ALASKA STATE LEGISLATURE  HOUSE SPECIAL COMMITTEE ON TRIBAL AFFAIRS  March 18, 2021 8:01 a.m. MEMBERS PRESENT Representative Tiffany Zulkosky, Chair Representative Dan Ortiz Representative Zack Fields Representative Geran Tarr Representative Mike Cronk MEMBERS ABSENT  All members present COMMITTEE CALENDAR  PRESENTATION: Role Of Tribal Health Organizations in COVID-19 Response - HEARD PREVIOUS COMMITTEE ACTION  No previous action to record WITNESS REGISTER DR. BOB ONDERS Administrator Alaska Native Tribal Health Consortium Anchorage, Alaska POSITION STATEMENT: Gave a PowerPoint presentation during the overall presentation, entitled "Role Of Tribal Health Organizations in COVID-19 Response." DR. ELLEN HODGES Chief of Staff Yukon-Kuskokwim Health Corporation Bethel, Alaska POSITION STATEMENT: Gave a PowerPoint presentation during the overall presentation, entitled "Role Of Tribal Health Organizations in COVID-19 Response." ANGEL DOTOMAIN Alaska Area Director Indian Health Service Rockville, MD POSITION STATEMENT: Testified during the presentation, entitled "Role Of Tribal Health Organizations in COVID-19 Response." DR. MARK PETERSON Medical Director Norton Sound Health Corporation Nome, Alaska POSITION STATEMENT: Testified during the presentation, entitled "Role Of Tribal Health Organizations in COVID-19 Response." DR. ELLIOT BRUHL Chief Medical Officer Southeast Alaska Regional Health Consortium Juneau, Alaska POSITION STATEMENT: Testified during the presentation, entitled "Role Of Tribal Health Organizations in COVID-19 Response." ACTION NARRATIVE 8:01:27 AM CHAIR TIFFANY ZULKOSKY called the House Special Committee on Tribal Affairs meeting to order at 8:01 a.m. Representatives Ortiz, Cronk and Zulkosky were present at the call to order. Representative Field and Representative Tarr (via teleconference) arrived as the meeting was in progress. ^PRESENTATION: Role of Tribal Health Organizations in COVID-19 Response PRESENTATION: Role of Tribal Health Organizations in COVID-19  Response    8:02:31 AM CHAIR ZULKOSKY announced that the only order of business would be a presentation on the role of tribal health corporations in COVID-19 response. 8:03:00 AM DR. BOB ONDERS, Administrator, Alaska Native Tribal Health Consortium, shared a PowerPoint on the role of the Alaska Native Tribal Health Consortium (ANTHC) during the COVID-19 pandemic. Early on, efforts centered on mitigation, early identification, and eradication, he stated; securing Personal Protective Equipment (PPE) and testing were also key. When early identification and eradication was no longer possible, case counts surging in late fall 2020, the effort became centered on response, he shared. Currently, efforts were focused on vaccination and recovery. How the COVID-19 pandemic will respond to ANTHC's efforts to mitigate cases across Alaska remained to be seen, he said. Regions' implementation of quarantine policies and airport testing have significantly helped prevent hospitalizations, he imparted. High case counts on the road system eventually became so high that it became a challenge to keep COVID-19 out of rural areas, he stated. He shared slide 5, which showed on a line graph there had been fewer than 100 cases of influenza throughout the 2020-2021 season, compared to as many as 1,200 lab reports in seasons prior. This showed mitigation measures worked, he said. 8:07:26 AM DR. ONDERS shared slide 6 on ANTHC response to COVID-19, which noted systems became overwhelmed with many staff contracting COVID-19 and entire hospital wings full of patients who had tested positive for the virus. Staffing was made available through Indian Health Service (IHS) for ANTHC's alternate care facility at a critical time, he shared; without the additional facility ANTHC would have had to close earlier than it had. There were times in Fall 2020 when all three hospitals in Anchorage were closed, he stated, and the closures made a significant difference for Rural Alaska: for critical care patients and adult in-patients, ambulances could rotate around, but air transfers presented a challenge, he said. Every ambulance would be taken in, but it happened in the fall that ANTHC was not able to take air transfers. Alaska lacked redundancy in critical care physicians, critical care nurses, and even critical care beds, so mitigation measures and prevention became key. 8:10:11 AM DR. ONDERS shared slide 7 on COVID-19 vaccine allocation, which he called the most beneficial of all the phases thus far. The "Sovereign Nation Supplement," as it was called, through IHS with its unique government-to-government relationship with tribes in Alaska, allowed for additional vaccines on top of what had already been allocated. This significantly improved the vaccination effort across the state in terms of per-capita allocations, he shared, adding that tribal health organizations had the flexibility to prioritize locally and get the vaccine out quickly. Tribal healthcare systems prided themselves on relationships with patients, and the extensive databases made it easy to identify who was high-risk early on. Up-to-date contact information made it easy to roll the vaccine out to vulnerable populations expediently, he imparted. DR. ONDERS shared there were 27 tribal health organizations and 12 major tribal regions across Alaska. From the standpoint of ANTHC, with the vaccine out, working with tribal health organizations across the state to get the vaccine to where it was most needed was the main thing. Areas have been more successful at getting the vaccine out and areas have been challenged, he stated, and there has been some reallocation of the vaccine to those areas it was still needed. He emphasized the protection of everyone in the community, not just the tribal members. To successfully mitigate the spread of COVID-19, everyone must be kept safe, he added. 8:14:03 AM CHAIR ZULKOSKY asked if there was a sense of the total number of vaccines made available through the Sovereign Nation Supplement. DR. ONDERS replied no, but he could find out. DR. ONDERS moved onto slide 9, a bar graph which showed variability of vaccine rollout among tribal regions, looking at both boroughs and tribal health organizations which served those boroughs. The goal was to get the vaccine to communities which needed to get their immunization rates higher, he related. On slide 10, gleaned from State of Alaska data, Dr. Onders presented a line graph showing in November and December of 2020 Alaska Native people having about three times higher COVID-19 case counts, hospitalizations, and mortality rates than the rest of the population. The Sovereign Nation Supplement, which allowed for early administration to areas of need, changed that. This was indicated on the graph, he pointed out, as the supplement was able to provide a disproportionate advantage to communities at risk. 8:18:10 AM DR. ONDERS went over slide 11, the morbidity and mortality report from March 17, 2021. Alaska ranked number two in states getting out vaccines to communities most at risk. Fifteen different variables were used to determine social viability across the US, he shared. He once again gave credit to the supplement for the expedient rollout. 8:21:19 AM DR. ELLEN HODGES, Chief of Staff, Yukon-Kuskokwim Health Corporation, presented a PowerPoint on the COVID-19 pandemic response by the Yukon-Kuskokwim Health Corporation (YKHC). She shared that over a year ago, in March 2020, YKHC's Incident Command Team had been activated. While the virus was not known to be in the region at that time, YKHC had been preparing for the outbreak with planning, training, and drills. In response to the worldwide PPE shortage, YKHC began making masks for internal and village clinic distribution. Moving onto slide 3, Dr. Hodges shared between April and August 2020 YKHC prepared for an influx in patients by doubling available beds and identifying alternative care sites, as well as by developing strategies for staff to follow if a major surge hit. They set up an internal contact tracing team, developed expanded telehealth capabilities to serve communities while travel was not feasible, and set up widespread testing with drive-through and walk-in testing in the hospital parking lot, as well as testing at hub airports in the region, meeting every flight that landed in Bethel, Aniak and St. Mary's to offer testing, and by beginning widespread testing in villages that had positive cases. DR. HODGES shared by July over 7,000 tests had been performed and 22 positive cases had been found. Rapid response teams were developed to travel to villages with positive cases and assist in treatment and testing. 8:23:51 AM CHAIR ZULKOSKY asked how many contact tracers were on YKHC's COVID-19 response team. DR. HODGES said at first four, then five, then with the advance of the pandemic, about 12. DR. HODGES shared between September and December 2020 YKHC set up weekly meetings to discuss precautions and answer questions. Participants included tribal and city governments, school districts, individual villages, and internal YKHC staff. Village trips for testing and assisting with positive patients continued, she added, as did the emphasis on testing into 2021. As of March 2021, upwards of 74 thousand tests had been completed, she shared. By the end of December there were 3,644 cases in the Yukon-Kuskokwim Delta (Y-K Delta); the average was 50 100 new cases per day; and the peak of 135 cases in one day occurred in mid-November, she shared. 8:25:29 AM CHAIR ZULKOSKY asked if there was an assessment of what percentage of tests conducted in the YKHC service area were processed through the state public health lab, and the percentage processed commercially or otherwise not through a state lab. DR. HODGES said a small percentage; YKHC relied heavily on the Alaska Native Medical Center to process most tests. DR. HODGES pointed out by way of a bar graph that the Y-K Delta had the highest COVID-19 rates in Alaska, especially during the months of October - December 2020 and January 2021. For many weeks these were also the highest case rates in the US, she added. From December 2020 to present, when vaccines had become available, a distribution plan was set up to get to all 47 villages using charters: to begin with, 30 villages were visited in four days with multiple teams to administer vaccines to health care workers. Vaccine eligibility was then expanded to the elder population shortly into this effort, and eligibility was immediately opened on trips to villages as it was understood that everyone in a village must be vaccinated to get the pandemic under control. DR. HODGES shared between December 18, 2020 and January 9, 2021 YKHC completed 57 village visits throughout the Y-K Delta, and that all YKHC villages with clinics were visited with some receiving multiple visits. Village trips continued, on a weekly basis, to administer the second shot as needed, and the first shot to new people. A vaccine administration space was set up at the hospital in Bethel in mid-December, she shared. As of March 17, 2021, patients 16 years old and older were eligible to receive the vaccine, and 53.2 percent have received at least one shot, 43.8 percent have received both. 8:29:53 AM CHAIR ZULKOSKY asked how quickly the YKHC service region was able to expand vaccinations at tribal health facilities to non- tribal health beneficiaries. DR. HODGES replied within two weeks, especially elders. By December 23, 2020, all residents 65 and older were eligible; by mid-January, all residents were eligible. The vaccination rate played a huge part in the enormous drop in cases [by the end of January], she pointed out. 8:31:40 AM REPRESENTATIVE ORTIZ asked if there had been an assessment as to why the high case counts happened. DR. HODGES replied three or four different factors were at play: crowded, multi-generational homes with poor ventilation; lack of access to adequate sanitation (60 percent of homes in the region did not have sewer) increasing rate and severity of respiratory illness; infrastructure issues regarding housing and access to medical care. REPRESENTATIVE ORTIZ stated these imbedded and difficult problems needed to be truly addressed, COVID-19 pandemic notwithstanding. DR. HODGES shared in terms of future efforts YKHC would continue vaccination distribution in all villages utilizing both health aides and visiting providers. Some villages have achieved over 95 percent [vaccinated] of those eligible, she stated. In terms of future efforts, YKHC would resume routine village visits by providers as often as possible for medical, dental and vision appointments and provide public information on the status of the virus in the region. Lastly, she stated, YKHC kindly requested the Legislature pass House Bill 76, which would allow tribal health services to continue to grow, especially in the light of decreased ability to transfer patients by air. She expressed gratitude for telehealth services and shared resources. 8:37:24 AM REPRESENTATIVE TARR asked if, after the public health declaration, telehealth services should be made permanent. DR. HODGES replied yes, telehealth had been very well-received, and it should remain, for the well-being of all people. Especially for routine follow-up appointments this would be desirable, she added. DR. HODGES stated variants to COVID-19 continued to emerge in the Y-K Delta, and the best defense was to get as many people vaccinated as possible, maintain masking and social distancing, and minimize group activities. 8:40:12 AM REPRESENTATIVE ORTIZ asked if "vaccine breakthrough cases" meant fully vaccinated people had acquired the virus. DR. HODGES replied yes, and those folks were almost always asymptomatic. REPRESENTATIVE ORTIZ asked if there was any state or national data that indicated the effectiveness of current vaccinations on the variants. DR. HODGES replied yes, both Pfizer and Moderna vaccines had proven effective against known variants. 8:42:54 AM REPRESENTATIVE FIELDS, referencing an Alaska Daily News article about low vaccination rates and high infection rates in the Matanuska-Susitna valley, asked about the risk of such an area for the rest of Alaska, given the reality of travel, and how it endangered folks in the rest of the state. DR. HODGES replied it was very dangerous as such an area would allow the virus to replicate and potentially create more variants. She added the best defense was to vaccinate and not leave such "reservoirs" of unvaccinated people. She pointed out that Alaska already had such a reservoir with people aged 16 and under. REPRESENTATIVE FIELDS asked what guidance she had to encourage folks to get vaccinated DR. HODGES replied that continuing education and accurate information including risks of not getting vaccinated. She cautioned against inaccurate information spread on social media and recommended instead engagement with public health officials and respected leaders in the community. 8:45:41 AM CHAIR ZULKOSKY asked about the arc of eligibility expansion that occurred in the Y-K Delta with respect to the initial wave of vaccinations that came out in mid-December 2020. DR. HODGES replied the first vaccines arrived December 16, 2020 and went out to villages December 18. Six or seven days later, it was realized elders could be vaccinated in the villages and elsewhere. It was made sure there was good outreach to tribal councils so Village Public Safety Officers and others responding to the pandemic would be able to receive the vaccine. Each village had some method of responding to folks who had to be in quarantine or who tested positive, she said. She continued by adding by the second week of January 2021 it had been decided there was enough vaccine and enough interest to offer vaccine to anyone 16 and over in villages; shortly thereafter in Bethel. 8:49:52 AM CHAIR ZULKOSKY asked Dr. Onders how many COVID-19 tests had been processed through ANTHC's lab and when testing had been expanded. DR. ONDERS replied he would send numbers, and testing had been expanded March 22. He added ANMC had the first high-capacity analyzer in the state. 8:53:48 AM ANGEL DOTOMAIN, Alaska Area Director, shared in FY 20 the Alaska Native Health Service distributed more than $161 million to tribal health partners from the Alaska CARES Act and other supplemental funding. Through the IHS National Service Center, PPE and Abbott ID analyzers for COVID-19 testing were also distributed. The IHS helped with staffing shortages and data collection for vaccine preparation as well, she explained. The IHS worked to distribute vaccines as tribes all chose the State of Alaska for their jurisdiction. Ms. Dotomain also expressed her happiness with the Abbott ID testing system. 8:57:25 AM REPRESENTATIVE TARR asked what it meant that tribes chose Alaska as their jurisdiction in terms of vaccine distribution. DR. DOTOMAIN replied that tribes across the US had the option of selecting their state for jurisdiction or the IHS. Since Alaska had a longstanding vaccine process which had been perfected over many years it was the better choice, especially with the knowledge that data management was going to be difficult, and it would have been harder to report into the IHS system. 9:00:09 AM DR. MARK PETERSON, Medical Director, Norton Sound Health Corporation, shared Norton Sound Health Corporation (NSHC) knew they had to have a very aggressive prevention strategy. Only about 10 thousand people resided in NSHC, he stated, and some still had a healthy fear of pandemics dating back to the Spanish Flu. Nome had been shut down to very limited air travel initially, and they were also able to hold off the virus until they developed a good testing strategy, he shared. It was decided to put an Abbott ID testing system in every village, he imparted, adding that NSHC had looked for a large-capacity testing system but couldn't get one. They were just putting one in at the time of the hearing, he said. Each village as well as the city of Nome had mandatory quarantine requirements, he said. 9:07:14 AM DR. PETERSON showed a slide on COVID-19 data from The Norton Sound/Bering Strait Region from January 1 to March 14, 2021. He pointed out that the close to 67 thousand tests were mostly done on the Abbott ID analyzers, and that since the region only had 12 thousand people each person had been tested six times early in the pandemic. There have been 324 total positive cases by this time, and two villages with large outbreaks. By the time of the outbreaks, analyzers, aggressive testing, and contract tracers were in place, he stated. The region was now on the life-saving vaccine tract, he said, crediting the combination of statewide allocation and IHS distribution. He shared a slide on vaccination percentages, sharing the first half of the population was "not a problem" to get vaccinated, but the second half may be "a little more difficult." He pointed out the region had "pretty good numbers," with most villages being well over 50 percent vaccinated and 63 percent of all eligible folks having received the vaccine. It was still an uphill battle to get to 70 percent, he said. Testing has eased a bit since vaccines have proven effective, he said. 9:12:04 AM REPRESENTATIVE FIELDS asked if NSHC was doing all vaccinations in Nome or if another entity was providing vaccinations for non- Tribal citizens. DR. PETERSON replied that the clinic in Nome had traditionally done all vaccinations for tribal beneficiaries and non- beneficiaries and would continue to do so. He echoed others' appreciation for telehealth as well. Educated folks in the region were worried about the large number of COVID-19 cases in the Matanuska-Susitna valley, he shared. 9:15:35 AM REPRESENTATIVE CRONK said he would be looking into why the basketball tournament would be taking place in a hotspot. DR. PETERSON agreed and said residents had expressed discontent that no rapid testing was available at the tournament. REPRESENTATIVE CRONK expressed his belief a double standard was at play, there were many safer places in the state in which to hold the tournament, and student athletes' best interest was not at the forefront. 9:18:51 AM CHAIR ZULKOSKY asked about the arc of decision making regarding expanding eligibility criteria for vaccinations in the Norton Sound region, especially how quickly decisions to expand were able to be made. DR. PETERSON replied that the whole region had been open to people aged 16 and older since January 2021, which has been very effective, adding anything that reduced roadblocks to getting more people getting vaccinated would be helpful. 9:22:00 AM REPRESENTATIVE CRONK asked if there was a preference in brands of vaccines. DR. PETERSON replied that the vaccine that is available is the one to get. REPRESENTATIVE CRONK asked if the vaccine would help with chronic symptoms of COVID-19. DR. PETERSON said he didn't believe so, and that COVID-19 was also not as simple a disease as was once thought, with a good percentage of people showing chronic symptoms. 9:25:25 AM DR. ELLIOT BRUHL, Chief Medical Officer, Southeast Alaska Regional Health Consortium, stated Southeast Alaska Regional Health Consortium (SEARHC) provided a different tapestry of care to 27 different locations. He shared a timeline which tracked SEARHC's actions since the beginning of the COVID-19 pandemic, beginning with the establishment of an incident command center to allow for consistent communication with employees and outside agencies. Weekly meetings were held with IHS regarding resources and PPE, and emergency operations centers set up. Supplies including PPE and ventilators were obtained, the former through IHS. Increased training for respiratory care, particularly in remote areas, was a focus, he stated, as was gaining access to testing. 9:31:36 AM DR. BRUHL also expressed appreciation for Abbott ID analyzers. Regarding the Governor's orders regarding care, practices at SEARHC were being constantly retooled and ultimately testing every employee every week. Telehealth helped maintain continuity of service, he stated, and allowed for safe engagement of patient care. He did express hesitation for the "Wild West" nature of telehealth that was developing nationally and the vulnerability of the health care system in Alaska to clinics and providers outside the state drawing care out of our own systems, especially in remote locations in which the result could be a corrosive effect. It was expensive to provide services anywhere in the state, he said, so to have them being drawn upon from outside was highly concerning. 9:35:51 AM REPRESENTATIVE ORTIZ asked if there was a direct connection between the continued ability of the state to deliver telehealth medical services and the extension of the emergency declaration specifically titled "emergency declaration;" if, he offered, House Bill 76 were to be adopted without the title "emergency declaration" it would be problematic in terms of receiving telehealth services. DR. BRUHL replied yes, special relationships were in place and the cancellation cut off those special relationships. Patients and clinicians alike had come to rely on telehealth and those relationships, he stated. It was concerning that patients may be drawn away by other telehealth providers who were not aware of patients' situation in Alaska, he stated. DR. HODGES said having [emergency] extension is essential for telehealth, particularly with regard the handling of the behavioral health crisis in her region. It was also good to receive specialty care through ANTHC, she said, but regarding behavioral health it was essential. REPRESENTATIVE ORTIZ said he in no way doubted telehealth for state residents, but the problem was there seemed to be political considerations; he asked if it would it be a problem if for telehealth's continuance if "an extension of the emergency declaration" were not included in the title of legislation. DR. HODGES said she didn't think so, especially if the legislation allowed for the services to continue, and a permanent solution were on the way. DR. PETERSON agreed with the summation telehealth was essential for behavioral health. REPRESENTATIVE ORTIZ clarified his question was based on a constituent's inability to receive telehealth benefits because the emergency declaration was no longer in place, and if out-of- state providers were then required to go back and look at specific pieces of passed legislation to determine they could still provide services. 9:45:35 AM CHAIR ZULKOSKY asked if the flexibilities afforded through a disaster declaration such as House Bill 76 provided the expansion support that health providers were looking for but also provided finite sunset to expansions so that Alaskan medical professionals could tease out any problems with drawing Alaskan entities outside the state; the temporary measure needed to have a sunset provision to protect Alaska institutions, she stated. DR. BRUHL said the emergency declaration has been essential to being able to respond to the crisis, and leaders needed to be creating systems that were safe. If systems were unable to be maintained because predatory health systems were projecting opportunities for patients to go outside of the state looking for care, in the end it will be destructive to the system, undermining its infrastructure, he said. Coming to a legislative structure should be paramount, he stated. 9:50:13 AM REPRESENTATIVE ORTIZ said he was wondering how important it was to include the title "emergency declaration," and if it didn't, how much out-of-state providers would be expected to "delve into the weeds" regarding their continuation of providing telehealth services. 9:52:43 AM DR. BRUHL turned back to the timeline, talking about partnerships with school districts and mitigations that reflected CDC guidelines dovetailed with local school board preferences. He shared SEARHC had performed over 107 thousand tests. Vaccine began to arrive in December, he shared, and SEARHC attended and distributed vaccine in a steadfast manner which made him proud, in storms, by boat, and by float plane, he shared. This reflected medical needs of communities and gave a lot of hope, he stated, particularly regarding past pandemics' ravaging of remote areas. A system using QR codes allowed patients to sign up using their smartphones which has been key to success, he stated. 9:58:07 AM DR. BRUHL shared the availability of vaccine exceeded recommendations of the state, so they moved quickly, already vaccinating anyone 16 and older regardless of risk group. Over 11 thousand people have received the first vaccine and 9 thousand their second, he stated. Well over 70 percent in smaller communities and 50 percent of larger communities had also been vaccinated, he shared. Vaccine had been provided to communities which did not have a strong IHS presence, including Juneau, Petersburg, and Skagway, he shared. 10:02:58 AM ADJOURNMENT  There being no further business before the committee, the House Special Committee on Tribal Affairs meeting was adjourned at 10:02 a.m.