SENATE BILL NO. 193 "An Act requiring the Department of Health and Social Services to apply for a waiver to establish work requirements for certain adults who are eligible for the state medical assistance program." 9:25:40 AM HEATHER CARPENTER, STAFF, SENATOR PETE KELLY, introduced the bill. She stated that a Section 11.15 was a broad waiver, and it was a way to "bend the rules" of what was currently required. She shared that there had been a change in policy to accept waivers that test the hypothesis that requiring work or community engagement as a condition of eligibility would result in more beneficiaries being employed, or engaging in other productive community engagement. Thus producing increased health and wellbeing. She shared that President Trump signed an executive order called, "Reducing Poverty in America by Promoting Opportunity and Economic Mobility." She shared that the executive order had a strong focus on work requirements for work capable people. She stated that the Medicaid program was established to help the most vulnerable Alaskans, and it must continue to do so; however, the safety net program should not be used to hold people down indefinitely. She asserted that the legislation sought to use the Medicaid program to lift individuals to a better quality of life by requiring twenty hours of work activity, volunteering, or subsistence activities each week. The legislation included several protections that would exempt individuals from the work requirement including children; certain parents and caretakers; individuals with certain medical conditions; individuals enrolled in an education or training program; and people who were pregnant. She stated that the bill would impact approximately 25,095 Medicaid enrollees, or approximately 10.5 percent of the total enrollment. 9:29:55 AM Ms. Carpenter discussed the Sectional Analysis (copy on file): Section 1: Amends AS 47.07.036 to direct the DHSS to apply for a section 1115 waiver of the Social Security Act to establish a work requirement for adults in the Medicaid program who not meet the criteria to be exempted. The waiver must include the following: (1) Requires an able-bodied Medicaid recipient to participate in work activities for a minimum of 20 hours each week. Actively seeking employment, participating in an education or training program, volunteering, engaging in subsistence activities, or caregiving also are counted towards the 20-hour requirement. (2) If a Medicaid recipient is also receiving benefits under Alaska Temporary Assistance Program and in compliance with the work requirements listed under AS 47.27.035, then they automatically meet the work requirement for Medicaid. (3) Exempt Medicaid recipients who are: a. Children or elderly (Under 18 years old and over 65 years old) b. The parent or caretaker of a dependent child of up to 12 months of age and the parent or caretaker is providing home care for the child c. The parent or caretaker of a child experiencing a disability and the parent or caretaker is providing home care for the children d. The caretaker of a relative who is experiencing a disability and requires 24- hour care e. The parent or caretaker of a child under six years of age and the parent or caretaker demonstrated that appropriate child care is not available f. Unable to work for medical reasons, as determined by a licensed medical professional g. Pregnant h. Currently receiving unemployment insurance benefits i. Participating in a tribal work program (4) Temporary exemptions for: a. Experiencing a family hardship outside of the control of the parent or caretaker b. A victim of domestic violence (5) Ensure that the work requirement does not impact a Medicaid recipient from obtaining substance abuse treatment (6) A notification to all Medicaid receipts once the waiver is approved, and a 90 day notice of non-compliance with the work requirement before benefits are terminated. 9:34:04 AM Senator Stevens wondered how people would be notified of the available scholarships. Ms. Carpenter replied that the state had a rich history within the Department of Labor and Workforce Development (DOLWF). She noted that there were various financial resources through that department. She shared that there was a Medicaid reform bill in 2016 that asked that the department inform individuals on Medicaid of education options or work availability. She stated that the department had a process outlined through the fiscal note. Senator Stevens assumed that the department would provide what was available. Senator von Imhof noted that the Sectional Analysis included the phrase, "there parameters align with the current Temporary Assistance for Needy Families (TANF) program." She wondered how the requirements and exemptions aligned with TANF. Ms. Carpenter replied that they were almost completely aligned. She noted that there may be one provision that was not included. Senator von Imhof wondered whether Department of Health and Social Services (DHSS) had an existing program to monitor hours for Medicaid recipients. Ms. Carpenter replied that the department had work requirements in place for both food stamps and the temporary assistance program, but the federal government had never allowed a work requirement for Medicaid. Senator von Imhof felt that the tracking process was in place, so the current practices could be built upon. Ms. Carpenter agreed. Co-Chair Hoffman appreciated the inclusion of subsistence. He wondered how to document subsistence. Ms. Carpenter replied that there had not been a system for documenting the subsistence. She stated that the waiver allowed for flexibility to work with the tribes. Co-Chair Hoffman remarked that it should be tracked with minimal paperwork, because those living the subsistence life rarely had detail to paperwork. 9:40:20 AM Senator Olson wondered whether only 10 percent of the enrollees would be affected by the legislation. Ms. Carpenter replied that the number with exemptions was 25,095 individuals, which was 10.5 percent of the current program. Senator Olson wondered whether there was similar implementation in any other states, and queried the success in those states. Ms. Carpenter replied that it was a brand new program. She stated that Kentucky had a waiver approved, but there was current litigation around that waiver. Vice-Chair Bishop asked for more discussion with DLWD SENATOR PETE KELLY, SPONSOR, discussed the bill. 9:44:20 AM JEREMY PRICE, STATE DIRECTOR, AMERICANS FOR PROSPERITY, spoke in favor of the bill. He stated that Kaiser Family Foundation put Medicaid enrollment at 1 in 5 in the nation; and 25 million Americans were within the population of able bodied adults that were part of the expansion population. He noted that Alaska was headed for some serious problems, because there were no limits on enrollment in Medicaid. There was a desire to preserve the program for those that need it the most. He felt that government assistance should be a "hand up" and not a "hand out", except for those that truly need the program. He noted that New York, Maine, Alabama, Georgia, and Kansas enacted welfare reform with a focus on food stamps. He stated that after enacting work requirements for food stamps, there was a massive reduction in welfare assistance and increased employment for low skilled workers. He stressed that there was clear and convincing evidence that worklessness led to depression, and depression led to bad things. He felt that there was a link to mental and physical health. Senator Micciche stressed that there may be opportunities missed without development expectations. Co-Chair Hoffman requested a brief description of Americans for Prosperity. Mr. Price replied that Americans for Prosperity was an organization dedicated to removing barriers of opportunities for Alaskans and Americans. He stated that they advocated for lowering regulations; making it easier for people to start small businesses; and lowering taxes; empowering individuals to develop their own future and economic fortune. Co-Chair Hoffman queried the number of members from rural Alaska in Americans for Prosperity. Mr. Price responded that he did not have that number. Senator von Imhof noted that one of the possible challenges was that folks may earn income to rise above eligibility limits, yet may not earn enough to pay for insurance coverage. She queried ideas to address that transition time. Mr. Price replied in the negative. Senator von Imhof noted that Americans for Prosperity was a strong think tank, and had money to research important issues with nationwide stakeholders to discuss the impacts of a particular issue. She urged examination of the program. Mr. Price agreed. 9:52:45 AM ALYSON CURRY, LEGISLATIVE LIAISON, PLANNED PARENTHOOD VOTES ALASKA, testified against the bill. She stated that, in Alaska, over one quarter of the Planned Parenthood patients were Medicaid beneficiaries; and over 80 percent were women. She stressed that everyone had access to needed health care, regardless of their income. She stated that the enrollment restrictions in SB 193 would decrease access to health care in the state, and would have disproportionate impact on women. She stated that Medicaid covered one in five women of reproductive age, and was the source of coverage for nearly one-half of women giving birth. She stressed that many women faced barriers to work, like transportation, housing, and education. She remarked that, in rural Alaska, the work requirements would essentially prevent many women from accessing basic preventative health care. She remarked that restricting women from preventative care, such as contraception, was bad for women's health and bad for the state's budget. She remarked that the state saved seven dollars for every one dollar it invested in family planning, because it was cheaper to invest in contraceptive coverage than to pay for costs associated with unintended pregnancies. She felt that the bill would remove many women from Medicaid who were attempting to avoid pregnancy, but then require the state to cover the cost of their unintended pregnancy after losing access to publicly funding family planning. She announced that research had shown that punitive work requirement did not actually decrease poverty, and in some cases could push families deeper into poverty. She felt that the bill would cut Alaskans off from the care they depend on without improving their economic stability. She noted that the numerous fiscal notes made it clear that it would do so at significant cost to the state. Vice-Chair Bishop queried the definition of "punitive." Ms. Curry replied that it was punitive to kick someone off of Medicaid because they were either unable to find work or unable to work. Vice-Chair Bishop did not feel that twenty hours was not "out of line." He asked that they meet to discuss further exemptions. Ms. Curry agreed. 9:57:05 AM Senator Micciche noted that the bill also allowed volunteer opportunities. He wondered if there was a problem with requiring someone to participate in valuable social activities. Ms. Curry replied that she found great value in giving back to the community, but felt it was a fallacy to believe that the people who were currently on Medicaid did not have a desire to contribute to their community. She did not see how requiring 20 hours of volunteer work rather than seeking employment would increase someone's economic standing. Senator Micciche felt that the bill provided multiple ways for people to contribute. He noted that the government must be there for those that could not work. He remarked that there were individuals who were displaced to receive services, because healthy individuals were receiving services. He wondered whether services should be prioritized in a way that recognized someone's inability to work above asking for a reasonable contribution from those who were capable of working. Ms. Curry replied that she felt that those that were able to community already contributed to the community in their own capacity. She stressed that Planned Parenthood had a hard line stance that everyone deserves access to health care. She felt that the bill focused on the Medicaid expansion population. Senator Micciche felt that the bill did not address the expansion population, because that population was already working. He stressed that the focus was on another population in the eligibility categories. Senator von Imhof felt that Medicaid eligibility for some populations was not health based, but income based. She remarked that a recipient could be healthy, but at a certain level of income to qualify for Medicaid. She noted the extraordinary number of exemptions that would target the Planned Parenthood population. She queried concerns about a tribal work program versus the Medicaid work program. Ms. Curry replied that she could not answer that question. 10:02:48 AM MIKE COONS, PRESIDENT, ALASKA CHAPTER, ASSOCIATION OF MATURE AMERICAN CITIZENS, PALMER (via teleconference), spoke in support of the bill. He stated that the welfare reform had laid the ground work to get more Americans back to work, while protecting and strengthening the safety for the truly needy. He felt that federal agencies must take advantage of the opportunity to roll back harmful "Obamacare" policies to trap families in dependency, and cost taxpayers billions. Co-Chair MacKinnon CLOSED public testimony. Senator Stevens hoped to provide educational opportunities for the recipients. Co-Chair MacKinnon believed that health was important, and services were available for some who could not provide for themselves. She wondered whether benefits were increased to someone with a child. 10:07:40 AM MONICA WINDOM, DIRECTOR, DIVISION OF PUBLIC ASSISTANCE, DEPARTMENT OF HEALTH AND SOCIAL SERVICES, introduced herself. Co-Chair MacKinnon wondered whether benefits were increased to someone with a child. Ms. Windom replied that the benefit would not increase. Co-Chair MacKinnon wondered how many pregnancies in Alaska were covered by Medicaid. 10:08:22 AM JON SHERWOOD, DEPUTY COMMISSIONER, DEPARTMENT OF HEALTH AND SOCIAL SERVICES, replied that he did not have the exact number. He stated that, historically, Medicaid covered approximately 50 percent of pregnancies. Co-Chair MacKinnon stated that she already had the number. She announced that 50 percent of all live births were covered by Medicaid. She noted that the bill would affect program growth in other areas such as food stamps. Senator Micciche noted that the federal poverty line was affected by a child, so it would affect the benefit. Co-Chair MacKinnon stressed that the child would qualify for Medicaid. Ms. Carpenter announced that the bill was not only directed the expansion population. She stated that the CMS guidance letter specifically addressed, "able bodied enrollees in Medicaid." She agreed that it included the expansion population, but was not entirely the expansion population. She agreed to have conversations off the record. She shared that she had stories of people who were told that they were too disabled to work, but felt that it was disingenuous. She announced that she was excited to see what the Trump administration would present for work requirements, and changing the welfare programs. She felt that work was an amazing opportunity to prosper and grow. SB 193 was HEARD and HELD in committee for further consideration.