HJR 14-FCC: INCREASE RURAL HEALTH CARE BUDGET  3:19:49 PM CHAIR KITO announced that the first order of business would be HOUSE JOINT RESOLUTION NO. 14, Urging the Federal Communications Commission to increase the Rural Health Care Program budget sufficiently to adjust for inflation, advances in technology and the services available with increased broadband, and the increase in demand for broadband-based services and provide for any unused funds to be carried forward to future funding years, ensuring that rural communities in the state continue to have access to affordable broadband telehealth services. 3:20:25 PM TIM CLARK, Staff, Representative Bryce Edgmon, Alaska State Legislature, advised that during the last few years, rural Alaska has made great strides in long-distance delivery of healthcare via telemedicine. These broadband services expand locally available treatment options for an increasing number of maladies, including substance abuse treatment; and the service accelerates diagnosis, treatment, and assists Alaskans in avoiding expensive travel for care. Except, he explained, these broadband services are about to hit a roadblock because the existence of such services depends upon support from the Federal Communications Commission (FCC) Rural Health Care Universal Services Support Program. The budget for this program has been capped at the same level since its establishment in 1997, and the $400 million budget has been enough to meet demand. Although, he noted, after two decades of advances in technology, increases in demand, and the effects of inflation, the FCC now expects that in 2017 the demand may exceed the budget cap for the first time. This resolution urges the FCC to increase the Rural Health Care Universal Services Support budget sufficiently to adjust for inflation, keep with advances in technology, the services available with increased broadband, and meet the increase in demand for broadband based services in Alaska. Additionally, he explained, the resolution encourages the FCC to index the program budget for inflation, and allow any unused funds to be carried forward to future funding years, thereby allowing healthcare providers to continue improving access to care in rural Alaska. 3:23:16 PM REPRESENTATIVE SULLIVAN-LEONARD asked whether there is a state match on this item for telehealth for the rural areas. MR. CLARK responded no, and he said it is entirely funded through Universal Services Support program charges. 3:23:53 PM JENNIFER HARRISON, Chief Executive Officer, Eastern Aleutian Tribes, advised that this is a complicated program as far as submitting an application and getting bids from local telecommunications firms, and it is quite expensive. The amount of money that the Eastern Aleutian Tribes receives to get internet for its eight clinics along the Aleutian Islands is substantial. Without this funding, she offered, the Eastern Aleutian Tribes would be looking at possibly closing clinics, so the funding is important. She stressed that travel costs to the Aleutian Islands are approximately $1,000 round trip, therefore, every trip patients do not take saves a substantial amount of money. Also, she explained, not all patients have access to travel assistance provided by Medicaid or the Alaska Tribal Health Compact, and in the event this program was removed, the higher levels of care would not be available to these individuals and would dramatically decrease their quality of health. The Eastern Aleutian Tribes support HJR 14, she emphasized. 3:25:39 PM COLIN UNDERWOOD, Manag Communications, offered support for the legislation and noted that the nationwide healthcare industry, particularly in Alaska, has seen a revolution in the manner in which healthcare is provided. He pointed out that many federal laws have been enacted to incentivize the digital transformation of healthcare, and while that is "wonderful," no attention is made to this program that supports the vital backbone infrastructure necessary to deliver that digital telehealth network, he said. This resolution voices support to the FCC by pointing out the importance of also funding this program. He remarked that while the federal government continues to incentivize and provide requirements modernizing moving to a digital platform, it is also important to continue programs that have been in existence for nearly 20 years unmodified. 3:26:55 PM REPRESENTATIVE BIRCH referred to distance delivery for education, healthcare, and asked whether there is a point where "you've got enough bandwidth" in a community. MR. UNDERWOOD responded that the FCC published an updated national broadband plan in 2010 that included a study showing that for any community health center, the minimum recommended bandwidth was 10 megabits symmetrical, which means 10 megs downloaded as well as 10 megs uploaded to provide basic healthcare services. Unfortunately, he said, Alaskans do not have the luxury of many healthcare specialists in these remote locations and many critical access hospitals and community health centers based in Anchorage or elsewhere around the state, provide some of that specialty care. He explained that will doing so will; increase broadband demands "from that base level right there," including video conferencing, real time telehealth services, and those types of opportunities. Additionally, he pointed out, technology has increased in the healthcare space now with x-rays and digital imagining for example, and the quality has quadrupled which also increases file sizes. He offered a scenario of a patient in an emergent situation who may require a 64 slice CT scan, wherein a few years ago that scan may have been 8 slices, but the result is now a much better picture and diagnosis. The FCC has some minimum guidelines, he said, and the rest is driven by technology demands in providing the best care possible in Alaska. 3:29:45 PM REPRESENTATIVE BIRCH referred to 10 megabits symmetrical, and commented that it did not sound like much and asked whether it was sufficient for a healthcare center. MR. UNDERWOOD clarified that that is the amount the FCC deemed a minimum standard, however most community health centers are looking to move to 50 megabytes. He related that the hospitals Alaska Communications is serving today are looking at hundreds of megabytes, with one customer closer to a gigabyte in connectivity because there is a tremendous demand for broadband services to deliver these high-quality healthcare services. 3:30:46 PM REPRESENTATIVE BIRCH referred to his initial question and asked how much bandwidth is enough because he was trying to get a sense of a $400 million cap and what it provides to the extent it is an allocation or request. He asked Mr. Underwood's sense of the education requirement, whether that was a competing interest for the Universal Services support funds and how many people were drawing on the fund. He assumed, he said, that it was a share of whatever people pay every month on their phone bill, but asked whether there are other competing interests in Alaska and other communities. MR. UNDERWOOD answered that the universal service Schools and Libraries program (E-Rate) budget nationwide is $3.9 billion and it was increased again this year. That program, he explained, has been able to adjust every year for inflation, and "We are asking now for the same consideration for the healthcare program." As to competition, he advised that the funds are separate in that healthcare and education are not competing for the same dollars, but are being pulled out of the same Universal Services fund bucket. 3:32:34 PM REPRESENTATIVE BIRCH asked the size of the Universal Services fund bucket upon which all are collectively drawing. MR. UNDERWOOD said he would have to get back to Representative Birch. REPRESENTATIVE BIRCH said, "We are paying a bit of that, aren't we?" MR. UNDERWOOD agreed, and he said every month funds come out of an individual's telephone bill which reads: "USS Universal Services" or something similar, and that charge goes into that nationwide bucket, he said. REPRESENTATIVE BIRCH surmised that this resolution is attempting to obtain a larger share for Alaska's rural communities. MR. UNDERWOOD agreed, and he said Alaska uses the largest percentage of the program given its geographic size, diversity, and how each of the communities are spread out. He explained that there are unused funds in the Universal Services program and this resolution asks to reallocate some of those unused funds to this program in order to match the demands the federal government put on healthcare providers. Wherein, he offered, the federal government requires that "You must transform to digital healthcare and you must integrate with electronic health records." This resolution, he reiterated, simply asks that the FCC recognize those federal requirements and helps support these healthcare providers to continue providing the best healthcare possible, he said. 3:34:07 PM REPRESENTATIVE BIRCH asked whether anything other than healthcare and education was fed by the Universal Services Fund that comes to Alaska. MR. UNDERWOOD replied that there are two other programs, the rural healthcare program, and E-rate, a life line program and subsidy for low income families for mobile or landline dial tone service, as well as the High Cost or Connect America Fund which is typically geared toward certain telecom providers to help build out in high cost areas. REPRESENTATIVE BIRCH asked how many dollars were involved because the rural communities probably have needs in all four of the areas being discussed. He asked how many dollars the coordinated programs add up to for Alaska, presuming the components were healthcare, education, life line, and Connect America. MR. UNDERWOOD opined that for the 2015 fund year for healthcare and E-Rate, the State of Alaska received approximately $100 million for rural healthcare subsidies, and the E-Rate program was closer to $80 million. As far as the other two programs, he said he was unaware of the amount of money brought into the state. Although, he commented, it may be important to note that the education and healthcare entities in communities serve as the "anchor tenant" and provide a lot of the backbone connectivity into those communities. That connectivity, he explained, could later provide additional services and without healthcare and education there was not the business case to build a lot of the infrastructure out there. 3:37:10 PM JON ZASADA, Director, Policy Integration, Alaska Primary Care Association (APCA), advised that the Alaska Primary Care Association (APCA) supports the work of Alaska's federally qualified community health centers. He offered that 25 of its 29 members benefit from the Rural Health Care Program (RHC) and receive almost $38 million per year in subsidies for internet service. Passage of this resolution would assist Alaska's federal delegation in its negotiations in raising the cap, modernizing this program, and instituting an inflation-proofing component so this does not happen in the future, he said. The APCA members are fearful that if the cap is not raised and pro- rated billing is implemented, many will move from paying roughly $500 per month, to $5 or $10,000 per month for internet services. Clearly, he commented, that would negatively affect their sustainability and ability to serve patients. Reverting back to low bandwidth or undedicated internet service is not a possibility for providers who use the service to operate their [audio difficulties] based electronic health records to support telemedicine and have images reviewed by specialists far away, he stressed. The APCA would appreciate the support of this resolution. 3:39:39 PM CHAIR KITO opened public testimony on HJR 14. 3:39:53 PM VERNE BOERNER, President/CEO, Alaska Native Health Board, advised that the Alaska Native Health Board is the statewide voice on Alaska Native Health issues, it is a 28-member organization representing tribes from [audio difficulties] organizations carrying out health services on behalf of the 229 federally recognized tribes in Alaska and over 158,000 Alaska Native people. Additionally, she said, the Alaska Native Health System serves as a critical component of the Alaska Public Health System by providing care and services to thousands of non-Alaska Native people and Alaskan veterans. She expressed that this resolution helps to improve access to telehealth, thereby improving quality of life by reducing travel costs, intervening earlier at a lower cost and with greater success. The January 28, 2016 Broadband Progress Report showed significant improvements by digital divide from the FCC persists, she said. The report stated that the benchmark speeds of 25 megabits per second per downloads, and 3 megabits per second uploads remains a problem, and that the divide in rural Alaska is quite extreme. The February 15, 2015 report showed that 81 percent of rural areas do not have access to that minimum benchmark of 25 megabits per second for download and 3 megabits for upload, and this program is crucial in protecting early access to care in rural communities. 3:42:34 PM CHAIR KITO advised that public testimony would be left open for HJR 14. [HJR 14 was held over.]