SB 38-MEDICAL ASSISTANCE:BREAST/CERVICAL CANCER  SENATOR DAVIS informed the committee that she is very disappointed that no public hearing on SB 38 will occur today. She contacted many people about this hearing and was not told until she arrived at the meeting that the public hearing will not occur for another week. She expressed frustration that she has been working very hard to get this bill before the committee, only to find that DHSS will be giving a presentation on it instead, which it has already done. CHAIRWOMAN GREEN said the previous input from DHSS was about the general Medicaid program, not specifically on medical assistance for breast and cervical cancer. She felt it was important to go back and get an update on this specific program. Her intent was not to prevent anyone from testifying on this bill. She asked DHSS to proceed. TAPE 01-37, SIDE B MS. MARY DIVEN, Division of Public Health, DHSS, gave the following overview of the early detection for breast and cervical cancer program. The Center for Disease Control (CDC) funds a screening program that provides screening for breast and cervical cancer. To be eligible, a woman's income must be less than 250 percent of the poverty level, or she must be uninsured or underinsured, or her insurance deductible must be too high to make the costs of screening affordable. The intent of this program is to detect cancers early to reduce death and illness from the cancers. CHAIRWOMAN GREEN asked Ms. Diven to review the original thought behind providing free screening. MS. DIVEN explained the federal government determined that lower income women were dying from breast and cervical cancer at higher rates than the rest of the population. Therefore, the government created this program to provide free screening for early detection. The program included outreach to attract women who were not getting an annual screening. She noted all states have signed onto this program. CHAIRWOMAN GREEN asked what choices the state was given regarding the poverty level when it signed onto that program. MS. DIVEN said the eligibility cap was recommended at 250 percent of the poverty level, which is what the state chose. The CDC did not propose a lower range or a floor. She noted that there is a range of eligibility rates that other states have selected. The lowest is 185 percent with one state at that range, while the high end is 250 percent with 35 states at that range. CHAIRWOMAN GREEN asked what would have happened had Alaska chosen 133 percent. MS. DIVEN said DHSS would have screened fewer women and would have detected fewer women with cancer. CHAIRWOMAN GREEN asked if the state could have set the limit at 133 percent. MS. DIVEN said she believes that the CDC told DHSS that it was to use the 250 percent level because Alaska's screening numbers were not high. COMMISSIONER PERDUE said she would get the answer to that question for the committee. CHAIRWOMAN GREEN said she read that the CDC had a range, which is what she is trying to establish. Number 2160 SENATOR DAVIS asked if people whose income is at 133 percent of the poverty level would already be covered. She said she thought the purpose of SB 38 was to pick up women whose income was above that level. MS. NANCY WELLER, Division of Medical Assistance, explained that not everyone who is low income is eligible for Medicaid. A single adult without children who is not elderly or disabled is not likely to be eligible for Medicaid. SENATOR DAVIS asked if that would be the case if that person's income was at 133 percent of the poverty level. MS. WELLER said that person would not be eligible even if their income was at 20 percent of the poverty level. SENATOR WILKEN noted that on pages 12 through 16 (Notice of Availability of Funds) of the federal law, the floor for eligibility is set out at 100 percent of the poverty level. MS. DIVEN pointed out those numbers do not pertain to qualifications for the program; those numbers apply if a fee is charged so that no fee can be charged to a woman who is at 100 percent of the poverty level. COMMISSIONER PERDUE clarified that, regarding Senator Davis's question about eligibility for Medicaid, eligibility depends on whether a woman is covered under the Temporary Aid for Needy Families (TANF) program or whether she is covered under a disability program or in general. She asked Ms. Weller to elaborate on the criteria. MS. WELLER explained that Medicaid is a categorical program so that clients generally have to fit within one of the following groups: families with children, pregnant women, elderly, or disabled. Therefore a woman whose children are grown, but who is not 65 or older or permanently disabled, will not be eligible for Medicaid, regardless of her income or how sick she might be. COMMISSIONER PERDUE added that women in those groups would be covered at a different income level. Women eligible for the TANF program are covered at 72 percent of the poverty level; disabled women are covered at up to 250 percent of the poverty level. She noted the purpose of SB 38 is to fill in the hole of income eligibility for women who are not yet 65 but whose children may be grown. Those women comprise a very important target population for risk of breast and cervical cancer. Number 1974 SENATOR WILKEN asked Commissioner Perdue to let the committee know what the floor is regarding income eligibility. COMMISSIONER PERDUE agreed. SENATOR LEMAN asked Commissioner Perdue to provide the committee with a chart of the eligibility level in all states that participate in this program. SENATOR DAVIS asked if a woman is determined to be eligible for screening at the 185 percent level, her treatment eligibility would be at the same level. COMMISSIONER PERDUE said that is correct. MS. WELLER told the committee that Congress enacted legislation to provide this Medicaid option last December (2000). This new option is for women who have been screened through the CDC breast and cervical cancer detection program. The Medicaid option is more limited than the CDC program because women with any creditable coverage are not eligible. The CDC program screens women who are underinsured or have high deductibles or have an insurance policy that excludes these services. She noted Alaska Native women were precluded from this option because of Indian Health Service (IHS) coverage, which has led to some confusion about the Governor's letter. In that letter, the Governor noted that 70 women were potentially eligible for the screening program but the fiscal note covers 42 women because Alaska Native women were excluded. CHAIRWOMAN GREEN asked if this program is being developed in Alaska for 42 women in the first year. MS. WELLER said that is correct. She added that the fiscal note estimates were taken from actual Medicaid expenditures for clients with breast and cervical cancer who were qualified for services under another category. Number 1862 CHAIRWOMAN GREEN asked if the majority of women in need in Alaska already receive coverage through other Medicaid programs. MS. WELLER said a much larger number are already receiving treatment under Medicaid than are potentially eligible under the new option. COMMISSIONER PERDUE clarified that question really applies to all women in Alaska who have cancer, many of whom would not qualify for this program and who do not have insurance. She said one of the reasons this bill is important is that early detection and treatment of these diseases improves the outcome remarkably. CHAIRWOMAN GREEN asked if early detection and treatment has the same result for other diseases. COMMISSIONER PERDUE replied there are many diseases for which early detection is equally important, such as glaucoma and heart disease. Some of those screenings are available at the Alaska Health Fairs. CHAIRWOMAN GREEN said she believes it is important to review what is not covered in Alaska because there is no enabling legislation. She asked if the optional groups, under Medicaid, can be added by DHSS through regulation. MS. WELLER answered that the document entitled Medicaid Services and Groups not in Current State Law contains a list of other Medicaid services or groups that have budgetary implications but may not require legislation. CHAIRWOMAN GREEN asked what the services for 12 month continuous eligibility for children entails. MS. WELLER explained that the 12 month continuous eligibility for children was an option that was added to the Medicaid statute when the Denali Kid Care program was created. It is allowed under federal law, the idea being to get children into the program and keep them on it for continuity of health care so that once they apply they are eligible for an entire year. Right now, DHSS has the authority under state law to provide coverage under Medicaid for 12 months but it is covering those clients for six months. CHAIRWOMAN GREEN asked what the non-emergency transportation within communities of residence service is about. MS. WELLER said that Medicaid now pays for transportation services between communities but it does not pay for transportation services within a community, so that transportation to and from a doctor or dentist within Anchorage is not covered for an Anchorage client. Number 1610 CHAIRWOMAN GREEN asked what is covered under school based services. MS. WELLER explained that category would cover actual health care services provided in schools, such as therapy. CHAIRWOMAN GREEN asked if the services for tobacco cessation and offering more liberal financial eligibility and coverage of policies are categories that could be enhanced. MS. WELLER said DHSS is allowed, under federal rules, to disregard additional income or assets in order to make more people eligible for the Medicaid program. CHAIRWOMAN GREEN noted the list contains a whole raft of options that requires legislative approval. The one she hears the most about is adult dental services. COMMISSIONER PERDUE acknowledged that current Medicaid services in that area are lacking. CHAIRWOMAN GREEN said the committee has to look at, whenever a new program is considered, how these other services that could be provided but have never been adopted compare. She said it is especially difficult when the committee is faced with a bill that will treat 42 people this year and will provide services for more people in the future. Number 1518 SENATOR DAVIS asserted that the screening program for breast and cervical cancer already exists and it is provided for women whose income is up to 250 percent of the poverty level. She asked if the state does not participate in the Medicaid option for treatment of those cancers, whether it will lose the screening program. COMMISSIONER PERDUE said DHSS does have some flexibility on where to set the screening, but if it tightens the eligibility criteria for screening, it will be returning federal money. CHAIRWOMAN GREEN asked what continuation of the CDC program for screening has to do with whether or not Alaska decides to participate in the Medicaid option for breast and cervical cancer treatment. COMMISSIONER PERDUE said she believes Senator Davis was asking what would happen if the state lowered the screening eligibility. SENATOR WILKEN asked if the change in federal funding is shown in any of the documentation provided. MS. DIVEN said it is not because Alaska's screening level was set at 250 percent of the poverty level in the grant application to the CDC. SENATOR WILKEN asked if the eligibility limit was set at 185 percent, for example, what DHSS would trade. MS. DIVEN answered, "Federal funds and the number of women whose cancers are detected early." SENATOR WILKEN asked if that is shown in the documentation. MS. DIVEN said it is not because the current agreement with CDC was set at 250 percent. SENATOR LEMAN asked if DHSS has a chart of the income eligibility guidelines used by other states for treatment under Medicaid for breast and cervical cancer. MS. DIVEN explained the treatment is set at the screening level. They must be the same. SENATOR LEMAN asked if the eligibility criteria for treatment is changed, the criteria for screening must be changed. MS. DIVEN said that is correct. SENATOR LEMAN asked why the CDC would care if Alaska wanted to screen at a higher income level, if the state pays for it. MS. DIVEN asked if Senator Leman was asking whether the state could set the eligibility criteria at 200 percent for screening but use state general funds for the other 50 percent. SENATOR LEMAN said yes, or use some other source of money to make up the 50 percent. MS. DIVEN said, to her understanding, that would not conflict with the rules of the program but it would increase the amount of state general funds needed, rather than using the federal funds available. SENATOR DAVIS asked why Senator Leman would want to change that even if the state portion was from a stream of money other than general funds. That other stream of money could be used for something else while the federal funds are already available for the same purpose. She also asked if 250 percent of the poverty level equals about $52,200 net for a family of four. MS. DIVEN said that is the gross income. COMMISSIONER PERDUE indicated that the profile of the typical client who will be helped by SB 38 is a middle-aged or older woman. If a woman has raised several children but they are no longer dependents, her income, to be eligible would have to be about $26,000 per year. The TANF population is made up, primarily, younger women who are raising children. CHAIRWOMAN GREEN referred to a letter she received about a young woman who repeatedly presented herself to doctors with symptoms of cancer and was never referred for prescreening. She died within a year of cervical cancer. She asked if that woman would never have been covered under this program because she was 23 or 24. COMMISSIONER PERDUE said the woman may have, but she was pointing out that the profile of most women who would helped by SB 38 is older. CHAIRWOMAN GREEN expressed concern about some of the descriptions she has seen about this bill as a program for older women over 65, if it does apply to women of all ages who qualify. She noted the program was supposedly established to eliminate disparity. She asked what that disparity refers to. MS. DIVEN answered the disparity is in the number of women who die from breast and cervical cancer who did not receive screening. Number 1064 CHAIRWOMAN GREEN said she knows no one in the legislature who does not desire to help people but she feels it is ironic that men with prostate or other cancers are not offered a similar option. SB 38 makes a small portion of the population more special than others who are suffering from other diseases. She asked Ms. Diven to discuss the criteria for the priority populations. MS. DIVEN read [from page 2 of the Notice of Availability of Funds]: Criteria for priority populations are uninsured or under- insured older women who are racial, ethnic and cultural minorities, such as American Indians, Alaska Natives, African-Americans, Hispanic, Asian/Pacific Islanders, lesbians, women with disabilities, and for women who live in hard to reach communities in urban and rural areas. She pointed out that those are the women who die more frequently from breast and cervical cancer. CHAIRWOMAN GREEN asked how DHSS refers to that criteria. MS. DIVEN explained that the criteria refers to providing outreach to make sure that an attempt is made to reach those women. A variety of methods for outreach have been used, including the ministerial association affiliated with the YWCA in Anchorage, door-to-door outreach in low income zip code areas, coupons in newsletters to certain groups, etc. That language says DHSS needs to put a little more effort into reaching those populations who are dying at a disproportionately higher rate. CHAIRWOMAN GREEN asked if because of the IHS participation, Alaska Native and American Indian women are not provided treatment under Medicaid. MS. DIVEN said that is correct. CHAIRWOMAN GREEN asked if uninsured and underinsured women are eligible for the screening while only uninsured women are eligible for the treatment if they are within 250 percent of the poverty level. MS. DIVEN said that is correct with co-pays. CHAIRWOMAN GREEN asked for a review of the co-pay aspect. Number 760 MS. WELLER explained that the co-payments and co-insurance for adults on Medicaid are $50 per day to a maximum of $200 for each inpatient hospital admission; 5 percent of outpatient hospital expenses, such as chemotherapy or radiation; $3 per physician service; and $2 for each prescription drug. CHAIRWOMAN GREEN asked if Medicaid can charge a premium. MS. WELLER said Medicaid cannot charge premiums. COMMISSIONER PERDUE stated that DHSS supports SB 38 and she noted that, regarding why this population is being separated out, Congress has given the states an opportunity to enter into a cost agreement to make a significant difference in a limited number of women's lives. It is a modest proposal: it will not solve the problem of access of care for all women who need breast or cervical cancer treatment. DHSS is faced everyday with dealing with people who fall outside of the line for government help, therefore they are familiar with the arbitrary nature of this type of coverage. It is a sad fact of life. She understands that the committee is struggling with that issue, but that is the world we live in. She felt the question before the committee is whether a state investment of $175,000 for this population is money well spent to save lives. She asked the committee to support the bill. Number 607 SENATOR LEMAN expressed concern about DHSS's collection of data regarding its ability to provide the legislature with information regarding the link of certain behaviors to breast and cervical cancer. He noted that DHSS acknowledged a link between tobacco use but he has read a fair amount of research that demonstrates a high correlation with other behaviors. He asked if government puts money into fixing a problem when it occurs, whether it shouldn't be putting money into preventing the problems. He said he recognizes that cancer strikes at random sometimes and there are no apparent linkages but there are some behaviors that can be changed. He asked if DHSS is committed to identifying those correlations and investing effort into changing those behaviors to minimize problems later on. COMMISSIONER PERDUE replied that she feels Senator Leman has a very good point in that the approach to public health should be to look at ways to minimize the risk for the next generation. She pointed out the screening program entails taking medical histories of women, looking at lifestyles, providing counseling, and collecting forensic data on the family to let women know if they are high risk. That approach is being taken on a one-to-one basis in doctors' offices. SENATOR LEMAN said he does not expect to see individual data but he would hope that DHSS could start looking at data so that it can come to some conclusions and suggest changes. He said he would want to know all of the risk factors for cervical or breast cancer. CHAIRWOMAN GREEN asked Ms. Carol Edwards to testify as she will not be available to testify next week. Number 388 MS. CAROL EDWARDS, an oncology nurse and a member of the Alaska Nurses Association, and current health policy liaison and a former director on the board of the Oncology Nursing Society, said during her 20 years as an oncology nurse she has cared for many women with cancer, particularly breast cancer. It is a devastating experience for any individual to receive a diagnosis of cancer. She has long advocated early screening and detection of cancer as it is the most important way to improve the quality of life and it saves dollars. If cancer is found early, it is often treatable and cured. However, that can only occur if the cancer is treated. She believes it is inhumane and cruel to offer testing and diagnosis of cancer but not treatment. Our national government has provided funds to screen and diagnose breast and cervical cancer and it has provided 70 percent of the dollars needed to treat those cancers. Our state must provide only 30 percent of the cost. Women diagnosed with cancer worry not only about their future but the future of their families. She asked the committee to not ask her to tell them there is no hope of life because the government will not provide the money for treatment. SENATOR LEMAN pointed out that a previous testifier told the committee that anyone in Alaska who has cancer is able to get treatment as hospitals do not turn people away. The question instead is who will pay for it. He said the committee is debating the issue of cost shifting, not whether treatment should be provided. SENATOR DAVIS thanked Ms. Edwards for her testimony and said Ms. Edwards was saying the federal government will pay for 70 percent of the treatment. She believes the state should support that program, otherwise women who are diagnosed will have to figure out who will provide services and will force them to ask for a handout when they are in pain and agony. TAPE 01-38, SIDE A SENATOR DAVIS stated support for SB 38. MS. EDWARDS said, regarding Senator Leman's question about the behavioral risks for cancer and education, there is a link between cervical cancer and sexually transmitted diseases, therefore education for young people regarding protection and abstinence would have an impact. She said she strongly agrees with Senator Leman regarding the need for education. She has advocated for the use of tobacco money for tobacco cessation programs and education for youth. She suggested using that same source of money for an education program about cervical cancer. CHAIRWOMAN GREEN repeated her concern is that SB 38 raises a public policy issue in which the government has chosen two particular diagnoses for which it raises the income limit, while it ignores all other diagnoses. She suggested that maybe the government should be looking at cancer treatment coverage for everyone in the state. She noted all cancers are special, which is why this issue is so troublesome for the committee. She pointed out that none of the other optional programs on the Medicaid list are being considered at this time and some of those programs have a far greater constituency. She referred to a document from the Health Care Financing Administration (HCFA) that contained frequently asked questions and answers about the Breast and Cervical Cancer Prevention and Treatment Act of 2000 and asked how a woman would access the CDC Title XV funds program. MS. DIVEN said the CDC Title XV funds program is the screening program. CHAIRWOMAN GREEN asked how she would find out where services are provided under that program. MS. DIVEN said that she would go to one of the screening providers or she could call the 800 number on the coupon or advertisement for information about the location of screening providers. CHAIRWOMAN GREEN asked if she would be referred to a physician's office. MS. DIVEN said she would be referred to a physician who is enrolled in the CDC program. CHAIRWOMAN GREEN asked how many physicians are enrolled in Alaska, in general. MS. DIVEN said there are 38 screening providers and 59 diagnostic providers in the state. CHAIRWOMAN GREEN asked if they differ. MS. DIVEN said they do but a mammogram could be considered to be screening or diagnostic, depending on the type. A woman might go to a nurse practitioner for cervical cancer screening and a gynecologist for the colposcopy for the diagnosis. A woman might go to a physician for a screening who finds a lump and then be referred to a surgeon for a fine needle aspiration to find out if the lump is malignant. CHAIRWOMAN GREEN asked if that is in the referral after the screening. MS. DIVEN said the CDC program covers the screening and diagnostic phase. CHAIRWOMAN GREEN asked Ms. Diven to describe the first option under which CDC allows grantees the flexibility to extend the definition of "screened." MS. DIVEN said the first option applies to providers enrolled in the CDC-funded program. CHAIRWOMAN GREEN asked for an example of someone who is funded in part by Title XV funds. MS. DIVEN said that might apply to a practice with five physicians who are enrolled providers. In Alaska, DHSS enrolls them as providers in the program. CHAIRWOMAN GREEN asked Ms. Diven to explain the grant or contract options for providers. MS. DIVEN said some states provide grants; Alaska has provider agreements in which it pays on a fee-for-service basis. CHAIRWOMAN GREEN asked if the provider agreements are made in advance of services. MS. DIVEN said they are. She also explained that women would also be eligible for Medicaid treatment if they have been screened by health centers that do not receive Title XV funds but provide services to low income women. CHAIRWOMAN GREEN asked if a woman could get screened and then get retroactive approval for that provider. MS. DIVEN said no, and that Chairwoman Green has the list of enrolled providers. CHAIRWOMAN GREEN asked for an explanation of whether there is any income test under Medicaid for women under this new eligibility criteria. MS. WELLER explained that women who are already found to be income eligible for the CDC program cannot be required to undergo another income eligibility test by the state. CHAIRWOMAN GREEN asked if an eligible woman could have assets. MS. WELLER said she could. MS. DIVEN said that question is not part of the eligibility criteria so that question is not asked. CHAIRWOMAN GREEN said that the state cannot impose the typical Medicaid asset or eligibility standards for treatment on women whose eligibility is based on CDC screening which sets up a distinct standard for this one group of Medicaid recipients. MS. DIVEN said there are multiple standards for Medicaid clients. CHAIRWOMAN GREEN asked if those other standards can be applied to this group of women. MS. WELLER said the 250 percent income standard is the only income related standard. CHAIRWOMAN GREEN noted that the Health Care Financing Administration (HCFA) has found that asset related questions would be appropriate as part of the Medicaid application process only to the extent necessary to determine if the individual is otherwise eligible for Medicaid. She asked whether DHSS determines when women are being screened whether they are otherwise eligible for Medicaid. MS. WELLER said it does and would put them into a regular Medicaid- eligibility category. MS. DIVEN said that would be done during the screening process because that would cover the screening costs also. CHAIRWOMAN GREEN asked what questions can be asked for the screening. MS. DIVEN said women are asked whether they have insurance to cover the screening but there is no asset test. SENATOR WILKEN asked for clarification of question 10. MS. WELLER said these women are already eligible for the CDC program. The document says that Medicaid cannot require an additional income test of the CDC clients. She reads the document to say no, these women have already been found to be income eligible for the CDC screening program so Medicaid would not do another income test for the treatment program. SENATOR LEMAN asked if passive income or capital gains are considered in the income test. MS. WELLER said the income test is based on gross income. CHAIRWOMAN GREEN asked if that includes the permanent fund dividend. MS. WELLER said it depends on when a person applies because the Medicaid application is prospective and is based on the month when the application is submitted. CHAIRWOMAN GREEN said she thought it was based on annual income. MS. DIVEN said there is an annual and monthly schedule. The annual schedule is divided by 12. CHAIRWOMAN GREEN asked which schedule DHSS uses regularly. MS. DIVEN said for the screening program, either can be used. CHAIRWOMAN GREEN asked if there were any further questions. [There were none.] SENATOR DAVIS commented that she appreciates all of the information that has been provided on the Medicaid program and she thanks Chairwoman Green for bringing a lot of information to the committee's attention. She believes a lot of work needs to be done and that she can see the need for further work on this issue by the committee. However, she believes the problems with the Medicaid system should not be tied to SB 38 because SB 38 is a way to start helping people. CHAIRWOMAN GREEN thanked all participants. She expressed concern that there is no incentive in federal guidelines to decrease the number of Medicaid recipients. The programs have been designed with an emphasis on increasing the number of recipients. She said the committee would be remiss to overlook what these programs will cost the state. She then adjourned the meeting at 3:34 p.m.