ALASKA STATE LEGISLATURE  HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE  February 21, 2023 3:01 p.m. MEMBERS PRESENT Representative Mike Prax, Chair Representative Justin Ruffridge, Vice Chair Representative CJ McCormick (via teleconference) Representative Dan Saddler Representative Jesse Sumner Representative Zack Fields Representative Genevieve Mina MEMBERS ABSENT  All members present COMMITTEE CALENDAR  HOUSE BILL NO. 59 "An Act relating to Medicaid eligibility; expanding eligibility for postpartum mothers; conditioning the expansion of eligibility on approval by the United States Department of Health and Human Services; and providing for an effective date." - HEARD & HELD PREVIOUS COMMITTEE ACTION  BILL: HB 59 SHORT TITLE: MEDICAID ELIGIBILITY: POSTPARTUM MOTHERS SPONSOR(s): RULES BY REQUEST OF THE GOVERNOR 02/03/23 (H) READ THE FIRST TIME - REFERRALS 02/03/23 (H) HSS, FIN 02/21/23 (H) HSS AT 3:00 PM DAVIS 106 WITNESS REGISTER ANNE ZINK, MD, Chief Medical Officer Alaska Department of Health Juneau, Alaksa POSITION STATEMENT: Introduced HB 59 with a PowerPoint presentation and answered questions. EMILY RICCI, Deputy Commissioner Alaska Department of Health Juneau, Alaska POSITION STATEMENT: Introduced HB 59 with a PowerPoint presentation and answered questions. REBEKAH MORISSE, Section Chief Women's Children's and Family Health Anchorage, Alaska POSITION STATEMENT: Responded to questions pertaining to HB 59. ACTION NARRATIVE 3:01:55 PM CHAIR MIKE PRAX called the House Health and Social Services Standing Committee meeting to order at 3:01 p.m. Representatives McCormick (via teleconference), Ruffridge, Sumner, Fields, and Prax were present at the call to order. Representatives Saddler and Mina arrived as the meeting was in progress. HB 59-MEDICAID ELIGIBILITY: POSTPARTUM MOTHERS  3:03:14 PM CHAIR PRAX announced that the only order of business would be HOUSE BILL NO. 59, "An Act relating to Medicaid eligibility; expanding eligibility for postpartum mothers; conditioning the expansion of eligibility on approval by the United States Department of Health and Human Services; and providing for an effective date." 3:03:51 PM ANNE ZINK, MD, Chief Medical Officer, Alaska Department of Health, provided a PowerPoint presentation, titled "HB 59: Postpartum Medicaid Extension." She began on slide 3, describing HB 59 is intended to extend postpartum coverage of Medicaid from 60 days to 12 months to help cover postpartum medical and health concerns. She stated that HB 59 would help support growing families, help improve Alaska's maternal and child health future, simplify Medicaid coverage renewal, and save long-term cost dollars. 3:05:15 PM DR. ZINK continued to slide 4, titled "What Are the Stakes?" and showed the higher maternal mortality rates of the United States of America compared to other developed countries. She followed with slide 5, which read as follows [original punctuation provided]: Pregnancy-related deaths occur well beyond the 60-day postpartum period 29% of pregnancy-related deaths in the U.S. not including those caused by accidents, homicides, and suicides occur 43 to 365 days postpartum For every pregnancy-related death, there are 70 to 80 cases of severe maternal illness and morbidity in the postpartum period Medicaid-enrolled women are especially vulnerable to pregnancy-related death as they are more likely to experience chronic conditions, pre-term or low-weight births, and severe maternal morbidity DR. ZINK added that 51 percent of all births in Alaska are covered by Medicaid, but 71 percent of all maternal deaths - if they have coverage - are covered by Medicaid. 3:06:35 PM DR. ZINK outlined "Pregnancy-Associated Deaths in Alaska" on slide 6, which read as follows [original punctuation provided]: In 2021, Alaska's overall pregnancy-associated death rate exceeded the previous 5-year average by 109% Among deaths in 2015-2019: 73% occurred >6 weeks post- delivery Among deaths reviewed by Alaska's Maternal and Child Death Review (MCDR) committee during 2016-2022, 88%  were potentially preventable, and 44% were associated with barriers to health care access DR. ZINK added that in rural regions the pregnancy-associated death rate increased by 184 percent compared to 69 percent in our urban regions. 3:07:32 PM EMILY RICCI, Deputy Commissioner, Alaska Department of Health, continued the PowerPoint, on slide 7, "What Can Alaska Do About It?," which read as follows [original punctuation provided]: Section 9812 of the American Rescue Plan Act (ARPA) added the time-limited option for allowing states to extend postpartum coverage from the required 60 days to 12 months for eligible beneficiaries through March 1, 2027. The Consolidated Appropriations Act of 2023 (CAA-2023) revised ARPA to make the optional coverage extension permanent. 3:09:19 PM MS. RICCI outlined why the legislature should pass a bill, as shown on slide 8, "Why a Bill?," which read as follows [original punctuation provided]: The Legislature must approve all optional groups for Medicaid coverage in statute AS 47.07.020 Women who are eligible for Medicaid in Alaska based on their pregnancy currently only receive coverage for 60 days postpartum In Alaska, 51% of births are covered by Medicaid 3:09:42 PM DR. ZINK continued to slide 9, "Benefits to Alaskans," adding that that 41 states had already opted to take advantage of the American Rescue Plan Act (ARPA). Slide 9 read as follows [original punctuation provided]: Improves maternal health outcomes Prevents gaps in health care coverage and improves health care access Improves maternal mental health Mental health conditions contributed to 31% of pregnancy-associated deaths in Alaska between 2014 and 2018 14% of Alaskan mothers who had a baby in 2020 had symptoms of postpartum depression Addresses disparities in maternal health outcomes Medicaid plays a vital role in addressing disparities in maternal mortality and morbidity rates Postpartum period is an especially vulnerable time for parents recovering from substance use disorders Extending postpartum coverage increases access to screening and education about chronic diseases such as diabetes and high blood pressure 3:11:28 PM DR. ZINK followed with slide 10, by the same name, which read as follows [original punctuation provided]: Improves child health outcomes Parental enrollment in Medicaid is associated with a 29% higher probability that a child will receive an annual well-child visit Maternal mental health matters not only because of maternal mortality; it is intimately tied to the health and development of the child Maternal depression can lead to negative outcomes in children including delayed cognition and social- emotional/behavioral development 3:12:07 PM DR. ZINK outlined "Cost Savings" of HB 59 on slide 11, which read as follows [original punctuation provided]: The Congressional Budget Office (CBO) estimates that by 2024, about a quarter of postpartum beneficiaries will live in states that elect the new option and that extended Medicaid coverage will result in almost $6.1  billion in federal spending over the first ten years  and expected to grow over time The CBO estimates that not only are their federal and state cost savings, but this will decrease ACA subsidy  cost for private insurance Savings from averted severe maternal morbidity: Medicaid-enrolled pregnant women with severe maternal morbidity cost an average of $10,134 annually compared to $6,894 for those without Savings from prevention: Preventing gaps in coverage ensures access to primary and preventive care, including management of chronic conditions and screening for mental health conditions, substance use, and intimate partner violence 3:13:26 PM DR. ZINK displayed slide 12, "Mental Health," which contained an infographic from Mathematica outlining the key takeaways of perinatal mood and anxiety disorders, and the impact of the mother and child is an estimated $14.2 billion. Slide 12 continued as such [original punctuation provided]: Drug/alcohol use or substance use disorders were documented in 72% of Alaskan pregnancy-associated deaths reviewed by the MCDR Committee during 2016-2022 Increasing access to screening and treatment for substance misuse during and after a pregnancy may reduce costs for the index child as well as subsequent pregnancies and births Alaska Medicaid paid 3.9 times as much per infant for those affected by Neonatal withdrawal compared to nonaffected infants 3:14:25 PM DR. ZINK continued to slide 13, "Alaska Supports HB 59," which lists who supports extending postpartum Medicaid Coverage. The list read as follows [original punctuation provided]: The American College of Obstetricians & Gynecologists (ACOG) The American Medical Association The American Academy of Pediatrics The Society for Maternal-Fetal Medicine The American College of Physicians The American Academy of Family Physicians The American Hospital Association The American Psychiatric Association The American College of Cardiology The American Osteopathic Association The March of Dimes The Alaska Native Tribal Health Consortium The American Heart Association 3:14:44 PM MS. RICCI, in response to a question from Representative Saddler about whether Alaska is under ARPA legislation, stated that Alaska is not under ARPA legislation, but HB 59 would allow Alaska to take advantage of the extension provided by ARPA. In response to a follow-up question, she confirmed there was no time limit to take advantage of the Consolidated Appropriations Act of 2023 (CAA-2023). MS. RICCI, in response to a question from Representative Saddler about why the state did not take advantage of this opportunity earlier, stated that the focus was primarily on the pandemic, cyber-attack, and other items, and the department is taking advantage of this offer as early as it can. 3:17:29 PM DR. ZINK, in response to a question from Representative Ruffridge about the original temporary coverage extension to postpartum eligibility that preceded CAA-2023, said that it was during 2022, and that it was supposed to expire in 2027. REPRESENTATIVE RUFFRIDGE stated that if it was presented as an option in 2022, then it may have not been available to the legislature in its entirety. DR. ZINK said she did not know its exact date and was not able to confirm Representative Ruffridge's statement. She added that many other states are implementing Section 9812 of ARPA right now. 3:19:34 PM DR. ZINK moved to slide 15, "Healthy Family Initiative," which read as follows [original punctuation provided]: Strong families are the foundation of a healthy  society and a vibrant economy.  4-year statewide investments in the health and well- being of Alaskan families Governor Dunleavy proposed $9.5M (UGF) in FY 24 operating budget for Healthy Families activities within DOH: Postpartum Medicaid extension Office of Health Savings TB and congenital syphilis mitigation DR. ZINK added that under the Healthy Families Initiative that the Governor has put forward, the three major pillars were healthy beginnings, access to health care and healthy communities. 3:20:23 PM MS. RICCI listed the four sections of HB 59 on one slide each, starting on slide 17 and ending on slide 20, which read as follows [original punctuation provided]: MS. RICCI explained what HB 59 does, as shown on slides 17-20, which read as follows [original punctuation provided]: Section 1 Adds a new section (o) to AS 47.07.020, authorizing the department to implement an extension of postpartum Medicaid coverage up to the maximum period authorized under federal law. Section 2 Amends the uncodified law to add the requirement for submission of a Medicaid state plan amendment to allow Medicaid beneficiaries to receive postpartum coverage for up to 12 months. Section 3 Amends the uncodified law to establish the requirement that the commissioner of health notifies the revisor of statutes within 30 days of federal approval of the state plan amendment. Section 4 Establishes that the postpartum extension takes effect on the day after the date the commissioner notifies the revisor of statutes as described above. 3:21:39 PM DR. ZINK clarified that April 1, 2022, was the first time that this legislation would come about as part of ARPA. She followed with a story about a patient that she had seen who had lost health care access after pregnancy and was struggling with alcohol use. The patient was able to re-enroll into Medicaid, which allowed her to get clean and sober. 3:22:50 PM REPRESENTATIVE MINA asked how many individuals are uninsured and go into private insurance after losing Medicaid coverage after the current 60 days. 3:23:31 PM MS. RICCI was not able to provide specific data on the question. She added that, from the fiscal note, about 1,500 women indicated that they would lose coverage after the 60 days, and additionally there were about 2.300 women who experienced gaps in health care over the following 10 months after postpartum coverage. She concluded that under the current coverage of Medicaid "it is not streamlined, it is not simplified, and it is ... very dependent on an individual's economic status." MS. RICCI, in response to a follow up from Representative Mina about how the ending of eligibility is notified to the individuals, specified that generally a notice is received through the mail some time before their enrollment ends. 3:25:47 PM DR. ZINK clarified her previous story following Representative Saddler's question, stating that the Medicaid coverage the patient was able to re-enroll in was able to support the patient's sobriety. DR. ZINK, in response to a question from Representative Saddler about the reasoning of the 60-day postpartum coverage, said that it was originally established from Centers for Medicare and Medicaid Services (CMS) in 1986, and there has been a lot of research since that time that provides increasing evidence to extend coverage to the first year postpartum. 3:27:54 PM DR. ZINK, in response to Representative Saddler, clarified that the extended coverage is focused on both physiological and psychological aspects of care. DR. ZINK, in response to a follow up from Representative Saddler asking why only 12 months, said that it was what is offered to them, as well as having coverage end for the mother and child at the same period. 3:29:38 PM MS. RICCI added to Dr. Zink's response with emphasis on the simplicity of the current offer through CMS. 3:30:30 PM REPRESENTATIVE RUFFRIDGE asked for more information about the non-injury related deaths. 3:31:19 PM REBEKAH MORISSE, Section Chief, Women's Children's and Family Health, said she didn't have the exact causes on hand, but offered to provide them later. 3:31:54 PM REPRESENTATIVE SADDLER asked for clarification on whether postpartum coverage is for all services, or just those pertaining to postpartum care. MS. RICCI confirmed it was for all services. 3:32:21 PM DR. ZINK, in response to a question from Chair Prax about how individuals lost coverage of Medicaid, stated that it is because they do not renew coverage during the 60-day period. 3:33:23 PM MS. RICCI, in response to a follow-up question from Chair Prax, clarified that Medicaid does not have pre-existing conditions exclusions, and few private insurance plans maintain pre- existing exclusions. 3:34:23 PM REPRESENTATIVE SADDLER asked if there is a limit to how far Medicaid expansion will go and whether every Alaskan would eventually be covered under Medicaid. MS. RICCI assured that HB 59 is "specific, targeted, and narrow," and only extends pre-existing coverage without creating a new eligibility group. She expanded that Medicaid is intended to take an upfront cost but provide long term savings, as seen in Texas. 3:36:09 PM REPRESENTATIVE SADDLER said he wished to see hard evidence of the savings provided by Medicaid. He also asked Ms. Ricci to provide an example of what an unnecessary expansion of Medicaid would be. MS. RICCI replied that she hesitated to speculate on what expansions would be unnecessary. 3:37:04 PM MS. RICCI, in response to a question from Chair Prax asking to clarify that the individual Medicaid costs would decrease over the long term, said that it is very difficult to quantify what different variables affect what. She added that there has been work in Texas that is able to demonstrate cost-savings. 3:38:50 PM DR. ZINK added to Ms. Ricci's response and provided the examples that the first states to take advantage of this opportunity were non-expansion states. They determined that the most targeted intervention that they could implement with the longest-term benefit was expanding postpartum care. She further expanded on Texas, clarifying that it was looking at a managed care program that expanded coverage to 12 months and that the state was able to see a decrease in high-risk pregnancies, the highest causes of death were less influenced by pregnancies, and there was a decrease in chronic conditions. 3:39:57 PM DR. ZINK, in response to Representative Saddler, clarified that although Texas used a managed care program, Alaska would likely see similar results. 3:40:42 PM REPRESENTATIVE RUFFRIDGE opined that although cost-saving is important, the committee should consider that saving a life should be thought of as well. He expressed that he would rather save a life if given the opportunity. 3:41:58 PM CHAIR PRAX said he appreciated the concern but reminded the committee members that they must look at the comparative cost of the state's budget. He mentioned that HB 17 also has a similar question, adding costs for pregnancy prevention that have economic consequences down the road. 3:43:03 PM REPRESENTATIVE FIELDS added that expanding coverage reduces cost, as the cost of churn [individuals disenrolling and re- enrolling] is more expensive than being covered for 12 months. 3:43:31 PM DR. ZINK expressed that she would be happy to provide more information on churn in the Medicaid system. She added that there is additional work being done by Medicaid Enrollment and Spending in Alaska (MESA) looking at how Medicaid can manage medical costs long term, and she acknowledged that it is difficult to see the cost savings of these individual bills. 3:44:28 PM REPRESENTATIVE FIELDS added that since expanding postpartum coverage would reduce child abuse, it would then reduce costs in other departments such as the Office of Children's Services (OCS). 3:44:54 PM DR. ZINK continued to add the Alaska Department of Health has the Alaska Longitudinal Child Abuse and Neglect Linkage Project (ALCANLink) that looks at the return on investment of reducing adverse child experiences and increasing protective factors and showing the long term economic and health benefits. She referenced the previous information from the Mathematica infographic and how the $14.2 [billion] cost is so big as it includes many other sources of cost to the state. 3:46:35 PM REPRESENTATIVE SADDLER asked if there is any part of the CMS system that balances the cost of medical care with saving a life. DR. ZINK responded by assuring that she must balance the budget on a policy level, which can conflict with what she wants as a parent or what she wants as a physician. She added that the Center for Disease Control and Prevention's (CDC's) Health Impact in 5 Years (HI-5) project can show what up-front investments are able to provide the largest long-term health benefits, and that expanding postpartum care is one of the most important places to implement cost-effective and health- effective care. 3:49:35 PM REPRESENTATIVE FIELDS requested to move back to slide 4 and discuss how much the U.S. spends per capita on maternal care compared to the other countries that have a [10] times lower death rate. DR. ZINK said that is depends on how maternal care costs are calculated, but the U.S. usually spends more per individual on health care costs. She added that the health of an individual is about 80 percent determined by factors outside of the health care system. She emphasized that putting up-front costs into targeted policies can reduce long-term costs and provide better health outcomes. 3:52:04 PM REPRESENTATIVE SADDLER asked if there is any evidence that helping fathers will also provide benefits. DR. ZINK agreed firmly that helping fathers would also provide similar benefits, but highlighted the legislature is taking advantage of an opportunity provided by CMS. 3:52:54 PM CHAIR PRAX announced that HB 59 was held over. 3:53:05 PM ADJOURNMENT  There being no further business before the committee, the House Health and Social Services Standing Committee meeting was adjourned at 3:53 p.m.