JOINT HOUSE & SENATE HEALTH, EDUCATION & SOCIAL SERVICES COMMITTEE February 14, 1996 9:02 a.m. SENATE MEMBERS PRESENT Senator Lyda Green, Chairman Senator Loren Leman, Vice-Chairman Senator Johnny Ellis Senator Judy Salo SENATE MEMBERS ABSENT Senator Mike Miller HOUSE MEMBERS PRESENT Representative Cynthia Toohey, Co-Chair Representative Gary Davis Representative Tom Brice Representative Caren Robinson HOUSE MEMBERS ABSENT Representative Con Bunde, Co-Chair Representative Al Vezey Representative Norman Rokeberg COMMITTEE CALENDAR Presentation by the Alaska Native Health Board. WITNESS REGISTER Lincoln Bean, Sr., Chairman Alaska Native Health Board 1345 Rudakof Circle, Alaska 99508 POSITION STATEMENT: Presented the opening statement. The following Alaska Native Health Board members presented the Alaska Native Health Board's legislative priorities for fiscal year 1997: Cindy Thomas, Morgan Solomon, Tim Kaganak, Anne Marie Holen, Cheryl Edenshaw, Michael Hunt, Katherine Grosdidier ACTION NARRATIVE TAPE 96-9, SIDE A Presentation by the Alaska Native Health Board  Number 003 CHAIRMAN GREEN called the Joint House & Senate Health, Education and Social Services (HESS) Committee to order at 9:02 a.m. and invited the Alaska Native Health Board to begin its presentation. LINCOLN BEAN, Chairman of the Alaska Native Health Board (ANHB), appreciated the time to present their legislative priorities. He noted that the committee had copies of the ANHB State Legislative Priorities for the Fiscal Year 1997 booklet. He pointed out that the ANHB has identified two health priorities this year. The first being water and sanitation services for rural communities and the second is the increase in state tobacco taxes. He said that the ANHB would like to work with the committee on these issues in order to develop plans for improvements in state policies and services. The members of the Alaska Native Health Board attending the meeting then introduced themselves. Number 120 CINDY THOMAS, Coordinator of the Rural Alaska Sanitation Coalition, acknowledged the past legislature for continuing to fund sanitation at a level allowing work to continue at the existing $1 billion of unmet needs. She hoped to see that same commitment next year. She pointed out three priorities for village water and sanitation: (1) Sustained consistent funding. Ms. Thomas pointed out that the federal government's legislation contains authorization language in the Department of Administration for sustained funding at the federal level. Hopefully the state and federal governments will continue to work in a partnership on this in order to receive the needed levels of funding. (2) Resources for operations and maintenance. Ms. Thomas felt that the Remote Maintenance Worker (RMW) program and the Rural Utility Business Advisors should both be viewed as a capital investment as well as a public health investment. EPA has made a commitment of $1.1 million over the next two years, but that requires a state match in some form. (3) Water and sanitation services for all village health clinics. Over 30 communities still operate without water and sewer. There was a commitment from Alaska in the fiscal years 1993 and 1994 to provide supplemental funds to hook these clinics to water and sewer services. That is not present in the 1995 or 1996 budgets. There is $325,000 to start up that program. Ms. Thomas pointed out that the booklet contains a list of the villages and the funding needed to meet their sanitation needs. The total funding necessary for all those villages would be approximately $800 million which does not include basic compliance, new homes, or health clinics. SENATOR LEMAN asked if a portion of the quarter million dollar match by Alaska could be obtained through local matches. CINDY THOMAS explained that the program requires state and local matches. The communities are expected to match dollar for dollar, $1 million, which is not reflected in the booklet. The state is also expected to match the $1 million in cash or kind. The total program would then be $3 million. Number 199 REPRESENTATIVE TOOHEY inquired as to where the funding would normally be received regarding the care and maintenance of the projects. CINDY THOMAS said that it had historically come from RMW through over the shoulder training. There is also water plant operator training through the village safe water program. Indian Health Services also contributes a small portion of their funding for training. Ms. Thomas noted that training in the areas of management of the system, the collection of fees and maintenance of the stock and supplies is also necessary. Currently, there is no funding for that training. MORGAN SOLOMON, ANHB member, stated that rural water and sanitation is an important issue and has been since statehood. He was happy that the Knowles' Administration recognized the need for sound water and sanitation in rural areas. There is a $1 billion program for rural water and sanitation. Mr. Solomon emphasized that water and sanitation is a must due to the environmental impact poor sanitation creates. He reiterated the need for a commitment from everyone - the House, the Senate, the Administration - to improve water and sanitation in Alaska. Mr. Solomon pointed out that not long ago the North Slope Borough utilized its bonding capabilities to fund water and sewer for Barrow which still continues today and will eventually include all the North Slope villages. The Nenana and the central regions need the same program that the North Slope Borough now enjoys. He acknowledged that oil money is diminishing. He discussed his wonderful experience in receiving running water. Honeybuckets should only be in museums. The youth of this state are its most important asset and they should grow up in clean environments. There are lots of problems associated with unsanitary surroundings one of which is hepatitis. Number 294 REPRESENTATIVE TOOHEY pointed out that the booklet notes the following contributions to rural water and sanitation by the corresponding legislatures: FY1993-$24 million, FY1994-$26.5 million, FY1995-$21.7 million, FY1996-$21.5 million. She applauded Mr. Solomon's efforts. SENATOR LEMAN expressed concern with the cost of delivering these projects in rural Alaska. He was convinced that the current system practically ensures that the highest cost project is done. How can a quality product be delivered at a cheaper cost? MORGAN SOLOMON believed that arctic condition type facilities should continue. Such facilities mechanically maintain themselves. Feasibility studies should be utilized in order to avoid cost overruns. Number 323 In response to Senator Leman, MORGAN SOLOMON said that the project in Wainwright has worked well. The project is no longer a demonstration project. Water and sewer will come on-line this year under Phase I. Phase II is scheduled to begin in March. SENATOR SALO inquired as to the year Mr. Solomon received his toilet. MORGAN SOLOMON said that he received his toilet about six years ago. TIM KAGANAK, ANHB member, said that the issues remain the same. The biggest need in rural Alaska is water and sewer. He informed the committee that these projects are done in phases, often the second year is not funded and the project is frozen. Number 370 Mr. Kaganak informed the committee that in his area there are 58 clinics in the villages. These clinics need to be clean. He emphasized that some of the clinics have honeybuckets and do not have running water. This lack of sanitation should not be present in any health clinic. Mr. Kaganak said that clean water and sanitation could be achieved if everyone worked together. He emphasized that many legislators have constituents that do not have running water. Furthermore, the tuberculosis outbreak remains. Number 398 ANNE MARIE HOLEN, Manager of the Tobacco Control Program at ANHB, expressed frustration with the way the tobacco tax has become politicized in regards to dealing with the fiscal gap. As members of the HESS committees, Ms. Holen hoped the tobacco tax would be viewed as a public health benefit. A major tobacco tax increase would be justified even without a fiscal gap. The revenues generated, the over $40 million per year, could be seen as a bonus. Ms. Holen stated that the real benefit of the tax is in the significant reduction of nicotine addiction, especially among Alaska's youth, and tobacco related death and disease in Alaska. According to research, taxation is the single most powerful weapon in reducing tobacco use. The tobacco tax increase would keep youths off of drugs, reduce the leading cause of death in Alaska, reduce the economic impact of tobacco use ($300 million a year per the Section of Epidemiology), generate money, while enjoying support across all political spectrums. Ms. Holen informed everyone that last month a Robert Wood Johnson Foundation Survey reported that 74 percent of Alaskans support a $1 per pack increase in the cigarette tax. This is a nonpartisan issue. Ms. Holen commented that tobacco use is not merely a Native problem in Alaska. Rates of the use among white Alaskans is also higher than the national average. She noted that non-smokers face the effects of exposure to second-hand smoke, the burden of high health care costs, and the heart ache of seeing others struggling with nicotine addiction and disease caused by tobacco use. Tobacco use in Alaska kills more Alaskans than airplane crashes, automobile crashes, alcohol, and firearms combined. The Legislature has a responsibility, which is specified in Alaska's Constitution, to take meaningful action to address the epidemic of tobacco related death and disease in Alaska. Number 440 SENATOR LEMAN asked Ms. Holen to estimate the ratio of the cost of tobacco use in terms of health care versus the revenue derived from its use. Based on 1991 data, ANNE MARIE HOLEN said that for every $1 raised in tobacco tax revenues $7 worth of detrimental impact on the economy resulted. That detrimental impact is health care costs, lost work time, or lost productivity. REPRESENTATIVE ROBINSON asked Ms. Holen if she had discussed the notion of placing a portion of the revenue generated from the tobacco tax in the Children's Trust to be utilized for prevention. ANNE MARIE HOLEN did not know how that would be done legislatively, but would support the concept. Ms. Holen mentioned that in other states that have raised tobacco taxes and appropriated money for tobacco control programs, the impact of the tax increase is magnified. CHERYL EDENSHAW, ANHB member, reiterated that the ANHB has been a long time supporter of the tobacco tax increase. She expressed concern with Alaska's high rate of smoking in Alaska in comparison to the rest of the United States. She informed the committee that one in five deaths in Alaska is caused by tobacco which is more than those killed by AIDS, airplane crashes, automobile accidents, fires, falls, and firearms all combined. The Alaska Native rate of smoking is higher than that for all races combined. Alaska's Native population comprises 16.5 percent of the entire state's population and accounts for 23.2 percent of Alaska's smoking related deaths. Ms. Edenshaw acknowledged that a tobacco tax would not eliminate the use of tobacco, but the benefits far outweigh the harm. A tax increase is one of the most effective methods to reduce tobacco consumption, death, and disease. The ANHB urges the committee to support the passage of SB 234 and HB 442 as recommended by the Long-Range Financial Planning Commission and Governor Knowles. Number 483 MICHAEL HUNT, Yukon-Kuskokim Health Corporation board member, discussed his travel experiences in which he has seen many youth using tobacco as well as deaths of the elderly tobacco users. He informed the committee that he quit smoking 28 years ago and believed that he had extended his life 10 to 15 years. He feels healthy. This tobacco tax could cut tobacco use by one-third. Mr. Hunt also supported SB 234 and HB 442. In conclusion, he urged the committee's support of the tobacco tax in order to strive for better health for all Alaskans. KATHERINE GROSDIDIER, Executive Director for South Central Foundation, explained that it is a nonprofit arm of the Cook Inlet Region. The foundation serves the Anchorage Native population and represents them on the ANHB. She passed out information regarding the Anchorage Native Primary Health Care Center which should be added to the committee packet. The new Alaska Native Medical Center was planned in the early 1980s. The Anchorage population has grown and the need for primary care services has doubled. When the new Alaska Native Medical Center opens in 1997, the center will contain fewer primary care rooms than needed. Number 535 Ms. Grosdidier explained that the foundation proposes to open a 38,000 square foot primary care facility which would be located in front of the new hospital. She passed around diagrams illustrating the position of the primary care facility and its layout. The facility would provide an additional 60 rooms in order to meet the needs of the increasing population of Anchorage. The facility would have 140 full-time employees which is a $60 million payroll per year. She pointed out that the facility would have two floors which would house primary care clinics, family medicine, pediatrics, and mental health. This facility would provide statewide services to the Anchorage population. More than 200 tribes support this project as well as the Alaska Native Health Care and Indian Health Service system. She informed the committee that lease payments have been secured through private and federal funding; operation funds are provided. Currently, money is accumulating for this project through South Central Foundation's third party revenues. She said that the foundation is looking for a state match for a federal match of $875,000. The total need is $1.75 million for medical equipment and voice data communication. She emphasized that the new facility's plan and methodology was wonderful for the 1980s, but the growing population of the 1990s which increased the space needed for the primary care was overlooked. Number 563 REPRESENTATIVE TOOHEY said that this was the first she had heard of this facility. She was appalled at this need and the shortsightedness that has created this need. Where did the funding come from for the new hospital? KATHERINE GROSDIDIER replied that it all came from federal funds. REPRESENTATIVE TOOHEY inquired as to the federal government's position on this new construction. KATHERINE GROSDIDIER explained that the foundation is meeting with a congressional delegation which reported that if there is a state match, the federal government would be amenable to giving the $875,000. That would be half of the match for the medical equipment and the data voice communication. The federal government would provide the funding for the building. In response to Representative Robinson, KATHERINE GROSDIDIER stated that currently, there is no funding in the Governor's capital budget for this. SENATOR SALO commented that was her first time hearing of the need for the primary care facility. The hospital looks huge now. KATHERINE GROSDIDIER agreed that this a surprise to everyone, but the need is a result of the methodology used in the early 1980s. The facility is a solution developed by the South Central Foundation who was informed of the problem by Indian Health Services about two years ago. Ms. Grosdidier pointed out that little administrative space was used in order to maximize the number of primary care exam rooms. TAPE 96-9, SIDE B Ms. Grosdidier discussed the waiting problems in the new hospital. Clinicians need two exam rooms; putting one patient in an exam room while seeing another patient is more efficient. Number 585 REPRESENTATIVE TOOHEY asked if the notion behind this was to bring everyone to Anchorage. Will the health center treat people statewide? Why is this collecting everyone; what happened to the hospitals in Bethel and Nome? KATHERINE GROSDIDIER explained that Bethel and Nome's hospitals will continue to operate for their constituents. The Alaska Native Medical Center is a statewide referral hospital which offers out- patient services. The South Central Foundation operates many of the primary care services which is why the foundation is involved. The out-patient services that provide services statewide will be moved to this new clinic and would continue to provide statewide services. REPRESENTATIVE TOOHEY expressed concern with the decrease in available funds nationwide due to the increasing population. Why would everyone be brought to Anchorage, increase travel costs, in lieu of health care money? KATHERINE GROSDIDIER explained that the current user population in the Anchorage area is over 100,000 patient visits; the statewide referral system accounts for 25 to 35 percent. Ms. Grosdidier explained that people receive out-patient care in the Bethel area, but if they visit Anchorage and need an out-patient service then they come to the hospital. Only those visiting or requiring in- patient services would utilize the Anchorage hospital, otherwise, their own regional hospitals are used for out-patient services. Currently, more than 70 to 80 percent of the out-patient users are Anchorage based Native people. CHAIRMAN GREEN thanked everyone for their presentation. There being no further business before the joint committee, the joint meeting was adjourned at 10:49 a.m.