waiver,  suggesting a  discussion for                                                               
the metrics to  the correct waiver for Alaska.   She relayed that                                                               
the  overall  goal  was  to  bring down  the  rates  for  private                                                               
insurance payers.                                                                                                               
CHAIR SEATON  noted that  insurance for people  who have  not had                                                               
insurance was a high cost model,  especially if there was not the                                                               
90,  95,   and  100  percent   reimbursement  from   the  federal                                                               
government.   He  declared that  expensive care  in Alaska  was a                                                               
problem and there needed to be a  way to reduce the cost of care.                                                               
He questioned  whether super utilizers  were also found  in Rural                                                               
REPRESENTATIVE  TARR reflected  on the  aforementioned report  on                                                               
super utilizers,  stating that  25 percent of  them lived  in her                                                               
constituency neighborhoods.   She  relayed that  a look  at where                                                               
people  live and  where the  bus route  was could  help determine                                                               
these neighborhoods,  especially when a  hospital was on  the bus                                                               
route as it  was the only form of transportation  for many of the                                                               
super utilizers.  She shared that  there was a proposal to open a                                                               
primary health care  clinic in one of her  neighborhoods, but she                                                               
questioned  whether Medicaid  would  pay  for those  individuals'                                                               
CHAIR SEATON pointed out that  whereas hospitals were required to                                                               
offer charity care,  primary clinics were not required  to do so.                                                               
He shared that the hospital in  Homer had bought two of the local                                                               
REPRESENTATIVE  TARR reflected  on individuals  trying to  access                                                               
mental health care services through  the hospital emergency rooms                                                               
and other facilities  "not well situated to provide  that kind of                                                               
care."   She questioned  whether this  situation would  change if                                                               
there was Medicaid Expansion to  allow for access to other health                                                               
care services.                                                                                                                  
CHAIR  SEATON  opined that  this  was  a  big issue  in  Medicaid                                                               
Expansion, as it  required parity for mental  and physical health                                                               
treatment.   He commented that, as  there were a lot  of Alaskans                                                               
with behavioral  health issues,  it would  be interesting  to see                                                               
how  those services  were brought  up  and running  to serve  the                                                               
needs of an expanded population.                                                                                                
4:10:09 PM                                                                                                                    
REPRESENTATIVE WOOL  reported a result  of the closure  of mental                                                               
health facilities  in many  states was  for a  lot of  the mental                                                               
health population  ending up  in jails, where  there was  not any                                                               
treatment,  and  which  only  incurred   more  state  debt.    He                                                               
expressed hope that  there would be some relief of  stress to the                                                               
prison  system  in Alaska  if  those  incarcerated primarily  for                                                               
mental health  issues could be  treated outside the  system, with                                                               
Medicaid making the payments.                                                                                                   
REPRESENTATIVE  TARR   pointed  to   potential  savings   in  the                                                               
corrections budget,  as incarceration was not  the best treatment                                                               
for individuals  with mental  health issues.   She  declared that                                                               
she was passionate  about showing a greater respect  and care for                                                               
neighbors with these  mental health challenges.   She shared that                                                               
an  individual without  access to  primary care  and specifically                                                               
access  to  the  services  for  medication,  could  not  be  well                                                               
regulated in  their behaviors which often  lead to confrontations                                                               
with  the legal  system, and  then  back into  corrections.   She                                                               
reflected  on the  cost to  each of  these systems  while dealing                                                               
with this problem, suggesting that  these dollars could be better                                                               
spent.   She declared  her passion  to better  meet the  needs of                                                               
people for  improving health outcomes,  and allowing  Alaskans to                                                               
live better lives.  She relayed  that it often took several times                                                               
for an individual to deal  with breaking a serious addiction, and                                                               
that going  to jail  did not  support this.   She  suggested that                                                               
outcomes   would  be   much  improved   if   there  was   earlier                                                               
intervention  with  "a good  strong  support  network and  social                                                               
safety net programs."                                                                                                           
4:15:44 PM                                                                                                                    
CHAIR SEATON  reported that he  had met with the  commissioner of                                                               
the Department of Corrections (DOC).   He declared that there was                                                               
not  any data  regarding nutritional  deficiency and  an adequate                                                               
supplement  for   the  hormone  against  depression   which  also                                                               
regulated the  immune system,  Vitamin D.   He lauded  the Alaska                                                               
Pioneer Homes for recognition to the  necessity of Vitamin D.  He                                                               
reported that  there was currently  data which looked at  all the                                                               
worldwide  randomized control  trials  on Vitamin  D without  any                                                               
biological flaws in the data.   He stated that these trials found                                                               
that raised Vitamin  D levels had the same overall  effect to the                                                               
population as  anti-depressant drugs.   He  pointed out  that, as                                                               
these  drugs were  considered  an  adequate treatment,  something                                                               
else that people  could manufacture though their  own skin should                                                               
be  addressed.    He  declared   the  need  to  provide  adequate                                                               
nutrition in the  corrections system.  He said that  only one bad                                                               
interaction between  an officer  and an inmate,  either suffering                                                               
from depression from  inadequate Vitamin D, would  cost more than                                                               
an entire  budget to  pay for  Vitamin D for  everyone.   He said                                                               
that  there was  not any  data  that said  that it  was good  for                                                               
people  to  be kept  in  a  deficient state  of  Vitamin  D.   He                                                               
declared  that he  would bring  this issue  to discussions  about                                                               
corrections and ways to keep the prison population lower.                                                                       
4:19:45 PM                                                                                                                    
REPRESENTATIVE  TARR read  from a  case  that the  U. S.  Supreme                                                               
Court  was considering:    "if the  Supreme  Court rules  against                                                               
subsidies, any  exchange not  operated by  the state  itself will                                                               
lose the ability to help  people pay for their health insurance."                                                               
She stated  that this would  impact Alaska, as Alaska  had chosen                                                               
not to do  its own state exchange, but  had, instead participated                                                               
in the federal  exchange.  She relayed that, in  2014, 88 percent                                                               
of the  people who  enrolled on  the exchange  received subsidies                                                               
and  that should  Medicaid  Expansion not  become  a reality  for                                                               
Alaska, it was not known what  would happen to Alaskans if the U.                                                               
S. Supreme Court ruled against  the subsidies.  She declared that                                                               
it was necessary to understand the  impacts of this court case on                                                               
those people who were already receiving subsidies.                                                                              
CHAIR SEATON  clarified that the subsidies  for private insurance                                                               
was not  the proposed Medicaid  Expansion population.   He stated                                                               
that if this  was not worked out, it was  unknown "how the system                                                               
might fall  apart if all of  those that are getting  subsidies in                                                               
private insurance are no longer able to do that."                                                                               
REPRESENTATIVE STUTES asked for a definition of the exchange.                                                                   
REPRESENTATIVE  TARR explained  that  it was  the federal  market                                                               
place, as the  State of Alaska had not created  its own exchange.                                                               
She  pointed  out that  Alaskans  buying  health insurance  as  a                                                               
result  of the  Patient Protection  and Affordable  Care Act  was                                                               
usually  done  through  this  federal  exchange.    She  directed                                                               
attention to those  people eligible for a subsidy  with an income                                                               
that was 100 - 400 percent  of the federal poverty level, whereas                                                               
anyone below  100 percent  were not  eligible.   She acknowledged                                                               
Chair  Seaton's definition  that Medicaid  Expansion would  cover                                                               
people  below 138  percent of  the  federal poverty  level.   She                                                               
asked  about people  in  the 100  - 138  percent  of the  federal                                                               
poverty  level  who  were  eligible for  a  subsidy  through  the                                                               
exchange, but  could not afford  to purchase health  insurance if                                                               
the subsidy was discontinued.                                                                                                   
CHAIR SEATON  said that this  should be answered at  the upcoming                                                               
discussion on Medicaid as he was also unsure of the answer.                                                                     
4:23:29 PM                                                                                                                    
REPRESENTATIVE  WOOL  acknowledged  that  he  had  bought  health                                                               
insurance  through   the  federal   exchange  and  that   it  was                                                               
subsidized  so what  would otherwise  be expensive  insurance was                                                               
more affordable.  He shared  that losing the subsidy would affect                                                               
those  with lower  income,  offering his  belief  that "it  would                                                               
really turn  the health care world  on its head.   They'd have to                                                               
redo the whole thing."                                                                                                          
CHAIR  SEATON  pointed  out  that   this  was  not  the  Medicaid                                                               
population, except  for the  possibility of  those in  the window                                                               
between 100 - 138 percent of the federal poverty level.                                                                         
REPRESENTATIVE  TARR   asked  whether   an  individual   who  had                                                               
purchased health care  would return to being a  super utilizer if                                                               
there  was not  any  Medicaid Expansion  and  no health  exchange                                                               
subsidy.  She questioned this cost to the system.                                                                               
CHAIR SEATON said  that it was a known cost  prior to the Patient                                                               
Protection and Affordable Care Act,  so that, even with repeal of                                                               
the exchange,  an expansion  of Medicaid  would still  cover that                                                               
lower income population.                                                                                                        
REPRESENTATIVE  WOOL   shared  discussions  he  had   heard  that                                                               
Medicaid  Expansion could  create  a  disincentive for  increased                                                               
employment, as  this could remove eligibility  for Medicaid, even                                                               
though the  federal subsidy [through  the Patient  Protection and                                                               
Affordable   Care  Act]   would  still   keep  health   insurance                                                               
affordable.   He allowed that there  could be some truth  to this                                                               
dependent upon the outcome of King v. Burwell.                                                                                
4:28:53 PM                                                                                                                    
REPRESENTATIVE  TARR declared  that  Alaska was  an aging  state,                                                               
with a "silver  tsunami" heading in its direction,  as Alaska had                                                               
the  fastest growing  senior population  [in the  country].   She                                                               
expressed her agreement that there  must be a focus on prevention                                                               
and early  intervention.   She noted  that preventative  care was                                                               
required under  the Patient Protection  and Affordable  Care Act,                                                               
pointing out  that this was  much less expensive,  especially for                                                               
home and community  based services, and she  expressed her desire                                                               
that the  state policies reflect  the commitment to elders.   She                                                               
offered her belief that the state  had previously not done a good                                                               
job for low cost services.                                                                                                      
CHAIR SEATON  reflected on discussions of  prevention and studies                                                               
regarding  delay  in the  risk  of  occurrence  and the  rate  of                                                               
Alzheimer's Disease.                                                                                                            
REPRESENTATIVE  VAZQUEZ  said   that  [Medicaid]  expansion  only                                                               
provided Medicaid  for those  aged 18  - 65  years, and  that, as                                                               
anyone younger  than 65  years was not  elderly, she  was unclear                                                               
for the  statement regarding Medicaid providing  more services to                                                               
seniors.   She declared  that seniors  were covered  by Medicare.                                                               
She  expressed her  serious concern  for the  costs and  equities                                                               
with a  possible expansion.   She relayed that the  current group                                                               
of eligible  individuals were funded  with a federal match  of 50                                                               
percent  and  that  the  expansion  population  would  include  a                                                               
younger population funded  at much higher levels,  which would be                                                               
progressively  reduced  to  a  90 percent  federal  match.    She                                                               
declared that  there would  be a  temptation to  cut back  on the                                                               
first  eligible population,  the  elderly and  disabled, as  they                                                               
were only  funded at 50 percent  federal match.  She  stated that                                                               
there  would  also  be  pressure  as  there  was  a  shortage  of                                                               
providers, especially  for Medicare  patients.  She  opined that,                                                               
as Anchorage  had a shortage  of providers, it would  take months                                                               
for an  elder on  Medicare to  get care.   She stated  that there                                                               
were  equity issues  with  expansion, as  the  veterans' and  the                                                               
elderly would have less benefit.                                                                                                
CHAIR SEATON  suggested that  it would  be best  to take  each of                                                               
these issues  one at a  time.   He noted that  Medicaid Expansion                                                               
would  create a  population that  was healthier  when it  reached                                                               
eligibility for  Medicare, as  they would  have had  health care.                                                               
He clarified that  it had not been proposed for  Medicaid to take                                                               
over Medicare.                                                                                                                  
REPRESENTATIVE  VAZQUEZ  replied  that  many  issues  were  being                                                               
researched regarding  Medicaid and Medicaid Expansion.   She said                                                               
that  some  studies were  counter  intuitive,  that the  Medicaid                                                               
population, even  though they  have access to  care, "may  not do                                                               
better overall in health."                                                                                                      
CHAIR  SEATON asked  that  this information  be  shared with  the                                                               
committee.   He suggested  addressing whether  Medicaid Expansion                                                               
would  influence the  population  which currently  received a  50                                                               
percent reimbursement.  He opined  that it was not being proposed                                                               
to expand  coverage into  that program.   He questioned  how this                                                               
program would influence Medicare for its adequacy of care.                                                                      
REPRESENTATIVE WOOL offered his belief  that people over 65 years                                                               
of age  could still  get Medicaid,  dependent on  their financial                                                               
situation.   He opined that there  was also an asset,  as well as                                                               
an income, parameter.                                                                                                           
CHAIR  SEATON stated  that the  Department of  Health and  Social                                                               
Services would  discuss the integration of  Medicaid and Medicare                                                               
in an upcoming committee meeting.                                                                                               
4:39:44 PM                                                                                                                    
REPRESENTATIVE  TARR   stated  that  an  advantage   of  Medicaid                                                               
Expansion  was that  more people  had  more access  for a  longer                                                               
period  of their  life,  and  she spoke  about  the benefits  for                                                               
preventative services and the continuum  of care.  She offered an                                                               
example of  adult onset diabetes,  that the  corresponding issues                                                               
were less problematic and less costly if addressed earlier.                                                                     
REPRESENTATIVE VAZQUEZ  said that  people with  no income  or low                                                               
income were  able to  go the  Anchorage Neighborhood  Clinic, and                                                               
were charged  on a  sliding scale  based on  income.   She stated                                                               
that there was  some health care available,  and she acknowledged                                                               
that it could be made better.                                                                                                   
REPRESENTATIVE VAZQUEZ  expressed her  concern for  the projected                                                               
cost  to Medicaid  Expansion,  stating that  it  was the  biggest                                                               
driver in the state budget.                                                                                                     
CHAIR SEATON asked if she  was referencing the chart, "The Bottom                                                               
Line:" [Included in  members' packets] put together  by the Lewin                                                               
REPRESENTATIVE  VAZQUEZ explained  that  she  was addressing  the                                                               
projected costs by the Lewin  Group, Evergreen Economics, and the                                                               
projected state  savings by the  Department of Health  and Social                                                               
Services.  She offered her belief  that the cost to the state was                                                               
unknown, and  that it  was necessary  to be  "extremely careful."                                                               
She  suggested  that, from  the  experience  of other  states,  a                                                               
change  and  flexibility  to  the  program  was  not  necessarily                                                               
allowed.  She cited some examples.                                                                                              
CHAIR SEATON  offered his understanding  that there was  a letter                                                               
to the State of Alaska  which itemized the repayment schedule and                                                               
the ramp down procedure should  the state decide to withdraw from                                                               
Medicaid Expansion.   He offered his belief that  the state would                                                               
be able to opt out if it supplied a transitional plan.                                                                          
REPRESENTATIVE  TARR referenced  the history  of eligibility  for                                                               
Denali Kid  Care with its  original basis  on 200 percent  of the                                                               
federal  poverty level,  which  was subsequently  lowered to  175                                                               
percent of the federal poverty  level, then had its income levels                                                               
frozen, which were  later unfrozen, although the  attempt to move                                                               
the basis  back to 200 percent  of the federal poverty  level was                                                               
defeated.   She reported that over  the life of this  program the                                                               
state  had been  able to  make modifications,  and that  this had                                                               
been done  openly to the  public, so that, if  necessary, changes                                                               
could be  made to the  Medicaid Expansion program should  they be                                                               
4:47:34 PM                                                                                                                    
CHAIR  SEATON  noted that  there  was  the  question of  cost  or                                                               
savings to the  State of Alaska.  He pointed  out that the Alaska                                                               
Mental  Health  Trust  Authority  had  volunteered  to  pay  $1.5                                                               
million of  administrative costs for  the first year.   He stated                                                               
that  those hospitals  currently  offering charity  care with  no                                                               
reimbursement,   which   would   then  shift   to   100   percent                                                               
reimbursement,  should  voluntarily   contribute  back  into  the                                                               
program as  the state was  absorbing all the risk  for converting                                                               
charity  care  to reimbursable  care.    He clarified  that  this                                                               
contribution  could  not be  mandatory  or  a  tax, as  this  was                                                               
illegal  under   federal  law,   although  nothing   prevented  a                                                               
voluntary  contribution to  the state.   He  asked for  any other                                                               
ideas of money to help pay  for expansion, which was estimated to                                                               
bring  in about  $145 million  to  the private  providers in  the                                                               
state  during  the first  year,  should  the program  include  an                                                               
estimated 50  percent of the  eligible participants.   He pointed                                                               
out that  more than $300  million would  be spent in  the private                                                               
economy of  the state should  all the eligible  recipients enroll                                                               
in the program.  He noted  that it was necessary to balance these                                                               
private  jobs with  the potential  risk to  the state  should the                                                               
savings not be  as much as projected, and the  state was actually                                                               
having  to  expend money.    He  questioned whether  the  private                                                               
industry was willing to voluntarily offset  some of the risk.  He                                                               
offered  his hope  that there  could  be a  secure mechanism  for                                                               
offsetting some of the state risk.                                                                                              
REPRESENTATIVE VAZQUEZ said that  uncompensated care by hospitals                                                               
was   paid   for   by   Medicaid   and   Medicare   through   the                                                               
disproportionate payments.                                                                                                      
CHAIR SEATON relayed his understanding  from DHSS that almost 100                                                               
percent  of  those  payments  went  to  API,  and  the  hospitals                                                               
themselves did not get the reimbursement.                                                                                       
REPRESENTATIVE  VAZQUEZ stated  that  the  hospitals had  offered                                                               
figures for their  net income in 2013, and not  for the requested                                                               
information regarding  their receipts for  disproportionate share                                                               
payments resulting from uncompensated care.                                                                                     
CHAIR  SEATON said  that it  would be  necessary to  separate the                                                               
monies for "who receives what."   He suggested that, as the state                                                               
received the money  and distributed it, it should  be possible to                                                               
find the exact distribution.                                                                                                    
4:54:49 PM                                                                                                                    
REPRESENTATIVE  TARR suggested  that  the Anchorage  Neighborhood                                                               
Health Center could answer questions at the upcoming discussion.                                                                
CHAIR SEATON  offered his  agreement, and  pondered if  there was                                                               
any other organization  in Juneau that would  like to participate                                                               
in this discussion.                                                                                                             
REPRESENTATIVE  WOOL  referenced  the  various  reports  for  the                                                               
projected costs,  if any, to the  state, which he declared  to be                                                               
the  crux of  the issue.    He stated  that the  validity of  the                                                               
numbers seemed  to be in question.   He pointed to  the report by                                                               
the Lewin  Group, noting  that they were  a subsidiary  of United                                                               
Health,  the  largest private  health  insurance  company in  the                                                               
country.  He suggested that this  group could have an interest in                                                               
whether  someone purchased  public or  private health  insurance,                                                               
and  that there  had been  a lot  of speculation  for a  possible                                                               
conflict of interest.                                                                                                           
CHAIR SEATON  pointed out  that the other  issue of  disparity in                                                               
the  reports  was for  the  reimbursement  rates by  the  federal                                                               
REPRESENTATIVE VAZQUEZ  added that  DHSS had previously  used the                                                               
Lewin  group  for studies  and  reports.    She stated  that  the                                                               
difference in  estimates by  the reports  was dramatic,  with the                                                               
Lewin Report estimating  a cumulative cost between  2016 and 2020                                                               
of $210  million, whereas Evergreen  estimated a  cumulative cost                                                               
during  this time  period of  $48 million,  and DHSS  estimated a                                                               
cost savings  of $35 million.   She declared that this  "needs to                                                               
be sorted out."                                                                                                                 
CHAIR  SEATON  said  that  it  was a  valid  question  which  the                                                               
committee  would pose  to  DHSS.   He expressed  the  need of  an                                                               
explanation from  the department  for the difference  between the                                                               
estimates, and what was the basis for each.                                                                                     
5:01:16 PM                                                                                                                    
REPRESENTATIVE  TARR suggested  that  a  deeper discussion  about                                                               
Indian  Health Service  (IHS) beneficiaries  and its  limitations                                                               
would be  valuable.  She  stated that IHS beneficiaries  were not                                                               
covered 100 percent.                                                                                                            
CHAIR SEATON  noted that  there should  also be  discussion about                                                               
the intermediate levels of care in  Rural Alaska.  He offered his                                                               
belief  that  many   mental  health  issues  were   a  result  of                                                               
isolation,  and   he  declared   his  desire  to   further  these                                                               
discussions.    He  questioned whether  Medicaid  had  a  village                                                               
model,  suggesting  that  a  system  for  Alaska  could  be  very                                                               
different than a  system in California.   He  pointed out that he                                                               
represented    16   different    communities   that    were   not                                                               
municipalities,  but   had  the  same  Department   of  Commerce,                                                               
Community  &   Economic  Development  (DCEED)  definition   as  a                                                               
village.    He  suggested  the   development  of  a  model  which                                                               
integrated training to get to  the intermediate level of care for                                                               
these villages, which could move toward a level of prevention.                                                                  
REPRESENTATIVE  VAZQUEZ expressed  her  concern  with the  broken                                                               
DHSS  payment  system,   formerly  known  as  MMIS,   as  it  was                                                               
absolutely critical  for the identification of  over utilization,                                                               
duplication of services and billing,  and overlapping of provider                                                               
billings.    She  noted  that   the  department  had  not  had  a                                                               
surveillance utilization  review database software  program which                                                               
would  flag the  above issues.   She  added that  the eligibility                                                               
system was also not fully  functional, which made it difficult to                                                               
determine true eligibility.                                                                                                     
CHAIR SEATON  pointed out that  July 1  would be the  rollout for                                                               
the new coding  system, although it might need to  be held back a                                                               
month if there was Medicaid  Expansion, to ensure that there were                                                               
not any coding problems as a result of the expansion.                                                                           
REPRESENTATIVE WOOL  stated that a software  system was secondary                                                               
to having health care for people  who were worried about how they                                                               
would  pay for  health care.    He expressed  agreement that  the                                                               
neighborhood  health  clinics did  offer  services  on a  sliding                                                               
scale; however,  as there was  an expectation for a  cash payment                                                               
up front,  this was an issue  for some people.   He declared that                                                               
there were people who would greatly benefit from expansion.                                                                     
5:08:14 PM                                                                                                                    
There being no  further business before the  committee, the House                                                               
Health  and  Social  Services   Standing  Committee  meeting  was                                                               
adjourned at 5:08 p.m.                                                                                                          

Document Name Date/Time Subjects
Alaska Pioneer Home-3.17.2015.pdf HHSS 3/17/2015 3:00:00 PM
Presentations by DHSS
Brief Summary - Memory Care- pioneer homes.pdf HHSS 3/17/2015 3:00:00 PM