HOUSE HEALTH, EDUCATION AND SOCIAL SERVICES STANDING COMMITTEE March 9, 1994 3:00 p.m. MEMBERS PRESENT Rep. Cynthia Toohey, Co-Chair Rep. Con Bunde, Co-Chair Rep. Gary Davis, Vice Chair Rep. Al Vezey Rep. Harley Olberg Rep. Bettye Davis Rep. Irene Nicholia Rep. Tom Brice MEMBERS ABSENT Rep. Pete Kott COMMITTEE CALENDAR *HB 468: "An Act extending the termination of the Citizens' Review Panel for Permanency Planning." PASSED OUT OF COMMITTEE HB 414: "An Act creating the Alaska Health Commission; relating to the delivery, quality, access, and financing of health care; relating to review and approval of rates and charges of health insurers; relating to certain civil actions against health care providers and health insurers; repealing Alaska Rule of Civil Procedure 72.1; and providing for an effective date." HEARD AND HELD (* First public hearing.) WITNESS REGISTER ROBERLY WALDRON, Deputy Commissioner Services to the Public Department of Administration 900 W 5th Ave., Ste. 710 Anchorage, Alaska 99501-2029 Phone: (907) 258-6117 Position Statement: Testified in support of HB 468 SHERRIE GOLL, Lobbyist Alaska Women's Lobby; KIDPAC P.O. Box 22156 Juneau, Alaska 99802 Phone: (907) 463-6744 Position Statement: Testified in support of HB 468 NANCY USERA, Commissioner Department of Administration P.O. Box 110200 Juneau, Alaska 99811-0200 Phone: (907) 465-2200 Position Statement: Offered amendments to HB 414 STEVE LEBRAUN, Account Manager Aetna Health Plan P.O. Box 91032 Seattle, Washington 98111-9132 Phone: (206) 467-2803 Position Statement: Testified in support of HB 414 (spoke via offnet) JAY LIVEY, Deputy Commissioner Department of Health and Social Services P.O. Box 110601 Juneau, Alaska 99811-0601 Phone: (907) 465-3068 Position Statement: Answered questions on HB 414 BONNIE NELSON, Representative Alaska Public Interest Research Group 20615 White Birch Rd. Chugiak, Alaska 99567 Phone: (907) 688-3017 Position Statement: Testified on HB 414 (spoke via teleconference) PREVIOUS ACTION BILL: HB 468 SHORT TITLE: FOSTER CARE REVIEW PANEL SPONSOR(S): REPRESENTATIVE(S) TOOHEY,Ulmer,Brown,Nordlund JRN-DATE JRN-PG ACTION 02/14/94 2374 (H) READ THE FIRST TIME/REFERRAL(S) 02/14/94 2374 (H) HES, FINANCE 03/09/94 (H) HES AT 03:00 PM CAPITOL 106 BILL: HB 414 SHORT TITLE: COMPREHENSIVE HEALTH CARE SPONSOR(S): RULES BY REQUEST OF THE GOVERNOR JRN-DATE JRN-PG ACTION 01/28/94 2182 (H) READ THE FIRST TIME/REFERRAL(S) 01/28/94 2182 (H) HES, JUDICIARY, FINANCE 01/28/94 2182 (H) -2 FISCAL NOTES (GOV, DCED) 1/28/94 01/28/94 2183 (H) GOVERNOR'S TRANSMITTAL LETTER 02/15/94 (H) HES AT 03:00 PM CAPITOL 106 02/15/94 (H) MINUTE(HES) 03/02/94 (H) MINUTE(HES) 03/04/94 (H) HES AT 03:00 PM CAPITOL 106 03/04/94 (H) MINUTE(HES) 03/09/94 (H) HES AT 03:00 PM CAPITOL 106 ACTION NARRATIVE TAPE 94-41, SIDE A Number 000 CHAIR TOOHEY called the meeting to order at 3:07 p.m., noted members present and announced the calendar. She brought HB 468 to the table. She indicated that Deputy Commission Waldron was in attendance. She then passed the gavel over to Rep. Bunde who presided over portions of the remainder of the meeting. CHAIR BUNDE stated that perhaps there might be a conflict of interest as his aid, Patty Swenson, is a member of the Foster Care Review Panel. REP. TOOHEY said she had no objections. HB 468 - FOSTER CARE REVIEW PANEL Number 106 (Chair Bunde stated for the record that Rep. Nicholia arrived at 3:08 p.m.) Number 125 REP. CYNTHIA TOOHEY, Prime Sponsor of HB 468, stated that the legislation would extend the sunset date for citizen's review panels for permanency planning until 1997. She indicated that the proposal had bi-partisan support and passed the legislature unanimously in 1990 and was signed into law. The purpose of external citizen reviews is to assure that children do not linger unnecessarily in out-of- home care, and they receive the support and benefits of a permanent home as soon as possible. REP. TOOHEY further indicated that in the United States almost 500,000 children pass through state foster care systems each month. She said U.S. judges, social workers, attorneys, and child advocacy groups have recognized that the foster care system is failing to respond to the needs of many abused and neglected children and their families. Crowded court calendars and understaffed child welfare agencies are contributing to the increase in the number of children in the system and their length of time spent in substitute care. REP. TOOHEY said that among solutions proposed by child advocacy organizations were the implementation of permanency planning case work and foster care placement monitoring through regular case reviews. To help monitor the situation, citizen volunteers were selected to sit on review panels in 24 states, including Alaska. She indicated that the Department of Administration (DOA) implemented a model project in Anchorage that began reviews in December of 1993. REP. TOOHEY stated that as the result of an audit the Division of Legislative Audit recommended to extend the sunset date to 1997 to allow the Anchorage project sufficient time to gather data that will determine the panels' effectiveness. The length of time children remain in foster care and the savings associated with children no longer being part of the foster care system are factors that determine the panels' effectiveness. REP. TOOHEY maintained that HB 468 has the support of the Alaska Chapter of the National Association of Social Workers, the Alaska Foster Parent Association, and the National Association of Foster Care Reviewers. She then indicated that Roberly Waldron from DOA and Randy Welker form Legislative Audit were present to answer questions. Number 237 REP. B. DAVIS asked if there was someone from DOA to testify. CHAIR BUNDE said yes. REP. B. DAVIS said she was interested in the zero fiscal note. REP. TOOHEY asked if Rep. B. Davis would like her to address the fiscal note. CHAIR BUNDE suggested that the committee hear from Roberly Waldron. Number 240 ROBERLY WALDRON, Deputy Commissioner, Services to the Public, Department of Administration, testified in support of HB 468. She stated that in regards to the zero fiscal note that it does not cost the DOA anything to sunset or not sunset. Although, she said, there is a cost to implement the program, but that would be addressed through another avenue, not through the proposed legislation. Number 278 REP. B. DAVIS asked what other avenue would address the implementation. She said it was her understanding that the appropriation would have to come from the legislature unless it is already in the department's budget. She felt that nothing would be accomplished if the sunset date were to be moved when there would be no funds to implement the program. MS. WALDRON explained that currently there is $125,000 in the budget for fiscal year 1995. She said if the bill does not pass and there is no phase-out year, the $125,000 and the phase-out year would still be in effect. REP. B. DAVIS asked if the $125,000 would carry through 1995. MS. WALDRON said yes. Number 308 MS. WALDRON stated that it took quite some time to get the panels appointed through the governor's office, but the reviews began in December 1993. She said the system is working very well and all of the panelists are extremely dedicated to their cause. She also indicated that foster parents have responded positively to being part of the review panels. She said the model project will answer the questions of whether the panels will work and if children will be placed in permanent situations faster. She further stated that there will be seven months of documentation to determine the panels' effectiveness. Number 369 REP. TOOHEY explained that in other states the system has proven it saves money. She said there is a considerable cost difference between paying foster care for placement of children and home care. CHAIR BUNDE asked how much the program costs per year. MS. WALDRON explained that $125,000 pays for three workers and pays for rent and supplies, but not for the full year. She said in the next fiscal year they would have to stop when the funds are completely depleted, but there would be sufficient data at that time to determine the effectiveness of the program. Number 401 CHAIR BUNDE clarified his question and said for the program to continue another $125,000 would be needed to carry the program through fiscal year 1995. MS. WALDRON explained that the amount is what is in the budget for a continuation level, and it is not an additional $125,000. CHAIR BUNDE said he understood that, but asked if that amount would take the program through to the end of fiscal year 1994. MS. WALDRON explained that in the current fiscal year the program has $125,000. There is $125,000 in budget request for FY 1995. CHAIR BUNDE asked for testimony from Sherrie Goll. Number 423 SHERRIE GOLL, Lobbyist, Alaska Women's Lobby and KIDPAC, testified in support of HB 468. She stated that the present law had unanimous support in both legislative bodies and it was decided that the program would have a positive impact on children. She said foster care "drift", children who are improperly tracked and spend much unnecessary time in the system, is a very significant problem. She indicated that in the Executive Summary of the Annual Report, seventeen cases were addressed in the month of December and pointed out that one child was adopted. She said the panelists, who were appointed by Governor Hickel, are not paid. She said the social workers that are involved are pleased with the process and the additional input. MS. GOLL asserted that the intent of the bill is to have panelists be composed of local citizens from all over the state as opposed to the model program in Anchorage. She stressed how important the program is to children in the foster care system. She then indicated that the money is in the budget, but it is not enough money to expand the program. She said even if the Finance Committee cut the money from the budget, it would be a shame to have the law "go off the books," which is why the termination date should be extended. Number 525 CHAIR BUNDE asked for further testimony. There being none, he closed public testimony and asked for further discussion from the committee. REP. OLBERG asked how much it costs to keep a child in a foster home for one night. REP. TOOHEY explained that costs vary by the child's age and geographical location. She said zero to 30 months equals $19.33 per day or $579 per month, or $7055 per year. A child that is 31 months to 11 years costs $17.80 per day and 12 years to 19 years is $20.40 per day. She said the average is $18.97 per day or $6828 per year. Rep. Toohey anticipated the next question to be how many children are in foster care in Alaska and deferred to Ms. Waldron. Number 567 MS. WALDRON answered between 1100 and 1600 children per month are in foster care. REP. TOOHEY said there is not much fluctuation. CHAIR BUNDE asked for further discussion. He then asked the pleasure of the committee. REP. B. DAVIS made a motion to pass HB 468 out of committee with individual recommendations and accompanying fiscal note. CHAIR BUNDE asked if there were any objections. REP. OLBERG objected. Number 602 CHAIR BUNDE called for the vote. Reps. Bunde, G. Davis, B. Davis, Nicholia, and Toohey voted Yea and Reps. Olberg and Vezey voted Nay. Chair Bunde declared that HB 468 was so moved. He then handed the gavel over to Rep. Toohey who presided over portions of the remainder of the meeting. Number 628 CHAIR TOOHEY brought HB 414 to the table. HB 414 - COMPREHENSIVE HEALTH INSURANCE ACT CHAIR TOOHEY stated that the committee would meet Saturday, March 13, 1994. The committee took a brief technical at- ease to discuss a common meeting time and decided to meet from 1:00 p.m. until 3:00 p.m. and that the meeting would be teleconferenced. Chair Toohey then indicated that there were several amendments to address and asked Commissioner Usera to testify. Number 635 NANCY USERA, Commissioner, Department of Administration (DOA), testified on HB 414 and offered several amendments. She stated that the DOA had five amendments in draft form to address and asked for guidance from the Chair on how to proceed. CHAIR TOOHEY asked Commissioner Usera to present the amendments on Saturday and asked that she stay to answer questions. She then said that there were four additional amendments. REP. OLBERG asked if that meant there is a total of nine amendments. CHAIR TOOHEY said yes and it's only the beginning. COMMISSIONER USERA said that some of the department's amendments have similar intent to the other four amendments. Number 735 CHAIR TOOHEY asked Commissioner Usera to indicate where the similarities are as the discussions progress. REP. BRICE asked for copies of the department's amendments. COMMISSIONER USERA asked for copies to be made. Number 760 CHAIR TOOHEY made a motion to move her Amendment 1. REP. BRICE objected for purposes of discussion. CHAIR TOOHEY asked for discussion. She indicated that page 1, line 8, addresses public health, and said she felt it would be better to include public health within HB 414. She said, after the word health care on page 1, line 8, delete the phrase "is a vital public interest" and insert the phrase "the maintenance of the public's health is vital to the public interest." CHAIR TOOHEY further indicated that on page 1, line 11, after the word "insurance" the word "and" should be deleted; and on page 1, line 12, after the word "malpractice" the phrase "the lack of population based public health services" should be inserted. COMMISSIONER USERA interjected and asked in regard to the amendment, "Are we saying that in fact there aren't enough services or that the services that we have are poorly coordinated?" She asked if the word "coordination" might be used instead of the word "services." She felt the definition would be clearer. CHAIR TOOHEY read the suggested phrase, "...the lack of population based public health services coordination." She asked for discussion. Number 869 REP. G. DAVIS noted that all three sets of amendments that were submitted were similar and suggested that any changes that needed to be made in any of the amendments be done on Saturday. He felt the Saturday meeting would address the details of all submitted amendments. REP. OLBERG asked if there were three people submitting very similar amendments. He suggested looking at all three versions at the same time. CHAIR TOOHEY concurred. REP. OLBERG noted that Commissioner Usera's Amendment 1 and Chair Toohey's Amendment 1 were remarkably similar. REP. G. DAVIS interjected, "...as does Rep. Brice's number 2." REP. OLBERG suggested that perhaps the three sets of amendments could be sent to a bill drafter and returned to the committee as one amendment. Number 906 COMMISSIONER USERA said there is a lot of similarity between two of the amendments and there is a tremendous difference in the third amendment, although they address the same subject. REP. BRICE asked what the difference is and suggested that his amendment is more in depth. COMMISSIONER USERA said, "This is very similar to the public health bill, commission bill, that was put in. What this does is drop those provisions in under this commission, which philosophically... certainly we're O.K. about... but my recollection is that that bill had a fairly hefty fiscal note on it." REP. BRICE said, "Where's your fiscal note on this?" CHAIR TOOHEY said it is $800,000. REP. BRICE asked what the fiscal note is for Amendment 1 from the DOA. Number 930 CHAIR TOOHEY said Rep. Sitton's bill has a $3 million fiscal note. REP. BRICE said the amendment is similar but would provide a lot more structure and focus on the direction of the commission. He said, "I think that the major questions of the fiscal note would probably be coming about due to the fact of the meeting of the commission, the establishment of the commission, the staff of the commission... that type of stuff. My understanding is quite possibly that as an advisory committee, this would be a subset of the commission established by (HB) 414 with probably other members pulled in. And, I'm sure we can minimalize the fiscal note." CHAIR TOOHEY said there is a great difference in the amount of people that Rep. Brice's amendment calls for than that of HB 414. REP. BRICE said the differences needed to be discussed regarding how the public health commission should work. Number 963 CHAIR TOOHEY asked the committee how they wanted to address the numerous amendments. REP. BRICE stated that he would be out of town for the Saturday meeting and requested that the public health issue be addressed when he returns the following Wednesday. REP. VEZEY said, "If you snooze you lose, and we should move ahead." REP. G. DAVIS agreed with Rep. Olberg in that the committee can address the public health issue now. REP. BRICE asked Commissioner Usera where she saw the fiscal impact in his amendment. Number 990 (Rep. Bunde resumed as Chairman for the remainder of the meeting.) CHAIR BUNDE recognized Commissioner Usera. COMMISSIONER USERA said, "In the way that the amendment that Rep. Toohey... which is similar to the one we have drafted... does have some fiscal impact." She said there will be meeting costs and travel costs associated with the concept. She reiterated that what the DOA is trying to do is find a cost effective way to address the issue, and no one will be happy with the limitations put on the commission by fiscal constraints. She asserted that when a bill becomes very specific, it must also be priced out specifically. The more provisions that are mandated, the more costly the legislation becomes. Number 031 REP. BRICE disagreed and said the commission needs to have direction and greater focus. He felt there should be some type of analysis and that there would be no significant fiscal impact. He suggested that travel and per diem could be priced down. He felt as a policy matter that the legislature should establish clear guidelines for the function of the commission. COMMISSIONER USERA suggested that if the word "must" under subsection B, page 2, is changed to "may," it would avoid leaving the state open to law suit. She said that she has seen more suits in the last two years than she wants to see for the rest of her lifetime because of mandates that use words like "shall" and "must." She said if the word "may" is used, it would satisfy Rep. Brice's concerns that there be guidance for the commission, but would not lock the state into a mandate situation that could be exposed to possible litigation. TAPE 94-41, SIDE B Number 000 REP. OLBERG asked if there were two sets or three sets of amendments. REP. BRICE said he personally had three amendments. CHAIR BUNDE indicated that he had one set that was numbered 1-4. He then asked Rep. Brice which amendment he was speaking to. REP. BRICE said he was speaking to his own amendment. REP. TOOHEY said she would withdraw her Amendment 1 to simplify matters. CHAIR BUNDE stated that Rep. Toohey withdrew her Amendment 1. He then stated that matters would be further simplified if Rep. Brice were to present a fiscal note on his amendment. Number 052 REP. B. DAVIS asked if both Rep. Brice's amendment and the department's amendment were being discussed. CHAIR BUNDE indicated that no amendment had been moved and said all were up for discussion. REP. OLBERG said, "I believe that there is only one amendment that makes any changes to page 1." CHAIR BUNDE said, "That being Amendment 2, by Rep. Brice." REP. OLBERG said, "No, that being Amendment 1, by Commissioner Usera." Number 077 CHAIR BUNDE indicated for clarity that Commissioner Usera's amendment would be called Administration Amendment 1. REP. OLBERG said, "...this amendment does not appear to conflict with any other amendment, and if we dealt with it individually, then we could cast it aside and clarify things even more." CHAIR BUNDE thanked Rep. Olberg for his astute observation and asked him to continue. REP. OLBERG made a motion to adopt Administration Amendment 1. REP. BRICE objected for discussion purposes. CHAIR BUNDE asked if all members were fixed on the correct amendment and said that it is the second page of the Administration hand-out, now labeled Administration Amendment 1 (Amendment A.1) Number 120 REP. BRICE said the amendments do not conflict conceptually except that his amendment is more in depth than the Administration Amendment 1. He urged that the commission be established with a purpose and cited the many different aspects of public health; i.e., clean water and sewer, public health nurses, and maternal and child health care. He said he had no problem with Administration Amendment 1, but it should give focus and direction to the commission. REP. G. DAVIS agreed and said it would be beneficial to give as much direction as possible to the commission. He said he would have faith in the commission that they would carry out all the provisions within Rep. Brice's amendment. REP. OLBERG suggested adopting Administration Amendment 1 in its entirety because it only conflicts in one area with Rep. Brice's Amendment 2. He said then it could be set aside and they go on to Administration Amendment 2 and compare it to the adopted amendment. CHAIR BUNDE, for clarity, reiterated Rep. Olberg's suggestion. The committee agreed to proceed accordingly. REP. NICHOLIA concurred and said that Rep. Toohey's and Commissioner Usera's amendments were basically the same. CHAIR BUNDE asked for further discussion. He said the motion to adopt Administration Amendment 1 was before the committee. He asked for any objections. REP. BRICE objected. Number 268 CHAIR BUNDE called for the vote. Reps. G. Davis, Vezey, Olberg, B. Davis, Nicholia, Toohey, and Bunde voted Yea, and Rep. Brice voted Nay. Chair Bunde declared that Administration Amendment 1 was so moved. He then brought Administration Amendment 2 to the table. REP. OLBERG said, "I'd like to get on the record, Mr. Chairman, the fact that that could have been the pinnacle of my legislative career right there." REP. B. DAVIS said, "We better discuss this, so that we have the intent fully on the record." Number 312 COMMISSIONER USERA stated that there is concern that HB 414 does not specify a single payer system. She said many of the amendments address issues that are implicit in the bill and that the amendments would drive the costs up by being so specific. She explained that Administration Amendment 2 specifies that one of the comprehensive reform proposals to be analyzed by the commission would be a single payer system. CHAIR BUNDE asked for discussion. He asked for someone to move the amendment. REP. TOOHEY said it was so moved. REP. OLBERG suggested to number all of the Administration amendments at one time. He then specified Administration Amendments 3-5 (or A.3 through A.5) CHAIR BUNDE said Amendment A.2 was before the committee and asked for further discussion. Number 369 REP. G. DAVIS said it was his understanding that one of the key health care reform proposals is a single payer system and asked Commissioner Usera to address the issue. COMMISSIONER USERA stated that she thought that option would be implied in the process. She said, "If I may be frank; this is politics. This is... Gee, it doesn't specify that the current single payer system proposal would be one that would be there... The outline in the governor's bill is that the plans be evaluated with either those requested by the governor or by a majority vote of the commission, who are appointed by the governor, and that there might be some political brinkmanship going on which would eliminate the current single payer system as one of those being evaluated. Certainly we didn't anticipate that kind of pettiness when we did this, but if it makes people feel better, more comfortable, that would be a serious consideration for this commission. We felt it was worth putting in the bill." Number 400 CHAIR BUNDE said, "New to the legislative process, are you?" COMMISSIONER USERA said, "No, Sir. I love it." REP. TOOHEY said the idea is fair because there are people in the state that would like to see the single payer system and others who would not. REP. G. DAVIS asked how employer-based and HMO would be protected without specifying their inclusion. COMMISSIONER USERA replied that the DOA could try to identify the key proposals, but it is difficult to anticipate the end result of the various proposed plans, and pointed out how dramatically the Clinton plan has changed in the period of a month. She asserted that at least one proposal based on a single payer strategy and at least one based on a managed care approach would be reviewed by the commission. CHAIR BUNDE said, "I would just observe for the record that this amendment does not indicate the single payer as the program that would have the priority." COMMISSIONER USERA said that is correct. REP. B. DAVIS made a motion to adopt Amendment A.2. CHAIR BUNDE, hearing no objections, said the amendment was so moved. He indicated that there were witnesses on teleconference that wanted to testify on the legislation in general. He further indicated that there was a person on teleconference from Seattle, Washington. Number 430 STEVE LEBRAUN, Account Manager, Aetna Health Plan, testified via offnet in support of HB 414. He stated that Aetna carries the largest share of health insurance in Alaska concentrated in benefits for larger employers in the public and private sector. He said Aetna supports the general direction of HB 414 because it provides for immediate and achievable steps towards health care reform along with more thorough analysis of structure, costs, and alternatives of universal care. He stated that the alternative legislation dismantles and throws out much of the current system and leaves tremendous power to an appointed commission. He said the federal health care plan is likely to pass congress and many of the provisions would be mandatory in all states. Individual employers should have the opportunity to review and evaluate the most important details of health care reform, costs, benefit level, impact on quality, and impact on choice before having to decide whether to afford major changes in the Alaska delivery system. He maintained that many details of the proposals, both federal and state, are not available and said there is no consensus on the best way to change the current system to allow for universal and more affordable health care. MR. LEBRAUN further stated that he supported the requirement for a single payer form and the creation of voluntary purchasing pools for small employers and individuals. He said the use of purchasing pools would address the portability problems under the current system. He also recommended purchasing pools be used for people in between employment. He further recommended the use of electronic filing systems and electronic medical records and billing systems to reduce the "hassle factor" for consumers and to improve data collection capabilities. MR. LEBRAUN stated that the disclosure of provider rates would better inform the consumer and would facilitate better coordination of public health programs with emphasis on preventive care. He indicated that the long term objective for the commission would be to provide the simplest and most cost effective means of providing universal care by directing alternate benefit plans, ranging from catastrophic care to comprehensive. The commission should estimate the cost of each alternative and suggest the most appropriate way to administer the plans. Mr. Lebraun suggested that if federal health care acts pass this year, the commission could also determine whether Alaska should take action. He indicated that there are provisions within HB 414 regarding the proposed form of rate regulation and the arbitration section and Aetna was concerned about those issues. He said that further commentary would be sent in writing upon request to the committee regarding those issues. Number 587 CHAIR BUNDE asked for the written commentary. He then asked for teleconference testimony from BONNIE NELSON. There was no response from teleconference. He then said that Administration Amendment 3 (A.3) was before the committee. REP. OLBERG made a motion to adopt Administration Amendment 3 and also pointed out that there are three proposed amendments regarding page 5, line 6, and they are conflicting. He indicated that he had carefully reviewed the page and line references of all the amendments and sorted out any conflicts. CHAIR BUNDE asked Commissioner Usera to clarify a technical amendment to her amendment. COMMISSIONER USERA said the amendment is a list of what the commission shall do and would add a new Section 7 after the adoption of the first amendment and would be renumbered accordingly. Number 643 REP. BRICE said he did not see where his amendment and Commissioner Usera's amendment were conflicting. REP. OLBERG said that Administration Amendment 1 establishes a public health advisory committee and Rep. Brice's amendment establishes a public health improvement plan advisory committee. He asked if the two were synonymous. Number 657 REP. BRICE suggested that may be the same. CHAIR BUNDE asked the members to address Amendment A.3. REP. OLBERG stated that Amendment A.3 adds Section 7 to page 5 after line 6; but Amendment A.1 and Rep. Brice's amendment conflict because they both establish a public health improvement plan advisory committee. COMMISSIONER USERA said Rep. Brice's amendment is not on the table for discussion. CHAIR BUNDE indicated that Amendment A.1 has been adopted and asked for Rep. Brice to address his amendment. REP. BRICE asserted that if his amendment was adopted it would be Section 8. REP. OLBERG maintained that all Amendment A.3 does is add Section 7 to page 5, line 6. COMMISSIONER USERA indicated that it is the DOA's intention for the commission to collect information in aggregate from providers who would by regulation be required to provide the information in that form. She also said that the state would need federal waivers because of some of the confidentiality provisions in federal programs needed to collect necessary information. She indicated that a fiscal note of approximately $100,000 is associated with the amendment, because to travel to Washington, D.C., costs time, money and lawyers. She said the estimate came from the Division of Insurance as what they felt it would cost to obtain federal waivers. Number 712 CHAIR BUNDE said, "We're looking at a program now that costs... let's just round that off to $1 million." REP. G. DAVIS asked Commission Usera if there is anything in the federal health care proposals that might reduce or eliminate the waivers. COMMISSIONER USERA said she would defer to Deputy Commission Jay Livey on that question. Number 720 JAY LIVEY, Deputy Commissioner, Department of Health and Social Services, testified on HB 414. He stated that the federal waivers are ERISA (Employee Retirement Security Act) waivers that state that states do not have the authority to regulate people who self-insure. The amendment would allow the state to obtain waivers so the proper information could be obtained for those who are self-insuring. He was not sure if this was relative to all the bills that address comprehensive health care. Number 740 REP. G. DAVIS said that federal legislation would amend ERISA. COMMISSIONER LIVEY agreed. CHAIR BUNDE asked for further testimony or discussion on Amendment A.3. REP. B. DAVIS made a motion to adopt Amendment A.3. CHAIR BUNDE, hearing no objections, said Amendment A.3 was so moved. He then brought Administration Amendment 4 to the table. REP. OLBERG made a motion to adopt Amendment A.4 and explained that it would add verbiage to four different pages. Number 764 COMMISSIONER USERA stated that pooling to provide insurance coverage for children needed to be addressed and the amendment addresses that concern. CHAIR BUNDE asked for questions or objections. Hearing none, Chair Bunde stated that Amendment A.4 had been accepted. He then brought Administration Amendment 5 to the table. REP. OLBERG made a motion to adopt Amendment A.5. Number 794 COMMISSIONER USERA addressed the amendment. She said there is a need to ensure greater consumer participation in the health care process and the intent of the amendment would require providers to have a rate sheet for standard procedures. Additionally, it requires, upon request of the consumer, that a specific estimate be provided for the costs based on an evaluation of the consumer's physical condition. She said if the provider fails to comply and a complaint is filed, an annual penalty of $500 would be charged to the provider. She then said that once a penalty had been enforced in a calendar year, the provider would not be assessed any additional penalties. She maintained that currently most providers have rate sheets, and only penalizing one time for a considerable dollar amount would help curtail providers from engaging in the appeal process. TAPE 94-42, SIDE A Number 000 CHAIR BUNDE asked if it would be the provider's responsibility to inform the consumer that there is a rate sheet. COMMISSIONER USERA explained that there is a provision within HB 414 that requires the provider to disclose to the consumer that they are entitled to the rate sheet and estimate information. It must either be posted or it must be contained in some type of a disclosure form. CHAIR BUNDE said it was his hope that people could look after themselves. COMMISSIONER USERA indicated that the amendment would read, "A provider shall place the following statement either on a form to be signed by the patient or in a conspicuous location on an easily readable sign: You are entitled to a charge estimate for a medical procedure before the procedure is performed by your health provider." Number 057 REP. TOOHEY said she would prefer to see a sign displayed at the front reception area of a doctor's office. She said there should also be a list of charges posted to make the consumers aware of their choices. REP. BRICE suggested that perhaps provider's rates could be included in their advertising as well. REP. OLBERG indicated that there are four references to page 7, line 22, interspersed among the submitted amendments. He said two of the amendments are similar and two are not. He suggested that if Amendment A.5 were adopted, then it could be fine tuned with Rep. Toohey's Amendment 3, then Rep. Brice's and Toohey's Amendment 4 could be included as friendly amendments. CHAIR BUNDE thanked Rep. Olberg for his guidance. REP. B. DAVIS proposed an amendment to the amendment and indicated that the language specifies up to $500, not a flat $500 penalty. She said she would like the penalty to be up to $1000. COMMISSIONER USERA said she would consider it a friendly amendment. CHAIR BUNDE asked Rep. B. Davis to move the amendment. REP. B. DAVIS made a motion to amend Amendment A.5 to change the penalty to "up to $1000." She then specified the line change in the amendment. CHAIR BUNDE asked for questions, discussion, or objections. Hearing none, Chair Bunde stated that the amendment to Amendment A.5 was so moved. He then asked Rep. Toohey if she would like to propose an amendment. REP. TOOHEY stated that she would like to amend Amendment A.5 to include a provision that would require the mandatory posting of rates and estimates in the providers front reception area. COMMISSIONER USERA indicated that the change would go under subsection A of the adopted Amendment A.5. She then indicated that some practitioners would have to supply "a blue book" of the costs, citing that they offer so many different procedures. She said that the list could be limited to the top 20 procedures or grouped by diagnosis related categories. She then asked Rep. Toohey if it would be practical. Number 283 REP. TOOHEY agreed that it may not be practical, but there should be a notice that indicates that prices are available upon request. COMMISSIONER USERA said that Rep. Toohey's proposed amendment could be added to subsection C of Amendment A.5. She said the phrase for a list of standard charges could be added at the end of the subsection. CHAIR BUNDE asserted that the language is redundant because the consumer would be entitled to a charge estimate and would also be entitled to a list of procedures. He asked how many procedures would a consumer inquire about in one day. Number 330 REP. BRICE asked what the cost would be to have a data base established where a consumer could call a state number, use a touch-tone phone on a menu system to obtain information on providers in specific areas, and then be transferred to a voice mail box of a chosen provider who would then have a menu system to provide procedural costs. COMMISSIONER USERA stated that there is a provision in an alternative bill that requires the rates to be reported to the commission. She said her amendment would not require that and the fiscal note associated with it would be astronomical. REP. BRICE said he knows that the system is being used in other states and that some one in the private sector is profiting from it. CHAIR BUNDE suggested that the list of rates for common procedures be provided. REP. TOOHEY said she withdrew her amendment. Number 406 CHAIR BUNDE stated that Amendment A.5 was before the committee and asked for a motion. REP. B. DAVIS made a motion to adopt Amendment A.5. CHAIR BUNDE, hearing no objections, announced that Amendment A.5 was so moved. REP. B. DAVIS asked if Rep. Brice's amendments were going to be addressed. REP. BRICE made a motion to adopt his amendment. Number 421 CHAIR BUNDE asked Rep. Brice to speak to his amendment. He then indicated that due to technical difficulties earlier, teleconference testimony from Anchorage had been postponed and proceeded to ask for teleconference testimony from BONNIE NELSON. Number 425 BONNIE NELSON, Representative, Alaska Public Interest Research Group (AKPIRG), testified via teleconference on HB 414. She stated that AKPIRG supports a single payer system and urged the committee to include the plan. She also said that she would like to see the elimination of the restrictions on preexisting conditions. She said she also would like to see that type of discrimination eliminated from private insurance companies. She indicated that the Americans with Disabilities Act requires employers to hire handicapped persons, but if the person is medically expensive, their claim affects the businesses' premium rates and she felt that it was unfair for both large and small businesses. MS. NELSON further stated that AKPIRG also recommends that the commission be comprised of a broad range of consumers. She said the Clinton proposal indicates that a commission member may not have any official relations to companies or providers that pose a conflict of interest, i.e. health care providers and insurance companies. She continued to read from the provisions in the Clinton proposal that specified the varying types of conflicts of interest. Number 604 CHAIR BUNDE stated that the committee had the information that Ms. Nelson was reading from and thanked her for her testimony. REP. TOOHEY asked if Ms. Nelson was recommending that commission members not be members of the medical community. MS. NELSON said she was not recommending that they not be from the medical community and suggested that a retired doctor could participate as a member. She said there should be no monetary conflict of interest. She felt there should be persons with expertise, but conflicts of interests should be avoided. Number 635 REP. BRICE said, "...possibly on page 2, section B, to alleviate the concerns of the department maybe we can... on that line... state... the plan developed by the committee under A of this section should recognize the need... to probably take it down a step with a little bit... take it down a step from shall and to make sure that there's a lot of concern here to address these questions." COMMISSIONER USERA offered language that she felt would address the concern. She indicated that Amendment A.1, subsection A, would be referenced to page 1, section A of Rep. Brice's amendment. She said the sentence, "The commission shall consider public and private health care professionals, labor organizations, businesses, the educational system, the Alaska Public Health Association, the Alaska Mental Health Board, and the Alaska Native Health Board to serve on the public health advisory committee as well as recognizing the need for geographic, ethnic, and cultural diversity..." would be inserted at the end of the subsection. REP. BRICE said the language was acceptable to him. Number 699 CHAIR BUNDE asked if the change was too much to be a technical amendment or is it an amendment to the amendment? REP. BRICE suggested that it would be an amendment to the amendment. CHAIR BUNDE asked if Rep. Brice would propose that Amendment A.1 be amended with the aforementioned language. REP. BRICE said, "So moved." CHAIR BUNDE asked Commissioner Usera to repeat the language. COMMISSIONER USERA said in Amendment A.1, Section 6, subsection A, line 3, after the period following the word commission, the following sentence would be inserted: "The commission shall consider public and private health care professionals... and the Alaska Native Health Board to serve on the Public Health Advisory Committee as well as recognize the need for geographic, ethnic, and cultural diversity." CHAIR BUNDE stated that the motion was before committee. He asked for discussion or objections. Hearing none, Chair Bunde indicated that the amendment to Amendment A.1 had been adopted. Number 732 COMMISSIONER USERA suggested an amendment that would add subsection C to Amendment A.1. She said, "...establish a public health advisory committee which... there would be a subsection C... may develop a public health implementation improvement plan... which (1) recognizes the need for... goes down as is included in Rep. Brice's amendment. And, (2) may include... and the rest of that section remains the same." REP. BRICE made a motion to adopt the proposed amendment to Amendment A.1. CHAIR BUNDE, hearing no objections, stated that the amendment was so moved. He then said he hoped to see the revised workdraft before the next meeting and suggested that the committee would further discuss the bill before passing it out of committee. COMMISSIONER USERA indicated that the department would update fiscal notes accordingly to accompany the new committee substitute (CS). REP. TOOHEY reminded all those present that there would be a meeting on Saturday, March 12, 1994 to further discuss and work on HB 414. Seeing no further business before the committee, CHAIR BUNDE ADJOURNED meeting at 4:43 p.m.