ALASKA STATE LEGISLATURE  HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE  February 2, 2023 3:03 p.m. MEMBERS PRESENT Representative Mike Prax, Chair Representative CJ McCormick Representative Justin Ruffridge Representative Dan Saddler Representative Jesse Sumner Representative Zack Fields Representative Genevieve Mina MEMBERS ABSENT  All members present COMMITTEE CALENDAR  PRESENTATION(S): DEPARTMENT OF HEALTH - HEARD PREVIOUS COMMITTEE ACTION  No previous action to record WITNESS REGISTER HEIDI HEDBERG, Commissioner Designee Department of Health Anchorage, Alaska POSITION STATEMENT: Co-offered a PowerPoint presentation on the Department of Health. ANNE ZINK, MD, Chief Medical Officer Division of Public Health Department of Health Anchorage, Alaska POSITION STATEMENT: Co-offered a PowerPoint presentation on the Department of Health. EMILY RICCI, Deputy Commissioner Department of Health Juneau, Alaska POSITION STATEMENT: Co-offered a PowerPoint presentation on the Department of Health. JOSEPHINE "JOSIE" STERN, Assistant Commissioner Finance Management Services Department of Health Juneau, Alaska POSITION STATEMENT: Co-offered a PowerPoint presentation on the Department of Health. ACTION NARRATIVE 3:03:52 PM CHAIR MIKE PRAX called the House Health and Social Services Standing Committee meeting to order at 3:03 p.m. Representatives Fields, Sumner, Saddler, McCormick, Ruffridge, Mina, and Prax were present at the call to order. ^PRESENTATION(s): DEPARTMENT OF HEALTH PRESENTATION(s): DEPARTMENT OF HEALTH    3:05:03 PM CHAIR PRAX announced that the only order of business would be a presentation on the Department of Health. 3:06:02 PM HEIDI HEDBERG, Commissioner Designee, Department of Health, stated that the presentation would serve to provide information regarding the Department of Health, with some focus on the backlog of the Division of Public Assistance. She introduced herself and fellow presenters and relayed her experience working for the Division of Public Health (DPH) for 13 years, the last four years as the director of the division. She invited Dr. Anne Zink to begin the PowerPoint. 3:07:52 PM ANNE ZINK, MD, Chief Medical Officer, Division of Public Health, Department of Health, offered a brief overview of her work history and how her work as a medical professional led to focus on policy, then began the PowerPoint presentation [hard copy included in the committee packet], addressing slides 2-4, "State of Health." She spoke about the puzzle pieces necessary for good health and well-being [shown on slide 2]: neighborhood and environment; education; long-term service & supports; access to health care; economic stability; and physical health; transportation and housing; adverse childhood experiences; cost of care; and social connectedness. She stated that healthy people make healthy economies; 80 percent of what makes people healthy lies outside of the healthcare system. She noted that there are varied lenses when considering healthcare. DR. ZINK spoke about the leading causes of death, comparing Alaska with the U.S. as a whole, and life expectancy at birth versus health care expenditures per capita [slide 3]. Alaska has more deaths per capita compared to the rest of the country in accidents, suicide, and liver disease. She noted one way to consider how the state is doing is by considering the cost of healthcare. Alaska is ranked twenty-ninth in the country in terms of life expectancy but ranks the second highest in cost of healthcare per capita. 3:12:57 PM DR. ZINK discussed Alaska's health improvement plan [slide 4], which read as follows: Healthy Weight and Nutrition Environmental Health Healthcare Access Alcohol, Tobacco, and Substance Misuse Mental Health & Suicide Injury and Violence Infectious Disease Cancer & Chronic Disease Social and Protective Factors checkbld Thirty health objectives with specific targets to reach by 2030 provide a common framework with strategies and actions to achieve each target checkbld Partnering with Alaska Native Tribal Health Consortium (ANTHC) checkbld Serves as roadmap for stakeholders to work together on upstream health improvements checkbld Annual progress report on each target DR. ZINK talked about report cards showing data from 2010 and 2020, as well as annual interim report cards. She turned the presentation back over to Commissioner Designee Hedberg. 3:14:32 PM COMMISSIONER DESIGNEE HEDBERG directed attention to slide 5, "Healthy Families Initiative," which read as follows: Strong families are the foundation of a healthy society and a vibrant economy. • 4-year statewide investments in the health and wellbeing of Alaskan families • Governor Dunleavy proposed $9.9M (UGF) in his FY2024 operating budget for Healthy Families activities within DOH: checkbld Postpartum Medicaid extension checkbld Office of Health Savings checkbld TB and congenital syphilis mitigation checkbld Fresh Start Campaign COMMISSIONER DESIGNEE HEDBERG noted the three color-coded topics on slide 5: Healthy Beginnings [yellow], including prioritization of child and maternal health, emphasis on prevention measures, and improvement of child care and after school programs; Health Care Access [red], including mental and physical health care, working with partners to create a robust healthcare workforce, seeking better health outcomes, and "aging in place"; and Healthy Communities [blue], building on existing efforts to create healthful workplaces and affordable housing, and reducing the burden of infectious and chronic diseases through the "Fresh Start" campaign. She said this initiative is supported with federal funds. 3:16:40 PM DR. ZINK picked up the presentation on slide 6, "Office of Health Savings," which read as follows: • Reducing health care costs while improving the health of Alaskans • Positioned within DOH Commissioner's Office checkbld Initial savings focused on Medicaid program checkbld Innovative payment models checkbld Pharmacy costs and improved access to critical medications DR. ZINK pointed to a graph on the right of slide 6, which shows health care expenditures per capita in "Alaska vs. United States" from 1991 to 2020, and in about 2000 there was an increase in the amount Alaska spends. 3:18:47 PM COMMISSIONER DESIGNEE HEDBERG resumed on slide 7, which addresses the reorganization of the former Department of Health and Social Services (DHSS), [on July 1, 2022, via Executive Order 121], into two departments: the Department of Health (DOH) and the Department of Family and Community Services (DFCS), and which lists the offices within each department as follows: [DOH] checkbld Commissioner's Office checkbld Finance & Management Services checkbld Health Care Services checkbld Behavioral Health checkbld Senior & Disabilities Services checkbld Public Assistance checkbld Public Health [DFCS] checkbld Commissioner's Office checkbld Finance & Management Services checkbld Alaska Psychiatric Institute checkbld Juvenile Justice checkbld Alaska Pioneer Homes checkbld Office of Children's Services COMMISSIONER DESIGNEE HEDBERG offered an update on the department split, as shown on slide 8, which read: • Shared IT Resources Developing a roadmap to separating resources • Information Technology Debt Seeking contractors and modernizing systems to improve efficiency and quality of service • Improving the Continuum of Care Establishing a coordinated system across DOH and DFCS to ensure person-centered care • Complex Care Identifying solutions to address systemic gaps in access to care for patients with complex needs COMMISSIONER DESIGNEE HEDBERG discussed slide 9, "Finance and Management Services," which read: FMS provides financial, administrative, facilities, and technology services to the department • Budget • Revenue & Finance • Information Technology Services checkbld HIPAA Compliant • Human Resources • Grants and Contracts checkbld $173+ million distributed in grants checkbld 500+ operating grantees • Program Integrity • Medicaid, Allocations, and Audit Services COMMISSIONER DESIGNEE HEDBERG described Finance and Management Services as the "backbone" of DOH. She then introduced Emily Ricci to provide an overview of the Division of Senior and Disabilities Services, the Division of Behavioral Health, and the Division of Health Care Services. 3:23:03 PM EMILY RICCI, Deputy Commissioner, Department of Health, offered a brief work history. She then covered slide 10, "Division of Senior and Disabilities Services," which read as follows: SDS promotes health, well-being and safety for individuals with disabilities, seniors and vulnerable adults by facilitating access to quality services and supports that foster independence, personal choice and dignity. Programs checkbld Home and Community Based Services (HCBS) checkbld Adult Protective Services (APS) checkbld Infant Learning program checkbld General Relief program Highlights from FY22 checkbld 10% Medicaid rate increase for HCBS providers checkbld $8 million in American Rescue Plan Act funds for HCBS providers checkbld Full funding allocated to improvements to HCBS for seniors and people with disabilities checkbld Stakeholder engagement DEPUTY COMMISSIONER RICCI moved on to slide 11, "Division of Health Care Services." She called this division "the heartbeat of the Medicaid Program." She discussed the slide, which read as follows: HCS's mission is to provide to all eligible Alaskans access and oversight to the full range of appropriate Medicaid services. We also protect Alaska's most vulnerable populations through our certification and licensing sections. Programs checkbld Administering Medicaid services $45-50 million weekly check write checkbld Background Check Unit (BCU) checkbld Licensing (Residential & Facilities) checkbld Transportation checkbld Tribal reclaiming Highlights from FY22 checkbld Fiscal agent transition checkbld $155 million in claims recovery checkbld $45 million in pharmacy savings checkbld $74 million in tribal reclaiming checkbld 22K+ determinations issued on background check applications DEPUTY COMMISSIONER RICCI talked about staffing challenges and efforts to shorten "turnaround" time in relation to services. She highlighted fiscal agent services in relation to processing claims and a contract in the works. 3:29:37 PM DEPUTY COMMISSIONER RICCI discussed slide 12, "Division of Behavioral Health," which read: DBH has a commitment to improving the quality of life of Alaskans through the right service to the right person at the right time. Programs checkbld Behavioral health Medicaid Services (State Plan & 1115 Waiver) checkbld Tobacco enforcement checkbld Alcohol Safety Action Program checkbld Treatment and Recovery Team checkbld Suicide prevention Highlights from FY22 checkbld 988 Implementation and the Zero Suicide Initiative checkbld 180 grant awards checkbld Expanded services checkbld $190 Million claims paid through 1115 Waiver DEPUTY COMMISSIONER RICCI summarized the work being done in the division. 3:32:08 PM DR. ZINK took up slide 13, "Division of Public Health," which states that the division "is committed to protecting and promoting the health of Alaskans." She discussed the functions of the eight programs within the division, listed on the slide: Chronic Disease Prevention & Health Promotion; Epidemiology; Health Analytics and Vital Records; State Public Health laboratories; Public Health Nursing; Rural & Community Health Systems; State Medical Examiner's Office, and Women's, Children's & Family Health. The rest of slide 13 read as follows: Highlights checkbld Healthy Alaskans 2030 checkbld Eliminated age restrictions for services at Public Health Centers checkbld Expanded work on addressing the opioid epidemic including distribution of ~20K naloxone kits checkbld Fresh Start Campaign 3:38:13 PM COMMISSIONER DESIGNEE HEDBERG picked up the presentation at slide 14, "Division of Public Assistance," and discussed the issue of backlog. Slide 14 read as follows: DPA promotes self sufficiency and provides basic living expenses to Alaskans in need. Programs checkbld 18 Public Assistance programs checkbld Child Care Assistance & Licensing Highlights checkbld Provided public assistance to ~300K Alaskans per month checkbld $95.5 million in COVID-19 relief for childcare COMMISSIONER DESIGNEE HEDBERG listed the 18 programs. Within Food and Public Assistance are the following eight programs: the Supplemental Nutrition Assistance Program (SNAP); the Supplemental Nutrition Assistance Education Program (SNAP-ED); the Women, Infant and Children (WIC) Program; the Breastfeeding and Peer Counseling Program; the Commodities Supplemental Food Program; the WIC Farmer Market Nutrition Program; the Senior Farmer Market Nutrition Program; and the Pandemic Electronic Benefit Transfer (Pandemic EBT). Within Medical Assistance are the following programs: Medicaid, which resides within Healthcare Services; and Chronic and Acute Medical Assistance (CAMI). The next group is Assistance to Seniors and Disabilities, which contains the Adult Senior Assistance and Benefits Program. Then there is Heating and Water Assistance, under which are the following three programs: Heating Assistance; Water Assistance; and the Alaska Affordable Health Program. The next group is Assistance for Families with Dependent Children, including: the Alaska Temporary Assistance Program (ATAP); and the Childcare Assistance Program. Finally, there is the General Relief Assistance Program. 3:41:49 PM COMMISSIONER DESIGNEE HEDBERG addressed the issue of the backlog, which begins on slide 15, which read as follows: 1. IT systems 40-year legacy system checkbld Eligibility Information System (EIS) was never fully migrated to ARIES checkbld Fiscal crisis delayed efforts to modernize systems 2. Pandemic Manual Processing of benefits checkbld DPA was unable to automate the SNAP Emergency Allotments (EA), resulted in manually issued benefits processed by staff for over 2+ year checkbld The Pandemic Electronic Benefit Transfer (P-EBT) benefits issued by DPA on behalf DEED checkbld When the state public health emergency ended and Food and Nutrition Service (FNS) clarified policy, recertifications restarted for SNAP 3. Cyber Attack in May 2021 checkbld Pivoted existing IT staff to protection of personal health information, forensic analysis, and recovery efforts checkbld The majority of DPA systems were taken down requiring substantial manual processing checkbld Planned system changes that would have brought online forms and other improvements were further delayed COMMISSIONER DESIGNEE HEDBERG explained that the image on slide 16 is a COBOL stream showing what the eligibility information systems looks like. She then moved to slide 17, "Public Assistance Backlog: IT Systems," which read as follows: checkbld Most eligibility staff will need to access up to 9 systems: Eligibility Information System (EIS), Alaska's Resource for Integrated Eligibility Services (ARIES), Energy Community Online System (ECOS), ILINX Document Management System, current? Workload Management Tool, WinStar, SAM (DOL interface), Instant Eligibility Verification System (IEVS), Genesys Virtual Call Center checkbld The Department needs more programmers capable of coding in the Public Assistance mainframe which requires various outdated programing languages such as COBOL, Natural, and ADABAS. checkbld DOH has one IT programmer who can code in COBOL, one of the languages required to update EIS where SNAP applications are worked. 3:47:36 PM MS. RICCI presented slide 18, regarding SNAP and Medicaid backlog, which read as follows: checkbld Team focused on oldest SNAP recertifications and applications first . checkbld All September recertification benefits were issued for SNAP. checkbld Certain Medicaid applications and recertifications are impacted by the backlog. These include new applications submitted without a SNAP application and those stored in the legacy system. checkbld Open enrollment period for the Federally Facilitated Marketplace from October 2022 January 2023 also created a recent influx of applications. checkbld Estimate difficult to determine due to lack of definition in system. Duplicate applications or those transferred in error all appear as outstanding. 3:50:37 PM COMMISSIONER DESIGNEE HEDBERG picked back up on slides 19 and 20, regarding the backlog of the Virtual Call Center, and which read as follows: VCC went live April 2021 checkbld VCC allows DPA to serve the entire state equitably, including communities that do not have in-person lobbies available. checkbld VCC allows a client to wait anywhere to talk to an eligibility technician instead of only having the option to wait in person in a lobby and perhaps not be seen that day. checkbld Incoming phone calls are recorded, which allow for training and ability to review calls if calls come in from Governor's Constituent Relations or Legislative offices. checkbld Lobbies have historically been over crowed (sic) and at times hostile, creating difficult situations for vulnerable Alaskans and our DPA staff members. High call volume 1,000 to 1,500 calls a day. checkbld The VCC is temporarily dedicated to gathering information from each client. They are not processing applications in real time as of 10/25/2022. This allows more callers to talk to a live person each day. checkbld Each Wednesday, the division reassigns staff from the VCC to process applications. VCC is still available for emergency access on those days. checkbld The VCC automatic menu options vary depending on the amount of staff available to answer the phone, which can be frustrating to callers. checkbld We welcome input and suggestions on further improvements we can make. 3:59:26 PM COMMISSIONER DESIGNEE HEDBERG covered the key points of addressing the backlog, as shown on slide 19, which read as follows: checkbld Pursuing contractors to program EIS checkbld Pursuing contracting to support the VCC checkbld Crisis Communication checkbld Security evaluations and security guards for DPA lobbies checkbld Recruiting and onboarding both permanent eligibility technicians and long term non- permanent positions 4:00:46 PM COMMISSIONER DESIGNEE HEDBERG moved on to slide 22, "Suggestions from Partners," which read as follows: 1. Lengthen certification periods 2. Waive unnecessary interviews 3. Streamline the review of housing, utilities, and dependent care costs 4. Implement broad-based categorical eligibility 5. Extend one month of SNAP benefits for all who are delayed because of agency fault 6. Establish a cost effectiveness threshold and compromise overpayment claims 7. Recruit and train more fee agents 8. Improve website capacity. COMMISSIONER DESIGNEE HEDBERG noted the current certification period for SNAP is six months, and the plan is to extend that to 12 months. The department agrees with suggestions two and three, and will review suggestion four. Regarding suggestion five, she said the department does not have the mechanism to be able to add a month automatically. The department will review its options under the federal program rules in consideration of suggestion six. It agrees with suggestion seven but has some restrictions. Finally, the division has improved aspects of its website capacity, with security in mind. 4:05:55 PM MS. RICCI addressed slide 23, "Unwinding of Continuous Enrollment for Medicaid," which read as follows: checkbld Beginning March 2020, states were required to maintain eligibility status for Medicaid beneficiaries checkbld Starting April 1, Alaska will begin Medicaid eligibility redeterminations checkbld Alaska has 12 months to complete redeterminations for all active Medicaid cases checkbld Redetermination Plans are submitted to CMS by February 15th checkbld DOH will work with stakeholders to maximize public communication starting in February MS. RICCI said an omnibus bill passed Congress and clearly outlined a timeline for ending continuous enrollment for Medicaid, which is March 31. She spoke about having the systems in place to manage the redetermination effort. She mentioned two system names: Alaska's Resource for Integrated Eligibility Services (ARIES) and the Electronic Information System (EIS). The latter is problematic for the division currently. She noted, however, that the majority of Medicaid applications are stored in ARIES, which is newer and has support available. She talked about efforts to inform Alaskans as to what to expect and to ensure that people are covered. She pointed out that while the redeterminations will begin April 1, resulting disenrollment from the Medicaid program will begin to occur May 31 60 days later. 4:14:12 PM JOSEPHINE "JOSIE" STERN, Assistant Commissioner, Finance Management Services, Department of Health, offered a brief account of her work experience, then presented the "Operating Budget," shown on slide 24. She explained that the slide reflects a comparison of the FY 22 actuals to the FY 22 management plan, and the proposed FY 24 governor's budget that was released on 12/15/22. She said slide 24 does not include departmental support services, Human Services, Community Matching Grants, and Community Initiative Matching Grants, which are generally presented as a consolidated item, the reason being that the change associated with the bifurcation of the former two departments occurred in departmental support services; this item was pulled out of the slide because it did not provide "an accurate apples to apples comparison across fiscal years." She stated that with the inclusion of departmental support services, the total operating budget in "FY 2024 governor" is approximately $3.14 billion." She noted there are 1,453 full- time positions within DOH, and the majority of the FY 24 budget, "as well as the Department of Health," resides in Medicaid Services; the total funds in Medicaid Services is approximately $2.5 billion. COMMISSIONER DESIGNEE HEDBERG stated that that concluded the presentation. 4:16:29 PM CHAIR PRAX invited questions from the committee. 4:17:09 PM MS. RICCI, in response to a request for clarity regarding Medicaid enrollment and eligibility, emphasized that the goal is to avoid unintentionally disenrolling anyone from Medicaid. In response to a follow-up question, she said she thinks every state is attempting to do as many automatic renewals as possible. She then confirmed that the division is looking at whether it can use SNAP eligibility when considering Medicaid eligibility. 4:21:25 PM MS. RICCI, in response to a question from Representative Mina regarding resources available for enrollment following the predetermination process, said the department wants to leverage every opportunity, and she advised people to make sure their information is updated. She added that eligibility technicians would be available to assist. In response to a follow-up question, she said there is currently not a way in which to offer this to be done online. She said the division is establishing a web page regarding redetermination. 4:25:26 PM MS. RICCI, in response to Representative Ruffridge, said current discussion about a communication plan is considering what type of advertising can be done and what kind of support from stakeholders can be leveraged. She mentioned that CMS has provided a toolkit for states to use as needed. 4:28:39 PM DR. ZINK, in response to a question from Representative Sumner regarding rates of death [from slide 3], said DOH puts together an annual death report, which classifies different causes of death. She talked about the complexity of causes of death and explained that these reports list the primary cause of death. She offered to supply the committee with more information on this subject. 4:31:17 PM DR. ZINK, in response to Chair Prax, regarding life expectancy and healthcare costs, said back in about 2018, rural communities were driving the more expensive per capita costs of healthcare. She said there are a lot of ways that states pay for healthcare, and she indicated a trend in focusing more on prevention. That is particularly challenging in Alaska based on its size. She talked about working with tribal leaders. 4:34:14 PM MS. RICCI, in response to a question from Representative Fields regarding slide 10, gave information regarding the Infant Learning Program. She said she could follow-up regarding the number of individuals who participate in the program. 4:36:06 PM DR. ZINK, in response to a question from Representative Mina regarding slide 13, spoke about chronic disease and opioid addiction. Beside the distribution of Naloxone, the department works with communities and with the Department of Public Safety (DPS) regarding opioid remediation. She talked about counterfeit pills mixed with fentanyl and how deadly that is. She said the department wants youth to know about that danger, and is working with industry to distribute Naloxone kits. She offered to provide more information. 4:39:46 PM DR. ZINK, in response to Representative Ruffridge, talked about the Prescription Drug Monitoring Program (PDMT) and determining its strengths and weaknesses. She talked about an opioid dashboard that provides statistics, and understanding data in order to take action. She said she thinks use of the data will be beneficial in transforming health systems, and she spoke about the lack of internet technology (IT) infrastructure being a huge challenge in Alaska. 4:42:45 PM DR. ZINK, in response to questions from Representative Mina regarding slide 6 and the Office of Health Care Savings, said the department needs personnel to help with this area of health care savings. She said there has been focus on pharmacy and Medicaid in terms of seeking savings, and there is more to do, including reaching out to other divisions. She said the current budgetary "ask" is "quite small" and spreads across all divisions. Another consideration is the use of federal grants. She mentioned a change to emergency billing. She noted the database is within the Division of Insurance. In response to a follow-up question, she offered to find the request for proposals (RFP) from the Health Payment and Utilization Database (HPUD). 4:46:33 PM DR. ZINK, in response to a question from Chair Prax regarding postpartum care and the cost of programs, said Medicaid is required to cover it for the first 60 days; however, many states have moved to cover for 360 days. She said that early data out of California and Texas have shown that [moving to the lengthier coverage time] has resulted in a decrease in maternal deaths, as well as an increase in life expectancy for the mother in that first year. She said it can be difficult to do a cost-benefit analysis, but there are estimates available from national data suggesting significant savings. 4:48:47 PM COMMISSIONER DESIGNEE HEDBERG, in response to Representative Saddler regarding the length of time it will take to update programming, described different "arcs of effort" necessary. First, she said, is the move from 6 to 12 months for SNAP certification. Additional reprogramming needs to happen, and she offered to bring back that information at a later date. 4:50:33 PM COMMISSIONER DESIGNEE HEDBERG, in response to a question from Representative Ruffridge regarding slide 17 and error rates, confirmed there are errors, but she does not know the percentage. 4:52:02 PM DR. ZINK, in response to a question from Representative Ruffridge regarding slides 5 and 6, talked about prevention and a four-year plan utilizing existing and future plans to create a healthy Alaska. She noted there is a web site available on this topic. Regarding the phrase, "payment for prevention," she spoke about incentives to both providers and patients. 4:55:40 PM MS. RICCI, in response to a second question from Representative Ruffridge regarding pharmacies, talked about saving through a pharmacy program, including rebates for use of certain types of medications and being more aggressive with outlining medications that are more economical while offering the same benefit. She talked about the Office of Health Savings considerations and "leveraging the volume that Alaska has in its different types of state programs to purchase or negotiate lower rates for prescriptions and then make that available to the general public." 4:57:58 PM COMMISSIONER DESIGNEE HEDBERG, in response to a question from Representative Mina, said the skill set to work in the aforementioned virtual call center is minimal because it would require answering the phone and collecting certain information and documents; it is "clerical at best." That information is shared with eligibility technicians. In terms of minimum qualifications for technicians, she said she would follow up with information at a later date. 4:59:37 PM COMMISSIONER DESIGNEE HEDBERG, in response to a question from Representative Ruffridge, said currently the department has a total of 458 PCNs in the division, and she would follow-up at a later date to let the committee know how many of those are eligibility technicians. 5:00:16 PM CHAIR PRAX asked how to best communicate with the department so that each committee member can "get up to speed" on this information. COMMISSIONER DESIGNEE HEDBERG recommended contacting Courtney Enright, Legislative Liaison for the Department of Health. 5:01:58 PM ADJOURNMENT  There being no further business before the committee, the House Health and Social Services Standing Committee meeting was adjourned at [5:02] p.m.