HOUSE HEALTH, EDUCATION AND SOCIAL SERVICES STANDING COMMITTEE January 20, 1993 3:00 p.m. MEMBERS PRESENT Rep. Cynthia Toohey, Co-Chair Rep. Gary Davis, Vice Chair Rep. Tom Brice Rep. Pete Kott Rep. Irene Nicholia Rep. Harley Olberg Rep. Al Vezey MEMBERS ABSENT Rep. Con Bunde, Co-Chair Rep. Bettye Davis, excused COMMITTEE CALENDAR Overview of the Department of Health and Social Services WITNESS REGISTER Dr. Ted Mala Commissioner Department of Health and Human Services P.O. Box 110601 Juneau, Alaska 99811-0601 465-3030 ACTION NARRATIVE TAPE 3, SIDE A Number 000 CO-CHAIR CYNTHIA TOOHEY called the meeting to order at 3 p.m. and noted members present. (Rep. Bunde arrived at 3:01 p.m.) CHAIR TOOHEY announced the purpose of the meeting was to hear a 45-minute overview of the Department of Health, Education and Social Services. DR. TED MALA, Commissioner of the Department of Health and Social Services, welcomed the committee to Juneau on behalf of the department's 2,000 employees and expressed his pleasure at the prospect of working with the committee. DR. MALA referred committee members to a 22-page overview of the department and an organizational chart on the last page. (The publication, "Alaska Department of Health & Social Services: An Overview," herein incorporated as Attachment 1, is on file at the House Health, Education and Social Services committee room, 106 Capitol, and will be filed at the Legislative Research Library at the end of the second session of the 18th Legislature.) DR. MALA said the department has seven divisions and one deputy commissioner each for financial programs for direct services programs. DR. MALA introduced Dr. Brian Saylor, deputy commissioner for Direct Services; Deborah Wing, director of the Division of Family and Youth Services; Loren Jones, director of the Division of Alcohol and Drug Abuse; Margaret Lowe, director of the Division of Mental Health and Developmental Disabilities; Dr. Peter Nakamura, director of the Division of Public Health. DR. MALA also introduced Jay Livey, deputy commissioner for Financial Programs, and his key division directors Kim Busch, director of the Division of Medical Assistance and Jan Hansen, director of the Division of Public Assistance. Dr. Mala also introduced Janet Clarke, director of the Division of Administrative Services. Dr. Mala expressed the hope that each division could sometime make its own presentation to the committee. Number 096 DR. MALA began his presentation with the Division of Public Health, referring to page 9 of Attachment 1. The division has 373 employees across the state, and administers seven programs, he said. The state provides public health nursing services to all areas of the state, except the Municipality of Anchorage, the East Aleutians Borough and the North Slope Borough, which have assumed responsibilities for their own public health. He stated the Public Health Laboratories' main virology lab is based at the University of Alaska, Fairbanks, with other labs in Anchorage and Juneau. He said the department has proposed studying the feasibility of merging the three to save time and money. A radiological lab has addressed the radioactive contamination at Point Hope. Information gathered by the Bureau of Vital Statistics helps the department plan its public health programs, he explained. DR. MALA said Alaska has the nation's highest per capita rate of work related deaths, with 87 deaths on the job in 1992, most of them commercial fishermen who drowned without wearing life vests, and some from aircraft crashes. In 1991, there were 79 work-related deaths, 38 of them commercial fishermen, who are involved in the state's highest-risk job. The department works with the Alaska office of the National Institute of Occupational Safety and Health on the problem, Dr. Mala said. DR. MALA mentioned the Budget Request Units, a program established by the legislature in 1981, which allow the legislature to make direct financial grants to special rural regional health corporations. He said there is currently debate over the need to continue the program for those corporations that have since developed mature health care systems. DR. MALA referred to an epidemiology bulletin, one of the department's periodic publications. The department is planning to publish a 1992 annual report within three weeks, which would also serve as a report card on public health in the state, he said. Number 245 DR. MALA stated the Division of Mental Health and Developmental Disabilities, with 440 employees, has many interested advocacy groups. He outlined the division's programs and institutions as presented in Attachment 1, starting on page 13. He noted the Alaska Youth Initiatives program serves about 77 children, with 26 names on a waiting list. He said the Advocacy and Public Education includes a suicide prevention program which distributes $860,000 to rural villages for home-grown programs, which are sometimes combined with peer counselor training programs, and with other drug and alcohol prevention programs. Dr. Mala noted the department tries to use para-professional workers in villages to save money and keep services available. DR. MALA referred to the mental health division's institutions. The department hopes to replace the Alaska Psychiatric Institute in Anchorage, a 30-year old institution with serious structural problems, despite its acceptable outward appearance. The presence of asbestos requires frequent costly emergency maintenance, which can reach $1 million some years for maintenance and asbestos abatement. Though built with 219 beds, it currently houses 130 patients, and ten years' study has shown a new institution could have but 114 beds, as long as it was buttressed by a strong community mental health care program. Number 330 DR. MALA stated the Harborview Developmental Center mental hospital in Valdez has reduced its patient load, but still has some patients of 20 years' residence and more. The department had considered either closing the hospital or expanding it to reduce per-resident costs reaching $100,000 per year. The department decided to remodel existing wings to accommodate elderly patients requiring long-term psychiatric nursing care, who are difficult to accommodate at other nursing homes. Number 341 DR. MALA outlined the Division of Alcohol and Drug Abuse, as described on page 19 of Attachment 1. The division has 29 workers. Alcohol abuse is the top cause of injury accidents in the state, and an estimated 35,000 Alaskans suffer from alcohol abuse. About 30 babies each year are born with Fetal Alcohol Syndrome, and another 130 with some Fetal Alcohol Effect, many of them born to Alaska Natives, he said. Dr. Mala said such births are extraordinarily costly, resulting in "million dollar babies." Number 375 DR. MALA noted that department officials traveling around the state to assess needs and concerns in rural areas have learned of major problems with alcohol and inhalant abuse. He added that the department is trying to focus on inhalant abuse in Western Alaska, after two children in Nome died after sniffing gasoline. DR. MALA described the Division of Family and Youth Services, with 594 employees, divided into Family Services and Juvenile Corrections functions, as described starting on page 1 of Attachment 1. Number 404 In 1992, the division made a major change in philosophy, trying to keep families with troubled or abused children intact, instead of removing such children from their families. This change has resulted in the removal of 140 fewer children from their homes in FY 1993 than in previous years, Dr. Mala said. DR. MALA described the state's main juvenile detention facilities, including the McLaughlin Youth Center in Anchorage, with both honor cottage and full security detention areas. Other centers operate in Fairbanks, Juneau, Bethel and Nome, which with probation officer services allow young offenders to remain close to home. He noted the department is trying to train and certify corrections and probation officers to improve their ability to detect more serious problems in their charges, such as sexual abuse or serious mental problems, which might require them to be in more secure environments. Number 457 DR. MALA referred to the Division of Medical Assistance, with 56 employees, based in Juneau and Anchorage, as described starting on page 7 of Attachment 1. The department predicts the division's budget ought to rise by 12 percent in fiscal 1994. Dr. Mala said he anticipates the division will spend about $130 million in state general funds, and another $160 million in federal funds. He said the department may be able to win 50-50 matching federal funds for Medicaid programs the state now pays for alone, which could save up to $2 million this year. DR. MALA predicted the issue of containing the high state costs for Medicaid programs would be an issue for the legislators. The administration is considering the results of a task force on cost containment and is planning its responses. Some possibilities include more managed care, expansion of some state employees' medical benefits, centralized drug purchases and electronic billing. Number 511 DR. MALA referred to the Division of Public Assistance, as outlined on page 3 of Attachment 1. The division has 428 employees, he said. The demand for welfare services and attendant costs are rising significantly, by up to 15 percent across the nation. The division receives about $108 million from state funds, and spends about $223 million including federal matching funds, an amount that he expects to rise 8.7 percent in the next year. DR. MALA said state residents receive about $52 million in federal food stamps each year. In FY 1993 there were 14,920 people receiving food stamps, a number projected to rise to 15,536 next year. DR. MALA stated about 12,380 people receive federal energy assistance. Aid to Families with Dependent Children was paid to about 12,485 in FY 1993, a number he said was projected to rise to 13,858 next year. Adult Public Assistance was paid to 8,908 people in the last fiscal year, a number projected to go up to 9,664 in the next year. DR. MALA said the department is working on ways to reduce these numbers and expects much public and committee discussion on the issue. He discussed his goal to link state welfare and employment services programs in communities, possibly locating them in the same building. He described a current program, under which an applicant cannot receive welfare without accepting federal education or job training, and which offers free child care during such training. The program served 925 people last year, and the department expects to have 1,340 next year, he said. Number 549 DR. MALA described the Division of Administrative Services, as outlined starting on page 21 of Attachment 1. DR. MALA said a department-wide problem is the lack of sufficient modern equipment, such as computers to allow staff to perform more direct services and less clerical work. Such equipment could make research data available on-line to staffers around the state. DR. MALA complained that unfunded federal mandates such as the Americans With Disabilities Act which requires the state to spend millions, to improve handicapped access to public facilities, but providing no funding. Another example is a measure aimed at limiting transmission of blood-borne pathogens on the job, administered by the U.S. Department of Labor's Occupational Safety and Health Administration. The state has been fined under the measure, and needs to budget for compliance, Dr. Mala said. TAPE 3, SIDE B Number 000 DR. MALA briefly mentioned several areas of activity in the department, including international circumpolar cooperation. He said it is important to work with Canada and Russia to plan disaster response, and emergency medical treatment of those in remote areas. Given increasing international travel across the Bering Sea, he said, Alaska and Russia should arrange rapid emergency response by the nearest emergency response technicians, regardless of the victims' citizenship. DR. MALA mentioned the reorganization of welfare fraud and medical assistance prevention programs in the state, and the assignment of an Alaska State Trooper to welfare fraud prevention. He noted that some cases have resulted in confiscation of some property for sale at auction to recover state funds. Such programs can receive generous federal matching support, up to 90-10 matches, he said. Number 030 In summarizing his presentation, DR. MALA invited the committee to hear presentations from his division directors, and reminded the committee of the scope of his mission and budget, which reaches $700 million per year, including federal matching funds. Number 070 CHAIR TOOHEY thanked Dr. Mala for his presentation and entertained questions from the committee. Number 080 REP. IRENE NICHOLIA asked which three villages were participating in the mental health division's Village Research and Demonstration Projects, as outlined in Attachment 1. Number 100 DR. MALA responded he didn't know, but would find out and tell her. REP. NICHOLIA asked if that program was part of the Behavioral Health Aide program DR. MALA answered that the aide program overlaps with that and other programs. REP. NICHOLIA asked if funds for the demonstration projects program would be increased this year, and whether local health services programs would be involved in establishing such projects. DR. MALA said he would have his legislative liaison, Elmer Lindstrom, work with her on those programs. Dr. Mala stated it was up to the legislature to decide whether the state would fund regional or community health service providers. REP. NICHOLIA further asked whether the Division of Family and Youth Services' Purchased Services program was a statewide program. MS. DEBORAH WING, director of the Division of Family and Youth Services, answered that Purchased Services covers a wide range of services, through contracts, grants and bids, and rural communities are aware of their options to participate. In response to Rep. Bunde's question, JANET E. CLARKE, director of the Division of Administrative Services, said her division employs about 100 people. REP. BUNDE asked if there were efforts to encourage more communities to follow the example set by Anchorage, the North Slope Borough and the Aleutians East Borough in assuming local public health responsibilities from the state. DR. MALA answered that the department has been working this year to produce state health plans that might call for such action. He said Fairbanks voters have repeatedly rejected such an initiative out of fear it would increase their taxes, and Ketchikan had a similar experience. REP. BUNDE expressed his concern over the high rate of teen pregnancy in Alaska and encouraged Dr. Mala to address that problem. DR. MALA remarked that the department had recently put a public health nurse in the Juneau-Douglas High School to work with students on that problem. Number 186 REP. BUNDE asked about the possibility of selling Harborview mental hospital in Valdez to a private operator. DR. MALA remarked the department would love to do so, but to date has had no takers. He said the state has repeatedly offered to sell the facility, which incorporates the city hospital, to the city for $1, also without success. A proposal to close Harborview down and place its residents in communities failed due to lack of money or infrastructure, Dr. Mala said. REP. BUNDE stated that Lloyd Rupp, commissioner of the Department of Corrections, had in conversations mentioned the possibility of having those in short-term alcohol and drug intervention programs pay the costs for such programs. Rep. Bunde asked Dr. Mala whether there were plans to implement such an action. DR. MALA said no, partly because some of those involved are minors, but he indicated his willingness to consider Rep. Bunde's suggestion that permanent fund dividends could be used to compensate treatment costs even for minors. REP. BUNDE asked whether parents of children born with fetal alcohol syndrome were asked to pay any of the cost. DR. MALA said such costs are so high that even taking parents' permanent fund dividends would represent but a small fraction of the total costs. He added that there have been several cases in which such children or their estates have later tried to sue their parents for negligence, though apparently without success. Number 242 REP. BUNDE informed Dr. Mala that a bill may be introduced to allow minors charged with major crimes to be tried as adults in state courts. He also asked how often residents in McLaughlin Youth Center return to the prison system. DR. MALA answered that the rate of recidivism into crime is about 50 percent, a rate lower than he would have thought. He said he did not know how often inmates at McLaughlin returned to that same institution, but he would find out and relay the information. REP. BUNDE applauded the idea of linking employment services and welfare, and asked Dr. Mala for more suggestions on how to slow and reverse the rate of increase in welfare rolls. DR. MALA said he intended, during a more detailed presentation on the Division of Public Assistance, to discuss ideas on how to reduce the financial incentives for people to enroll in, or remain in, welfare programs. The department is examining the possibility of receiving federal waivers to allow state welfare recipients to retain savings or otherwise get ahead financially, and he would like to make a more detailed presentation on such plans. Dr. Mala announced the department would attend a special two-day meeting of the National Governors' Association on welfare reform, to be held in Oregon in early February. Number 297 CHAIR TOOHEY asked whether the state compensates those cities and boroughs that accept public health responsibilities for such programs. DR. MALA replied that the state pays such cities an amount equal to what such services would cost the state. REP. G. DAVIS inquired as to the truth of the idea that Alaska's welfare system is so generous as to attract indigents from outside the state. DR. MALA answered that his staffers said no. REP. G. DAVIS also asked whether the department could find itself paying increasing amounts of money to provide health care to citizens of Russia. DR. MALA responded that the department's international cooperation with Russia is limited to emergency services to those in the Bering Sea. REP. NICHOLIA asked how the announced $460,000 cut in federal funding for alcohol and drug abuse prevention programs in Alaska in FY 1994 would impact the state's efforts in that area. DR. MALA said the cut was a significant source of worry, and the department was seeking replacements for that money. REP. NICHOLIA also asked where the counseling, emergency shelters, family mediation, patenting classes, home detention services and other elements of the family preservation program would be offered, and expressed her hope that they could be offered in Bush Alaska. DR. MALA remarked such programs would be offered in the state's major communities. Number 349 BRIAN SAYLOR, Deputy Commissioner for Direct Services, noted the department was reviewing the responses to a request for proposals on intensive home-based services and would soon issue its short list. At Rep. Nicholia's query, MR. SAYLOR said the department was working that the department does work with regional health organizations on such programs. REP. NICHOLIA asked how the department's circumpolar health initiatives related to regional health concerns. MR. SAYLOR said the initiatives help bring Natives together across international lines to address such problems as alcoholism and other community health problems through traditional methods and to try to improve current programs. ADJOURNMENT CHAIR TOOHEY thanked Dr. Mala and his staff for their presentation. There being no further business before the committee, Chair Toohey adjourned the meeting at 4:10 p.m.