Legislature(2015 - 2016)CAPITOL 106
11/03/2015 10:00 AM House HEALTH & SOCIAL SERVICES
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Presentation: Proposals for Increasing Wellness and Prevention to Reduce the Number of People Accessing Medicaid or Other Health Care Services, Initiatives for State Government, Social Programs and General Practice. | |
Adjourn |
* first hearing in first committee of referral
+ teleconferenced
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ALASKA STATE LEGISLATURE HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE November 3, 2015 10:04 a.m. MEMBERS PRESENT Representative Paul Seaton, Chair Representative Liz Vazquez, Vice Chair Representative Neal Foster Representative David Talerico Representative Geran Tarr Representative Adam Wool MEMBERS ABSENT Representative Louise Stutes COMMITTEE CALENDAR PRESENTATION: PROPOSALS FOR INCREASING WELLNESS AND PREVENT TO REDUCE THE NUMBER OF PEOPLE ACCESSING MEDICAID OR OTHER HEALTH CARE SERVICES, INITIATIVES FOR STATE GOVERNMENT, SOCIAL PROGRAMS AND GENERAL PRACTICE. - HEARD PREVIOUS COMMITTEE ACTION No previous action to record WITNESS REGISTER JEFF GOODELL, Building Manager Maintenance Legislative Administrative Services Legislative Affairs Agency Juneau, Alaska POSITION STATEMENT: Discussed the current seismic retro-fit construction project, maintenance department, and safety issues within the Capitol building. NELLY AYALA, RN, MSN Division of Public Health, Program Manager Department of Health & Social Services Anchorage, Alaska POSITION STATEMENT: Presented Chronic Disease Prevention Health Promotion, Diabetes Prevention and Control. PATRICK SIDMORE, Planner Alaska Mental Health Board Advisory Board on Alcoholism and Drug Abuse Department of Health and Social Services Juneau, Alaska POSITION STATEMENT: Discussed links to health and economic outcomes. JAY BUTLER, Chief Medical Officer/Director Division of Public Health Department of Health and Social Services Juneau, Alaska POSITION STATEMENT: Clarified the source of the three research papers. MARK ERICKSON, M.D. Alaska Psychiatric Institute (API) Anchorage, Alaska POSITION STATEMENT: Testified regarding vitamin D and depression. ACTION NARRATIVE 10:04:04 AM CHAIR PAUL SEATON called the House Health and Social Services Standing Committee meeting to order at 10:04 a.m. Representatives Foster, Vazquez, Talerico, Tarr, and Seaton were present at the call to order. Representative Wool arrived as the meeting was in progress. ^PRESENTATION: PROPOSALS FOR INCREASING WELLNESS AND PREVENTION TO REDUCE THE NUMBER OF PEOPLE ACCESSING MEDICAID OR OTHER HEALTH CARE SERVICES, INITIATIVES FOR STATE GOVERNMENT, SOCIAL PROGRAMS AND GENERAL PRACTICE. PRESENTATION: PROPOSALS FOR INCREASING WELLNESS AND PREVENTION TO REDUCE THE NUMBER OF PEOPLE ACCESSING MEDICAID OR OTHER HEALTH CARE SERVICES, INITIATIVES FOR STATE GOVERNMENT, SOCIAL PROGRAMS AND GENERAL PRACTICE. 10:05:18 AM CHAIR SEATON reminded the committee that today it would review different proposals and opportunities to help people stay well and; therefore, avoid placing a burden on the health care system. 10:05:52 AM REPRESENTATIVE TALERICO described himself as a "rubber meets the road" type of fellow and that health safety and safe environments have always been a concern. He explained it is likely that 3 out of 100 workers will file a worker's compensation claim in the United States, and there may be 11-13 fatalities today in the United States' workplace. He advised the United States has lived with those statistics for quite some time and the goal of safety professionals throughout the country, and hopefully all private business and government organizations, is to bring the number to zero. He offered that a person witnessing a fatality at the workplace can sometimes take years to recover and its traumatic effects can take a person to a numb stage. He offered that safety officers are concerned with an avalanche of "those things" happening because the focus suddenly goes away from the actual job and the safety portions of it. 10:08:46 AM JEFF GOODELL, Building Manager, Maintenance, Legislative Administrative Services, Legislative Affairs Agency, advised that the maintenance department purchased updated safer equipment, such as a saw-safe table saw that will shut off should a human part, wet wood, or a piece of metal contact the blade. He explained that additional safety measures have been taken, such as: air filter boxes installed in the shop; and safety gear is required and should an individual work on a piece of equipment without safety equipment, the individual is banned from that piece of equipment for a period of time just to get the message across as eyes, ears, and lungs are very important. As far as the building in general for all of its tenants, within the seismic retro-fit all of the Asbestos Containing Material (ACM) is being removed that "we are in contact with within the project delineation." He pointed out that the Capitol Building was built during the late 1920s - early 1930s, and pipe was insulated with asbestos wrap. He advised he has received authority in areas outside of the project but that are exposed to eye sight, and people's access, to have ACM removed for everything within his reach. Although it is expensive, the United States is targeting buildings for ACM removal, and even though he does not have that luxury, everything he can get to has been removed by the abatement contractor, he explained. Mr. Goodell noted that "we" are doing our best to improve the air quality in the building, and within that goal a number of heat recovery and ventilation (HRVs) units will be implemented next year. He noted there is a three-year process for Phase 2 of the retro-fit, and commented that he will doing everything he can physically and economically to improve the quality of the building. 10:13:44 AM CHAIR SEATON asked for more detail regarding safety exercises or meetings. MR. GOODELL responded that daily and weekly they discuss any issue personnel is interested in. Previously bulletins were used, but many of the purchased bulletins predominantly did not pertain to this particular environment and they are in search of a "more practical, more maintenance based" weekly bulletin, he advised. He related that he is "constantly" reminding his maintenance and custodial staff about safety, and should an individual notice something to bring it forward. 10:15:25 AM REPRESENTATIVE FOSTER recalled previous safety meetings he had been involved with and described them as important in that they can save a life, limb, [or injury]. He asked whether there is anything the committee or state can do to "get back to the basics," and suggested a possible safety education campaign for public awareness. 10:16:31 AM REPRESENTATIVE TALERICO offered that it is encouraging that Mr. Goodell presented today as one of his main focuses are safety activities, and that safety is considered on a routine basis under his leadership. He pointed out that Mr. Goodell's subordinates are well aware of his commitment to safety in that it provides a better environment for the worker. Representative Talerico commented that everyone in a management or leadership role, whether government or private, should take a safety role and lead as there are tremendous educational opportunities and suggested googling safety. He said, "safety first." 10:18:42 AM CHAIR SEATON offered appreciation that the subject of maintenance safety is discussed and noted that the state workforce includes secretaries and office personnel. He opined that feedback has not been obtained from the commissioners of other departments as to how they address ongoing or possible safety problems of every shift as there have been lots of workman's compensation claims within the office personnel. He suggested a letter to each commissioner from the committee inquiring as to what they are doing with each class of their personnel to promote safety and, thereby, not requiring health care. He asked Representative Talerico for more information regarding his previous safety meetings and employment. 10:21:08 AM REPRESENTATIVE TALERICO answered that many private industries [hold safety meetings], spurred by reducing the costs of health care and insurance, and noted that workers often support an entire family. He explained that many workplaces have adopted a "safety share;" a daily event for work crews or individuals to ascertain that an awareness is brought forth to be alert and safe in a work environment. He related that safety share requires participation and everyone involved is encouraged to routinely share a safety moment, such as sharing something of a very serious nature that may not be obvious to some people. He remarked that he advises his staff that one of the largest workplace injuries is referred to as "slips, trips, and falls," and sometimes the daily reminder can not only avoid the injury but the costs associated with the injury. He offered that recently it was actually safer to work in the mining industry than working in a big box store, which may have a lot to do with focus. The Occupational Safety and Health Administration (OSHA) has very distinct, rigid safety rules to abide by and over the years many people covered by the Mine Safety and Health Administration (MSHA) have determined the best way to do this is to get very aggressive with their safety programs. Consequently, he explained, workers are safer and they save money, yet beyond that there is a quality of life issue for the injured worker. He agreed that the committee should learn from all of the departments where they are on safety for their employees. 10:25:03 AM CHAIR SEATON commented that the House Health and Social Services Standing Committee is looking at initiatives, projects, proposals, and procedures to ascertain that the state has not only a healthy workforce, but healthy citizens. He related that a number of legislators went to the North Slope and stayed at the ConocoPhillips Alaska facilities for lunch and noted that at every stairwell is a "3 points of contact" sign requiring that all workers use the handrail. Many times staff and legislators do not use the handrail and may trip and, he said, hopefully there will be other ideas to share with the legislators of their responsibilities with their staff. 10:26:34M REPRESENTATIVE FOSTER admitted to being the latest victim in the area of texting and falling down the stairs. REPRESENTATIVE TALERICO related that the "3 points of contact" is a standard in most industrial sites, and under MSHA rulings during an inspection of a company if MSHA witnesses someone not utilizing "3 points of contact" when using a staircase or getting on or off pieces of equipment it is an automatic citation and fine because it keeps people safe. CHAIR SEATON expressed appreciation on focusing on safety, together with nutrition and staying off drugs. 10:27:36 AM REPRESENTATIVE VAZQUEZ mentioned areas in office work that need adjusting in the focus for safety, such as the correct way to pick up items, avoiding eye strain, stretch to avoid muscle strain, and carpel tunnel syndrome. REPRESENTATIVE TALERICO expressed appreciation to Mr. Goodell for staying "on top of this" and expressed confidence in his leadership. 10:28:57 AM REPRESENTATIVE WOOL asked whether anyone has lost any appendages on the table saw here. MR. GOODELL responded no, not on his watch or the few years prior to his employment. CHAIR SEATON stated that the committee will solicit from the different departments how they are attempting to control [injuries] and their procedures for health in their workplace. 10:29:44 AM CHAIR SEATON announced the next order of business would be the presentation of Diabetes Prevention and Control. 10:30:27 AM NELLY AYALA, RN, MSN, Division of Public Health, Program Manager, Department of Health & Social Services, offered a power point presentation to explain what the Diabetes Prevention and Control Program is doing to help people stay well and increase diabetes awareness in Alaska. She turned to slide 2: "Chronic Disease Prevention & Health Promotion," and said the slide shows a whole person with many chronic diseases, and that each of the chronic diseases risk factors are addressed by projects and programs within the Chronic Disease Prevention and Health Promotion. MS. AYALA turned to slide 3: "What is Diabetes." She said that diabetes is a problem in the body that causes blood glucose (sugar) to raise higher than normal. She advised that within this presentation, the discussion is Type 2 diabetes as it is the most common form of diabetes in the country and Alaska. With regard to Type 1, the estimates are that approximately 5-10 percent of children are affected, she advised. Type 2 risk factors include: weight; inactivity; fat distribution especially around the mid-center, belly or abdomen; family history - a sibling or parent with Type 2 diabetes; age - as a person ages Type 2 is more commonly seen and quality of life is important in aging; race - Alaska Native, African Americans, Hispanics, Asian Pacific Islanders; pre-diabetes diagnosis - estimated that within five-years diabetes will occur unless lifestyle behavior is changed; Gestational diabetes - diabetes while pregnant or having a baby nine pounds or heavier puts the woman at greater risk of type 2 diabetes; and Polycystic Ovarian Syndrome increases risk for diabetes. 10:33:38 AM MS. AYALA turned to slide 4: "Diabetes and Prediabetes Prevalence in Alaska (BRFSS 2013)," and explained the chart as data from the Behavioral Risk Factor Surveillance System 2013 (BRFSS), which is the nation's premier system of health related telephone surveys collecting [indisc.] data about United States' residents regarding their health risk behaviors, chronic health conditions, and use of all preventive services. She advised the chart represents the percentage of Alaskans age 18 and older diagnosed with pre-diabetes and diabetes. She explained that pre-diabetes is a condition in which individuals have a blood glucose level higher than normal but not high enough to classify as diabetes. She said the people listed in the numerator answered the question yes, as to whether they were ever told by a health care professional they had diabetes or were pre- diabetic, border-line diabetic or diabetic during pregnancy. The denominator represents all adults age 18 and older that responded to the diabetes and prediabetes question, excluding all unsure answers. She pointed out that the chart indicates 6.5 percent out of 100 Alaskan women are estimated to be diabetic, while 10.5 out of 100 Alaskan women are estimated to be pre-diabetic. Individuals age 65 and older are at greatest risk for pre-diabetes and diabetes; 45-64 age group are second largest; and the 34-44 age group is slowly rising, she advised. 10:36:47 AM MS. AYALA turned to slide 5: "Age-Adjusted Diabetes Prevalence in Adults, Alaska (BRFSS)" and said the graph indicates that from 1991-2013 there is a slow increase with time depending upon issues. Slide 6: "Cost of Diabetes." She explained that in 2010, the annual cost of care for the U.S. Medicaid diabetes group is approximately $14,229; and for those without diabetes in the same age group on Medicaid was approximately $4,568. She pointed to 2012, and said for the Medicaid diabetes group in the United States, the estimated cost was $13,741; and those without diabetes was $5,853. Table 2: "Incurred cost of Medicaid beneficiaries 20 years and older in AK" represents numbers from the 2014 Evergreen Report. She pointed out that the 2012 diabetes Medicaid beneficiaries included 5,938 people, incurred cost per diabetic beneficiary was $26,468, and the total cost of diabetic beneficiary was $157,167,553. [The chart also indicates the costs for 2013 and 2014.] 10:38:55 AM MS. AYALA turned to slide 7: "The Key is Prevention." Risk factors for Type 2 diabetes include: inactivity, obesity and now smoking has been shown as a causal relationship, she explained. Educating people on the major complications of diabetes is important because this year the CDC estimates that one out three people do not know they have pre-diabetes, and one out four people do not know they have diabetes, she said. MS. AYALA turned to slide 8: "Among Alaska Adults with Diabetes." She offered that it is known that 19 percent smoke, 30 percent are inactive, and 59 percent are obese. She opined she is unclear as to how many of the individuals knew they were diabetic. Ms. Ayala turned to slide 9: "What is the Diabetes Prevention and Control Program?" She said it is a program housed by the Chronic Disease Prevention & Health Promotion Division, and works hand-in-hand with Obesity, Tobacco, Cancer, and Cardiovascular Disease Prevention and Stroke Programs to prevent these diseases. She explained that the program focuses mainly on Type 2 diabetes for adults in Alaska, and access to resources for those affected by Type 2 diabetes. 10:41:03 AM MS. AYALA turned to slide 10: "Barriers." She explained that Alaskan barriers include: access to health care and continuity of care, such as the military and seasonal workers; referrals to community resources as education, information, and communication must be increased; and community level case management because there is a lack, community resources often don't know about other resources available within that city or town and it is difficult in "spreading the word" about diabetes self-management classes and residents often do not know resources are available within their community. She pointed out that barriers also include financial, such as: insurance coverage in that some resources are not covered; staffing in programs as staff burnout with complaints of too many tasks for one person, low morale; costs of implementation, evaluation, and follow-through in programs to ascertain that people are receiving the highest quality care in sustainable programs; and cost of effective health communication plans and reaching Rural Alaska and not focusing solely on the urban areas. She pointed to a barrier of knowledge on impact of chronic disease on the overall health that includes: a person suffering more than one chronic disease and a person over 65 years of age is considered a complex patient; and that the direct relationship in Alaska between tuberculosis and diabetes, obesity and diabetes, and smoking and diabetes is being reviewed. A final barrier could be: education on the chronic disease and self-managing a disease as people need to feel empowered, need to know they can actually control their diabetes or chronic disease, knowing about prevention, and that changing life style behaviors can delay the progression of disease up to 11 years. 10:44:37 AM MS. AYALA turned to slide 11: "Community-Based Approaches." She said the current focus is on community-based approaches in more people being screened via partnerships with local organizations for diabetes especially, she reiterated, when one out of three people do not know they have pre-diabetes and one out of four do not know they have Type 2 diabetes. She advised that screening partnerships include: Alaska Health Fairs, Inc., to provide free HbA1c tests; Diabetes Lipid Clinic provide free HbA1c tests; Providence Outreach Center to inform the public about Alaska Health Fairs; YMCA to inform the public about Alaska Health Fairs and provide paper screening tests for those who do not want to do a blood test; Alaska Commercial to provide the public with paper screening tests in their store; Anchorage Neighborhood Health Centers to include information about screening in their website and Facebook page; and American Diabetes Association to get more paper screening tests throughout Alaska and generate more health fairs at new locations. MS. AYALA turned to slide 12: "Community-Based Approaches," includes working with local organizations to spread the word about diabetes because if it is not discussed people tend to forget about it because they think "it could not happen to them." She offered that community-based organizations approach spreading the word, increase awareness about diabetes, and those organizations include: the American Diabetes Association; Alaska Commercial Stores; Alaska Public Media; ANTHC Special Diabetes Program for Indians; YMCA; Faith-based organizations; Alaska Primary Care Associates; Providence Hospital involves tele- medicine, tele-health, and creating programs to reach other areas such as, Sitka Hospital, SEARHC, and Kodiak. 10:47:30 AM MS. AYALA turned to slide 13: "Programmatic Approaches." She said that a focus is the self-management program to empower patients, such as those with a chronic disease, or a care taker of a person with a chronic disease, or requesting information regarding diabetes or a chronic condition. She explained it is a six-week program, meets once a week in a group setting (10 people or more,) is evidence-based and is recommended by the 2015 ADA clinical guidelines. The goal, she offered, is to teach individuals the goals necessary to adopt healthy habits and promote the idea of life style changes and behaviors. She explained that the self-management programs are offered in two way: Chronic Disease Self-Management Program (CDSMP); and, Diabetes Self-Management Program (DSME). 10:48:43 AM MS. AYALA turned to slide 14: "Programmatic Approaches." She offered that they are also working with patients affected by pre-diabetes, or at-risk of diabetes through the National Diabetes Prevention Program. This program, she explained, begins with 16-weeks of weekly meetings, then small group meetings monthly up to one year, with access to a CDC nationally recognized online program to support the monthly support group meetings. She said the online program is free of charge due to a partnership with Nutrition Quest, and the on-site locations include: Anchorage, Juneau, Fairbanks, and in the near future Seward. MS. AYALA turned to slide 15: "Benefits of DSME." The evidence-based benefits of the diabetes self-management education (DSME) are important as it reduces health complications including: heart disease, stroke, kidney disease, nerve damage, pregnancy complications and eye diseases; it can sustain successful long-term self-management with ongoing follow up and support; and lower hospitalization rates by 34 percent. She pointed out that DSME is included in the American Diabetes Association Standards of Medical Care in Diabetes and Clinical Practice Recommendations, and is noted as a best practice program. 10:51:05 AM MS. AYALA turned to slide 16: "Economic Savings of DSME." She proposed that one way to decrease the economic burden on the health care system is by taking the time to implement a successful DSME program. She pointed out that the Evergreen Report estimates that for each Alaska Diabetic Medicaid beneficiary the cost is $26,300, yet if every Medicaid enrolled diabetic in Alaska took at least one DSME class, there would be an estimated Medicaid cost savings of $6.9 - $36 million per year. She offered that this amount equals a net of $4 return investment for every $1 spent. 10:52:00 AM MS. AYALA turned to slide 17: "Pre-Diabetes." She explained that the online system is because of pre-diabetes "hot pockets" that are mainly in urban areas, such as Anchorage, Kenai, and the Matanuska-Susitna area, and it is important there is free and accessible [information] available. People are being advised, through various health fairs with their partnership with Alaska Health First, that [DSME programs] are available, evidence-based, and high quality, she offered. When signing up, a one-year free subscription is included and, she noted, there are long-term effects by changing life styles and habits. MS. AYALA turned to slide 18: "Summary Slide." Self-management programs help empower people and provide them with the tools necessary to take care of their health and, she pointed out, that the total annual cost of Alaskan diabetic Medicaid beneficiaries is $165.7 million. She stressed that diabetes prevention is needed and the CDC estimates that by 2050, one out of three people in the United States will have diabetes. She related that these people enjoy the services and the opportunity to learn from the programs. 10:54:23 AM MS. AYALA turned to slide 19: "Resources." She explained that the slide includes some of the diabetes resources available, such as "[email protected]; [email protected]; Http://list.state.ak.us. 10:55:09 AM REPRESENTATIVE TARR referred to Ms. Ayala's statement that the greatest increases of [pre-diabetes] are found in urban centers, and asked her to discuss the issue from a statewide perspective. MS. AYALA responded that the rate focuses on 6.5 percent per 100 people, and the more densely populated area would have the most people. 10:57:42 AM REPRESENTATIVE TARR pointed to the community outreach slides and noted that quite a number of organizations may be located in the urban center. She inquired as to whether they were working with the tribal health organizations, or working within some of the harder to reach areas of the state in community based prevention. MS. AYALA replied that they are working on a long-term partnership with the Alaska Native Health Consortium and are working. She said discussions have included how funding would be effective for this special diabetes program for Alaska Natives, and how the state can assist, she said. She then explained that on December 1, 2015, the Alaska Native Diabetes Conference takes place in Anchorage and all tribal health representatives will attend, and they will listen to understand the stakeholders' needs in developing sustainable programs before implementing or recommending a program. She said that Diabetes Prevention and Control has discussed creating a partnership with Alaska Health Fairs and its wellness base in order to implement a wellness program and use less resources that could be directed elsewhere. She explained that discussions have also taken place as to receiving recognition for the gold standard Diabetes Prevention Program (DPP), which was the first program by the Indian Health Board to be created for diabetes prevention and control. She remarked, in order to move in that direction, the staff must offer input as to what type of support would be needed as it would require creating more reports to become CDC recognized. She offered that they have been brainstorming issues in preparation for the December meeting, and that there must be a dialogue from tribal villages and their community leaders. 11:00:57 AM CHAIR SEATON pointed to slide 3, noting that the factors are not addressable as to age, family history, race, or pre-diabetes, which leaves weight, inactivity, obesity, and smoking, although mechanisms or prevention programs could address gestational diabetes. He asked whether they had reviewed what is different in Alaska and why the rate is higher than the rest of the United States. MS. AYALA responded that Alaska does not necessarily have a higher rate of weight and inactivity as Alaska fits with the rest of the United States. She related that obesity is a global epidemic. CHAIR SEATON questioned whether Alaska has a higher rate of diabetes. MS. AYALA replied no, in 2013, the rate of diabetes in Alaska was 7.1 percent, and approximately 7 percent for the national average. 11:03:07 AM REPRESENTATIVE TARR asked members to bring the committee materials to the next meeting. 11:04:10 AM CHAIR SEATON recessed to a call of the chair. 4:03:28 PM CHAIR SEATON reconvened the House Health and Social Services Standing Committee at 4:03 p.m. Representatives Talerico, Wool, Tarr, and Seaton were present at the call back to order. Representatives Vasquez and Foster arrived as the meeting was in progress. 4:04:16 PM REPRESENTATIVE TARR referred to the earlier presentation and asked the committee to keep the same risk factors in mind, such as tobacco use, alcohol use, diet, and obesity. She turned to the PowerPoint presentation entitled "Adverse Childhood Experiences [ACEs]," slide 1: "What is ACEs?" She said there was a 1998 landmark study that reviewed middle class adults to quantify health outcomes in relationship to traumas they may have experienced as a child. She explained that the study was performed in partnership with the Center for Disease Control (CDC) and the Kaiser Permanente Health Appraisal Clinic in San Diego, with over 17,000 participants. The study developed an ACEs 0-10 score for individuals in order to predict health outcomes which in turn assists in understanding how to achieve prevention savings, she remarked. REPRESENTATIVE TARR turned to slide 2: "What is your ACEs Score?" She read the 10 questions to the committee for their response. [The ACEs quiz can be found at www.npr.org/sections/health-shots/2015/03/02/387007941/take-the- ace-quiz-and-learn-what-it-does-and-doesn't-mean.] Following the questions, she noted that each member may want to use their ACEs score in context to the implications of high ACEs scores. 4:11:34 PM REPRESENTATIVE TARR turned to slide 3: "ACEs studies in Alaska." She said that two findings include: childhood trauma is more common than previously realized; and that the impacts of this trauma affects individuals over a lifetime and societies over generations. She described a current exciting genetics study called "Epi genetics" that reviews how experiences or environmental influences change the way a gene is expressed and that intergenerational trauma changes can occur at the cellular level and impact the next generation. REPRESENTATIVE TARR referred to [page 3, figure 3] of the handout entitled "Adverse Childhood Experiences Overcoming ACEs in Alaska," and advised the pyramid and circle [on page 5, figure 4, "Adverse Childhood Experience Cycle] are used to assist people in understanding the whole life experience. She referred to the pyramid example and said that adverse childhood experiences lead to social, emotional, and cognitive impairment, which leads to the adoption of health risk behaviors, which leads to disease, disability and social problems, which leads to early death. She referred to the circle and explained that it walks through how someone with early childhood traumas might be changed throughout their entire lifetime. 4:13:47 PM REPRESENTATIVE TARR turned to slide 4: "ACEs Scores in Alaska." She advised it offers the most recent percentage research, and that there is concern regarding individuals with a score of 4+ and how those scores can be reduced to improve health outcomes. She referred to the pinwheel in the handout entitled "Adverse Childhood Experiences Overcoming ACEs in Alaska," page 6, figure 5, of potential negative outcomes. She questioned that among the variety of undesirable health outcomes, what percentage of these can be linked back to ACEs. She explained that in an attempt to reduce costs, the pinwheel depicts that if the state could reduce the frequency of these particular adverse childhood experiences then the frequency of poor health outcomes would be reduced, thereby reducing costs. REPRESENTATIVE TARR referred to slide 5: "Select Negative Health Outcomes," and said, for example the Medicaid piece shows that 40.6 percentage of individuals currently receiving Medicaid services can be attributed back to high ACEs scores, current smokers 32 percent, heavy drinking 20.5 percent, and overall poor physical health 33.2 percent. She described this as a significant number of individuals who could potentially benefit by performing prevention efforts. 4:16:46 PM REPRESENTATIVE TARR turned to slide 6: "Costs Associated with ACEs," and referred to the pinwheel and said that 32 percent of the current smokers can be attributed back to ACEs, and approximately $576 million a year is spent on smoking related illnesses which could translate up to $186 million in savings. She offered that in reducing substance abuse by 20 percent there would be [Patrick Sidmore's figure] $250 million in savings and that reducing Medicaid cost by 40.6 percent would be a savings of $350 million. She explained that when translating this into the cost, the total in annual savings by preventing ACEs is approximately [$786] million. She related there is a double benefit in saving money and also improving health outcomes. REPRESENTATIVE TARR turned to slide 7: "Opportunities for Prevention." She offered that those include: trauma informed health care, and that trauma informed curriculum speaks to providing educators with tools to understand the life challenges some of their students are facing and improve their educational outcomes. She offered that a prevention opportunity could be the movie "Paper Tigers" that is being shown by Alaska Children's' Trust and community partners. Her concern is that with regard to ACEs, the state may currently be doing the wrong intervention and in doing so further isolate these students and cause a bigger challenge for them to succeed in school. She said that Trauma Informed Curriculum speaks to the idea that if educators can be provided with tools to understand some of these life challenges their students are facing, it would inform them as to how to administer curriculum in the classroom and improve student's educational outcomes. 4:19:32 PM REPRESENTATIVE TARR said that other states offer pilot programs, and that Vermont passed legislation to look into ACEs and determine additional opportunities to educate community members, and provide resources for individuals working especially with children. She remarked that Montana passed legislation in 2013, and that other initiatives are happening in other states. She referred to the handout entitled "Adverse Childhood Experiences Overcoming ACEs in Alaska," [page 7, table 2] and pointed to the areas marked in red where Alaska ranks at the top of those categories. In discussing recidivism and anti-recidivism efforts, she said, think of the life of a child growing up and that the repetitive instances of the trauma must be more damaging. Substance abuse in the home, domestic violence, and sexual assault impacts other behaviors, she related. When looking at how to prevent diabetes and its risk factors, such as tobacco use, alcohol use, and obesity, are things associated with having bad outcomes. There is much to gain if these adverse childhood experiences can be prevented in that it could prevent a whole series of costly health problems, she opined. 4:22:56 PM PATRICK SIDMORE, Planner, Alaska Mental Health Board, Advisory Board on Alcoholism and Drug Abuse, Department of Health and Social Services, advised there are links to health and economic health outcomes regarding cancer, heart disease, asthma, smoking and drinking. He said, for example injecting drugs, 78 percent of the people were linked back to ACEs. In other words, he explained, if all ACEs was eliminated, 78 percent of people injecting drugs would be eliminated. He said that powerful data has been replicated over and over in other countries and there are scores and scores of studies now. He advised they now have survey information on 8,000 Alaskans taken in 2013 and 2014, which will give them information about their ACEs scores and communities. He provided a recently completed document entitled "The Economic Costs of Adverse Childhood Experiences in Alaska" to the committee, and advised that six items were reviewed: Medicaid, smoking, binge drinking, arthritis, and obesity. He explained that they picked two states (Arkansas and Vermont) that performed well in ACEs, and overlaid their ACEs score onto Alaska's results and found that in Medicaid the state could save $32 million a year and smoking would be approximately $30 million less. The six items added up to a savings of over $90 million and it does not include the savings of the other approximately 20-30 measures linked to ACES, he offered. He said [ACEs] is catching on in communities throughout the state as a way to impact the health of their communities and hopefully have lower cost interventions early for young families to prevent this trouble down the road. He added that the CDC says that every child found with the substantiated report of harm costs the state $50,000 in childhood alone. The savings start right away, but the long term is "really where the money is," he said. 4:26:22 PM REPRESENTATIVE TARR pointed to the handout "Adverse Childhood Experiences Overcoming ACE's in Alaska," page 3, figure 1, "ACE Score and Suicide Attempt Prevalence," and stressed that ACEs may be an area to explore when discussing suicide prevention and missing pieces. She advised that men ages 18-24 are the highest rates of suicide, and if they had adverse childhood experiences it would have been a building problem in their life before they choose to finally take their life. The adverse childhood experiences program offers the potential for better health outcomes, she explained. She said she is hopeful opportunities will be taken to address ACEs as a legislative body, whether that means providing funding for a pilot program or legislators doing things in their communities as the opportunities are endless at this time. 4:28:10 PM REPRESENTATIVE FOSTER referred to grant programs and noted that previously money was appropriated for a program called the Qungasvik, which is out of the Alakanuk and Emmonak area. He reminded the committee that the whole area of Hooper Bay and the whole Lower Yukon has seen a rash of suicides, a high per capita number, and the unique reason the Qungasvik program worked was because it was culturally relevant and there were activities based in the local culture. He said that the results of the program showed that numbers were improving. 4:30:00 PM REPRESENTATIVE WOOL expressed that these kinds of studies are illuminating in that they can assess a person's upbringing and environment to determine a number and then correlate that number with certain unhealthy activities. Obviously, he noted, the goal is to eliminate unhealthy instances in a child's upbringing so their score is lower, and also to intervene later on and educate them. He asked whether there are programs to educate people about their high ACEs number, as well as trying to eliminate the behavior early on. REPRESENTATIVE TARR answered yes, such as the trauma informed curriculum and also building resiliencies. She noted there has been a bit of controversy over that concept, but the idea is that if the instances cannot be prevented from happening, how to help an individual be stronger in light of that and be resilient throughout their lifetime and avoid some of the unhealthy outcomes. She noted that an individual with an ACEs score of 1 has a 20 percent increased risk of heart disease; the score of 2 is twice as likely to experience humanoid disease, and 70 percent more likely to have heart disease; a score of 4 has a 3- 4 times higher risk of depression, is 5 times more likely to become an alcoholic, is 8 times more likely to experience sexual assault, and up to 10 times more likely to attempt suicide. She noted that it is likely that multiple things are going on in the home, such as alcohol or drug abuse and a parent goes to jail which could cause neglect. She asked Mr. Sidmore to comment on the recent study and neglect issues. 4:32:54 PM MR. SIDMORE advised that during the first year of the study using the behavioral risk factor surveillance system discussed earlier regarding diabetes. He explained that they did not include neglect, but did include neglect in the second year of the study. Neglect, he explained, is the most common reason children are taken out of their homes at OCS, and in reviewing the data today noted that neglect is highly correlated with the other adverse childhood experiences. He said they continue to learn from this and will put it out to professionals, and related that therapists around the state are using this more and more and explaining ACEs score with clients. Therapist are changing from "what is going on with you" to "what happened to you" and it is powerful and helpful to individuals to heal, he stated. 4:34:15 PM REPRESENTATIVE VAZQUEZ referred to the handout "Adverse Childhood Experiences Overcoming ACEs in Alaska," and noted that the Advisory Board on Alcoholism and Drug Abuse, and the Alaska Mental Health Board were involved. She pointed out that page 6, reads that 60.1 percent of individuals experiencing frequent mental distress have ACE scores, and asked the score. MR. SIDMORE explained that those numbers are a calculation commonly used in epidemiology called the "Population Attributable Fraction." He further explained that it is based upon a score of one-eight ACEs. He described it as a calculation that within the population with zero ACEs there is a certain percentage of people that will have "whatever" condition. The 60.1 percent would go away if all ACEs would go away, he said. REPRESENTATIVE VAZQUEZ surmised it is the range from zero to whatever. She suggested that the Alaska Mental Health Authority could be source of funding as they are supposed to be taking care of the mental health area, or at least assist in that process. REPRESENTATIVE TARR advised that she learned from Jeff Jessee, Alaska Mental Health Authority, that they like pilot programs. She opined that through the wisdom of the members of the legislature that possibly ideas could be addressed and approach them to determine whether they would be a good partner in obtaining additional research. 4:36:29 PM CHAIR SEATON surmised that a portion of the legislature's problem in looking forward is "really long-term solutions," when discussing eliminating things in childhood to prevent problems in adolescence and adulthood. He opined that in moving forward his hope is reviewing interventions and changing the mechanisms of interventions because this is such a long-term process that if there are no changing interventions accomplishing things in the nearer term it is going to be hard to wait around for 18, 19, 40 years to say "what was the effect." He said that removing stressors from life, and ACEs identifies a multitude of them, is helpful in the health of individuals. He said he hopes next year the committee will discuss some of the directed changes in interventions and changes in the way things are currently dealt with. He agreed with Mr. Sidmore's statement that instead of telling an individual there is something wrong them, rather to say this is what happened to you so the individual can take control and make intentional changes in their life. 4:38:38 PM REPRESENTATIVE WOOL noted that some things can have a dual function, such as recidivism and alternate sentencing practices, in that by reducing prison populations it would save the state money immediately, and also have the effect of preserving a home situation. REPRESENTATIVE TARR surmised it is difficult to quantify how to undertake long-term change and also live within a world of budget pressure. She offered that she recently learned about the Heckman Equation and will obtain more information. She said, it essentially shows opportunities for how to actually quantify the evolution over a long period of time, and how to see some of those changes. An area most promising, she advised, is the trauma informed curriculum and what happens in schools, and that there could be an immediate improvement in graduation results, academic performance, as well as a reduced number of suspensions and behavioral outbursts that are costly for a school district to address. She noted the CDC website has more information on outcomes. CHAIR SEATON passed the gavel to Vice Chair Vazquez. 4:41:04 PM REPRESENTATIVE VAZQUEZ asked Chair Seaton to proceed with his presentation. 4:41:12 PM CHAIR SEATON referred to the booklet that mainly targets surgery entitled "Reducing Negative Health Outcomes Through Prevention," and a handout on Vitamin D, published by the Emery University Hospital validating the use of Vitamin D. He reminded the committee that Dr. L. Ray Matthews, Director of the Surgical Intensive Care Unit at Grady Memorial Hospital testified last year and presented information to the committee. There were questions regarding the components of vitamin D, Omega 3, fatty acids, and whether vitamin D was doing its job. He noted that the vitamin D initiative at Emery University Hospital verifies that vitamin D, at least as one of the components, is making a difference on those health care outcomes that the protocol works on. The goal is how to better understand the immunological basis of causes of depression and other mental health concerns and how that could provide a primary health care prevention window into reducing Alaska's behavioral health needs. He explained that there is a growing body literature indicating that inflammation and inflammatory markers, such as the pro- inflammatory cytokines, have a strong association with depression. In cases of major depression, the inflammatory response system is often activated and higher levels of inflammation appear to increase the risk for the development of new depression cases and pointed to "cytokines and depression" and how the immune system causes depression. Articles include "Immunology of major depression," "Meta-analysis of cytokines and major depression," "Association of high sensitivity C- reactive protein with de novo major depression." 4:44:19 PM CHAIR SEATON related that it is interesting when discussing cytokines, as those are chemicals the body produces that influences how the genes work and vitamin D is one of the major controllers of cytokines in the body. He listed known environmental factors that can elevate the risk of depression including: stress, poor diet, and vitamin D deficiency. Chair Seaton pointed to an article that depression is an inflammatory disease, and other studies found that the association between vitamin D supplementation and reduced inflammatory markers are associated with depression, as well as the association between vitamin D deficiency and suicide. A couple of the articles state that depression is an inflammatory disease but where does the inflammation come from, and they get into the details of how exactly that works. He said that previous double-blind randomized controlled trials out of India show that bodily inflammation such as gingivitis was drastically reduced by vitamin D supplementation. 4:46:02 PM CHAIR SEATON referred to an article entitled "Suicidal Patients are Deficient in Vitamin D," that is associated with pro- inflammatory status in the blood. He offered that [it is important] to look at the immunological basis of depression because it is known that these things are a basic cause of depression, then treating that immunological basis. Vitamin D supplementation is also associated with an increased sense of well-being as the article "Randomized comparison of the effects of vitamin D3 adequate intake versus 100 mcg. (4000 IU) per day on biochemical responses and the wellbeing of patients," indicates they found that vitamin D levels at 4000 IU per day resulted in a definite wellbeing increase as well as limited respiratory tract infections, he explained. 4:47:23 PM CHAIR SEATON noted that last year an expert panel for the Department of Defense found sufficient scientific evidence to support an increase in the daily recommended intake of Omega 3 for military members. In fact, he noted, the panel said that given the strong evidence for the reduction of depressive symptoms and suicide prevention found "it would be unethical to not attempt elevating Omega 3 status among military personnel." He pointed out that diverse federal agencies are conducting expert panels regarding nutritional status and how Omega 3 and vitamin D can influence behavioral health. Chair Seaton opined that the committee needs to review ways to [help] people change the way they operate their lives, and that it is a very difficult position as found with obesity and smoking. He said that if there are things that can be done to change the immunological status of people and get to some of these bases of mental health, it offers a new outlook instead of just psychiatry. The problem regarding Alaska mental health is that there are a reduced number of providers, and those providers are in very short supply across the entire United States which makes trying to recruit to Alaska difficult. Looking at the immunological basis could be very important for Alaska, he noted. 4:49:58 PM CHAIR SEATON said physicians and primary care providers report spending a lot of time on behavioral health and they are really not trained to do that; however, there are some initiatives to get training for primary providers. Unfortunately, he remarked, that is a difficult job and if it is more related to treating the immunological basis the committee cannot ignore that. He reiterated that he is presenting findings to the committee on cytokines, and the immunological basis of depression and mental health, as it appears the issue has been somewhat ignored. He related that the Journal of Circumpolar Health had an excellent article on how the Native hospital and providers in Anchorage have been doing to [help] the primary health care providers identify mental health issues and depression issues so that treatment is followed up within 12 weeks. He acknowledged that it doesn't always happen, the percentages are in the reports, but it is something that needs to be done; however, one of the statements is that 40-60 percent of people receiving anti- depressants go off of them because they don't like the side- effects. When reviewing the "Vitamin D and Depression: A Systematic Review and Meta-Analysis Comparing Studies with and without Biological Flaws" article by Simon Spedding, it reviewed vitamin D usage without biological flaws and found that vitamin D supplementation had basically the same size effect as anti- depressant drugs. A consideration should be looking at an alternative that has the same size effect but do not have the same kind of depressive side effects. He pointed out that nutrition is one of the biggest things the state can effectively, cheaply, and quickly change within the status of Alaskans and noted the changes in technology in that drying fish and meat used to be all sun dried. He explained that vitamin D is made with animal oil, exposing it to ultra-violet B rays, thereby changing it to vitamin D and strengthening the amount of vitamin D in the tissues. The process has gone to freezers and smoke houses with plywood roofs and tarps with the FDA saying everything has to be covered and screened. He opined that he does not know how it has changed the nutritional status of people across Alaska. There is a project underway now that he opined might be very enlightening for us all, he noted. 4:54:41 PM REPRESENTATIVE FOSTER opined that vitamin D appears to have many significant benefits and further opined that the medical profession probably agrees. He questioned how to get people to take their vitamin D, and suggested that when doctors ask their patients whether they had their flu shot to also ask whether they are taking their vitamin D supplements. He noted that the evidence is clear, and further questioned how to get everyone to take their vitamin D. CHAIR SEATON responded that education and people graphically being shown the results of the ongoing studies and offering people experience. He noted that various legislators have reported taking vitamin D supplements and that they've noticed a change in their daily lives and attitude, and also ask how to educate and offer experience to their constituents. Chair Seaton used an example of how he offered experience to people during his involvement in a health fair in Homer. At that time, they took a survey and offered that if the person would fill out a survey three-months from that date and return it, they would be given a three-month supply of 5,000 IU vitamin D. After reviewing 101 returned surveys, (10 percent of all people attending the health fair) he noted that the following results were surprising: people got more exercise; 40 percent of the people surveyed took over-the-counter pain relievers less often; 22 percent of the people consuming alcohol reported they consumed less alcohol, which lends support to the issue that people are self-medicating when feeling bad; 52 percent of the people reported a difference in their emotional state as they felt much better than during previous winters; and 98 percent of the people said they intend to continue taking their vitamin D supplements. He offered that there would be a health fair next week in Homer with starter kits for people. He said he tries to inform people that since they often do not get sunshine in Alaska for seven months out the year, they should get vitamin D another other way - whether it is eating sun dried fish, or taking supplements. He said, "I think when you look at the booklet that we had on surgery, which are an immediate thing, and which ... when the journal patient's safety in surgery comes out and says ... you know, we've reached the point of its ethical challenge to not test for and treat people before surgery with ... elevate their vitamin D levels. I think the medical community is realizing that the risk to their patients is high if they don't have them with an optimal immune system." 5:00:19 PM REPRESENTATIVE VAZQUEZ advised that Dr. Jay Butler provided three research papers included within the committee packet. 5:00:35 PM JAY BUTLER, Chief Medical Officer/Director, Division of Public Health, Department of Health and Social Services, stated he was unsure of the three research papers Representative Vasquez referred and asked whether someone else might be involved. REPRESENTATIVE VAZQUEZ specified that the first paper is entitled, "Vitamin D Supplementation to reduce depression in Adults: Meta-Analysis of randomized control trials," published by the Nutrition Journal. The second paper is entitled "Vitamin D Supplementation for Depressive Symptoms: A Systematic Review and Meta-analysis of Randomized Control Trials," published by National Institutes of Health Public Access. The third paper is entitled "Vitamin D and Depression: A Systematic Review and Meta-Analysis Comparing Studies with and without Biological Flaws," by Simon Spedding. DR. BUTLER opined that the papers came from Dr. Mark Erickson. 5:02:22 PM MARK ERICKSON, M.D., Alaska Psychiatric Institute (API), informed the committee that he submitted the three research papers, and that Chair Seaton is right on target with his emphasis on depression. He offered that a recent study showed that in 2010 depression became the second leading cause of global disability that is an enormous problem. He explained that from 2008-2013 he was the medical director of Behavioral Services, Southcentral Foundation, and in 2009 became aware of the research regarding the relationship between low vitamin D and depression. At the time, the relationship was somewhat equivocal but it looked promising. In 2013 the first meta- analysis basically confirmed that low vitamin D is associated with depression, but at the time he was medical director the research on whether raising vitamin D level by taking supplements improved mood was even more equivocal. He pointed out that this issue was discussed during staff meetings and that many staff, including himself, would routinely obtain vitamin D levels on patients and if the vitamin D level was low would supplement. DR. ERICKSON offered that over the weekend he went to the National Library of Medicine and looked for meta-analysis of the relationship between supplementing vitamin D and recovery from depression, he advised, and to his surprise there have been four published articles within the last year. He noted that two studies did [find an association] but were in subsets and he emphasized that all four analysis pointed out how relatively poor the quality of the research had been, and that the evidence suggesting a favorable relationship were performed better. The studies carefully measured the vitamin D level and it was found to be lower than normal. He said that the study population was verified to have clinical depression and they offered a vitamin D supplement that was substantial enough to raise the vitamin D level to a normal range. In these cases they showed exactly what would be expected of a decent study, but unfortunately the data is not as impressive as he would like. That said, he commented, there has been a tenfold increase in the number of publications on vitamin D over the last decade and he has little doubt that there are studies going on now that will likely verify in a randomized controlled way that increasing vitamin D levels in depressed people with low vitamin D will be helpful. Unfortunately, the data is still a little bit equivocal, but certainly strongly suggests that if studies are performed properly there will be good data, and offer an idea as to how much vitamin D to supplement, he related. 5:07:03 PM DR. ERICKSON noted there is a concern about primary prevention and opined that the literature for the primary prevention of adverse childhood experiences is stronger than is generally appreciated and said there has been an enormous amount of research about the basic biology of parental care over the last 15-20 years. He mentioned a study by Dr. Lane Strathearn, published in 2009 in pediatrics ["Adult attachment predicts maternal brain and oxytocin response to infant cues"], in that Dr. Strathearn was aware that when a mother breast feeds, not only is the baby fed but within the mother's brain there is a release of oxytocin (a bonding hormone), prolactin (also related to maternal care), and dopamine. He described it as an "elixir of bonding" so every time a mother nurses these chemicals are released in her brain increasing the likelihood that she will bond with her baby. Dr. Strathearn made the prediction that the longer the ratio of breast feeding would be associated with the reduced rate of child abuse and neglect. He pointed to a study cohort of Dr. Strathearn's in Australia, of over 6,000 mothers who had been followed for 15 years along with their children. Dr. Erickson said that they had verified maltreatment in these cases and found that mothers who breast fed longer than four months were almost five times less likely to maltreat their children. Dr. Strathearn controlled for 18 different potential confounding variables, including whether the mother wanted the baby, and whether she was using drugs, and he still found over a 2.5 (indisc.) reduction in rates of child maltreatment. He offered that this raises the question about what is known about increasing the duration of breast feeding. 5:09:09 PM DR. ERICKSON said that the gold standard, a United Nations Initiative, called the "Baby Friendly Hospital Initiative" is robust and has been around for 15-20 years. In 2011, the United Kingdom decided that 100 percent of all their hospitals would be baby friendly. Yet, he pointed out, the United States has only two percent of its hospitals baby friendly, but there is an initiative having to do with the quality birth experience of the mother which often double, triples, or quadruples the rate and duration of breast feeding. He noted this is just one example of how a fairly simple process can dramatically reduce and prevent child abuse and neglect, and that other possibilities include the learning of hormonal changes occurring in men as they become fathers as there are ways in which to leverage this. He stressed that there are probably a number of ways to prevent child abuse from ever happening if close attention is paid to the emerging biology of parental care. 5:10:40 PM CHAIR SEATON requested Dr. Erickson to forward his information in an email as the committee has been trying to determine effective health interventions. He asked whether the two percent figure for hospitals means that there is zero percent in Alaska or 100 percent of Alaska, and further asked what can this committee can do to help with those issues. He said the committee needs the background data, studies, and proposals coming forward from the department where the committee can add its weight and assistance in the efforts. 5:12:15 PM DR. ERICKSON related his understanding that Providence Alaska Medical Center is the only baby friendly hospital in Alaska, and that he will forward the requested pertinent publications. CHAIR SEATON said they would see about getting 100 percent of the hospitals [to be baby friendly]. He said that the meta- analysis studies take a systematic review, and turned especially to the meta-analysis "Vitamin D and Depression: A Systematic Review and Meta-Analysis Comparing Studies with and without Biological Flaw" by Simon Spedding that do not have biological flaws. In other words, he related, they are given enough vitamin D to raise the low [vitamin D level] and determined that "the effect size was comparable to that of anti-depressant medication." 5:14:50 PM DR. ERICKSON interjected that he entirely agrees with Chair Seaton's comments as it seems the Simon Spedding study is most reasonable. He said that, basically, in order to get to the point where vitamin D is part of a standard algorithm in medical care, a number of higher quality studies to verify Simon Spedding's study, must be performed. He reiterated there are several other ways to go about preventing child abuse and neglect by paying close attention to the biology of parental care. REPRESENTATIVE VAZQUEZ returned the gavel to Chair Seaton. 5:15:59 PM CHAIR SEATON pointed out that smoking is an issue that came across on many of the topics heard today, whether diabetes, ACEs, or adverse effects at surgery. He expressed hope that the committee can get the message across to students by taking the initiative and possibly advertising in their district's middle school and high school publications twice a year that it may limit their potentials for dating to only other smokers, and it might make a difference in their attitudes. He suggested the advertisement could read "Kissing a smoker tastes like licking an ash tray," and speculated that this would have more effect than the committee trying to start a big initiative to convince people not to smoke. 5:18:56 PM REPRESENTATIVE WOOL pointed out that vaping is becoming more prevalent with the upcoming middle school and high school students. CHAIR SEATON replied there are things that are not good, but the committee knows what is really bad. 5:19:44 PM REPRESENTATIVE TARR offered that she likes the idea of outreach to youth and asked what Chair Seaton envisions the committee's next step to be. CHAIR SEATON answered that the previous presentations identified smoking as a crucial issue for health, and that each committee member could form a message that works in their communities. He suggested that the members speak with students in their areas, formulate an initiative, and report back to the committee on the initiative and what feedback was received. He said smoking and clean conversation with students by committee members in the middle school and high school may be effective. 5:22:28 PM REPRESENTATIVE VAZQUEZ referred to Representative Tarr's study of "Adverse Childhood Experiences, Overcoming ACEs in Alaska," and asked whether this information had been received by the various school district's nurses and counselors. REPRESENTATIVE TARR responded that the information is new, and noted that the school nurses recently held their annual conference and a panel was on Erin's Law and discussing adverse childhood experiences. She described [the outreach] as beginning and opined that it will take more time as they work through with the different professionals. She reminded the committee that there is a lot of pressure on them right now with testing and different things. She opined that they are taking little steps to incorporate this information, but are making the information known known together with opportunities for additional training. She acknowledged that she could not say it has been implemented in every school or that every educators is currently aware of it. 5:23:42 PM REPRESENTATIVE VAZQUEZ asked about school counselors. REPRESENTATIVE TARR replied that the same is true for school counselors with some awareness. A challenge with health care providers is that certain information was part of the curriculum when they went through their schooling, which is why these profession require Continuing Education Credit because research is ongoing with new things are coming out, she said. Sometimes, she pointed out with state's practitioners, there is a gap in what was considered the relevant body of information at the time they were in school and what a student might learn today. There is the issue of trying to catch some people up to what the newest information is, which is where they are at with this particular information penetrating all of the professionals that might find it useful in their daily work, she explained. CHAIR SEATON noted that Homer adopted this most pervasively and that there is Mobilizing for Action through Planning and Partnerships (MAPP) that is a whole community-wide focus on improving health. He said it focused specifically on ACEs as one of the mechanisms in addressing things such as low socio- economic status, and that it will be hard to change some of the things considered in ACEs, such as smoking. 5:25:50 PM CHAIR SEATON asked whether the committee was in agreement to developing an initiative in their areas, and coming back to the committee with the progress made, after the interim. Chair Seaton noted that there was general agreement, and offered that should a member prefer not to participate they do not have to. He stated that should a member prefer not to put their name on the initiative, to send a copy to the committee [aide] and they will use the House Health & Social Services Standing Committee as the sponsor of the ad. Also, he pointed out, having this agreement makes it a legislative priority and should people need $20-$30 to put an advertisement in the student body paper they can use their office account. 5:27:32 PM REPRESENTATIVE TARR offered support for Chair Seaton's ideas of doing something and mentioned talking with health teachers, middle school principals in her area and stated that if the members work collaboratively they could cover Anchorage. She asked whether there could be a working group meeting prior to session to share ideas. CHAIR SEATON clarified that he does not believe a working group is necessary, and advised staying away from sex. He said he would like a copy of what the members are doing, and that committee approval is not required. He reiterated that the committee agreed the members will work on initiatives within their communities to share among the members. REPRESENTATIVE TARR commented that if other members come up with a great idea then possibly she could take the idea and go with it. CHAIR SEATON said he would like to see the committee moving forward with an action that is shown to be a large problem in Alaska's health care. 5:30:01 PM ADJOURNMENT There being no further business before the committee, the House Health and Social Services Standing Committee meeting was adjourned at 5:30 p.m.