Legislature(2023 - 2024)BUTROVICH 205
02/08/2023 01:30 PM Senate JUDICIARY
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| Audio | Topic |
|---|---|
| Start | |
| Presentation: Alaska's Behavioral Health System for Children | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
ALASKA STATE LEGISLATURE
SENATE JUDICIARY STANDING COMMITTEE
February 8, 2023
1:31 p.m.
MEMBERS PRESENT
Senator Matt Claman, Chair
Senator Jesse Kiehl, Vice Chair
Senator James Kaufman
Senator Cathy Giessel
Senator Löki Tobin
MEMBERS ABSENT
All members present
COMMITTEE CALENDAR
PRESENTATION: ALASKA'S BEHAVIORAL HEALTH SYSTEM FOR CHILDREN
- HEARD
PREVIOUS COMMITTEE ACTION
No previous action to record
WITNESS REGISTER
Mark Regan, Legal Director
Disability Law Center of Alaska
Anchorage, Alaska
POSITION STATEMENT: Provided commentary and answered questions
about Alaska's Behavioral Health System for Children
Presentation.
Dr. Anne Zink, Chief Medical Officer
Department of Health
Palmer, Alaska
POSITION STATEMENT: Provided commentary and answered questions
about Alaska's Behavioral Health System for Children
Presentation.
HEATHER CARPENTER, Policy Advisor
Department of Health
Juneau, Alaska
POSITION STATEMENT: Provided commentary and answered questions
about Alaska's Behavioral Health System for Children
Presentation.
FARINA BROWN, Acting Director
Division of Behavioral Health
Department of Health
Juneau, Alaska
POSITION STATEMENT: Provided commentary and answered questions
about Alaska's Behavioral Health System for Children
Presentation.
Emily Ricci, Deputy Commissioner
Department of Health
Juneau, Alaska
POSITION STATEMENT: Provided commentary and answered questions
about Alaska's Behavioral Health System for Children
Presentation.
CLINTON LASLEY, Deputy Commissioner
Department of Family & Community Services
Juneau, Alaska
POSITION STATEMENT: Provided commentary and answered questions
about Alaska's Behavioral Health System for Children
Presentation.
ACTION NARRATIVE
1:31:36 PM
CHAIR MATT CLAMAN called the Senate Judiciary Standing Committee
meeting to order at 1:31 p.m. Present at the call to order were
Senators Kaufman, Tobin, Kiehl, Giessel and Chair Claman.
^PRESENTATION: Alaska's Behavioral Health System for Children
PRESENTATION: ALASKA'S BEHAVIORAL HEALTH SYSTEM FOR CHILDREN
1:32:11 PM
CHAIR CLAMAN announced the consideration of a presentation about
Alaska's Behavioral Health System for Children. He pointed out
that the United States Department of Justice (DOJ) declined his
invitation to the hearing.
CHAIR CLAMAN stated that he read the report with reactions of
sadness, disappointment, and frustration. The report depicts the
results of chronic problems left untreated. Responding to the
report presents a legal question. The state must provide a
solution for Alaskan children in need of better behavioral
health options. He hoped the conversation would detail the legal
process and focus on a solution.
1:33:57 PM
MARK REGAN, Legal Director, Disability Law Center of Alaska,
offered information and a summary of findings. He stated that
his office filed a complaint with the DOJ in 2020 that led to an
investigation. The investigation resulted in the report that was
released in December 2022. He stated that the legal issue
involves the state's mental health services structure. The Title
II Americans with Disabilities Act requires the state to provide
mental health services to children in an integrated setting.
MR. REGAN continued that some Alaskan children receive mental
health services in out-of-state institutions because they do not
have access in their communities. He spoke about the North Star
Behavioral Health System where many children were treated in
state. The overriding preference is for children to receive
mental health services near their homes. The report points to
the lack of trained providers and well-equipped facilities.
1:38:28 PM
MR. REGAN expounded that his opinions did not present criticism
of the Office of Children's Services (OCS). He noted that some
small communities have one or two therapeutic foster homes. He
spoke about placement in the foster homes versus the traditional
therapeutic environments. He pointed to the report's disturbing
statements about children in restrictive institutional
environments. Children reportedly struggle with relocation and
the subsequent lack of connection with tribal communities,
friends and family members. He noted the problem of bringing
children home. He acknowledged the preference to treat children
in their homes or communities, however, there are situations
where a therapeutic foster home is the safest location.
1:42:18 PM
MR. REGAN talked about the North Star Behavioral Health System
and its limitations. He cited allegations about abuse and
neglect happening in the privately-owned facility. The report
addresses the lack of services in home communities. Those
services are available in the Lower 48. Returning home is often
difficult for children. He acknowledged the expert opinions of
the other invited testifiers in the room. He expected further
conversations and stated a lawsuit would be filed if discussions
break down. He appreciated the opportunity to meet the
obligations of the Americans with Disabilities Act.
MR. REGAN pointed to recommendations by the United States
Department of Justice Civil Rights Division on page 24 of the
report.
• Ensuring that community-based services are accessible and
available with sufficient intensity to prevent unnecessary
institutionalization. Services the State should ensure are
available and accessible include Home-Based Family
Treatment, Crisis Services, Therapeutic Treatment Home
Services, Community Recovery Support Services, and
Intensive Case Management.
• Coordinate with community-based service providers, tribal
stakeholders, and local governments in Alaska to ensure
that service planning and implementation is culturally
appropriate and responsive to the needs of Alaska Native
children and families.
• Support implementation of community-based behavioral health
services in school settings. As the Centers for Medicare
and Medicaid recently stated, to help ensure that Medicaid-
enrolled children can access the services they need.
schools are "uniquely positioned"57
• Develop adequate system-wide protocols for identifying
children at serious risk of institutional placement and
connecting them to appropriate, timely community-based
services as needed to avoid unnecessary
institutionalization.
• Develop adequate system-wide protocols to ensure that
children transitioning from institutions to the community
receive appropriate, timely community-based services as
needed to remain in their homes and communities to the
maximum extent possible.
• Ensure adequate oversight of Administrative Service
Organizations, State grantees, and Medicaid-enrolled
service providers and effective coordination among those
entities, hospitals, and law enforcement to avoid
unnecessary institutionalization.
MR. REGAN spoke beyond the report and about institutionalized
youth. These children were referred out of state because their
caretakers or North Star Behavioral Health System felt poorly
equipped to address their needs. He stated that Alaska
Psychiatric Institute (API) was the next step and often had full
beds. Alaska requires additional services and community options.
Alaska lacks the facilities and services to best care for
behaviorally challenged youth.
1:46:45 PM
MR. REGAN continued to speak about the Department of Health
(DOH) separation from the Department of Family and Community
Services (DFCS). He voiced the expectation for the departments
to address the issue collaboratively. He concluded by stating
that the report was more important than his opinions.
1:49:45 PM
DR. ANNE ZINK, Chief Medical Officer, Department of Health,
introduced herself and provided testimony. She expressed sadness
about the issues brought forward in the report. She stressed the
need for partnerships and systems that work for Alaskans. She
noted the seriousness of her work with the Department of Health
(DOH) and the Department of Family and Community Services
(DFCS). The lawsuit highlights gaps in the current system
recognized by both departments. She stressed her commitment to
the health and wellbeing of every Alaskan. The children deserve
supportive care, engaging families, communities and culture. She
initiated a brief overview of mental health care.
1:52:11 PM
DR. ZINK continued detailing escalating cases of behavioral
health problems. These issues began before the Covid-19
pandemic. An overall decrease in life expectancy was documented
during the past decade, with fatalities known as "deaths of
despair." She cited increases in suicide, overdose, homicide and
liver disease. The National Governor's Association declared a
focus on youth mental health. She noted work in the Lower 48 for
youth placement; every state has similar struggles. She posed an
analogy between organ transplants and children's behavioral
health services. Identifying adequate reimbursement, capital
investments and motivation allow for the development of new
services.
DR. ZINK mentioned the Medicaid 1115 waiver, which offers the
basic structure for Medicaid services. The report acknowledges
that the Medicaid services provided are not adequate for mental
health patients. She maintained that the federal funding
structure did not accommodate these systems. She testified to
greater challenges in Alaska due to greater distances between
communities. The lack of broadband connectivity provides yet
another challenge.
1:55:52 PM
SENATOR TOBIN spoke about cultural genocide. She asked about a
plan to address the subsequent trauma perpetuated by sending
children out of state for behavioral health services. She
wondered about a new bill or request for additional funding.
DR. ZINK referred to her transplant analogy. She communicated
that the services were compared because of challenges bringing
people home following travel to access health care currently
unavailable in the state.
1:57:31 PM
SENATOR TOBIN stressed that she wished to see a plan to fix the
problem.
SENATOR GIESSEL added that her interest is in reimbursement and
its barrier to services. She spoke to the issue of provider
recruitment and university education. She wondered about
innovative programs such as partial hospitalization.
HEATHER CARPENTER, Policy Advisor, Department of Health, Juneau,
Alaska, agreed that the issue spanned many departments and
divisions. She provided history regarding the United States
Department of Justice. The DOJ notified the Alaska Department of
Health and Social Services (at the time) on December 17, 2020.
The intent was to investigate whether the state violated Title
II of the Americans with Disabilities Act. She highlighted her
department's cooperation with the United States DOJ. She added
that Alaska's tribal health organizations participated in the
investigation.
MS. CARPENTER noted that the states undergoing similar
investigations include Maine, Nevada and West Virginia. She
spoke about Mississippi and the litigation posture. She
highlighted youths seeking services under Medicaid. She stated
that the senior and disability services division also serves
children with complex intellectual and developmental
disabilities as well as behavioral health services. She spoke
about high-level specialty care and the difficulties recruiting
providers such as psychiatrists to the state. She spoke to an
investment in the University of Alaska Anchorage social work
program to hire additional staff.
2:03:45 PM
MS. CARPENTER continued that community-based services required
additional providers for behavioral health and personal care.
She spoke about the pros and cons of telehealth as it relates to
children. She noted high-level concerns about the timing of the
investigation and findings. She intends to engage in settlement
discussions with the United States Department of Justice. She
stressed that litigation would provide an efficient or effective
way to improve the mental health system in Alaska. Her
preference would be to have settlement talks with that strategy
in mind.
MS. CARPENTER continued that a written response to the report
must be formulated. The intention was to allow for further
collaboration between the appropriate state departments and
divisions.
2:06:07 PM
CHAIR CLAMAN stated that the response would lead to another
committee hearing. He wanted the issue to receive the public
attention it deserved.
MS. CARPENTER agreed about the importance of the topic. She
informed the committee that the entire investigation happened
during the Covid-19 pandemic, which compromised travel to
crucial locations. The data collection was limited in its
usefulness. She stated that the staff visited only two rural
hubs.
MS. CARPENTER noted the report mentioned telehealth services as
a key solution. She stated that telehealth behavioral health
services increased tremendously through and after the pandemic.
She disagreed that the infrastructure was in place to provide
effective telehealth services. She highlighted various regions
of Alaska that rely on audio only for telehealth services.
2:10:45 PM
MS. CARPENTER pointed out that the 1915(c) Medicaid waiver was
not reviewed in the investigation. Those waivers address home
and community-based services. She pointed out page 21 of the
report noting the issue of complex care, which is of great
importance. She proposed the idea of an Alaska specific
intermediate care facility. She spoke about the state
establishment of the Alaska Mental Health Trust.
2:12:49 PM
CHAIR CLAMAN commented on the report, committee participation
and testimony. He spoke about in-state intermediate care and
long-term care. He stated that North Star Behavioral Health
System was not an inspiring facility due to understaffing and
undermanaging. He wondered if the legislature might see a
capital budget request pertaining to facility needs.
2:14:32 PM
MS. CARPENTER shared a personal story about a family member's
success traveling out-of-state for treatment following care with
the North Star Behavioral Health System. She commented that the
federal government did not contribute start-up capital funds.
The legislature funded only one institution: the Alaska
Psychiatric Institute (API).
2:16:07 PM
SENATOR GIESSEL repeated that the reimbursements do not
adequately cover costs. The successful non-profits rely on
grants to stay open.
2:16:44 PM
MS. CARPENTER spoke about the history of budget constraints
including the exclusion of inflation and or rate adjustments
directed by the legislature. She mentioned a rebasing process
for community behavioral health providers.
2:18:18 PM
SENATOR KIEHL referenced a report from 1998. The report
discussed the closing of Harborview Developmental Center in 1997
and outlined the deficiency in community-based services. He
quoted the report, "the needs of children with behavioral health
disabilities in Alaska who received services in institutions are
not materially different from those of other children who are
thriving in community-based settings in other states.
CHAIR CLAMAN asked Senator Kiehl to restate his question.
SENATOR KIEHL requested further investigation about the
important topic.
2:20:46 PM
SENATOR TOBIN echoed Senator Kiehl's sentiments. She expressed
interest in learning and contributing to a solution. She spoke
about many kids who are brown and should be served in their
communities. She spoke to the value of culturally relevant and
community-based services. Her question related to federal
resources for school counsellors and how the committee can help
leverage the federal assets.
MS. CARPENTER mentioned similar conversations with tribal health
organizations related to leveraging the 1115 Behavioral Health
Medicaid Waiver. She stressed that the department and
legislature must work closely with tribal health organizations
to fully implement those 1115 services. The waiver renewal is in
the public comment process. She mentioned a regulation package
to allow a 4.5 percent increase to 1115 Medicaid services. The
waiver is not linked to automatic inflation. The tribal health
partners can better address the need for culturally relevant
care. She pointed to housing barriers.
CHAIR CLAMAN asked about the tribal health partners. He wondered
if the department was waiting for the tribal health partners to
establish a plan first. He wanted to hear the department's plan.
MS. CARPENTER replied that the consultation and collaboration of
the tribal health partners was crucial to the plan. She stated
that presenting a plan to the federal government without
collaborating with the tribes would lead to criticism.
CHAIR CLAMAN asked for two suggestions that were presented to
the tribal partners.
MS. CARPENTER responded that suggestions involve implementation
of the Medicaid 1115 waiver.
CHAIR CLAMAN asked what two things the department wished to
accomplish with tribal partners related to the 1115 waiver.
MS. CARPENTER stated that the 1115 Medicaid waiver launched
during the pandemic. The regulations for the Behavioral Health
Services were opened in May of 2020. She noted that the
department supported onboarding new providers for partial
hospitalization because crisis services were critical.
2:25:46 PM
FARINA BROWN, Acting Director, Division of Behavioral Health,
Department of Health, Juneau, Alaska, responded that the
division addressed the 1115 Medicaid waiver. She explained that
the behavioral health demonstration waiver was approved and
bifurcated by the federal government due to the opioid epidemic.
A full waiver resulted. The substance use component was fast-
tracked. Those services "went live" in 2019. The department
ensures that they have authority through the Centers for
Medicare & Medicaid Services (CMS) for the full array of
enhanced services while operating in a fee-for-service paradigm.
Relationships with behavioral health partners were essential as
the partners must implement the service. She explained that the
Medicaid budget does not include resources for workforce or
capital. A rate was established under the 1115 waiver for
services. The initial goal was to increase rates and the 1115
waiver provided the vehicle for the increases. In March 2020,
the Covid-19 pandemic coincided with the planned launch of the
behavioral health component of the waiver.
MS. BROWN continued that the state is limited by the Medicaid
budget, which requires collaboration with behavioral health
providers. Change is created by ensuring that the services span
across various components of community participation. The
department sought to move forward with renewed efforts.
2:31:45 PM
SENATOR TOBIN asked if the department supports existing assets
for communities with the 1115 Medicaid behavioral health waiver.
She asked how many communities had existing services.
MS. BROWN replied that she would respond to the committee with
those data.
2:32:20 PM
SENATOR GIESSEL asked what the department needs from the
legislature.
2:32:42 PM
EMILY RICCI, Deputy Commissioner, Department of Health, Juneau,
Alaska, referred to the 1115 Medicaid waiver. The waiver
resulted from conversations recognizing that the system was
established incorrectly. The 1115 waiver exemplifies the largest
tool of change presented by the Medicaid program. The system
challenges existed for decades. She expected multiple solutions
with stakeholders including tribal health partners, the
behavioral health community and the legislature. She posited
that the health care system in 2023 was vastly different from
the system in December of 2019. She stated that the tribal
health partners helped the department ascertain realistic and
culturally appropriate solutions. The issue is systemic and
complex with multiple solutions available. Solutions and
investment needs require collaboration to prevent repeating past
mistakes.
2:36:19 PM
CHAIR CLAMAN asked a question about Medicaid funding and capital
expenses. He wondered about capital expenditure needs. He hoped
to see a request from the governor for capital funding.
SENATOR GIESSEL pointed out that vacant facilities in some
communities might be useful for clinics or partial
hospitalization programs.
SENATOR TOBIN noted that facilities in Nome existed that could
provide resources for Alaska's use.
2:39:41 PM
MS. RICCI responded with information about the department's work
related to complex care. She spoke to the fundamental change in
health care systems following the pandemic. Workforce continues
to pose the greatest challenge beyond issues like location and
facilities.
2:41:25 PM
CHAIR CLAMAN asked about workforce shortages. He wondered if the
department required additional legislative appropriations to
increase salaries.
MS. RICCI clarified that the workforce shortages involve health
care providers.
CHAIR CLAMAN reasoned that the non-state provider provides the
services and Medicaid rates must increase for reimbursement
purposes.
MS. RICCI agreed that reimbursement was part of the issue, but
the primary issue is a shortage of workforce. She spoke to
challenges recruiting workers to rural Alaska. She spoke to the
cultural challenges workers might encounter in some of the
vacant positions.
2:43:41 PM
DR. ZINK talked about rates and workforce. She explained that
the solution might be presented in a couple of buckets. The
rates and structure including the payment of the workforce.
Education is another key component. She highlighted the
identification of systems requiring coordination with each
other. The system must address current and future issues to
allow for flexibility. She mentioned complex care coordination
to identify needs and solutions. Ideas from collaboration
included better information technology (IT), healthcare savings,
and coordination between both departments.
2:48:38 PM
DR. ZINK continued that the system created must be nimble. She
pointed to the Complex Care Coordination Working Group with its
three pillars. The first pillar addresses individual cases. The
second pillar creates a feedback loop to allow for
identification of gaps or needs. The third pillar includes work
with external stakeholders. All three pillars influence each
other.
2:50:53 PM
SENATOR KIEHL responded that Dr. Zink's points sounded familiar.
He recalled the key strategies to the Bring the Kids Home
initiative from 2005-2014. He asked the testifiers to help the
legislature "help better" this time. He stated concern that the
proposed solutions remain the same following many years of
similar conversations.
DR. ZINK replied that the Bring the Kids Home process continues
with a difference in scope. The complex care coordination work
is designed for patients in Alaska requiring services from one
or more division that are not currently met. The effort involves
the Bring the Kids Home model by addressing the program's
barriers and boundaries.
2:52:20 PM
CLINTON LASLEY, Deputy Commissioner, Department of Family &
Community Services, Juneau, Alaska highlighted the department's
services. He noted that the separation of the Department of
Health and the Department of Family and Community Services
addressed many of the issues detailed in the hearing. The focus
on complex care was prioritized by both departments. His
department of family community services has four divisions
serving youth or children. Some of the children require services
for complex medical or behavioral health needs. The department
has approximately 2900 youth in out-of-home placement with 22
youth in out-of-state placement.
CHAIR CLAMAN asked about Ms. Carpenter's reference to 69
patients, while Mr. Lasley referenced 22 out-of-state youth.
MR. LASLEY responded that Alaska had 69 youth in out-of-state
treatment via the Medicaid program. He continued that the 22
individuals were under the care of the Office of Children's
Services and three youth were under the care of the Division of
Juvenile Justice. A total of 25 youth are serviced under the
Department of Family and Community Services.
CHAIR CLAMAN provided clarification that the 25 youths were
contained within the 69 mentioned earlier.
MR. LASLEY concurred and noted that some youths receive care
through Medicaid and others via the Office of Children's
Services. He spoke about API's ten youth beds. He recalled a
time when API was in a similar crisis, which presented
challenges like those North Star Behavioral Health System faced.
He spoke about safety considerations related to sending a child
out of state for treatment.
2:58:06 PM
MR. LASLEY spoke further about efforts for individuals with
complex needs. The treatment needs of the individual were
scrutinized. Efforts are made to keep children close to home
while obtaining culturally appropriate services. Placement
options are not always available in smaller communities. The
department recently hired a complex care coordinator. He pointed
to a request for an additional three positions proposed in the
Governor's FY 24 budget to build out the complex care team. He
mentioned the expansion of the Alaska Tribal Child Welfare
Compact with an additional $3.4 million for a primary focus on
prevention. The governor added $10 million in base funding to
the Office of Children's Services last year.
3:02:37 PM
SENATOR GIESSEL expressed appreciation for the department's
efforts. She appreciated the departments and the health care
professionals for serving the children in need.
SENATOR KIEHL echoed Senator Giessel's comments. He hoped that
the Alaska Mental Health Trust would be involved in future
hearings.
CHAIR CLAMAN stressed the importance of the topic.
3:05:33 PM
There being no further business to come before the committee,
Chair Claman adjourned the Senate Judiciary Standing Committee
meeting at 3:05 PM
| Document Name | Date/Time | Subjects |
|---|---|---|
| DOJ Investigation of the State of Alaska's Behavioral Health System for Children Findings Report 12.15.2022.pdf |
SJUD 2/8/2023 1:30:00 PM |