Legislature(2021 - 2022)BUTROVICH 205

03/22/2022 01:30 PM Senate HEALTH & SOCIAL SERVICES

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Audio Topic
01:33:29 PM Start
01:34:17 PM SB124
02:11:16 PM Presentation(s): the State of Alaska's Health
03:02:40 PM Adjourn
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+= SB 124 MENTAL HEALTH FACILITIES & MEDS TELECONFERENCED
Heard & Held
Presentation: Alaska's State of Health by
Dr. Anne Zink, Chief Medical Officer
+ Bills Previously Heard/Scheduled TELECONFERENCED
**Streamed live on AKL.tv**
                    ALASKA STATE LEGISLATURE                                                                                  
      SENATE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE                                                                    
                         March 22, 2022                                                                                         
                           1:33 p.m.                                                                                            
                                                                                                                                
                                                                                                                                
MEMBERS PRESENT                                                                                                               
                                                                                                                                
Senator David Wilson, Chair                                                                                                     
Senator Shelley Hughes, Vice Chair                                                                                              
Senator Mia Costello                                                                                                            
Senator Lora Reinbold                                                                                                           
Senator Tom Begich                                                                                                              
                                                                                                                                
MEMBERS ABSENT                                                                                                                
                                                                                                                                
All members present                                                                                                             
                                                                                                                                
COMMITTEE CALENDAR                                                                                                            
                                                                                                                                
SENATE BILL NO. 124                                                                                                             
"An  Act relating  to admission  to and  detention at  a subacute                                                               
mental health  facility; establishing a definition  for 'subacute                                                               
mental health  facility'; establishing  a definition  for 'crisis                                                               
residential  center'; relating  to  the  definitions for  'crisis                                                               
stabilization   center';  relating   to  the   administration  of                                                               
psychotropic  medication  in  a  crisis  situation;  relating  to                                                               
licensed facilities; and providing for an effective date."                                                                      
                                                                                                                                
     - HEARD & HELD                                                                                                             
                                                                                                                                
PRESENTATION(S): THE STATE OF ALASKA'S HEALTH                                                                                   
                                                                                                                                
     - HEARD                                                                                                                    
                                                                                                                                
PREVIOUS COMMITTEE ACTION                                                                                                     
                                                                                                                                
BILL: SB 124                                                                                                                  
SHORT TITLE: MENTAL HEALTH FACILITIES & MEDS                                                                                    
SPONSOR(s): RULES BY REQUEST OF THE GOVERNOR                                                                                    
                                                                                                                                
04/12/21       (S)       READ THE FIRST TIME - REFERRALS                                                                        
04/12/21       (S)       HSS, FIN                                                                                               
04/27/21       (S)       HSS AT 1:30 PM BUTROVICH 205                                                                           
04/27/21       (S)       Heard & Held                                                                                           
04/27/21       (S)       MINUTE(HSS)                                                                                            
04/29/21       (S)       HSS AT 1:30 PM BUTROVICH 205                                                                           
04/29/21       (S)       -- MEETING CANCELED --                                                                                 
05/04/21       (S)       HSS AT 1:30 PM BUTROVICH 205                                                                           
05/04/21       (S)       Heard & Held                                                                                           
05/04/21       (S)       MINUTE(HSS)                                                                                            
05/05/21       (S)       JUD REFERRAL ADDED AFTER HSS                                                                           
05/06/21       (S)       HSS AT 1:30 PM BUTROVICH 205                                                                           
05/06/21       (S)       <Bill Hearing Canceled>                                                                                
03/08/22       (S)       HSS AT 1:30 PM BUTROVICH 205                                                                           
03/08/22       (S)       Heard & Held                                                                                           
03/08/22       (S)       MINUTE(HSS)                                                                                            
03/15/22       (S)       HSS AT 1:30 PM BUTROVICH 205                                                                           
03/15/22       (S)       Heard & Held                                                                                           
03/15/22       (S)       MINUTE(HSS)                                                                                            
03/17/22       (S)       HSS AT 1:30 PM BUTROVICH 205                                                                           
03/17/22       (S)       Heard & Held                                                                                           
03/17/22       (S)       MINUTE(HSS)                                                                                            
03/22/22       (S)       HSS AT 1:30 PM BUTROVICH 205                                                                           
                                                                                                                                
WITNESS REGISTER                                                                                                              
                                                                                                                                
NANCY MEADE, General Counsel                                                                                                    
Office of the Administrative Director                                                                                           
Alaska Court System                                                                                                             
Anchorage, Alaska                                                                                                               
POSITION STATEMENT: Answered questions on SB 124.                                                                             
                                                                                                                                
STEVEN BOOKMAN, Senior Assistant Attorney General                                                                               
Human Services Section                                                                                                          
Civil Division                                                                                                                  
Department of Law                                                                                                               
Anchorage, Alaska                                                                                                               
POSITION STATEMENT: Answered questions on SB 124.                                                                             
                                                                                                                                
DR. ANNE ZINK, Chief Medical Officer                                                                                            
Department of Health and Social Services (DHSS)                                                                                 
Anchorage, Alaska.                                                                                                              
POSITION STATEMENT: Presented a PowerPoint on the State of                                                                    
Alaska's Health and answered questions on the Crisis Now model.                                                                 
                                                                                                                                
                                                                                                                                
ACTION NARRATIVE                                                                                                              
                                                                                                                                
1:33:29 PM                                                                                                                    
CHAIR DAVID WILSON  called the Senate Health  and Social Services                                                             
Standing Committee meeting  to order at 1:33 p.m.  Present at the                                                               
call  to  order were  Senators  Reinbold,  Costello, Hughes,  and                                                               
Chair Wilson. Senator Begich arrived shortly thereafter.                                                                        
                                                                                                                                
             SB 124-MENTAL HEALTH FACILITIES & MEDS                                                                         
                                                                                                                                
1:34:17 PM                                                                                                                    
CHAIR WILSON announced  the consideration of SENATE  BILL NO. 124                                                               
"An  Act relating  to admission  to and  detention at  a subacute                                                               
mental health  facility; establishing a definition  for 'subacute                                                               
mental health  facility'; establishing  a definition  for 'crisis                                                               
residential  center'; relating  to  the  definitions for  'crisis                                                               
stabilization   center';  relating   to  the   administration  of                                                               
psychotropic  medication  in  a  crisis  situation;  relating  to                                                               
licensed facilities; and providing for an effective date."                                                                      
                                                                                                                                
He noted  that the committee  started the amendment  process last                                                               
Thursday and stopped on Amendment 13.                                                                                           
                                                                                                                                
1:35:16 PM                                                                                                                    
At ease                                                                                                                         
                                                                                                                                
1:35:32 PM                                                                                                                    
CHAIR WILSON reconvened the meeting.                                                                                            
                                                                                                                                
CHAIR  WILSON acknowledged  that  Senator Begich  had joined  the                                                               
meeting.                                                                                                                        
                                                                                                                                
1:35:40 PM                                                                                                                    
SENATOR HUGHES  moved that the  committee rescind its  action [to                                                               
adopt] Amendment 10.1 to SB 124.                                                                                                
                                                                                                                                
1:35:46 PM                                                                                                                    
CHAIR WILSON objected for discussion purposes.                                                                                  
                                                                                                                                
1:35:50 PM                                                                                                                    
At ease                                                                                                                         
                                                                                                                                
1:36:25 PM                                                                                                                    
CHAIR WILSON reconvened the meeting.                                                                                            
                                                                                                                                
1:36:27 PM                                                                                                                    
SENATOR  HUGHES  explained that  she  held  discussions with  the                                                               
department. The  amendment applied  to voluntary  commitments but                                                               
must also apply  to involuntary ones. She said she  serves on the                                                               
next committee  of referral, the Senate  Judiciary Committee, and                                                               
would address  her concerns  in that  committee as  the amendment                                                               
does not meet the intended objective.                                                                                           
                                                                                                                                
1:36:55 PM                                                                                                                    
CHAIR WILSON withdrew his objection; he found no further                                                                        
objection, and the action [to adopt] Amendment 10.1 was                                                                         
rescinded.                                                                                                                      
                                                                                                                                
1:37:14 PM                                                                                                                    
SENATOR REINBOLD moved to adopt Amendment 13, work order 32-                                                                    
GS1730\B.2.                                                                                                                     
                                                                                                                                
                                                 32-GS1730\B.2                                                                  
                                                      Dunmire                                                                   
                                                      3/14/22                                                                   
                                                                                                                                
                                                                                                                                
                          AMENDMENT 13                                                                                      
                                                                                                                                
                                                                                                                                
     OFFERED IN THE SENATE               BY SENATOR REINBOLD                                                                    
         TO:  CSSB 124(HSS), Draft Version "B"                                                                                  
                                                                                                                                
     Page 3, following line 24:                                                                                                 
          Insert a new bill section to read:                                                                                    
     "* Sec.  11. AS  47.30.700 is amended  by adding  a new                                                                  
     subsection to read:                                                                                                        
          (c) When a crisis stabilization center, crisis                                                                        
     residential center,  evaluation facility,  or treatment                                                                    
     facility admits  a respondent  under this  section, the                                                                    
     crisis   stabilization   center,   crisis   residential                                                                    
     center,  evaluation  facility,  or  treatment  facility                                                                    
     shall, unless  the petition was  filed by  an immediate                                                                    
     family  member of  the  respondent, immediately  notify                                                                    
     the   respondent's  immediate   family,   or,  if   the                                                                    
     respondent  is a  minor, a  parent or  guardian of  the                                                                    
     minor, that the respondent has been admitted."                                                                             
                                                                                                                                
     Renumber the following bill sections accordingly.                                                                          
                                                                                                                                
     Page 4, line 17:                                                                                                           
          Delete "a new subsection"                                                                                             
          Insert "new subsections"                                                                                              
                                                                                                                                
     Page 4, following line 21:                                                                                                 
          Insert a new subsection to read:                                                                                      
          "(d)  When a crisis stabilization center, crisis                                                                      
     residential center,  evaluation facility,  or treatment                                                                    
     facility  admits  a  person  under  this  section,  the                                                                    
     crisis   stabilization   center,   crisis   residential                                                                    
     center,  evaluation  facility,  or  treatment  facility                                                                    
     shall   immediately  notify   the  person's   immediate                                                                    
     family,  or, if  the person  is  a minor,  a parent  or                                                                    
     guardian  of  the  person, that  the  person  has  been                                                                    
     admitted."                                                                                                                 
                                                                                                                                
     Page 13, lines 1 - 2:                                                                                                      
          Delete "secs. 1 - 27"                                                                                                 
          Insert "secs. 1 - 28"                                                                                                 
                                                                                                                                
     Page 13, lines 27 - 28:                                                                                                    
          Delete "sec. 23"                                                                                                      
          Insert "sec. 24"                                                                                                      
                                                                                                                                
     Page 13, line 29:                                                                                                          
          Delete "sec. 23"                                                                                                      
          Insert "sec. 24"                                                                                                      
                                                                                                                                
     Page 14, line 7:                                                                                                           
          Delete "Section 28"                                                                                                   
          Insert "Section 29"                                                                                                   
                                                                                                                                
1:37:17 PM                                                                                                                    
CHAIR WILSON objected for purposes of discussion.                                                                               
                                                                                                                                
1:37:25 PM                                                                                                                    
At ease                                                                                                                         
                                                                                                                                
1:39:38 PM                                                                                                                    
CHAIR WILSON reconvened the meeting.                                                                                            
                                                                                                                                
1:39:39 PM                                                                                                                    
SENATOR  REINBOLD   stated  that   Amendment  13   would  require                                                               
immediate notification of  a family member when  an individual is                                                               
admitted  to a  crisis stabilization  center, crisis  residential                                                               
center, evaluation facility, or treatment facility.                                                                             
                                                                                                                                
1:40:05 PM                                                                                                                    
SENATOR BEGICH  said he  understood the  intent, but  his concern                                                               
was to  ensure that the  contact with  family was safe,  and that                                                               
might  not happen  if Amendment  13 were  to pass,.  He suggested                                                               
that the  amendment could be  considered in the  Senate Judiciary                                                               
Committee. He maintained his objection.                                                                                         
                                                                                                                                
1:41:15 PM                                                                                                                    
SENATOR COSTELLO  wondered if adding  the language   or guardian                                                                
on lines 8 and 22, after "family" would address his concern.                                                                    
                                                                                                                                
1:41:54 PM                                                                                                                    
SENATOR HUGHES stated that she would  work on the language in the                                                               
Senate Judiciary  Committee to ensure that  parents and guardians                                                               
were notified and  that Senator Begichs  safety  concern was also                                                               
addressed.                                                                                                                      
                                                                                                                                
SENATOR  REINBOLD  said  her concern  was  for  immediate  family                                                               
members who  did not  know where the  person was  being admitted.                                                               
She  suggested  the  committee conceptually  amend  Amendment  13                                                               
today and  the next  committee of referral  could address  how to                                                               
avoid notifying family members in abusive situations.                                                                           
                                                                                                                                
1:44:39 PM                                                                                                                    
SENATOR  BEGICH  said  he  had  contemplated  Senator  Costello's                                                               
suggestion,   which  he   understood   would  add    respondents                                                                
immediate  family  or  guardian."  He  offered  to  withdraw  his                                                               
objection if she agreed to offer the amendment.                                                                                 
                                                                                                                                
SENATOR COSTELLO offered to make a conceptual amendment.                                                                        
                                                                                                                                
1:45:00 PM                                                                                                                    
CHAIR WILSON asked Ms. Meade to comment on Amendment 13.                                                                        
                                                                                                                                
1:45:36 PM                                                                                                                    
NANCY  MEADE,  General  Counsel,  Office  of  the  Administrative                                                               
Director,  Alaska Court  System, Anchorage,  Alaska, stated  that                                                               
she reviewed Amendment 13 and did not find any technical issues.                                                                
                                                                                                                                
1:45:54 PM                                                                                                                    
SENATOR COSTELLO moved Conceptual Amendment 1 to Amendment 13.                                                                  
                                                                                                                              
     Page 1, line 8:                                                                                                            
          Insert "or guardian" following "family"                                                                               
                                                                                                                                
     Page 1 line 22:                                                                                                            
          Insert "or guardian" following "family"                                                                               
                                                                                                                                
SENATOR COSTELLO stated  that it would read  "immediate family or                                                               
guardian" in both instances.                                                                                                    
                                                                                                                                
1:46:31 PM                                                                                                                    
CHAIR WILSON objected for purposes of discussion.                                                                               
                                                                                                                                
1:46:36 PM                                                                                                                    
CHAIR  WILSON offered  his view  that Conceptual  Amendment 1  to                                                               
Amendment  13  would  not  address  the  issue  of  notifying  an                                                               
immediate family member  that the admitted person  would not want                                                               
notified.  He  related  the  notification  could  be  a  brother,                                                               
sister, grandmother, mother, or another family member.                                                                          
                                                                                                                                
SENATOR BEGICH  agreed. He felt  comfortable that  Senator Hughes                                                               
would work on language in the next committee of referral.                                                                       
                                                                                                                                
CHAIR WILSON remarked  that generally, he did not  prefer to have                                                               
another committee  address an unfinished amendment.  He asked the                                                               
will of the committee.                                                                                                          
                                                                                                                                
1:47:43 PM                                                                                                                    
SENATOR REINBOLD asked if this relates to the full amendment.                                                                   
                                                                                                                                
CHAIR WILSON  answered that Conceptual  Amendment 1  to Amendment                                                               
13 was before the committee.                                                                                                    
                                                                                                                                
1:48:02 PM                                                                                                                    
CHAIR WILSON stated the committee would  take a roll call vote on                                                               
Conceptual Amendment 1 to Amendment 13.                                                                                         
                                                                                                                                
1:48:04 PM                                                                                                                    
SENATOR  HUGHES  stated  she understood  that  Chair  Wilson  was                                                               
uncomfortable  that the  issue was  unfinished. She  committed to                                                               
work on the issue in the  next committee of referral. She offered                                                               
support for  Conceptual Amendment  1 to ensure  that notification                                                               
to the immediate family occurs.                                                                                                 
                                                                                                                                
1:48:30 PM                                                                                                                    
At ease                                                                                                                         
                                                                                                                                
1:49:01 PM                                                                                                                    
CHAIR WILSON  reconvened the  meeting and asked  for a  roll call                                                               
vote.                                                                                                                           
                                                                                                                                
1:49:13 PM                                                                                                                    
A roll  call vote was  taken. Senators Begich,  Hughes, Costello,                                                               
and Reinbold  voted in favor  of adopting Conceptual  Amendment 1                                                               
to Amendment 13, and Senator  Wilson voted against it. Therefore,                                                               
Conceptual  Amendment 1  to Amendment  13  was adopted  on a  4:1                                                               
vote.                                                                                                                           
                                                                                                                                
CHAIR WILSON  announced that Conceptual Amendment  1 to Amendment                                                               
13 was adopted on a vote of 4 yeas and 1 nay.                                                                                   
                                                                                                                                
1:49:43 PM                                                                                                                    
SENATOR REINBOLD opined that parental  consent should be required                                                               
for   admission  to   the  crisis   care  facilities,   not  just                                                               
notification. She  said it  was easier to  modify and  adjust the                                                               
notification language once  it is in the bill.  She urged members                                                               
to vote yes.                                                                                                                    
                                                                                                                                
1:50:24 PM                                                                                                                    
CHAIR WILSON stated that some  patients do not always want family                                                               
members  informed of  their medical  conditions, especially  when                                                               
they  are not  minors.  He offered  his belief  that  this was  a                                                               
significant concern.                                                                                                            
                                                                                                                                
1:50:48 PM                                                                                                                    
SENATOR  HUGHES  offered  to  address   this  issue  and  Senator                                                               
Begich's  concern  that a  family  member  could be  abusing  the                                                               
person. She offered to review both  of those issues in the Senate                                                               
Judiciary Committee.                                                                                                            
                                                                                                                                
1:51:10 PM                                                                                                                    
SENATOR BEGICH commented that he  would have opposed Amendment 13                                                               
if  Senator  Hughes hadnt   indicated  she  would work  on  these                                                               
issues in the Senate Judiciary Committee.                                                                                       
                                                                                                                                
1:51:28 PM                                                                                                                    
CHAIR  WILSON   removed  his  objection;  he   found  no  further                                                               
objection, and Amendment 13, as amended, was adopted.                                                                           
                                                                                                                                
1:51:43 PM                                                                                                                    
SENATOR  REINBOLD moved  to adopt  Amendment 14,  work order  32-                                                               
GS1730\B.4.                                                                                                                     
                                                                                                                                
                                                 32-GS1730\B.4                                                                  
                                                 Dunmire/Foote                                                                  
                                                      3/14/22                                                                   
                                                                                                                                
                                                                                                                                
                          AMENDMENT 14                                                                                      
                                                                                                                                
                                                                                                                                
     OFFERED IN THE SENATE                BY SENATOR REINBOLD                                                                   
         TO:  CSSB 124(HSS), Draft Version "B"                                                                                  
                                                                                                                                
                                                                                                                                
     Page 7, line 30, following "if":                                                                                           
          Insert "the respondent is"                                                                                            
                                                                                                                                
     Page 8, line 1:                                                                                                            
          Delete all material and insert:                                                                                       
              "(2)  if the respondent is a minor,                                                                               
                    (A) the minor has the rights identified                                                                     
          in AS 47.30.700 - 47.30.815;                                                                                          
                    (B)  psychotropic medication may not be                                                                     
          administered  to  the  minor unless  a  parent  or                                                                    
          legal guardian has given  permission to the crisis                                                                    
          stabilization center or  crisis residential center                                                                    
         to administer the psychotropic medication; and                                                                         
                    (C)  a parent or legal guardian has the                                                                     
          right to be fully informed of possible side                                                                           
          effects of a proposed psychotropic medication."                                                                       
                                                                                                                                
1:51:46 PM                                                                                                                    
CHAIR WILSON objected for discussion purposes.                                                                                  
                                                                                                                                
1:51:48 PM                                                                                                                    
SENATOR REINBOLD  explained that  Amendment 14 would  ensure that                                                               
parental or guardian permission  is required before administering                                                               
psychotropic  drugs to  a minor  in a  crisis care  facility. She                                                               
stated her belief that informed consent is a critical right.                                                                    
                                                                                                                                
1:53:04 PM                                                                                                                    
SENATOR HUGHES said  she was unsure whether  Senator Reinbold was                                                               
present  during a  prior discussion  about the  need for  medical                                                               
personnel to give  medication during life-threatening situations,                                                               
such  as  a   person  experiencing  a  heart   attack.  In  those                                                               
instances,  medical  personnel  might  not have  time  to  get  a                                                               
parent,  guardian, or  other  family  member's permission  before                                                               
administering  drugs  or  providing procedures.  She  noted  that                                                               
minor athletes could  have heart attacks. She  related a scenario                                                               
where a minor was endangering  their life or others when admitted                                                               
to crisis  stabilization centers.  She asked Senator  Reinbold if                                                               
she was suggesting  that the center would have  to get permission                                                               
from a parent or legal guardian before saving the child's life.                                                                 
                                                                                                                                
SENATOR  REINBOLD recalled  a discussion  about  the language  in                                                               
Amendment 3.  She recognized  that the  court system  stated that                                                               
"serious" did not need to be  added, but a psychiatrist she spoke                                                               
to disagreed because  it required a higher  standard. She offered                                                               
his view  that the  committee should  revisit the  amendment. She                                                               
offered her belief  that a parent or guardian  should be involved                                                               
when psychotropic drugs  are administered because of  the risk of                                                               
side  effects. She  said  she  would want  a  parent or  guardian                                                               
involved  when administering  psychotropic drugs  during a  life-                                                               
threatening situation.                                                                                                          
                                                                                                                                
1:55:39 PM                                                                                                                    
SENATOR  HUGHES  agreed that  some  psychotropic  drugs were  not                                                               
administered  in life-threatening  situations. For  instance, she                                                               
understood that  lithium was used for  routine behavioral health,                                                               
which a crisis stabilization center  would prescribe. She offered                                                               
her view that  consent could be required unless  the minor's life                                                               
was endangered.  She asked whether  the sponsor would  be willing                                                               
to consider  an exception for  emergency situations in  which the                                                               
minor's life was at risk.                                                                                                       
                                                                                                                                
1:57:04 PM                                                                                                                    
SENATOR REINBOLD  said she  was open to  having an  exception for                                                               
life endangerment.                                                                                                              
                                                                                                                                
1:57:32 PM                                                                                                                    
At ease                                                                                                                         
                                                                                                                                
1:58:10 PM                                                                                                                    
CHAIR WILSON reconvened the meeting.                                                                                            
                                                                                                                                
1:58:11 PM                                                                                                                    
SENATOR BEGICH  asked whether these  rights were  already covered                                                               
in law.                                                                                                                         
                                                                                                                                
1:58:49 PM                                                                                                                    
STEVEN   BOOKMAN,  Senior   Assistant  Attorney   General,  Human                                                               
Services Section,  Civil Division, Department of  Law, Anchorage,                                                               
Alaska,  agreed   that  law  addresses  this   in  AS  25.20.025,                                                               
Examination  and treatment  of minors.  It essentially  says that                                                               
parents make decisions about minors.  It lists instances in which                                                               
a parent  cannot be contacted  or, if contacted, is  unwilling to                                                               
grant or withhold consent that  a minor can consent to treatment.                                                               
He  stated   that  the  concerns  voiced   earlier  about  crisis                                                               
medication, where  the alternative was  to tie someone  down, and                                                               
non-crisis medication  intended to  improve a  general condition,                                                               
was an important  distinction. He offered his view  that this was                                                               
addressed in the existing statute.                                                                                              
                                                                                                                                
1:59:49 PM                                                                                                                    
SENATOR BEGICH stated his belief that it was covered.                                                                           
                                                                                                                                
1:59:58 PM                                                                                                                    
CHAIR WILSON agreed.                                                                                                            
                                                                                                                                
2:00:11 PM                                                                                                                    
SENATOR REINBOLD  commented that  was what  she had  thought. She                                                               
stated that the bill  amends AS 47, not AS 25  and that these are                                                               
new residential centers.  She said she was told that  AS 25 would                                                               
not apply  to them. She  stated that  Amendment 14 would  make it                                                               
clear that the rights in Article  10 apply to the minors in these                                                               
new facilities.                                                                                                                 
                                                                                                                                
2:00:55 PM                                                                                                                    
SENATOR HUGHES  asked whether Legislative Legal  Services said AS                                                               
25 would not apply.                                                                                                             
                                                                                                                                
SENATOR  REINBOLD  answered  that  her information  came  from  a                                                               
patient  advocacy   group  concerned   about  the   new  subacute                                                               
facilities.  She  stated  that  Amendment 14  would  ensure  that                                                               
Article 10 rights also apply to minors.                                                                                         
                                                                                                                                
CHAIR WILSON  stated that Mr.  Bookman clarified that AS  25 does                                                               
apply.  He   noted  that  the  court   administrator  nodded  her                                                               
agreement that Title 25 would apply to SB 124.                                                                                  
                                                                                                                                
2:02:06 PM                                                                                                                    
SENATOR HUGHES asked for assurance  that AS 25 would separate the                                                               
life-threatening situations  from medication given to  soothe the                                                               
patient, such  that consent from  a parent or guardian  would not                                                               
be necessary.                                                                                                                   
                                                                                                                                
2:02:40 PM                                                                                                                    
MR. BOOKMAN answered  that he believed it would do  so. He stated                                                               
that  AS   25.20.025  covers  medical  treatment   generally.  He                                                               
indicated that regarding crisis medication,  the intent of SB 124                                                               
is  to  incorporate the  standard  currently  used in  evaluation                                                               
centers.  Under AS  47.30.838, a  crisis medication  may be  used                                                               
only  if  there's  a  crisis or  an  impending  crisis  requiring                                                               
immediate  use of  the  medication to  preserve  life or  prevent                                                               
significant  physical harm.  He offered  his belief  that a  mood                                                               
stabilizer or something  that is soothing would  not be permitted                                                               
because  that medication  would not  be necessary  to prevent  an                                                               
impending or actual  crisis. The crisis medication  would need to                                                               
have an  immediate effect. It  would not be permissible  under AS                                                               
47.30.838.                                                                                                                      
                                                                                                                                
2:04:08 PM                                                                                                                    
SENATOR HUGHES stated  that it made sense that AS  25 would apply                                                               
to situations  where a child is  rushed to an emergency  room for                                                               
treatment.  Although she  supports the  concept of  Amendment 14,                                                               
she  does not  support the  amendment. She  offered to  follow up                                                               
with Legislative  Legal Services for  assurances that AS  25 does                                                               
apply  and  that  parental  consent would  be  required  in  non-                                                               
emergency situations. If  not, she offered to raise  the issue in                                                               
the Senate Judiciary Committee.                                                                                                 
                                                                                                                                
2:05:03 PM                                                                                                                    
SENATOR REINBOLD  asked whether parental  and minor rights  in AS                                                               
47.37.815 apply to the new facilities.                                                                                          
                                                                                                                                
MR. BOOKMAN answered yes. He  explained that the minor would have                                                               
rights as  any patient  would. He clarified  that the  new crisis                                                               
stabilization centers,  and crisis residential centers  would not                                                               
have   the   ability   to  involuntarily   prescribe   non-crisis                                                               
medication. It is not an issue  for minors because the only way a                                                               
minor at one of these  centers could receive long-term medication                                                               
would be with  the parent or guardian's  permission. He explained                                                               
that the existing statute would  allow for a limited exception if                                                               
the parents were  unavailable and the minor was  mature enough to                                                               
consent.                                                                                                                        
                                                                                                                                
2:06:38 PM                                                                                                                    
SENATOR REINBOLD offered her view  that Amendment 14 was critical                                                               
because psychotropic  medication can cause  nightmares, increased                                                               
saliva, swelling of  the face, lips, tongue,  or throat, thoughts                                                               
of  suicide,  or other  harmful  side  effects. She  offered  her                                                               
support  for  informed  consent,  parental  involvement,  and  an                                                               
advocate or legal guardian.                                                                                                     
                                                                                                                                
2:07:42 PM                                                                                                                    
CHAIR WILSON maintained his objection.                                                                                          
                                                                                                                                
2:07:45 PM                                                                                                                    
A roll  call vote was taken.  Senator Reinbold voted in  favor of                                                               
Amendment 14,  and Senators Hughes, Costello,  Begich, and Wilson                                                               
voted against it. Therefore, Amendment 14 failed on a 1:4 vote.                                                                 
                                                                                                                                
2:08:05 PM                                                                                                                    
CHAIR WILSON  announced that Amendment 14  failed on a vote  of 1                                                               
yea and 4 nays.                                                                                                                 
                                                                                                                                
2:08:18 PM                                                                                                                    
CHAIR WILSON held SB 124 in committee.                                                                                          
                                                                                                                                
2:08:24 PM                                                                                                                    
At ease                                                                                                                         
                                                                                                                                
^PRESENTATION(S): THE STATE OF ALASKA'S HEALTH                                                                                  
         PRESENTATION(S): THE STATE OF ALASKA'S HEALTH                                                                      
                                                                                                                              
2:11:16 PM                                                                                                                    
CHAIR WILSON reconvened the meeting and announced the                                                                           
presentation on the State of Alaska's Health.                                                                                   
                                                                                                                                
2:11:58 PM                                                                                                                    
At ease                                                                                                                         
                                                                                                                                
2:12:16 PM                                                                                                                    
CHAIR WILSON reconvened the meeting.                                                                                            
                                                                                                                                
2:12:20 PM                                                                                                                    
ANNE ZINK,  MD; Chief Medical  Officer, Department of  Health and                                                               
Social Services (DHSS), Anchorage, Alaska, stated that she would                                                                
present   a high-level   overview   of  the  State  of  Alaska's                                                                
health. She paraphrased her prepared testimony, which read:                                                                     
                                                                                                                                
[Original punctuation provided.]                                                                                                
                                                                                                                                
     The goal  of this presentation  is to provide  you with                                                                    
     data   and   foundational   knowledge   so   that   the                                                                    
     legislative  branch,  the  executive  branch,  and  the                                                                    
     public  can work  together to  improve  the health  and                                                                    
     well-being of Alaskans.                                                                                                    
                                                                                                                                
     As the Chief  Medical Officer for the  State of Alaska,                                                                    
     I oversee  the Division  of Public  Health, I  serve as                                                                    
     the clinical  liaison across  state departments,  and I                                                                    
     work with clinicians throughout  the State and directly                                                                    
     care for patients in the Emergency Department.                                                                             
2:13:07 PM                                                                                                                    
     The health  of Alaskans  is greater  than DHSS,  or any                                                                    
     one Department or organization.  It involves many state                                                                    
     and federal agencies    as well as  thousands of health                                                                    
     care  providers, community  and  tribal  leaders    who                                                                    
     work tirelessly day in and day out.                                                                                        
                                                                                                                                
     The cost  of health care  and what the State  pays goes                                                                    
     beyond Medicaid    it includes the  State Retiree Plan,                                                                    
     the  Department  of  Corrections,  the  State  employee                                                                    
     health plan,  not to mention  the myriad of  grants and                                                                    
     contracts.                                                                                                                 
                                                                                                                                
     This presentation today  is for you    and for everyone                                                                    
     working to improve the lives of Alaskans.                                                                                  
                                                                                                                                
     The  goal  of  the  presentation  was  to  provide  the                                                                    
     committee with  data and foundational knowledge  so the                                                                    
     legislative  branch, executive  branch, and  the public                                                                    
     could  work together  to improve  Alaskans  health  and                                                                    
     well-being.                                                                                                                
                                                                                                                                
2:13:52 PM                                                                                                                    
DR. ZINK  reviewed slide 2,  consisting of puzzle  pieces listing                                                               
health  factors. The  slide stated  that  behind every  decision,                                                               
every policy,  every report, there  is a person.  She paraphrased                                                               
her prepared testimony, which read:                                                                                             
                                                                                                                                
[Original punctuation provided.]                                                                                                
                                                                                                                                
     Early in my career, one of  my mentors told me   always                                                                    
     do  what is  right for  the patient,  and remember  the                                                                    
     rest is noise.                                                                                                             
                                                                                                                                
     That advice  has guided me,  as a physician and  now in                                                                    
     my service to the State.                                                                                                   
                                                                                                                                
     The scope of  health care is broad and  complex, but we                                                                    
     must always  remain focused  on the  people we  serve                                                                      
     the individuals behind the puzzle pieces.                                                                                  
                                                                                                                                
     And health care  is more than seeing  a doctor. Studies                                                                    
     show that up to 80%  of a person's health is determined                                                                    
     by   factors  outside   of  traditional   health  care,                                                                    
     including  behavioral factors  such as  tobacco use  or                                                                    
     physical  activity, as  well  as  social, economic  and                                                                    
     community  factors  such  as  having  a  job,  housing,                                                                    
     access  to  food,  transportation,  or  even  community                                                                    
     connectiveness can contribute  heavily to outcomes such                                                                    
     as the length and quality of life.                                                                                         
                                                                                                                                
     This is why everything from  access to local trails, to                                                                    
     integrating  behavioral health  services,  matter in  a                                                                    
     person's overall health.                                                                                                   
                                                                                                                                
2:14:37 PM                                                                                                                    
DR.  ZINK  reviewed  slide  3,   Life  Expectancy  Trends,  which                                                               
consisted of two  graphs depicting national trends.  She said the                                                               
figure  on the  left-hand side  showed the  life expectancy  from                                                               
1880 to 2019,  which increased over time  except for disruptions,                                                               
such as the 1918 pandemic, WWI  and WWII. She highlighted that in                                                               
recent years the life expectancy  had flattened and was beginning                                                               
to decrease. She noted that  this was due primarily attributed to                                                               
overdose and suicide.  The COVID-19 pandemic is not  shown on the                                                               
slide, but if it were, it  would show a continued decline in life                                                               
expectancy. Historically  the most significant  transformation in                                                               
life expectancy  came from a  better understanding  of infectious                                                               
diseases by  providing clean water  and sewer to  protect health.                                                               
This  continues to  be a  struggle  throughout the  world and  in                                                               
Alaska. She noted that 32  communities lack functioning water and                                                               
sewer.                                                                                                                          
                                                                                                                                
DR. ZINK stated that the  next health care transformation came in                                                               
the  21st  Century  based  on   advancements  in  diagnostic  and                                                               
therapeutic  medicine, including  antibiotics, vaccines,  and lab                                                               
work. She  indicated that  despite advances,  infectious diseases                                                               
have persisted,  and health  care costs  have continued  to rise.                                                               
She noted  that not everyone has  the same access to  care or has                                                               
improved outcomes.                                                                                                              
                                                                                                                                
DR. ZINK directed  attention to the graph on  the right-hand side                                                               
of slide 3,  which showed a comparison of  life expectancy versus                                                               
health expenditures for  other countries compared to  the US. She                                                               
paraphrased her prepared testimony, which read:                                                                                 
                                                                                                                                
[Original punctuation provided.]                                                                                                
                                                                                                                                
2:16:14 PM                                                                                                                    
     Looking at  the graph on  the right comparing  what the                                                                    
     US  spends   on  health  care   per  capita   and  life                                                                    
     expectancy over time to  other developed countries, the                                                                  
     big  outlier in  the group  is  the US,  which has  the                                                                  
     highest health expenditures per  capita but lags behind                                                                  
     other developed countries in  life expectancy, and this                                                                  
     difference has accelerated over  time.  The reasons for                                                                  
     this are  multifactorial, hotly debated and  complex to                                                                    
     change, but  important to think  about in terms  of how                                                                    
     we spend our dollars towards health.                                                                                       
                                                                                                                                
     The health  of the population  and the amount  of money                                                                    
     we  spend on  health care  directly impacts  everything                                                                    
     from military  readiness to the ability  to educate our                                                                    
     children and  we know healthy economies  are built with                                                                  
     healthy people.                                                                                                          
                                                                                                                                
     For  example,  when  employers   spend  more  money  on                                                                    
     healthcare, less  money is available for  innovation or                                                                    
     other  investments.  Or  for schools     when  a  large                                                                    
     portion of the budget must  pay for health benefits for                                                                    
     employees  and  retirees,  that  translates  into  less                                                                    
     overall funding, and larger class sizes for students.                                                                      
                                                                                                                                
     The goal  is to use  each dollar as wisely  as possible                                                                    
     to  improve  health  outcomes of  Alaskans.  The  least                                                                    
     expensive  patients are  those who  are physically  and                                                                    
     mentally healthy.   What has become  increasingly clear                                                                    
     is that  the next major  impact on the  life expectancy                                                                    
     and the cost of care  will come less from novel medical                                                                    
     discoveries,  but   more  from  the  way   health  care                                                                  
     delivery is structured.                                                                                                  
                                                                                                                                
     It  will  take  providers, patients,  the  public,  and                                                                  
     policy makers working together  to make this meaningful                                                                  
     change.                                                                                                                    
                                                                                                                                
2:17:59 PM                                                                                                                    
DR. ZINK turned to slide 4, Your New Health Care System, which                                                                  
depicted a flowchart of services. She paraphrased her prepared                                                                  
testimony, which read:                                                                                                          
                                                                                                                                
[Original punctuation provided.]                                                                                                
                                                                                                                                
     So how do  we move forward? How do we  work together to                                                                    
     promote  and  protect  the  health  and  well-being  of                                                                    
     Alaskans?                                                                                                                  
                                                                                                                                
     First, we must look at how our systems align.                                                                            
                                                                                                                                
     This  map  is  not  a  meme. It  was  made  during  the                                                                    
     creation  of the  Affordable Care  Act to  outlines out                                                                    
     how  different  parts  of the  federal  government  are                                                                    
     involved in providing health care  to Americans.  It is                                                                    
     overwhelming,  but powerful  to spend  time looking  at                                                                    
     all the  connections which speaks to  the complexity of                                                                    
     health care delivery.                                                                                                      
                                                                                                                                
     It's also  worth noting that  this map only  applies to                                                                    
     federal  complexity, and  does not  address connections                                                                    
     between state government,  local municipalities, Tribal                                                                    
     health  care,  and  other   federal  health  care  like                                                                    
     Veterans Affairs and the Department  of Defense, or the                                                                    
     other health factors we spoke  of earlier like housing,                                                                    
     transportation, employment, education and more.                                                                            
     Soon it  can feel like  this 2D graph  is insufficient.                                                                    
     We need a 3D matrix.                                                                                                       
                                                                                                                                
2:18:46 PM                                                                                                                    
DR. ZINK reviewed slide 5, which consisted of an aerial                                                                         
photograph of Unalaska. She paraphrased her prepared testimony,                                                                 
which read:                                                                                                                     
                                                                                                                                
[Original punctuation provided.]                                                                                                
                                                                                                                                
     And  adding to  this  complexity is  the uniqueness  of                                                                    
     Alaska    including  our  large  size, vast  geography,                                                                    
     diverse cultures, and  transportation constraints, with                                                                    
     most of our state off road system.                                                                                         
                                                                                                                                
     Our geography and our uniqueness  can be our advantage.                                                                  
     The  distances and  cost in  Alaska force  us to  think                                                                    
     about health  care delivery differently.   For example,                                                                    
     take  a  patient with  head  trauma.  In other  states,                                                                    
     patients like  this are often  admitted to the  ICU for                                                                    
     monitoring.   But  here,   because   of  our   distance                                                                    
     constraints,  we  have  taken  a closer  look  at  this                                                                    
     practice. Alaska's trauma  committee created guidelines                                                                    
     that  have  enabled  many patients  to  stay  in  their                                                                    
     communities  safely. This  approach  reduces costs  and                                                                    
     supports patients, without compromising care.                                                                              
                                                                                                                                
     Our geography  and historical background have  also led                                                                    
     to unique  partnerships.  In  Alaska public  health and                                                                    
     health   care  are   Tribal   health,  school   health,                                                                    
     industrial health,  and military  health.   Our limited                                                                    
     resources and  distances foster relationships  not seen                                                                    
     at all at all, or to the same degree, in other states.                                                                     
                                                                                                                                
2:19:46 PM                                                                                                                    
     And  Health Care  is delivered  differently.   In  many                                                                    
     rural communities  the only health  care is  the tribal                                                                    
     health care system,  providing robust and comprehensive                                                                    
     care  to both  native and  non-native beneficiaries  in                                                                    
     some  of the  hardest to  reach regions  in our  state.                                                                    
     Hospital  have  had  to   design  their  hele-pads  for                                                                    
     military  Blackhawk  helicopters  because they  may  be                                                                    
     bringing  in the  next  trauma  victim, or  vaccination                                                                    
     efforts  aboard  deep-sea  fish processing  vessels  to                                                                    
     keep the crew active, working and healthy.                                                                                 
                                                                                                                                
     Alaska  has a  chance to  be  a leader  in health  care                                                                    
     reform  that is  focused on  the improved  outcomes for                                                                    
     the  whole  person  at  reduce   cost  if  we  use  our                                                                    
     geography  and  our   partnerships  to  our  collective                                                                    
     advantage.                                                                                                                 
                                                                                                                                
2:20:34 PM                                                                                                                    
DR. ZINK reviewed slide 6, a collage highlighting services and                                                                  
slogans the department provides to Alaskans. She paraphrased her                                                                
prepared testimony, which read:                                                                                                 
                                                                                                                                
[Original punctuation provided.]                                                                                                
                                                                                                                                
     And that  is the goal  within the Department  of Health                                                                    
     and Social Services.                                                                                                       
                                                                                                                                
     As  you  know  well,  the  work  done  by  the  current                                                                    
     department  of  DHSS  is  broad,  diverse,  and  serves                                                                    
     Alaskans at all stages of  life.  By simplifying health                                                                    
     care delivery, braiding funding,  and aligning care, we                                                                    
     can provide better  care for less cost, and  that was a                                                                    
     big  driver  behind  the split  of  the  Department  of                                                                    
     Health  and Social  Services,  which  goes into  effect                                                                    
     July 1st.                                                                                                                  
                                                                                                                                
     With the  Department of Family and  Community Services,                                                                    
     the focus will be on  providing direct care services in                                                                    
     24/7 facilities, as well as communities.                                                                                   
                                                                                                                                
     With the  Department of  Health, the  focus will  be on                                                                    
     data-driven strategies to  connect prevention to health                                                                    
     care payment, delivery, and  long-term services, in the                                                                    
     most effective way possible.                                                                                               
                                                                                                                                
2:21:18 PM                                                                                                                    
DR. ZINK reviewed slide 7, Health Care and Public Health, which                                                                 
depicted a three-bucket model. She paraphrased her prepared                                                                     
testimony, which read:                                                                                                          
                                                                                                                                
[Original punctuation provided.]                                                                                                
                                                                                                                                
     At this  point you  may be asking  yourself: how  do we                                                                    
     accelerate to this transition?                                                                                             
                                                                                                                                
     I find  this "three buckets"  model helpful to  look at                                                                    
     how  public  health  and health  care  complement  each                                                                  
     other  and overlap  to create  whole  person and  whole                                                                  
     community care, which is key to moving forward.                                                                          
                                                                                                                                
     Let's take  diabetes for example.   In  the traditional                                                                    
     health care setting, a provider  may test for diabetes,                                                                    
     provide  medication   for  their  disease,   and  offer                                                                    
     education  and training  on how  to live  as healthy  a                                                                    
     life as possible.                                                                                                          
                                                                                                                                
     Meanwhile,  the  public  health  system  helps  support                                                                    
     additional  education,   as  well   as  community-based                                                                    
     lifestyle programs  to improve access to  healthy foods                                                                    
     and  increase  physical  activity. Public  Health  also                                                                    
     sets up tools to help  patients and providers track and                                                                    
     manage diabetes and works with  policy makers to ensure                                                                    
     treatments   such  as   insulin   are  accessible   and                                                                    
     affordable.                                                                                                                
                                                                                                                                
2:22:11 PM                                                                                                                    
     The shadowed area shows where  the two systems overlap.                                                                  
     Together, these  systems support the patient,  but more                                                                    
     importantly  they  work  to prevent  other  individuals                                                                    
     from   developing  the   disease.   When  systems   are                                                                    
     integrated,  the patient  does  not  notice that  these                                                                    
     buckets  are separate,  AND  there  are fewer  patients                                                                    
     overall.                                                                                                                   
                                                                                                                                
     That is  the beauty and  the challenge - when  a system                                                                    
     works well, the user doesn't  even recognize there is a                                                                    
     system.   I flew  here this morning  and spent  my time                                                                    
     reflecting  on the  beauty and  wonder  of Alaska,  not                                                                    
     worrying if  they hundreds of systems  involved to make                                                                    
     my flight  safe, enjoyable and  on time would  work and                                                                    
     the same should be true for patients needing care.                                                                         
                                                                                                                                
     And  when we  are able  to invest  in public  heath, we                                                                    
     reduce the  overall burden of  disease.  We  now expect                                                                    
     our  children to  grow to  adults.   Our TB  wards have                                                                    
     been  converted to  universities,  our orphanages  from                                                                    
     infectious disease  into hospitals, our  expectation is                                                                    
     for health, not bracing for premature death.                                                                               
                                                                                                                                
2:23:05 PM                                                                                                                    
     As a  state and a  nation, we are familiar  with bucket                                                                    
     #1   the  delivery of health care - and  do a great job                                                                    
     with  it. The  health care  in Alaska  and the  U.S. is                                                                    
     generally incredible high quality,  but it comes a high                                                                    
     cost without always the expected benefit.                                                                                  
                                                                                                                                
     But it  is bucket  #2     health care  services outside                                                                    
        the traditional clinical setting  and bucket #3                                                                         
     interventions  that reach  a whole  population    where                                                                    
     our  collective  focus  can help  provide  savings  and                                                                    
     improve outcomes.  The braiding  is these buckets was a                                                                    
     big driver of the 1115 waiver.                                                                                             
                                                                                                                                
     What  is clear,  we must  not go  back on  efforts made                                                                    
     over the  last center  to improve the  public's health,                                                                    
     as it  will cost us  dearly, both financially  and with                                                                    
     the lives of our neighbors, friends and loved ones.                                                                        
                                                                                                                                
2:23:58 PM                                                                                                                    
DR. ZINK reviewed slide 8, The Role of Public Health. She                                                                       
paraphrased her prepared testimony, which read:                                                                                 
                                                                                                                                
[Original punctuation provided.]                                                                                                
                                                                                                                                
     Now let's  look a bit  closer at what public  health is                                                                    
     and what it does.                                                                                                          
                                                                                                                                
     Public health has  transformed substantially over time,                                                                    
     and  each development  has built  on what  came before.                                                                    
     In the field  of public health, we  commonly talk about                                                                    
     this evolution  as Public Health versions  1.0, 2.0 and                                                                    
     3.0.                                                                                                                       
                                                                                                                                
     In  Alaska, Public  Health 1.0  included public  health                                                                    
     nurses   who  diagnosed   and  treated   diseases  like                                                                    
     tuberculosis  alongside   the  creation   of  Community                                                                    
     Health  Aides, providing  clinical  care  to those  who                                                                    
     didn't have  it, and trying  to fill in gaps  in health                                                                    
     care.  Other parts  of  this  stage included  improving                                                                    
     sanitation,  food and  water safety,  ensuring vaccines                                                                    
     and   treatments   were   available  to   the   general                                                                    
     population.                                                                                                                
                                                                                                                                
2:24:39 PM                                                                                                                    
     In   1965,   Medicaid   and  Medicare   were   created,                                                                    
     essentially to  provide a  way to  pay for  health care                                                                    
     for  the elderly  and the  poor    in  other words,  to                                                                    
     provide  payment for  Public  Health  1.0. Today,  over                                                                    
     200,000 Alaskans are covered by Medicaid and Medicare.                                                                     
                                                                                                                                
     However,  there  were  still gaps  apparent  even  with                                                                    
     greater  access  to  health  care,  and  public  health                                                                    
     transformed  to  2.0  with  a  systematic  approach  to                                                                    
     address  risk  factors,  prevent  and  address  chronic                                                                    
     diseases,   and  address   emerging  threats   such  as                                                                    
     HIV/AIDS.                                                                                                                  
                                                                                                                                
     Then,  Public Health  3.0  expanded beyond  traditional                                                                    
     programs  and   services  to  work   collectively  with                                                                    
     partners  to   address  health  concerns   and  empower                                                                    
     individuals to be their most healthy and well selves.                                                                      
                                                                                                                                
     The pandemic has further challenged  the role of public                                                                    
     health, highlighting  unresolved gaps  in care  and the                                                                    
     need for improved informatics and information sharing.                                                                     
                                                                                                                                
     Our next  steps will  be to improve  the way  we gather                                                                    
     and  share  data  to   better  coordinate  health  care                                                                    
     delivery, collectively move  towards prevention, and to                                                                    
     ensure systems  are in place  to support  every Alaskan                                                                    
     with diverse needs.                                                                                                        
                                                                                                                                
2:25:50 PM                                                                                                                    
DR. ZINK reviewed slide 9, Cost and Life Expectancy, which                                                                      
consisted of a line graph. She paraphrased her prepared                                                                         
testimony, which read:                                                                                                          
                                                                                                                                
[Original punctuation provided.]                                                                                                
                                                                                                                                
     But how about the cost?                                                                                                    
                                                                                                                                
     This is a fascinating  look at health care expenditures                                                                    
     per state  compared to  life expectancy.   It is  a bit                                                                    
     old, made  by the  Alaska Department  of Administration                                                                    
     with  data through  2014, but  you can  see Alaska  and                                                                    
     North Dakota  standing out as  some of the  states with                                                                    
     highest  health  care cost  in  the  country, but  also                                                                  
     above average  life expectancy.  West Virginia  and the                                                                  
     District of Columbia stand out  as high cost, yet lower                                                                    
     than  average   life  expectancy.    States   that  are                                                                    
     achieving  higher   life  expectancy  at   lower  costs                                                                    
     include Hawaii, California, Colorado, and Arizona.                                                                         
                                                                                                                                
2:26:28 PM                                                                                                                    
     What  I also  find interesting  is that  more money  in                                                                  
     health  care   does  not   translate  to   higher  life                                                                  
     expectancy  when we  look across  states; in  fact, the                                                                  
     inverse appears to be true.                                                                                                
                                                                                                                                
     Rural states  also tend  to spend  more on  health care                                                                    
     than  more   urban  states,  but  there   are  numerous                                                                    
     exceptions.                                                                                                                
                                                                                                                                
2:26:46 PM                                                                                                                    
DR. ZINK reviewed slide 10, Health Care Reform Quadruple Aim.                                                                   
She paraphrased her prepared testimony, which read:                                                                             
                                                                                                                                
[Original punctuation provided.]                                                                                                
                                                                                                                                
     In  addition  to  the three  buckets  and  the  various                                                                    
     versions of  Public Health,  another framework  that is                                                                    
     helpful  for this  discussion is  the quadruple  aim of                                                                    
     health  care reform.  Often used  by hospital  systems,                                                                    
     this  framework  provides   four  goals  that  combined                                                                    
     together improve care and reduce costs.                                                                                    
                                                                                                                                
     Starting with  the patient's experience the  goal is to                                                                    
     improve  public access  to  health  data and  services,                                                                    
     empowering Alaskans to make healthy life choices.                                                                          
                                                                                                                                
     Then,  building  into  population health,  focusing  on                                                                    
     measuring  health  factors   and  health  outcomes  for                                                                    
     entire communities, providing  tools and connections to                                                                    
     health  systems,  and   connecting  public  health  and                                                                    
     health care.                                                                                                               
                                                                                                                                
     Next is  cost. We reduce  costs by aligning  how health                                                                    
     care  is  paid for,  and  by  investing more  money  in                                                                    
     prevention.      Examples   include   chronic   disease                                                                    
     prevention programs,  the use of telehealth  or digital                                                                    
     platforms,  and   programs  that  expand   care  within                                                                    
     community  settings. In  addition, tools  like an  all-                                                                    
     payer claims  database will help bring  transparency to                                                                    
     healthcare costs.                                                                                                          
                                                                                                                                
2:27:50 PM                                                                                                                    
     Critical  to all  this work  is the  health care  team,                                                                    
     both  direct and  indirect. We  can support  the health                                                                    
     care team through  reducing administrative burden, loan                                                                    
     repayment,  workforce  recruitment and  retention,  and                                                                    
     clinical support tools.                                                                                                    
                                                                                                                                
     When  all  four  of  these aims  are  working  smoothly                                                                  
     together, we achieve better results.                                                                                     
                                                                                                                                
2:28:17 PM                                                                                                                    
DR. ZINK reviewed slide 11, Causes of Death in Alaska, which                                                                    
consisted of two bar charts. She paraphrased her prepared                                                                       
testimony, which read:                                                                                                          
                                                                                                                                
[Original punctuation provided.]                                                                                                
                                                                                                                                
     So now let's  look at some data on  where Alaska stands                                                                    
     and how we compare to the  rest of the United States on                                                                    
     specific health issues.                                                                                                    
                                                                                                                                
     On the left  you see leading causes  of premature death                                                                    
     in  2020  for  Alaska  compared  to  the  US.  This  is                                                                    
     different than overall causes of death.                                                                                    
     In  2020,  the biggest  causes  of  premature death  in                                                                    
     Alaska and  the U.S. were due  to unintentional injury,                                                                    
     cancer and heart disease.                                                                                                  
                                                                                                                                
     Here's  where we  are different:  Alaska stands  out in                                                                    
     having  about  twice  the  amount  of  premature  death                                                                  
     caused  by suicide  and liver  disease compared  to the                                                                  
     U.S., as noted in red.                                                                                                     
                                                                                                                                
     Differences can be  due to multiple factors,  but a big                                                                    
     one  is our  health  behaviors. To  look  at how  these                                                                  
     behaviors contribute  to premature death in  Alaska, we                                                                    
     did  an analysis  of the  reasons behind  these deaths.                                                                    
     This is shown on the right.                                                                                                
                                                                                                                                
2:29:06 PM                                                                                                                    
     Looking at  leading causes of  over 20,000  deaths, 59%                                                                
     were potentially preventable at a younger age.                                                                           
                                                                                                                                
     We   then  looked   upstream   and  identified   deaths                                                                    
     attributable  to  specific  risk factors.  The  leading                                                                  
     risk  factors  contributing  to  premature  death  were                                                                  
     obesity, being  overweight, or physically  inactive, as                                                                  
     well as smoking tobacco.                                                                                               
                                                                                                                                
2:29:32 PM                                                                                                                    
DR. ZINK reviewed slide 12, Suicide Prevention, which consisted                                                                 
of two bar charts and a line graph showing the number of annual                                                                 
suicide attempts and mortality rates.                                                                                           
                                                                                                                                
     As  we  talked about  in  the  past slide,  looking  at                                                                    
     Alaska compared  to the  US, Alaska  had about  2 times                                                                  
     the  amount of  premature death  caused by  suicide and                                                                
     liver disease, so  let's dive into one  of those topics                                                                  
     a bit and talk about suicide.                                                                                              
                                                                                                                                
     Our  state  has  struggled  with  having  some  of  the                                                                    
     highest rates  of suicide in the  nation, often ranking                                                                    
     as the most suicides  per capita, and currently ranking                                                                    
     second in the nation behind Wyoming.                                                                                       
                                                                                                                                
     In  general, suicides  have had  an outsized  impact on                                                                    
     youth.   In  2019,  suicide was  the  leading cause  of                                                                  
     death for  youth and young  adults, ages 15-24.    This                                                                  
     was the only  age group in our state  where suicide was                                                                    
     the leading cause of death.                                                                                                
                                                                                                                                
     Nationally,  if you  look at  the graph  at the  bottom                                                                    
     left, suicides  between 1975-2015 for  15-19 year-olds,                                                                    
     the highest  for boys was  in the early 1990s.  It came                                                                    
     down, but is now steadily  increasing for both boys and                                                                    
     girls in the more recent years.                                                                                            
                                                                                                                                
     It  was great  to  see  in 2020  in  Alaska,  we had  a                                                                    
     decrease  in  the number  of  adolescents  who died  by                                                                  
     suicide,  and  a slight  decrease  in  suicides in  the                                                                    
     State  overall. However,  we have  seen an  increase in                                                                  
     suicide  attempts.  In  2021, there  was a  significant                                                                  
     increase in suicide attempts  for 11-14 year-olds, with                                                                    
     rates higher than  any other prior year.   We have also                                                                    
     seen increases  in suicide attempts for  people ages 60                                                                    
     and older.                                                                                                                 
                                                                                                                                
     Fortunately,  although we  have seen  increases in  the                                                                    
     overall number and rates of  suicide attempts, this did                                                                    
     not translate into higher suicide  rates.  An important                                                                    
     thing to remember  when we look at  data around suicide                                                                    
     attempts  is that  9 out  of  10 people  who survive  a                                                                
     suicide attempt DO NOT go on to die by suicide later.                                                                    
                                                                                                                              
2:31:20 PM                                                                                                                    
     Alaska's data  demonstrates a  similar pattern  to what                                                                    
     we are  seeing nationally.  In December 2021,  the U.S.                                                                    
     Surgeon  General issued  an advisory  to highlight  the                                                                    
     urgent  need  to  address  the  national  youth  mental                                                                    
     health crisis.                                                                                                             
                                                                                                                                
     DHSS has allocated additional  resources and funding to                                                                    
     support  mental  health  and suicide  prevention.  This                                                                    
     includes  specific training  such as  the Zero  Suicide                                                                  
     framework for  both behavioral health and  primary care                                                                  
     providers,  youth and  young  adult suicide  prevention                                                                  
     media  campaigns, expanding  the  Alaska Careline,  and                                                                
     partnering  with entities  such  as  the Department  of                                                                    
     Education and the Office of Children's Services.                                                                           
                                                                                                                                
2:32:05 PM                                                                                                                    
DR.  ZINK reviewed  slide 13,  Drug Overdose  Deaths Continue  to                                                               
Rise, consisting of  a bar chart showing the  overdose death rate                                                               
for  all drugs  and opioids  in Alaska  compared to  the US.  She                                                               
paraphrased her prepared testimony, which read:                                                                                 
                                                                                                                                
[Original punctuation provided.]                                                                                                
                                                                                                                                
     Now  let's  dive  into another  top  leading  cause  of                                                                    
     premature death: Unintentional  injuries. This category                                                                    
     includes   drug    overdoses   that    are   considered                                                                    
     unintentional  poisonings, motor  vehicle crashes,  and                                                                    
     unintentional falls.                                                                                                       
                                                                                                                                
     In 2020,  both Alaska  and the  US as  a whole  saw our                                                                    
     worst  drug   overdose  death   rates  yet.   Based  on                                                                    
     preliminary  data  from  2021,   in  Alaska,  the  drug                                                                  
     overdose death rate increased by over half from 2020.                                                                    
                                                                                                                                
     The  drug overdose  death rate  is  driven fentanyl,  a                                                                    
     synthetic  opioid that  is 50  times  more potent  than                                                                    
     heroin.  74%  of  opioid   overdose  deaths  in  Alaska                                                                  
     involved fentanyl in 2021.                                                                                               
                                                                                                                                
     In 2018  you see a dip  in Alaska compared to  the U.S.                                                                    
     This was  attributed to  increased screening  for those                                                                    
     at risk,  referral for treatment, linkage  to care, and                                                                    
     treatment  availability,  prescription drug  monitoring                                                                    
     programs and regulations,  and widespread messaging and                                                                    
     distribution of naloxone through DHSS's Project Hope.                                                                      
                                                                                                                                
2:32:53 PM                                                                                                                    
     It's important to note that  other drugs play a role as                                                                    
     well.   Methamphetamine-  and   other  psychostimulant-                                                                    
     involved overdose deaths continue  to rise due to their                                                                    
     increasing  purity  and  potency.   Approximately  two-                                                                  
     thirds  of  overdose  deaths   involve  more  than  two                                                                  
     substances -- excluding alcohol.                                                                                         
                                                                                                                                
     Many   of   the   overdose   deaths   in   Alaska   are                                                                    
     unintentional,  due   to  people  not   realizing  that                                                                    
     fentanyl  may   be  in   other  drugs   or  counterfeit                                                                    
     prescription medications.                                                                                                  
                                                                                                                                
     Just this  week, we saw 6  deaths in the Mat-Su  and at                                                                    
     least 17  overdose emergencies thought  to be due  to a                                                                    
     lethal batch of heroin,  resulting in a Narcotics Alert                                                                    
     to be issued by Mat-Su law enforcement.                                                                                    
                                                                                                                                
2:33:38 PM                                                                                                                    
DR.  ZINK  reviewed slide  14,  Charting  a path  forward,  which                                                               
depicted a sea  filled with icebergs. She asked  how Alaska could                                                               
move forward and how to take  the myriad of data points and chart                                                               
a  path through  this complex  world of  health care  delivery to                                                               
improve outcomes for Alaskans.                                                                                                  
                                                                                                                                
2:33:50 PM                                                                                                                    
DR.  ZINK  reviewed slide  15,  The  River  and the  Bridge.  She                                                               
paraphrased her prepared testimony, which read:                                                                                 
                                                                                                                                
[Original punctuation provided.]                                                                                                
                                                                                                                                
     To answer  that question,  I am going  to begin  with a                                                                    
     story that you may have heard before.                                                                                      
                                                                                                                                
     Imagine a  large river where  you see  someone downing,                                                                    
     so you race  in and pull them out, only  to see another                                                                    
     person struggling  in the river.   You look up  and see                                                                    
     hundreds of  people trying frantically to  save all the                                                                    
     drowning  people who  have fallen  into  the river.  As                                                                    
     everyone  along  the  shore tries  to  rescue  as  many                                                                    
     people as  possible, you  look up  and see  a seemingly                                                                    
     never-ending stream of people  downing, so you begin to                                                                    
     run  upstream. One  of other  rescuers hollers,  "Where                                                                    
     are you going? There are  so many people that need help                                                                    
     here." To which you reply,  "I'm going upstream to find                                                                    
     out why so many people are falling into the river."                                                                        
                                                                                                                                
2:34:30 PM                                                                                                                    
DR. ZINK  noted that this rings  particularly true for her  as an                                                               
emergency physician who  found herself more and  more involved in                                                               
public health  to try  to figure  out how  to move  upstream. She                                                               
continued:                                                                                                                      
                                                                                                                                
     Upstream  you find  a broken  bridge  that people  keep                                                                    
     falling off of,  into the water. By  fixing the bridge,                                                                    
     more people  cross the river without  falling in, which                                                                    
     requires much  less effort than  pulling people  out of                                                                    
     the river later.                                                                                                           
                                                                                                                                
     For  every dollar  we spend  on health  care, we  spend                                                                    
     about  3 cents  on  prevention, 6-10  cents on  primary                                                                    
     care  and  87-91 cents  on  acute  and specialty  care.                                                                    
     When  we  look  at  other countries  with  longer  life                                                                    
     expectancies at a  lower cost per capita,  they all get                                                                    
     there in  slightly different ways, but  constantly they                                                                    
     have  methods  for  paying  or  incentivizing  upstream                                                                    
     prevention.                                                                                                                
                                                                                                                                
     The other advantage to moving  ups stream and investing                                                                    
     in systems of care is  makes us more resilient when new                                                                    
     challenges  are  presented:  earthquakes,  ice  storms,                                                                    
     pandemics.  Preparedness is prevention.                                                                                  
                                                                                                                                
2:35:32 PM                                                                                                                    
DR. ZINK reviewed slide 16, Moving Upstream, consisting of a                                                                    
diagram of health factors and a photograph of two rural                                                                         
Alaskans. She paraphrased her prepared testimony, which read:                                                                   
                                                                                                                                
[Original punctuation provided.]                                                                                                
                                                                                                                                
     There  are  a  multitude  of factors  that  cause  poor                                                                    
     health, which  is not only  costly to  individuals, but                                                                    
     is a  shared burden  to our  communities. In  2020, our                                                                  
     Alaska  hospitals  billed  $1.0 billion  for  emergency                                                                  
     department visits and $4.4  billion for hospital stays.                                                                  
     As an emergency  room doctor, I can tell  you that care                                                                    
     can  be  life  saving,  and  not  all  illness  can  be                                                                    
     prevented.  But by focusing  on the health outcomes and                                                                    
     moving  upstream  to  find fix  the  proverbial  broken                                                                    
     bridges, we can save lives and save money.                                                                                 
                                                                                                                                
                                                                                                                                
     Today, I  want to  highlight three  key efforts  that I                                                                  
     think we can all get behind to move upstream.                                                                              
                                                                                                                                
     The  first  is  Healthy Alaskans,  the  State's  Health                                                                  
     Improvement Plan. It  is co-led by DHSS  and the Alaska                                                                  
     Native  Tribal   Health  Consortium.  The   mission  of                                                                    
     Healthy Alaskans  is to provide a  framework and foster                                                                    
     partnerships to  optimize health  for all  Alaskans and                                                                    
     their  communities. This  is our  roadmap for  upstream                                                                    
     improvements, with  communities, health  care entities,                                                                    
     Tribes, and other stakeholders working together.                                                                           
                                                                                                                                
     Healthy Alaskans sets goals every 10 years.                                                                                
                                                                                                                                
2:36:46 PM                                                                                                                    
DR. ZINK reviewed slide 17, Healthy Alaskan 2020 successes,                                                                     
which listed eight successes.                                                                                                   
                                                                                                                                
     1. Reduced cancer mortality rate                                                                                           
     2. Reduced percentage of adolescents who recently                                                                          
     used tobacco products                                                                                                      
     3. Reduced percentage of adults who are overweight                                                                         
     4. Increased percentage of adolescents who have 3 or                                                                       
     more adults from whom they could seek help                                                                                 
     5. Reduced percentage of adults who recently engaged                                                                       
     in binge drinking                                                                                                          
     6. Reduced percentage of adolescents who recently                                                                          
     engaged in binge drinking                                                                                                  
     7. Decreased percentage of adults who report not                                                                           
     affording a doctor in last year                                                                                            
     8. Increased percentage of population ages 18-24 with                                                                      
     a high school diploma                                                                                                      
                                                                                                                                
2:36:45 PM                                                                                                                    
DR. ZINK paraphrased her prepared testimony, which read:                                                                        
                                                                                                                                
[Original punctuation provided.]                                                                                                
                                                                                                                                
     Often  I get  asked, does  this really  work?   Can the                                                                    
     goals  established in  our  state's health  improvement                                                                    
     plan be  achieved?   Yes, but  by working  together, we                                                                  
     can do even more.                                                                                                        
                                                                                                                                
     Looking  back  on  the  2020  goals,  8  of  them  were                                                                  
     accomplished   including:  reducing   cancer  mortality                                                                
     rate, the  percentage of adolescents who  recently used                                                                    
     tobacco products  and the percentage of  adults who are                                                              
     overweight.                                                                                                              
                                                                                                                                
     We saw:                                                                                                                    
        • More youth reporting that they had 3 or more                                                                          
          adults they could seek help from, which reduces                                                                   
          the impact of adverse childhood experiences                                                                           
        • A decrease in the percentage of adults and                                                                            
          adolescents who recently engaged in binge                                                                           
          drinking                                                                                                            
        • An increase in the percentage of adults who could                                                                     
          afford a doctor                                                                                                     
        • An increase in the number of young adults with a                                                                      
          high school diploma.                                                                                                
2:37:30 PM                                                                                                                    
     All of those are great success stories.                                                                                    
                                                                                                                                
     Let's take a closer look at three examples:                                                                                
                                                                                                                                
     Reduction in Cancer Mortality (#1):                                                                                      
                                                                                                                                
     This was achieved through various efforts including:                                                                       
                                                                                                                                
        • The Alaska Comprehensive Cancer Control Plan                                                                          
          (2021-2025)                                                                                                           
        • The Alaska Cancer Partnership                                                                                         
      • Ladies First: Alaska Breast and Cervical Cancer                                                                         
          Early Detection                                                                                                       
        • Promoting primary prevention. In other words,                                                                         
          making the healthy choice the easy choice to stop                                                                     
          cancer before it starts by being active, eating                                                                       
          well and avoiding tobacco, to name a few                                                                              
          examples.                                                                                                             
     Binge Drinking Reduction (#5, #6):                                                                                       
      Efforts aimed at improving these goals include these                                                                      
     programs and campaigns:                                                                                                    
        - Healthy Voices, Healthy Choices Alaska                                                                                
        - Be [You] Campaign (teens)                                                                                             
        - ANTHC Substance Misuse Prevention Program                                                                             
        -                                                                                                                       
     Tobacco Use Reduction (#2):                                                                                              
          These inventions have helped with this goal:                                                                          
        - Tobacco Quit Line                                                                                                     
        - Smokefree Alaska Bill (2018)                                                                                          
        - DHSS Tobacco Prevention and Control Program,                                                                          
          Strategic Plan                                                                                                        
                                                                                                                                
2:38:03 PM                                                                                                                    
DR. ZINK highlighted two items on  the list related to efforts to                                                               
reduce  adult  and adolescent  binge  drinking  from the  Healthy                                                               
Voices,  Healthy  Choices  Coalition  campaign,  and  the  Alaska                                                               
Native   Tribal   Health   Consortium's  Substance   Misuse   and                                                               
Prevention Program.                                                                                                             
                                                                                                                                
DR. ZINK  noted that  the reduced  percentage of  adolescents who                                                               
recently  used tobacco  products involved  help with  the Tobacco                                                               
Quit Line,  a legislative partnership  with Smoke Free  Alaska in                                                               
2018,  and  the  department's   Tobacco  Prevention  and  Control                                                               
Strategic Plan.                                                                                                                 
                                                                                                                                
2:38:35 PM                                                                                                                    
DR. ZINK reviewed slide 18, Healthy Alaskans 2030 goals. She                                                                    
paraphrased her prepared testimony, which read:                                                                                 
                                                                                                                                
[Original punctuation provided.]                                                                                                
                                                                                                                                
     What does 2030 look like?  You can see from those three                                                                    
     examples of  success, one of the  common ingredients is                                                                    
     collaboration with diverse partners.                                                                                       
                                                                                                                                
     Healthy  Alaskan's  Goals  are   chosen,  as  they  are                                                                    
     finite, measurable,  and actionable  so that we  have a                                                                    
     common  framework and  common objectives.   We  can get                                                                    
     lost   on   the   mired   of   system,   diseases   and                                                                    
     interventions     this slide  deck  was  once over  100                                                                    
     sides on what  was important to share with  you all for                                                                    
     the State of Alaska's health  - but paring it down, and                                                                    
     collective working  on a few  key challenges we  can do                                                                    
     more together.                                                                                                             
                                                                                                                                
2:39:12 PM                                                                                                                    
     I  have provided  copies of  Healthy Alaskans  2030 for                                                                    
     you all,  including the goals  and metrics used  by the                                                                    
     plan.                                                                                                                      
     Healthy  Alaskans  regularly  monitors  each  goal  and                                                                    
     shares   progress  via   annual  scorecards.   It  also                                                                    
     maintains  a  list  of  evidence-based  strategies  and                                                                    
     actions to help reach the targets for each objective.                                                                      
                                                                                                                                
     And  we invite  you as  policy makers,  as well  as the                                                                    
     public,  health providers,  patients and  the press  to                                                                    
     take a  look these objectives  and join us in  making a                                                                    
     Healthier Alaska.                                                                                                          
                                                                                                                                
2:39:56 PM                                                                                                                    
DR. ZINK reviewed slide 19, Healthy You in 2022. She paraphrased                                                                
her prepared testimony, which read:                                                                                             
                                                                                                                                
[Original punctuation provided.]                                                                                                
                                                                                                                                
     A side effort has been taken  on by DHSS to bring extra                                                                    
     attention to  Healthy Alaskans 2030    the  Healthy You                                                                    
     in 2022 campaign.                                                                                                          
                                                                                                                                
     The past few  of years with the pandemic  has been very                                                                    
     long,  hard, and  for many  devastating  both  physical                                                                    
     and mental and  was the reason for  this renewed effort                                                                    
     on focusing on the basics of health.                                                                                       
                                                                                                                                
     The   campaign  draws   from   the   work  of   various                                                                    
     departments and  programs to help Alaskans  to focus on                                                                    
     being physically  and mentally well. The  first quarter                                                                    
     is focused on movement and  play, the second quarter is                                                                    
     on mental  health and well-being, the  third quarter is                                                                    
     healthy  eating  and sleep,  and  the  last quarter  is                                                                    
     healthy habits.                                                                                                            
                                                                                                                                
     We invite you  all   and every Alaskan    to help build                                                                    
     a  Healthy You  in  2022.   You can  find  more on  the                                                                    
     microsite HealthyYou.Alaska.gov                                                                                            
                                                                                                                                
2:40:47 PM                                                                                                                    
DR. ZINK reviewed slide 20, Data Modernization. She paraphrased                                                                 
her prepared testimony, which read:                                                                                             
                                                                                                                                
[Original punctuation provided.]                                                                                                
                                                                                                                                
     A   second   area  I   want   to   highlight  is   Data                                                                    
     Modernization.   Often, we think  of IT  as Information                                                                    
     Technology, but  more and more it  is really Innovation                                                                    
     Technology. It is hard to  change that which can not be                                                                  
     seen or measured.                                                                                                        
                                                                                                                                
     Early  in  the  pandemic,   we  enlisted  the  help  of                                                                    
     national  guard members  to enter  one lab  result into                                                                    
     three different systems.  It was clear, the  lack of IT                                                                    
     infrastructure  capabilities  hampered   not  only  our                                                                    
     response here in Alaska, but across the country.                                                                           
                                                                                                                                
2:41:18 PM                                                                                                                    
     Improved  data can  help  community  leaders know  what                                                                    
     health  challenges affect  their  community and  target                                                                    
     their  efforts;  health  care providers  see  the  more                                                                    
     complete picture  of the health  of their  patient; and                                                                    
     patients  have  better  access  to  their  own  records                                                                    
     empowering their health.                                                                                                   
                                                                                                                                
     There are many  large efforts happening at  a state and                                                                    
     national  level  on  data modernization.    Within  the                                                                    
     Department of  Health, we have  brought on a  new Chief                                                                    
     Health Data Officer to help lead all of these efforts.                                                                     
                                                                                                                                
     Key  to this  transformation is  creating a  governance                                                                    
     structure, and road map for  the numerous data systems,                                                                    
     and technologies  both within the State  and community,                                                                    
     to improve the health of Alaskans.                                                                                         
                                                                                                                                
     This,  however,   will  be  an  area   that  will  need                                                                    
     collective time  and attention  to achieve  the desired                                                                    
     outcomes.                                                                                                                  
                                                                                                                                
     Through  improved  data   modernization  that  provides                                                                    
     reliable,  understandable,  and  relevant data  to  the                                                                    
     public  at  their  fingertips, Alaskans  can  and  will                                                                    
     achieve  more.  Improved  data  modernization  is  more                                                                    
     cost-efficient, more  secure, and allows  for real-time                                                                    
     decision-making   to   better   support   health   care                                                                    
     providers and individuals.                                                                                                 
                                                                                                                                
2:42:24 PM                                                                                                                    
DR. ZINK reviewed slide 21, Health Care Workforce Support. She                                                                  
paraphrased her prepared testimony, which read:                                                                                 
                                                                                                                                
[Original punctuation provided.]                                                                                                
                                                                                                                                
     The third, or  last thing, I wanted  to highlight today                                                                    
     are the people who serve  Alaskans in health care, both                                                                    
     directly and indirectly such as much of public health.                                                                     
                                                                                                                                
     Alaska's health care workforce  has always been limited                                                                    
     and the pandemic has made  it even worse. For the first                                                                    
     time in 2020,  we saw a decrease in  Alaska Health Care                                                                    
     employment, leaving more work,  during the pandemic, to                                                                    
     fewer  people.   We will  not  be able  to improve  the                                                                    
     continuum of care, without a robust workforce.                                                                             
                                                                                                                                
2:42:56 PM                                                                                                                    
     Administrative   burdens,  malpractice   risk,  limited                                                                    
     training  and recruitment,  limited clinical  supports,                                                                    
     physical violence, and the  emotional exhaustion of the                                                                    
     work,   leave   providers   burnt  out,   leaving   the                                                                    
     profession and  sadly committing  suicide at  twice the                                                                    
     national rate.                                                                                                             
                                                                                                                                
     It is  important to remember  that burn out is  not the                                                                  
     failure of  the person,  but a  failure of  the system.                                                                
     In 2020 in  the US, 82% of  healthcare workers reported                                                                    
     emotional  exhaustion, 55%  reported questioning  their                                                                    
     career path, and  45% of nurses said they  did not have                                                                    
     adequate emotional  support.  We see  similar result of                                                                    
     the public  health workforce  with people  leaving this                                                                    
     critical profession at unprecedented rates.                                                                                
                                                                                                                                
     Though   collaboration  with   key  partners,   and  by                                                                    
     addressing  the bottle  necks and  barriers across  the                                                                    
     health  care   ecosystem,  we  can  grow   and  support                                                                    
     Alaska's health  care workers,  the backbone  and heart                                                                    
     of care in Alaska.                                                                                                         
                                                                                                                                
2:43:55 PM                                                                                                                    
DR. ZINK reviewed slide 22, Moving Forward. She paraphrased her                                                                 
prepared testimony, which read:                                                                                                 
                                                                                                                                
[Original punctuation provided.]                                                                                                
                                                                                                                                
     The focus  on moving upstream is  not new to us  in the                                                                    
     State of  Alaska. We are constantly  focused on finding                                                                    
     the root  of improved health    and this  critical work                                                                    
     continues in many forms.                                                                                                   
                                                                                                                                
     Whether we  are using  layered prevention  identify and                                                                    
     end  a GI  outbreak  related to  contaminated food,  or                                                                    
     changes  to  Medicaid  delivery,  by  working  together                                                                  
     upstream, we  can collectively keep  Alaskans healthier                                                                  
     and we can use our resources more effectively.                                                                           
                                                                                                                                
2:44:23 PM                                                                                                                    
     The Department of Health  and Social Services continues                                                                    
     to  move  forward  with our  partners  to  ensure  that                                                                    
     systems are  working for Alaskans, instead  of Alaskans                                                                    
     just working within systems.   We are more prepared and                                                                    
     more resilient to the myriad  of challenges we may face                                                                    
     from  tsunamis to  budget cuts,  infectious disease  to                                                                    
     forging  aggression when  we are  healthy and  well and                                                                    
     have  systems,  that  like  our  democracy  is  by  the                                                                    
     people, and truly for the people of this great state.                                                                      
                                                                                                                                
     This  slide shows  some of  the  milestones along  this                                                                    
     journey.                                                                                                                   
                                                                                                                                
     The  1115  Medicaid  Demonstration Waiver  is  a  great                                                                    
     example of  upstream prevention. This waiver  serves as                                                                    
     the  vehicle   to  redesign,  build,  and   expand  the                                                                    
     Medicaid  payment  for   behavioral  health  system  to                                                                    
     support at-risk  children and  families, and  use data-                                                                    
     driven,  integrated  systems  of care  to  improve  the                                                                    
     outcomes  for Alaskans  suffering from  mental illness,                                                                    
     substance use disorder, and more.                                                                                          
                                                                                                                                
     This work  then fits  with in the  work of  the "Crisis                                                                    
     Now model" which builds on three key systems:                                                                              
                                                                                                                                
      1. "Someone to Talk to" (a crisis call center that                                                                        
        coordinates in  real time) which is being  built with the                                                               
        ongoing  efforts  of 988.  Beginning  July  16, this  new                                                               
        three-digit  dialing will  connect people  in crisis,  or                                                               
        loved  ones worried  about their  family, to  support and                                                               
        resources.                                                                                                              
                                                                                                                                
      2. "Someone to Respond" (24/7 mobile crisis teams to                                                                      
        respond to a crisis in-person), and                                                                                     
                                                                                                                                
      3. "Place to go" (23-hour and short-term stabilization,                                                                   
        offering a  safe and supportive behavioral  health crisis                                                               
        placement  for those  who  cannot be  stabilized by  call                                                               
        center staff  or mobile crisis team  response). Juneau is                                                               
        going to  open the first 23-hour  stabilization center in                                                               
        Alaska.                                                                                                                 
                                                                                                                                
2:46:14 PM                                                                                                                    
     This Crisis Now model helps  to support people in need,                                                                    
     reduces  the  burden  on   law  enforcement  who  often                                                                    
     responds  to mental  health crises,  and gets  patients                                                                    
     care  more quickly  and in  the  least restrictive  way                                                                    
     possible, reducing ED  visits and inpatient psychiatric                                                                    
     admissions.                                                                                                                
                                                                                                                                
2:46:28 PM                                                                                                                    
     Those  are just  a few  examples of  the upstream  work                                                                    
     that  will  help  us  achieve  the  goal  of  healthier                                                                    
     Alaskans  and  reduced health  care  costs.  This is  a                                                                    
     journey we're  all on  together and  I look  forward to                                                                    
     working with  the Legislature and  all of  our partners                                                                    
     to achieve these goals. Your  support and work has been                                                                    
     critical to  these successes so  far and  will continue                                                                    
     to be critical in the months and years to come.                                                                            
                                                                                                                                
2:46:50 PM                                                                                                                    
DR.  ZINK   thanked  members.  She   stated  that   together  the                                                               
department and  the legislature  could provide  better care  at a                                                               
lower  cost to  Alaskans by  building on  the efforts  of Healthy                                                               
Alaskans  2030,  improving  data  modernization,  supporting  the                                                               
health care workforce, and finding ways to pay for prevention.                                                                  
                                                                                                                                
DR.  ZINK stated  that  she was  grateful  for the  legislature's                                                               
efforts  and  the Chair's  willingness  to  host this  first-ever                                                               
State  of  Alaska's  Health  presentation.  She  said  she  looks                                                               
forward to collectively improving care for all Alaskans.                                                                        
                                                                                                                                
2:47:21 PM                                                                                                                    
SENATOR  BEGICH  directed  attention  to slide  13  to  the  drug                                                               
overdose  deaths.  He  noted  that a  slow  increase  followed  a                                                               
significant decline  in 2017-2018.  He indicated he  was studying                                                               
the efficacy  of treatment  programs. He  said he  recognized the                                                               
impact of NARCAN, although the  drug is dispensed anonymously, so                                                               
it  cannot  be  tracked.  He  wondered  if  the  increase  was  a                                                               
reflection  of  reductions  or  the  effectiveness  of  treatment                                                               
grants.  He asked  what tool  would decrease  the death  rate and                                                               
whether it would be increased grant programs.                                                                                   
                                                                                                                                
DR. ZINK offered her view that  it was going up for many reasons,                                                               
so it  would take time to  understand it better. She  stated that                                                               
many people in the field  were concerned by the dramatic increase                                                               
in  overdose  deaths  related to  fentanyl.  She  explained  that                                                               
fentanyl  is 50  times more  powerful than  heroin and  that many                                                               
people may think they are  taking a prescription drug like Norco,                                                               
hydrocodone,  or oxycontin,  which  they  have previously  taken.                                                               
However, the drug is a  counterfeit pill laced with fentanyl. She                                                               
said  one  medication  is  lethal.  She  said  the  two  to  four                                                               
milligram  (mg)  dose  of  NARCAN, naloxone,  is  not  enough  to                                                               
overcome  the  level  of  fentanyl   in  the  victim.  Thus,  the                                                               
department  is  working  on  an  8  mg  dose,  plus  distributing                                                               
fentanyl patches so  people can test their drug  for the presence                                                               
of fentanyl.  She acknowledged  that more could  be done  to help                                                               
prevent people  from using  opioid drugs  and reduce  reliance on                                                               
the drugs.                                                                                                                      
                                                                                                                                
2:50:18 PM                                                                                                                    
SENATOR  BEGICH wondered  what specific  funding the  legislature                                                               
could  provide to  support the  work  being done  to address  the                                                               
fentanyl issue.  He indicated that  he lost a nephew  to fentanyl                                                               
use.                                                                                                                            
                                                                                                                                
DR. ZINK  said the work in  the field involves the  Department of                                                               
Public Safety and  the Department of Health  and Social Service's                                                               
Divisions of Behavioral Health and  Public Health. She offered to                                                               
research and report to the committee on specific funding needs.                                                                 
                                                                                                                                
2:51:39 PM                                                                                                                    
SENATOR REINBOLD referred to the  Crisis Now model. She noted she                                                               
had  constituents  who  expressed  concern  about  the  perceived                                                               
mistreatment of  disabled psychiatric patients,  including Access                                                               
Alaska  and  Faith  Myers.  One constituent  was  a  Russian  who                                                               
alleged  he was  held  in a  psychiatric  facility for  political                                                               
reasons.  She  asked what  the  Crisis  Now  model was  and  what                                                               
assurances  the  legislature  had  that these  abuses  would  not                                                               
occur.                                                                                                                          
                                                                                                                                
2:53:34 PM                                                                                                                    
DR. ZINK  acknowledged that as  an emergency  medicine physician,                                                               
she had  observed daily  the ways the  current system  is failing                                                               
patients.  She said  she understood  that  members would  receive                                                               
letters  expressing concern  or  frustration.  She recalled  that                                                               
people  literally  wore through  their  paper  scrubs awaiting  a                                                               
psychiatric evaluation and treatment.                                                                                           
                                                                                                                                
2:53:55 PM                                                                                                                    
DR. ZINK  explained that  the Crisis Now  model was  a collective                                                               
effort to  improve care. The  Crisis Now model would  provide the                                                               
person seeking mental health assistance  with 1) someone to call,                                                               
2) someone  to respond, and 3)  a place to go.  She elaborated on                                                               
the planned  mental health care  improvements. First,  people can                                                               
currently call Alaska  Care, but the federal  government has been                                                               
working to  create a  988 number  specifically for  mental health                                                               
assistance  and additional  resources, rather  than just  calling                                                               
911. Second,  law enforcement spends  significant time  trying to                                                               
stabilize  someone in  crisis. Crisis  Now  would provide  Mobile                                                               
Crisis teams trained  in mental health to respond to  a person in                                                               
crisis, helping  them get needed  support and resources,  so they                                                               
don't  end  up   in  an  emergency  room   (ER).  Currently,  law                                                               
enforcement picks up  the person in crisis and takes  them to the                                                               
ER, waiting  for a  behavioral health  clinician to  assess them.                                                               
The ER is  bright and loud and not a  therapeutic environment for                                                               
patients.  Third, Crisis  Now  would  provide short-term  23-hour                                                               
crisis stabilization centers. Someone's  wife may have left them,                                                               
or the person may have  experienced another acute event that made                                                               
them suicidal  or violent. However, being  able to go to  a place                                                               
to  talk,  cool  off,  or  get access  to  medication  can  help.                                                               
Sometimes people  need to  sober up,  and they  are more  able to                                                               
make decisions or connect to family and loved ones.                                                                             
                                                                                                                                
2:56:14 PM                                                                                                                    
DR. ZINK stated that ensuring  the system works requires everyone                                                               
to be involved, trying to  understand the system and the process,                                                               
reviewing data, and getting feedback  from constituents to ensure                                                               
that Crisis Now serves the people.                                                                                              
                                                                                                                                
2:56:41 PM                                                                                                                    
SENATOR  REINBOLD wondered  how to  ensure that  people won't  be                                                               
abused. She  asked whether the  department supports  an All-Payer                                                               
Claims  database.  She  further  asked   for  an  update  on  the                                                               
hospital's Federal Emergency Management Agency (FEMA) workers.                                                                  
                                                                                                                                
DR.  ZINK  responded  that ensuring  abuse  doesn't  occur  would                                                               
require constant monitoring.  She offered her view  that it makes                                                               
sense  in  Alaska  to  have  an  All-Payer  Claims  Database  for                                                               
improved transparency in overall  healthcare costs. Providers see                                                               
patients   with  numerous   payer   sources,   so  reducing   the                                                               
administrative  burden makes  sense, but  it is  challenging. She                                                               
offered  her  view that  FEMA  workers  were finished,  that  the                                                               
contracts  ended. She  noted  that many  took  full-time jobs  in                                                               
Alaska.                                                                                                                         
                                                                                                                                
2:57:45 PM                                                                                                                    
SENATOR HUGHES  recalled that Senator Begich  had questions about                                                               
drug overdoses.  She stated  that she received  an update  on the                                                               
Set  Free Alaska  pilot  project, designed  to  help people  with                                                               
addiction problems become productive  citizens. She reported that                                                               
it was going  well, and once data was collected,  it was possible                                                               
to replicate  it throughout the  state. She referred to  slide 9.                                                               
She  noted that  Alaska  was  on the  high  end  for health  care                                                               
expenditures based  on 2014 data.  She anticipated  that Alaska's                                                               
expenditures  would  be  even  higher  now.  She  encouraged  the                                                               
department to consider preventive and  primary care costs to move                                                               
Alaska forward. She recalled that  Alaska spends 80-90 percent on                                                               
specialty  acute care,  which needs  to be  addressed. She  noted                                                               
that  Director  Wing-Heier  reported  to  the  Senate  Labor  and                                                               
Commerce Committee that  some people pay a deductible  as high as                                                               
$15,000.  She surmised  that many  people are  not receiving  the                                                               
care they  need. She  emphasized the need  to reduce  health care                                                               
costs.                                                                                                                          
                                                                                                                                
3:00:09 PM                                                                                                                    
DR. ZINK responded that cost of  care was a huge limiting factor,                                                               
and people won't seek care  for serious injuries or health issues                                                               
because of the deductible costs.                                                                                                
                                                                                                                                
3:00:33 PM                                                                                                                    
CHAIR  WILSON  suggested  members  send their  questions  to  his                                                               
office and he would forward them to the department.                                                                             
                                                                                                                                
SENATOR REINBOLD said she had a list of 13 questions to submit.                                                                 
                                                                                                                                
3:02:40 PM                                                                                                                    
There being no further business to come before the committee,                                                                   
Chair Wilson adjourned the Senate Health and Social Services                                                                    
Standing Committee meeting at 3:02 p.m.                                                                                         

Document Name Date/Time Subjects
SB 124 Testimony 3.21.22.pdf SHSS 3/22/2022 1:30:00 PM
SB 124
SB 124 Amendments Considered 1-12 3.17.22.pdf SHSS 3/17/2022 1:30:00 PM
SHSS 3/22/2022 1:30:00 PM
SB 124
SB 124 Amend. 1-39 3.17.22.pdf SHSS 3/17/2022 1:30:00 PM
SHSS 3/22/2022 1:30:00 PM
SHSS 3/29/2022 1:30:00 PM
SHSS 4/7/2022 1:30:00 PM
SB 124
SB 124 CS Work Draft V. B.pdf SHSS 3/8/2022 1:30:00 PM
SHSS 3/17/2022 1:30:00 PM
SHSS 3/22/2022 1:30:00 PM
SB 124
SHSS- State of Health Presentation 3.22.22 .pdf SHSS 3/22/2022 1:30:00 PM
SB 124 Testimony 3.22.22.pdf SHSS 3/22/2022 1:30:00 PM
SB 124
SB 124 Ammend. Consider 13&14 3.22.22.pdf SHSS 3/22/2022 1:30:00 PM
SB 124
StateHealthImprovementPlan.HealthyAlaskans2030_Final.Revised-_02012022.pdf SHSS 3/22/2022 1:30:00 PM