SENATE HEALTH, EDUCATION AND SOCIAL SERVICES COMMITTEE February 16, 1998 9:00 a.m. MEMBERS PRESENT Senator Gary Wilken, Chairman Senator Loren Leman, Vice-Chairman Senator Lyda Green MEMBERS ABSENT Senator Jerry Ward Senator Johnny Ellis COMMITTEE CALENDAR ALASKA PUBLIC HEALTH IMPROVEMENT PLAN - Update by Dr. Peter Nakamura SENATE CONCURRENT RESOLUTION NO. 14 Establishing the Alaska Task Force on Parity for Mental Health. MOVED CSSCR 14(HES) OUT OF COMMITTEE PREVIOUS SENATE COMMITTEE ACTION SCR 14 - See HESS minutes dated 4/30/97, 1/30/98, 2/4/98 and 2/11/98. WITNESS REGISTER Dr. Peter Nakamura Division of Public Health Department of Health and Social Services P.O. Box 110610 Juneau, Alaska 99811-0610 POSITION STATEMENT: Gave the presentation on the Alaska Public Health Improvement Plan Deborah Erickson Division of Public Health Department of Health and Social Services P.O. Box 110610 Juneau, Alaska 99811-0610 POSITION STATEMENT: Provided information about the Alaska Public Health Improvement Plan Delisa Culpepper Alaska Public Health 1874 Wickersham Drive Fairbanks, Alaska 99507 POSITION STATEMENT: Provided information on the Alaska Public Health Improvement Plan Christine Huss Health Community P.O. Box 587 Kenai, Alaska 99611 POSITION STATEMENT: Provided information on the Alaska Public Health Improvement Plan Jerry Near Health Community Drawer 448 Soldotna, Alaska 99669 POSITION STATEMENT: Provided information on the Alaska Public Health Improvement Plan Walter Majoros Executive Director Alaska Mental Health Board 431 N. Franklin St. Juneau, Alaska 99801 POSITION STATEMENT: Commented on SCR 14 ACTION NARRATIVE TAPE 98-11, SIDE A Number 001 CHAIRMAN WILKEN called the Senate Health, Education and Social Services (HESS) Committee to order at 9:07 a.m. Present were Senators Wilken and Green. The first order before the committee was the Alaska Public Health Improvement Plan update by Dr. Peter Nakamura. CHAIRMAN WILKEN noted a Public Health Steering Committee was formed last interim. The presentation will be an update on the Steering Committee's work to date. DR. NAKAMURA, Director of the Division of Public Health (DPH), made the following comments. He came to Alaska to work as a pediatrician in 1969, and then became the director of the Public Health Program in Bethel. Many health related problems existed in Bethel at that time, and clinicians were able to diagnose and treat those health disorders. The major strides made in the field of public health have been in the elimination of deaths from tuberculosis, cholera, typhoid, and diphtheria. Public health officials made these strides in partnership with clinical practices. Despite that progress, Alaska still has a long way to go. Alaska was ranked number 48 out of 50 states in its immunization status. The population of children in the state doubled between 1980 and 1996. The number of vaccines now required to immunize children by the age of 19 is over 3 million doses. DR. NAKAMURA said no environmental health element existed within DPH when he became director in 1991. Today DPH is more able to respond to community health concerns about radiation and cancer or toxic waste. As a very young state, Alaska's public health system was developed by responding to crises, by using federal or oil industry dollars when available, and by focusing on special interests of individuals with influence. The Alaska Public Health Improvement Process will eventually lead to a plan. The Steering Committee needs to know what health services and systems are available to respond to public health issues in Alaska, not only within the state infrastructure, but in private health care systems, tribal corporations, and municipalities. DR. NAKAMURA stated the Steering Committee will also determine what capacities are available. With the assistance of federal agencies, some capacities to respond to environmental health issues were developed in the state but they have never been evaluated. Those systems and capacities need to be tied in with disease status to determine how Alaska fares relative to the rest of the nation. Health outcomes also need to be identified to determine where we could be. Once the systems, services, and capacities are evaluated, and the health outcomes are identified, a plan will be developed. The Steering Committee hopes to create a package that will allow policy makers to make decisions and pass legislation that will have the greatest impact based on health status, rather than on special interests, special opportunities, or prices. DR. NAKAMURA said the Alaska Public Health Improvement Plan is a significant and important process that requires the involvement of people with power, influence and knowledge, First, a Steering Committee was established, comprised of 35 individuals, including legislators. The process must be broad enough to identify the needs of communities and individuals, not those of the Division of public Health. The Steering Committee has formed partnerships with communities to ensure that true community needs are addressed. That process should be completed within two years. One community has health powers which allows that community to collect some funding on a tax basis to support health issues. No one knows whether specific communities can assume health powers, and to what degree. DEB ERICKSON, Health Program Manager in the Division of Public Health, DHSS, stated she has been coordinating the Alaska Public Health Improvement Process. The group received a $300,000 grant from the Robert Wood Johnson Foundation to fund staff support, and travel costs for the Steering Committee and a large workgroup who is conducting an assessment of the current system. MS. ERICKSON explained the project is divided into two phases. Assessment of the current system will occur during the first phase, which should be complete in six to eight months. Information is being gathered on the resources in the system, the rules, responsibilities and authorities, and the different players in the system. The focus of the second phase will be to determine what capacities will be needed in the public health system in the future, what the roles, responsibilities, and authorities of the different players should be, and identifying any necessary legal changes that need to be made to support that system. MS. ERICKSON said the three communities that were funded by the Kellogg Foundation are Fairbanks, the communities on the Kenai Peninsula, and Sitka. Those communities are working through the two-phase process at the local level and that information will be integrated in the state level process. Number 250 CHAIRMAN WILKEN asked who is involved from the Fairbanks community. MS. ERICKSON answered some of the key members are Rick Solie, Ellen Ganley, and Cheryl Kilgore. CHAIRMAN WILKEN asked if they are participating as representatives of groups. MS. ERICKSON replied people from the hospitals and health care sector have been very involved, and that the Public Health Nursing Center has been helping to coordinate the application process. CHAIRMAN WILKEN questioned whether the group of people is part of an agency or the Borough. MS. ERICKSON said there is a workgroup that is working with the Borough Assembly. The Assembly is considering passing a resolution in support of the process and is looking at being the funding agency for the grant. CHAIRMAN WILKEN asked if that same type of membership applies to Sitka and the communities in Kenai. MS. ERICKSON said yes, they are community coalitions and not specific organizations. CHAIRMAN WILKEN questioned whether the money flows directly to those groups, or through the state. MS. ERICKSON said the money is going directly to the communities from the Kellogg Foundation. DR. NAKAMURA explained all communities were invited to express an interest in partnership in this process by the Kellogg Foundation. Originally 30 communities were interested, but the application process was a year-long, time-intensive process, during which time a number of communities dropped out. The Foundation determined who was eligible. CHAIRMAN WILKEN asked where, on the process chart, would suggestions for new legislation be considered. DR. NAKAMURA said that will occur at the end point of the process. Throughout the process, public health law experts will be consulted to give guidance as to what other states have established and what issues should be addressed. SENATOR LEMAN noted that he has introduced SB 205 which pertains to the issue of health and safety self-audits. The Legislature passed the environmental audit part of the program last year. He believes the health and safety self-audits and environmental self-audits may have some affect on public health concerns. He encouraged the working group to look at that legislation and inform him of any concerns it may have. Number 335 MS. ERICKSON asked if the bill will increase accountability in the system and identify performance and outcome measures. SENATOR LEMAN answered the bill provides two incentives, limited immunity and limited privilege, to individuals and companies who audit their own operations and make required changes based on the audit results. DELISA CULPEPPER, representing the Alaska Public Health Association (APHA), made the following statements. The APHA represents about 200 public health professionals statewide, and has been working toward an organized public health plan for the past 11 years. It is pleased to be engaged in a formal process that will lead to a more structured view of public health needs in the state. It is increasingly important, during these times of increasing accountability and downsizing, that the APHA be engaged in determining the most effective public health activities. A clear and prioritized public health policy needs to be determined, along with a way to track progress. Some of the functions and activities that need to be addressed and prioritized are epidemic prevention, protecting the environment - housing, food, and water, promoting healthy behaviors and healthy public policy, monitoring the health conditions of the population, mobilizing communities to action around health issues, and training specialists and investigating and preventing disease. Alaska needs to create an infrastructure that will reflect those activities for the future. Number 391 CHRISTINE HUSS testified as a member of Healthy Communities in Kenai. Healthy Communities was a recipient of the Turning Point grant from the Kellogg Foundation. In the early 1990's a group formed to find funding sources for health insurance for people in Kenai communities. That goal did not carry through, so the group developed a program to look at all of the health needs of the community. One of the group's objectives is to develop new indicators. The group has promoted many new programs on the Kenai Peninsula. One apparent problem is the need to expand the public health facilities in the area. The current space is inadequate and prevents some services from being adequately provided. Number 418 JERRY NEAR, representing Healthy Communities, gave the following testimony. All communities are beginning to foresee the need to take responsibility for the assumption of various community needs, in view of pending budget constraints. A community foundation was recently formed and incorporated as a 501(c)(3) entity so that individuals can donate to the community and designate what the funds are to be used for. He informed committee members that he and Representative Gary Davis have put together a preliminary draft of a bill that deals with intestacy. Under this proposal, if heirs cannot be located, property will be held by the state for five years and then distributed to the various communities with foundations. The intent is to turn estates back to communities to be used as a resource for programs. Number 453 CHAIRMAN WILKEN asked how the money from the Turning Point grant will be used, and how it flows into the statewide effort. MR. NEAR said Healthy Communities has prepared a budget time line that encompasses a three year period. The money will be used to hire consultants. to take care of meeting costs, to pay for travel, and to pay some direct office expenses. The budget is still in the design phase. CHAIRMAN WILKEN asked what the end product will look like. MS. HUSS answered that their goal for the next year is to do an assessment of community needs which they hope to do by developing initiative teams to do the studies. She added most of the people working on this project are volunteers. CHAIRMAN WILKEN asked if Health Communities will be interacting with those involved from Fairbanks and Sitka. MR. NEAR said those people will meet with Healthy Communities, as well as with other community representatives around the nation. CHAIRMAN WILKEN asked what other states are undertaking such a project. DR. NAKAMURA said the State of Washington has been at this process for about eight years and is not quite finished. Washington participants have offered guidance to Alaska but Alaska is approaching its public health project in a different manner. MS. ERICKSON pointed out that originally 47 states admitted applications to the Foundation to fund similar projects; 14 were funded. The Foundations are supporting these projects because the public health community nationwide is recognizing the changing nature of health problems that affect communities, other health care systems, welfare reform, political climates, and increased recognition of the need for more local control and personal responsibility. This process will allow everyone to review what steps the public health system has taken over the last 50 years and what improvements need to be made for the next century. She thought Alaska will review parts of other states' models for the purpose of comparison, but believed that other states will eventually look to Alaska's redeveloped system as a model. CHAIRMAN WILKEN asked if the State of Washington has developed standards of measurement to determine whether any progress has occurred, and whether Alaska's group has discussed using similar standards. DR. NAKAMURA said he wants the state to know what is available by way of health systems and services and to feel comfortable in knowing what the capacity of those systems are and how they impact the things we read about in the newspaper: the number of accidental deaths, homicides, suicides, environmental issues, etc. He noted this process is energy intensive. He is concerned that if the goals are not achieved at this go-around, it will take a lot of convincing to get people to re-enter this process for a second time. Throughout this process the group needs the continued commitment and participation of the Legislature. CHAIRMAN WILKEN indicated he would like to see the development of standards of measurement in Box 5 on the process chart. He also suggested including the word "legislation" in Box 5. Number 520 CHAIRMAN WILKEN asked if Alaska's birth rate is increasing or decreasing. DR. NAKAMURA answered it is decreasing, as it is nationwide. CHAIRMAN WILKEN asked how Alaska compares nationwide. DR. NAKAMURA offered to provide that information at a later date. CHAIRMAN WILKEN inquired about the status of the new laboratory in Anchorage. DR. NAKAMURA stated DHSS is still in the process of determining the scope of the laboratory and taking into account the services the state will need over the next 50 years. He believes the laboratory will be a focal point of excellence for Alaska. CHAIRMAN WILKEN asked about the Life Alaska group. DR. NAKAMURA explained that Life Alaska provides human tissue services. DHSS recognizes the value of offering such a service in conjunction with its medical examiner lab. DHSS is reviewing Life Alaska's needs in conjunction with the other services as the priorities for the laboratory are being developed. SENATOR LEMAN noted that he has been very impressed with the Crime Lab. He encouraged Dr. Nakamura to think about designing the new facility with the understanding that it may need to be expanded in the future to consolidate all laboratory services in one location. DR. NAKAMURA maintained that possibility is being considered, and not only in the event that state services are consolidated, but also so that duplication with non-state services does not occur. CHAIRMAN WILKEN thanked Dr. Nakamura for updating the committee. SCR 14 - PARITY FOR MENTAL HEALTH TASK FORCE SENATOR LEMAN moved to adopt CSSCR 14(HES), version K. There being no objection, the motion carried. TAPE 98-11, SIDE B CHAIRMAN WILKEN explained version K incorporates the five amendments adopted at the previous meeting. SENATOR LEMAN referred to item #1 on page 2, lines 7-8, and expressed concern that the current phrase presumes that discrimination against people with mental disorders is occurring in health insurance policies. He maintained that if the word "discrimination" is understood to mean differences in policies then its use is legitimate. CHAIRMAN WILKEN asked Senator Leman if his concern is taken care of in the paragraph above which charges the Task Force with defining the four different classifications. SENATOR LEMAN maintained that insurance policies are designed to discriminate among users because certain classes of users are higher risks, such as teenage drivers, therefore such discrimination is appropriate. SENATOR GREEN suggested using the phrase "review health insurance coverage of persons with mental disorders," because the concern is coverage rather than policies. SENATOR LEMAN thought the existing language is acceptable as long as the intent is clear. CHAIRMAN WILKEN suggested deleting lines 7-8 altogether to eliminate the suggestion of discrimination. WALTER MAJOROS, Executive Director of the Alaska Mental Health Board, stated his interpretation of the word "discrimination" would mean the Task Force is to study differential treatment of people with mental illnesses versus people with physical disorders, which is the heart of the issue. CHAIRMAN WILKEN asked if that is taken care of on line 10, with the phrase, "special emphasis on parity, ...." SENATOR GREEN thought the first "WHEREAS" clause contains that intent. SENATOR GREEN moved to delete lines 7-8 on page 2. MR. MAJOROS stated the issue is one of clarity, and that if the Legislature wants the Task Force to look at the issue of differential treatment, lines 7-8 provide that mandate. CHAIRMAN WILKEN suggested adding the words "differential treatment" to lines 9-11. SENATOR LEMAN suggested using the language, "differential treatment in health insurance policies between coverage for mental and physical disorders" because it will clarify the heart of the issue. MR. MAJOROS felt that language would be acceptable. CHAIRMAN WILKEN announced the motion to delete lines 7-8 on page 2 carried with no objection. SENATOR LEMAN moved to create a new item #1, beginning on line 7, to read, "differential treatment in health insurance policies between coverage for physical and mental disorders;". There being no objection, the motion carried. SENATOR LEMAN moved to pass CSSCR 14(HES) as amended out of committee with individual recommendations and its accompanying zero fiscal note. There being no objection, the motion carried. CHAIRMAN WILKEN announced a Joint House and Senate HESS committee meeting is scheduled at 8:15 a.m. on Wednesday to hear about the Education Week "Report Card for Alaska" and the Traumatic Brain Injury Act. At 9:00 a.m. on Friday, the committee will hear a brief presentation from President Kelly of the University of Alaska Board of Regents, and at 10:00 will discuss SB 203. He adjourned the meeting at 10:10 a.m.