SENATE HEALTH, EDUCATION AND SOCIAL SERVICES COMMITTEE April 8, 1998 9:08 a.m. MEMBERS PRESENT Senator Gary Wilken, Chairman Senator Loren Leman, Vice-Chairman Senator Lyda Green Senator Jerry Ward Senator Johnny Ellis MEMBERS ABSENT None COMMITTEE CALENDAR SPONSOR SUBSTITUTE FOR SENATE BILL NO. 203 "An Act relating to phonemic awareness, letter-sound correspondence, word-attack skills, spelling, vocabulary, use of decodable text, reading comprehension strategies, and testing for basic reading and reading comprehension skills in the public school system." PASSED CSSB 203(HES) OUT OF COMMITTEE SENATE BILL NO. 160 "An Act relating to registration, inspection, and testing relating to radiological equipment in dentists' offices." PASSED CSSB 160(HES) OUT OF COMMITTEE SENATE BILL NO. 272 "An Act relating to children in need of aid matters and proceedings; relating to murder of children, criminally negligent homicide, kidnaping, criminal nonsupport, the crime of indecent exposure, and the crime of endangering the welfare of a child; relating to registration of certain sex offenders; relating to sentencing for certain crimes involving child victims; relating to the state medical examiner and reviews of child fatalities; relating to teacher certification and convictions of crimes involving child victims; relating to access, confidentiality, and release of certain information concerning the care of children, child abuse and neglect, and child fatalities; authorizing the Department of Health and Social Services to enter into an interstate compact concerning adoption and medical assistance for certain children with special needs; authorizing the establishment of a multidisciplinary child protection team to review reports of child abuse or neglect; relating to immunity from liability for certain state actions concerning matters involving child protection and fatality reviews and children in need of aid; relating to persons required to report suspected child abuse or neglect; relating to foster care placement and to payment for children in foster and other care and the waiver of certain foster care requirements; relating to the access to certain criminal justice information and licensure of certain child care facilities; amending Rule 218, Alaska Rules of Appellate Procedure; amending Rules 1, 3, 15, 18, and 19, Alaska Child in Need of Aid Rules; and providing for an effective date." HEARD AND HELD SENATE BILL NO. 266 "An Act relating to Medicaid coverage for certain eligible children and pregnant women; relating to primary care case management and managed care services as optional services and to premiums and cost-sharing contributions under the Medicaid program; establishing the Healthy Families Alaska program; and providing for an effective date." HEARD AND HELD PREVIOUS SENATE COMMITTEE ACTION SB 203 - See HESS minutes dated 2/20/98, 2/23/98, 3/23/98, 4/1/98. SB 266 - No previous Senate Committee action. SB 160 - See Labor and Commerce Committee minutes dated 3/5/98 and 4/2/98. SB 272- No previous Senate Committee action. WITNESS REGISTER Ms. Mel Krogseng Staff to Senator Taylor Alaska State Capitol Juneau, Alaska 99801-1182 POSITION STATEMENT: Testified for sponsor of SSSB 203 and SB 266 Dr. Shirley Holloway, Commissioner Department of Education (DOE) 801 West 10th Street, Suite 200 Juneau, Alaska 99801-1894 POSITION STATEMENT: Commented on CSSB 203 Barbara Thompson, Director Teaching and Learning Support Department of Education 801 W 10th St., Suite 200 Juneau, Alaska 99801 POSITION STATEMENT: Addressed fiscal note for CSSB 203 Dan Anderson POSITION STATEMENT: Supports SB 160 Kate Coleman Radiological Health Specialist Department of Health and Social Services (DHSS) P.O. Box 110601 Juneau, Alaska 99811-0601 POSITION STATEMENT: Opposed to SB 160 Catherine Reardon, Director Division of Occupational Licensing Department of Commerce and Economic Development P.O. Box 110806 Juneau, Alaska 99811-0806 POSITION STATEMENT: Commented on SB 160 Representative Fred Dyson Alaska State Capitol Juneau, Alaska 99801-1182 POSITION STATEMENT: Presented SB 272 Brant McGee Office of Public Adocacy Department of Administration 900 W 5th Ave., Suite 525 Anchorage, Alaska 99501-2090 POSITION STATEMENT: Supports and presented SB 272 Del Smith Deputy Commissioner Department of Public Safety P.O. Box 111200 Juneau, Alaska 99811-1200 POSITION STATEMENT: Supports and presented SB 272 Susan G. Wibker Assistant Attorney General Department of Law 1031 W 4th Ave., Suite 200 Anchorage, Alaska 99501-1994 POSITION STATEMENT: Supports and presented SB 272 Dean Guaneli Chief Assistant Attorney General Department of Law P.O. Box 110300 Juneau, Alaska 99811-0300 POSITION STATEMENT: Supports and presented SB 272 Russ Webb Deputy Commissioner Department of Health and Social Services P.O. Box 110601 Juneau, Alaska 99811-0601 POSITION STATEMENT: Supports and presented SB 272 Jay Livey Deputy Commissioner Department of Health and Social Services P.O. Box 110601 Juneau, Alaska 99811-0601 POSITION STATEMENT: Supports and presented SB 266 Bob Labbe Division of Medical Assistance Department of Health and Social Services P.O. Box 110660 Juneau, Alaska 99811-0660 POSITION STATEMENT: Supports and presented SB 266 ACTION NARRATIVE TAPE 98-32, SIDE A Number 001 CHAIRMAN WILKEN called the Senate Health, Education and Social Services (HESS) Committee to order at 9:08 a.m. Present were Senators Leman, Ward, Green, Ellis, and Chairman Wilken. The first order of business before the committee was SB 203. SB 203 - PHONICS CURRICULUM SENATOR GREEN moved to adopt CSSB 203(HES), version C, as the working document of the committee. SENATOR ELLIS objected. CHAIRMAN WILKEN described the changes made to the committee substitute, which was the result of incorporating input from interested parties, as follows. First, the purpose was expanded in Section 1. Second, the bill now requires, rather than encourages, school districts to adopt a balanced approach to language arts instruction that includes intensive systematic phonics. Third, language was included to clarify that CSSB 203 is part of the effort to begin preparing students for the high school exit exam. Fourth, mandatory tests for first graders was eliminated in Section 2, however, students in second and third grades will be tested. Fifth, language on page 2, line 6, requires testing to occur in the fall. On line 17, the provision that required schools to use phonics instruction if 25 percent or more of their students tested at or below the 25th percentile has been changed and now requires school districts to establish an alternative program that includes specific instructional methods for any student who scores below the 25th percentile on the nationally normed test. Language on line 24 requires DOE to compile a list of nationally normed tests. Finally, language on line 4 requires that a nationally normed test be used instead of an assessment developed by DOE. Number 086 SENATOR LEMAN stated language on page 2, line 11, references first graders, which may no longer be consistent with line 4. CHAIRMAN WILKEN noted lines 5 and 6 allow a first grader to be tested if a teacher believes that student may need additional help. Number 099 SENATOR ELLIS asked if a new fiscal note was submitted for the committee substitute. CHAIRMAN WILKEN said no. SENATOR ELLIS asked that the committee request a new fiscal note from DOE. CHAIRMAN WILKEN agreed. SENATOR ELLIS maintained that if a revised fiscal note is not requested, he would have to consider this bill an unfunded mandate because of the new requirements. SENATOR ELLIS withdrew his objection to adopt CSSB 203(HES), version C. Number 123 MEL KROGSENG, staff to Senator Taylor, sponsor of SSSB 203, reported that Senator Taylor reviewed the proposed committee substitute and he concurs with the changes. Also, Senator Taylor wanted the committee to know he appreciates the time it has spent on this piece of legislation. SENATOR LEMAN moved to report CSSB 203(HES) out of committee and then withdrew his attempt to move the legislation in order to hear testimony by teleconference. Number 140 CHAIRMAN WILKEN took teleconference testimony. COMMISSIONER SHIRLEY HOLLOWAY, Department of Education, stated she applauds the goal of CSSB 203, to ensure that all students leave the third grade as independent readers, but she again asked legislators to look at a comprehensive assessment plan. DOE believes such a plan is critical to provide the right building blocks for student success throughout the K-12 program. An entry and exit exam will not be adequate, especially if those exams consist of only one type of test. School districts need to use multiple kinds of assessments tied to what we want children to know and be able to do, and to test what is taught. Norm referenced tests are already given in Alaskan schools, in grades 4, 8, and 11, and students complete a writing assessment in grades 5, 7, and 10. DOE has been advocating, in terms of a comprehensive assessment, to keep the existing assessments and add a developmental profile when a student enters school at the age of five or six. The developmental profile would be done with the parent, and would look at a child's physical, social, intellectual, and emotional development to design a program based on the strengths and weaknesses that each child brings to the school system. DOE has also been advocating benchmark testing based on the standards for ages 5-7, 8-10, 11-12, and then the qualifying high school exam. Norm referenced tests are the least valued by teachers in our school system because those tests are not tied to what is being taught. DR. HOLLOWAY again asked legislators to reconsider tying the assessments to the standards because it is inconsistent to expect high school students to be successful on a qualifying high exam based on state standards when they entered the system being tested using a norm referenced test with nothing in between. She asked legislators to consider designing a law that requires testing at specific intervals, against academic standards in the areas of math, reading, and writing, and that intervention programs be required for all children. Nationally normed tests are built on a bell-shaped curve and are designed so that 25 percent of students score in the top and bottom quartiles. Testing should be done at primary, intermediate, middle school and the high school levels, and students' literacy skills need to be tracked throughout the public school experience. Testing is a critical aspect of a sound educational system, however testing is a waste of money unless the results are used to fix the problems they discover. Number 213 SENATOR GREEN asked Commissioner Holloway whether 90 percent of students could score in the bottom quartile of a nationally normed test if they were unprepared for the test. COMMISSIONER HOLLOWAY said the test is designed with the expectation that 50 percent of students will score above, and 50 percent will score below, the middle, and a good test sample will have 25 percent at either end. Commissioner Holloway said DOE wants all students to reach an independent reading level at the third grade level, and DOE knows the skills that must be learned to do that. Those skills should be the standards that students are tested against so that the tests drive instruction on a consistent basis, not only in the fall using one norm-referenced test. CHAIRMAN WILKEN remarked the committee wants schools to be able to find out whether a first, second, or third grader can read a book. He commented he does not approve of using a test that sets up 25 percent of students to fail it and automatically fall into a new system set up by the Legislature. The committee wants some sort of a benchmark used to determine whether a child can read "Dick and Jane." He stated the purpose of the test would simply be to learn whether a child is entering school with basic reading skills. He maintained this issue is being described as much more difficult than it is. COMMISSIONER HOLLOWAY stated it is her understanding that norm referenced tests are just that, norm referenced so that they test the normal distribution of children. She maintained a developmental profile would determine both expressive and receptive language development on day one so that the school system could begin working with that child to address his/her needs. If children enter school with a small vocabulary and a low comprehension rate in terms of their basic language skills, they are already set up to have problems. Steps need to be taken in kindergarten to enrich and enhance the language development of those students. Formalized assessment can take place down the road to be used as benchmarks. SENATOR ELLIS asked if the term "reading comprehension strategies" in line 2 of the title, is another phrase for the whole language approach to reading instruction. Also, SENATOR ELLIS stated page 2, line 18, contains a reference to "a governing body." He asked why that phrase was used instead of local school boards, or the state school board, and who will decide which governing body shall be used. SENATOR GREEN replied reading comprehension has to do with the ability to read and get meaning from what was read; to answer questions and discuss the idea of the reading material, versus being able to identify words, letter groups, or sound out words via phonetic instruction. SENATOR ELLIS commented the title refers to "phonemic awareness," which sounds like a phrase describing the phonics approach to reading instruction, and "reading comprehension strategies," which sounds like a phrase to describe the whole language approach. He asked if the sponsor has combined the two approaches in the titleto provide for a balanced approach. SENATOR GREEN explained "reading comprehension strategies" does not necessarily describe the whole language approach; it is the goal of any form of language instruction. SENATOR ELLIS asked whether phonemic awareness is the same as phonics. SENATOR GREEN stated many reading instruction approaches are phonics-based which means students learn to put words together by learning the sounds of the letters. SENATOR ELLIS asked if the title of the bill then excludes whole language as an instruction method. SENATOR GREEN answered it does not because word attack skills, spelling, vocabulary, use of decodable text, and reading comprehension strategies would be used in whole language instruction as well. Number 325 SENATOR ELLIS remarked his concern is that a balanced approach be used, and that no one method be excluded. He again asked for clarification of the governing body term. CHAIRMAN WILKEN replied that is the Legal Services term for school board. SENATOR ELLIS asked if it is the local school board rather than the state school board. CHAIRMAN WILKEN clarified it is the local school board. There being no further discussion on the bill, SENATOR LEMAN moved to report CSSB 203(HES) from committee with individual recommendations with a request for a revised fiscal note from DOE. Number 338 SENATOR ELLIS objected because no accurate fiscal note was available. BARBARA THOMPSON, Director of Teaching and Learning Support, DOE, commented the fiscal note submitted was based on the last version of the bill. She noted she received a copy of the new committee substitute late yesterday afternoon and did not have time to prepare a new fiscal note. The new committee substitute does contain provisions that will impact the cost. SENATOR ELLIS maintained his objection. The motion to pass CSSB 203 from committee carried with Senators Green, Leman, Ward, and Leman voting for the motion, and Senator Ellis against. CHAIRMAN WILKEN announced the motion to pass CSSB 203, with a revised fiscal note, to its next committee of referral, carried. SB 160 - DENTAL RADIOLOGICAL EQUIPMENT CHAIRMAN WILKEN informed committee members the version of the bill being addressed is CSSB 160 as amended in the Senate Labor and Commerce Committee. MEL KROGSENG, staff to Senator Taylor, sponsor of the measure, read Senator Taylor's sponsor statement for the record. She then summarized the bill as follows. SB 160 changes the procedures for inspecting and registering dental radiological equipment. Current DHSS inspections have been erratic and are unnecessary because the incidence of x-ray overexposure is so insignificant as to be non- existent. Some states have no such requirement. SB 160 will transfer those duties to the Board of Dentistry. Inspection activities will be done by the private sector, and equipment owners will be required to provide documentation to the board proving that an inspection was done by a qualified individual within the previous five years. Trained dental supply company technicians are far more qualified to perform such inspections than representatives from DHSS. SB 160 establishes criteria for inspector qualification. The civil penalty for non-compliance, to be levied by the Board of Dental Examiners, is a fine not to exceed $5,000 per violation. MS. KROGSENG explained DHSS was without a technician for several years delaying some inspections for seven years or more. She noted Dan Anderson, a technician to Dr. Helmberg (ph), was available on teleconference to answer technical questions. Number 394 KATE COLEMAN, Radiological Health Specialist for DHSS, stated she is one of two such specialists within DHSS. She made the following comments. This week is national public health week. Alaska could be diminishing the capacity of public health by diluting the regulation of dental x-ray. On the international radiation protection scene, the International Commission of Radiation Protection would like to lower the exposure to occupationally- exposed radiation workers. SB 160 will remove government regulation aimed at keeping that exposure as low as reasonably achievable. Questions about health effects and risks have been raised and answers are difficult to quantify, but most people are concerned about x-ray. MS. COLEMAN read the following excerpts from a paper by Dr. Stuart Smith of the UCLA School of Dentistry. "While the risks from dental radiography is certainly small compared to other risks that we assume in our daily lives, such as driving, smoking, and eating fatty foods, there is no basis to assume that it is zero. Prudence suggests we should be cautious because of the large number of people that receive dental x-rays. Recent studies suggest the lifetime cancer risk from exposure to low levels of ionizing radiation may be greater than previously estimated. The International Commission for Radiation Protection data show that estimated risk has increased four-fold. Cancers other than leukemia typically start to appear ten years after exposure and remain in excess for the lifetime of the exposed individuals." MS. COLEMAN provided the following information. There is an association with leukemia and radiation, the risk to children being greatest. Thyroid cancers increase in humans following exposure to ionizing radiation. About ten percent of individuals with thyroid cancer die from that disease. A case controlled study has shown an association between brain cancer and previous medical or dental radiography. Several studies have shown an association between salivary gland cancer and dental radiography. As long as there is a risk, it needs to be monitored. DHSS is responsible for protecting public health. SB 160 will create an absence of checks and balances. The credentials of inspectors contained in the bill are lax and do not address whether these individuals are qualified to calculate skin dose, film quality, to operate radiation measuring equipment, and to perform shielding calculations and scatter radiation measurements. A state certification program for inspectors should be in place to keep the standards high. She questioned whether the Board of Dental Examiners will provide the inspection procedures. The majority of problems in dental x-ray are a result of film processing and operator error. SB 160 creates duplicate functions within two state agencies. The type of organization proposed by SB 160 is unusual by any state's standards since the expertise of the professional board is so distant from radiation protection. It is wasteful to establish parallel lines of expertise in two separate agencies. AS 18.60.475(a)(7) authorizes DHSS to assist other state agencies in performing functions that require radiation expertise. This authorization shows cognizance of the unique qualifications necessary to understand and implement a responsible radiation control program. Alaskan citizens will not benefit from the passage of SB 160. Number 461 CHAIRMAN WILKEN stated he has trouble believing that dentists are not concerned about risks to people who work for them and would not take this on as part of their responsibilities. He noted he has received quite pointed comments from several dentists about how the current program does not work. MS. COLEMAN pointed out 25 percent of her job is radiological equipment testing. Last May, DHSS hired an additional inspector who inspects full time. She and the other inspector plan to inspect all of the facilities in the state on a three-year basis. She noted this is the first time the state has hired two inspectors, so they have actually just begun this program. Number 479 CATHERINE REARDON, Director of the Division of Occupational Licensing (DOL), indicated that DOL provides staff support to the Board of Dental Examiners who will be given the responsibility of ensuring that private inspections of equipment take place under SB 160. She stated from her perspective, she believes this bill originated as the result of frustration on the part of some dentists about paying a $50 per year per tube fee to DHSS for its radiologic inspection program. The frustration was due to the fact that state officials were not inspecting some dentists' radiological equipment for significant periods of time. Dentists have always had the option to hire private inspectors but they still had to pay the $50 fee. DHSS has not had enough staff to visit and inspect all dental offices, but it may now have that ability. Ms. Reardon expressed two concerns. First, she questioned whether the current system could be improved and stay within DHSS since the expertise for the inspections is within DHSS. The Board of Dental Examiners does not have detailed knowledge about radiologic health issues. The Board opposed the original version of SB 160 which differed significantly from the committee substitute in that it would have required the Board to actually do the inspections. The committee substitute leaves the inspection to the private sector. Regarding the qualifications of the private sector inspectors, she stated she was unable to determine whether the training requirements listed on page 1 of the bill would be sufficient. She pointed out rural dentists will need to pay the transportation cost of inspector visits. She indicated the DOL fiscal note reflects more staff time during the first two years, with a decline in staff assistance in the following years. She concluded her testimony by asking again whether it might be better to improve and fix the existing system. Number 529 SENATOR GREEN asked how long the current program has been in place. MS. COLEMAN informed committee members that Sid Heidersdorf originally came to Alaska in the 1960's as part of the U.S. Public Health Service and performed this function until he was employed by the state government in the 1970's. SENATOR GREEN asked if he worked as a private inspector. MS. COLEMAN stated he was a government employee who retired in the early 1990's. SENATOR GREEN said she would like to confirm whether there have been no inspections or sporadic inspections during the last 10 years. Number 542 MS. COLEMAN replied Mr. Heidersdorf was in her position, and spent about 25 percent of his time doing radiological inspections. Because he was the only state employee doing this work, he circulated film to dentists through the mail to be exposed and then he determined the radiation level. He prioritized which places to visit depending on the radiation levels, therefore he did not visit some places more frequently than every seven years. SENATOR GREEN asked if the same procedure continued after Mr. Heidersdorf's retirement. MS. COLEMAN explained there have been gaps in filling the radiological specialist position because it is difficult to find people with the appropriate qualifications. She offered to send committee members the list of DHSS inspections of dental facilities which is on a data base. SENATOR GREEN commented it is not too hard to see why a certain degree of frustration exists among equipment owners. MS. COLEMAN said yes, but that there is also a big misunderstanding about DHSS's function versus a repair persons'. DHSS does not do repairs, service people do. Service people do actual electrical work on the equipment. DHSS staff are health physicists. They take measurements with radiation detection equipment from the operator's point of view and the skin of the patient's point of view. They look at the film processing to determine where problems may exist and why a practitioner might have to use higher radiation levels, which is usually a processing problem. Under CSSB 160, technicians will not be looking at processing. CHAIRMAN WILKEN asked how many tubes are located in the state. MS. COLEMAN replied there are about 250 facilities; the average facility has three tubes. CHAIRMAN WILKEN asked if that meant three x-ray units. MS. COLEMAN said that was correct. DAN ANDERSON provided the following summary of Dr. Helmberg's written testimony via teleconference from Fairbanks. The first paragraph states that dentists themselves have been trained about radiation dangers which is usually a problem caused by sudden changes in film density, therefore dentists will not ignore the problem. Dr. Helmberg also questioned how, if a person can get cirrhosis of the liver from drinking alcohol, one could calculate the risk of getting it from drinking one glass of wine every New Year's Eve. He compared the dental x-ray danger to the person who drinks one glass of wine per year. As for DHSS's most recent concern about the financial hardship to remote dental facility owners, Senator Taylor has already put this concern to rest. Medical equipment technicians are regularly called upon to serve other medical and dental equipment in private and government facilities throughout the state. There being no further discussion on CSSB 160, SENATOR LEMAN moved to report CSSB 160 from committee with individual recommendations. SENATOR ELLIS objected. The motion carried with Senators Green, Leman, and Wilken voting for the motion, and Senator Ellis voting against it. CHAIRMAN WILKEN announced CSSB 160(L&C) was moved to the Senate Finance Committee. SENATOR ELLIS asked if a fiscal note accompanied the bill. CHAIRMAN WILKEN stated a fiscal note of about $12,000 was attached. TAPE 98-32, SIDE B SB 272 - CRIMES AGAINST CHILDREN/FOSTER CARE REPRESENTATIVE FRED DYSON joined the committee to testify on SB 272, and introduced his assistant, Lisa Torkelson. Representative Dyson noted they have been working on this issue as part of the Governor's Task Force since last August. A portion of HB 375 responds to changed federal legislation, another portion contains recommendations to problems identified by the task force and tragedies that occurred during the past year. His office and the Administration have spent at least 50 hours thrashing through this bill since the legislative session began. The House HESS committee passed out CSHB 375(HES) which represents the agreement between his office and the Administration. Some of the criminal provisions as well as some of the Child Support Enforcement Division provisions were removed from the committee substitute to more narrowly focus the bill. He urged committee members to consider the House HESS Committee version of HB 375. He informed the committee he plans to meet with Administration staff to hash out a few more details before the bill is heard in the Senate Judiciary Committee. Number 552 CHAIRMAN WILKEN stated the effort behind the development of this bill has included staff from each floor of the Capitol Building. He asked those who would be presenting the bill on behalf of the Administration to follow Representative Dyson's lead and discuss the current status of the legislation so that the committee can begin to tie up loose ends. BRANT MCGEE, Director of the Office of Public Advocacy, DEL SMITH, Deputy Director of the Department of Public Safety, SUSAN WIBKER, Assistant Attorney General with the Department of Law, RUSS WEBB, Deputy Commissioner of the Department of Health and Social Services, and DEAN GUANELI, Chief Assistant Attorney General of the Criminal Division of the Department of Law, joined committee members at the table to present SB 272 on the part of the Administration. MR. MCGEE presented the following brief history of this issue. The Office of Public Advocacy was the agency that brought to the public's attention last fall five cases that dramatized the ineffectiveness of the child protection system in those cases, as well as hundreds of others. The Office of Public Advocacy had court permission to release the facts of those cases which shed light on what had previously been a very secretive system, and secretive by law. The fact is, the system utterly failed those children. As the result of rising public concern, a Child Protection Task Force was formed. It included a lot of people who worked at an intensive series of meetings throughout the fall. All of the state agencies in the system were represented, as well as social work non-profit organizations, judges, guardians ad litem, Representative Dyson and other legislators. The task force discussed policy and resource questions; those issues are well presented in the child protection report. The task force then developed legislative recommendations based on real life, practical experience. SB 272 is the collective best thinking of dozens of experts in the field of child protection. MR. MCGEE discussed two of the basic themes contained in SB 272: time and accountability. SB 272 establishes time lines based more on a child's sense of time rather than an adult's. Two weeks, or six months can seem like a very long time to a young child. The time lines give a clear directive to all participants in the child protection system: the Division of Family and Youth Services (DFYS); parents; and the courts. The directive requires those participants to take action more quickly either to ensure that the child returns to a safe home or is permanently placed with a relative or other safe alternative. Changes in federal law require initiation of certain types of proceedings; SB 272 closes in the end points of that. The child protection system would have to deal with a case at the adjudication level within 120 days. Currently, those cases, because they are in the court system and involve multiple parties, take a very long time. It is not unusual for cases to last four to six years, and sometimes over ten years. Under SB 272, that will no longer happen. This bill has been nicknamed the "no-excuses bill." It establishes specific time lines and holds everyone involved accountable. DFYS will have to provide direct and timely services to the family to keep the family together and promote reunification. If those services are not successful, DFYS must make documented efforts to find a permanent safe home for the child. The bill preserves all legal safeguards in current law for parents, but parents will only have one year to get treatment and make the necessary behavioral or lifestyle changes that will allow them to safely parent their children. Parents can no longer wait for years to get treatment and they can no longer stop the legal process, or a termination trial, merely to start another treatment series. SB 272 requires the courts to conduct adjudication hearings within 120 days, and permanency hearings within one year, and decisions must be made at the trial and appellate court levels in a timely manner. Judges will no longer be able to treat children's cases as just another case. It prioritizes children's cases in court. Under federal law, DFYS will have to initiate termination proceedings if the child has been out of the home for 15 of the last 22 months. DFYS will have six months to initiate the termination trial itself. The judge has 90 days to issue a decision after the trial and the appellate court has 90 days to reach a decision after the case has been briefed. These requirements will dramatically shorten the lifespan of a case and will dramatically shorten the period of uncertainty and anguish that many children experience. Most importantly, this bill says to children that their interests are paramount. Children will no longer have to wait for years and years in foster care while their parents are given chance after chance to make changes in their lives. Mr. McGee urged the committee's swift and serious consideration of SB 272. Number 463 DEL SMITH stated his entire career, since the age of 18, has been in law enforcement, and he assumed when he began his career that the solution was always to build more jails to lock up criminals. His opinions have evolved since then. Ninety percent of chiefs of police surveyed believe that investing in children is a good crime prevention technique and he agrees. He stated it is common sense that victims of child abuse will have anger issues as they get older. In a recent case in Anchorage, an individual received a sentence of 115 years. The public record indicates that this individual was the victim of sexual abuse and other very unpleasant experiences during his childhood. That is not an excuse, but everything that can possibly be done to prevent crime should be, with an eye out for 15 years from now, or our society will be in substantially worse shape than it is now. The state cannot build enough jails or hire enough police to meet those needs. He strongly urged the Legislature to enact the provisions in SB 272. The law enforcement community views this bill as a crime prevention tool. He repeated it is time to get serious about what will happen in 15 or 20 years if abuse prevention measures are not implemented now. Number 435 SUSAN WIBKER informed committee members she is an assistant attorney general in the Anchorage office and does the human services cases, which are the child abuse and neglect cases. Both the Departments of Law and Health and Social Services asked her to work on this project, because, for one reason, she spent five years working in the Anchorage District Attorney's Office where she specialized in prosecuting child abuse cases. What she attempted to do in pulling this bill together was to use the recommendations of the team that both Brant McGee and Del Smith served on. In addition, several Supreme Court opinions came down that strongly recommended that Alaska's laws be changed because those laws were resulting in decisions that left children unprotected. Also, Congress just passed a law changing the way child protective service workers will practice with their cases. Some of those changes are drastic for social workers, one being the implementation of time lines. Cases will no longer be able to sit in the system for five or ten years anymore. For every case sitting in the system, there is a child languishing in a foster home or somewhere outside of their own home. SB 272 makes the child's health and safety the paramount concern, which is what will drive the system. If a child can go home, then DFYS will need to get the services in place to get that child home within one year to 15 months. If the level of violence in the family is so great that the child cannot return home, DFYS will have to find a permanent safe home for the child in the same amount of time. The time lines are important to the development of children. Children need to attach and bond in a place that they can call home where they know they will grow up. When that does not happen, children grow up with no attachments, no conscience, no ability to have empathy, and these are the homicidal children who commit violent crimes at very young ages. Research studies are showing that the way children are cared for at very young ages is directly related to how violent our streets are going to be later. MS. WIBKER explained one of the changes recommended by the federal law is that the system should not operate solely with the goal of preserving and reunifying the family which has been DFYS' mandate. At least half of the children who have died from abuse were reported to the child protection system but were left in, or returned too quickly to, dangerous homes. SB 272 prohibits leaving children in situations that involve a high level of violence. In other situations, the state is able to get involved early enough so that family preservation and reunification is the right goal, and it is the right goal for most of the children in the system. Those are the cases in which the treatment dollars spent are worthwhile. She repeated that the guiding force of the system will be the safety of the child. She asked committee members to please seriously consider the bill. Number 380 SENATOR LEMAN referred to Ms. Wibker's statement that in many cases, if the state intervenes early enough to change behavior, successful reunification can occur. He asked if SB 272 contains any provisions that allows groups, such as churches or other support structures other than the state, to help keep people accountable. He stated he has found that whether the problem is alcohol, substance abuse, or sexual misconduct, when people are accountable to others it helps reduce recidivism. He questioned whether SB 272 recognizes and/or encourages the use of churches or other groups instead of, or in addition to, state involvement. MS. WIBKER replied one of the items in the bill is the creation of a multidisciplinary team. One of the task force's recommendations was that information be shared more openly and that people from more disciplines be involved in the team that makes the decisions about a child. DFYS has been involved in forming those teams around the state. By working with child care providers, Alaska State Troopers, VPSOs, social workers, pediatricians, nurses, and others when there is a call of child abuse, teams can make decisions. That approach solves two problems: information is shared so that all involved know what the others are doing; and the expertise from people in many different disciplines will be used to help make the decisions rather than leaving the decision to one worker who is often isolated. SENATOR LEMAN questioned whether some team members can be people who are not part of the formal state system, but maybe ancillary to the state system, such as members of Big Brothers and Big Sisters. He stated he favors anything that can be done to enhance those relationships. Number 334 MR. MCGEE commented the task force spent a good deal of time talking about that possibility. He did not think there was anything in the bill that specifically addresses that concern. He stated SB 272 deals with the relatively small number of cases, eight percent, in which an investigation results in the filing of a petition. In the other 92 percent of cases, some of the allegations are determined to be unfounded, but it is obvious that the system falls down in the cases where evidence of family problems exists but not enough to warrant the filing of a petition. DFYS will form a family support unit to work with those kinds of families. The Office of Public Advocacy is supposed to help DFYS create a volunteer program to plug folks into a network, whether it be a church, school, or other community groups. Many of these folks do not have those attachments. Churches could help to arrange visitation with parents whose children are in custody. A lot of thought was given to the use of community resources on a policy level and a practical level, but the issue is not addressed in SB 272 because it primarily deals with the smaller fraction of cases. CHAIRMAN WILKEN noted he passed out, for the benefit of the committee, a document showing which legislators have worked on this whole issue and which legislators have picked up the ball in specific areas that need to be addressed. He also noted an audit of DFYS is in the committee packet. Number 301 DEAN GUANELI stated the primary thrust of SB 272 is civil child protection proceedings, to ensure that the child's best interests are paramount and that the timelines are shortened. Because abuse and neglect of children often spills over into criminal law, SB 272 contains criminal law provisions in those areas that the task force felt needed to be tightened. The bill makes a number of changes to the homicide law. Senator Halford introduced a bill that came to similar conclusions, adopted from many of the Governor's ideas. Senator Halford's bill recently passed the Senate so the changes to the homicide laws in SB 272 have already been addressed by the Senate. SB 272 also contains provisions to deal with neglect by parents that seriously jeopardizes children. Neglect will be an infraction so parents will not go to jail, but the provision will be a way to identify people who are passed out drunk time and again, or people with infants who have drugs in their homes. The provision will allow police officers to issue an infraction, notify DFYS, and provide the court the opportunity to order the person to treatment. It also holds a person criminally responsible if he/she leaves a child with a person who has previously abused the child and does so again. There are many situations in which one spouse is aware that the other spouse is abusing the child. Prosecutors find it very frustrating that they cannot take some action against the person who could have stopped the situation before a child died or was severely injured. He emphasized the criminal aspect of SB 272 is a small part of the bill; its main thrust is civil. Number 256 CHAIRMAN WILKEN commented it is obvious how important this issue is by the number of people working on it. He agreed with Mr. Smith's remark that we can build all of the jails we want, but the problem will not stop until it is addressed from the other end. He commended everyone who has taken up this effort. RUSS WEBB discussed the magnitude of the problem today. DFYS receives about 16,000 reports of child abuse or neglect each year. DFYS currently has about 1700 children in its custody in out-of- home care. DFYS will not be able to deal with the long term impact of this situation because children who are abused and neglected are 67 times more likely to become victimizers when they become juveniles or adults. Early intervention procedures must be established and SB 272 provides the tools to create those procedures. One of the key elements of today's discussion is that child protection is not any single agency's responsibility. It takes a team effort, involving not only government agencies but communities as well. This bill provides opportunities to use that teamwork more effectively, sharing information and working with communities. SENATOR ELLIS asked if the committee is in the process of formulating the committee's work plan on the child protection bill. CHAIRMAN WILKEN said a lot of people have already picked this issue up. He thought it was important to advise the committee of all of the different efforts taking place. Whether the Senate HESS committee does anything has yet to be determined. SB 266 - MEDICAID COVER/HEALTHY FAMILIES AK PROGRAM JAY LIVEY, Deputy Commissioner of DHSS, gave the following overview of SB 266 with Bob Labbe of the Medicaid Division and Pam Muth from the Division of Public Health. The Kennedy Hatch bill passed Congress last fall. That legislation made federal money available to states to expand health care coverage for children. Alaska's allotment from that bill is about $5.6 million. A state match is required which will amount to $2.2 million. DHSS has estimated that 23,000 children in Alaska are uninsured, of which about 11,500 are under the 200 percent poverty level. The 200 percent poverty level in Alaska amounts to $33,000 for a family of three. The federal requirements for implementation are as follows. The benefit package that is provided to children through this program must meet certain standards. It must contain a certain amount of prevention coverage for children and well-child care. Second, each child served must be screened for medicaid eligibility; Congress does not want medicaid eligible children to be on the child health program because of its higher federal match. Third, the federal law requires that any Indian Health Service (IHS) eligible children, who are also eligible for the new child health program, must be served by the child health program. Number 148 SENATOR GREEN asked if families with IHS coverage cannot be encouraged to use that coverage instead. MR. LIVEY replied DHSS could discuss the options available for health care with those families but the federal law requires that if an individual, who is eligible for IHS, wants to sign up for the child health program, that individual could not be refused based on the IHS eligibility. MR. LIVEY continued the overview. The state did get considerable flexibility in designing the new program. DHSS can decide the level of eligibility for the coverage and the delivery mechanism for the program itself. The state has the option of impementing the child health program through a medicaid expansion, a private coverage expansion, or a combination of the two. The Governor's bill uses a medicaid expansion and increases the level of eligibility to 200 percent of the poverty level for children and pregnant women. Currently, the Alaska medicaid program is at the federal minimum levels of coverage. DHSS chose to implement this program through the medicaid program for two reasons. First, the state will get a lot more bang for each general fund dollar spent, and second, an administration has already been established for the medicaid program that is serving 50,000 children. MR. LIVEY discussed a few other related points. The first is the relationship between child health expansion and welfare reform. The welfare reform program has helped people get off of public assistance and into jobs but many of those jobs do not provide health care coverage. The child health program will allow many of those families to continue their health care coverage while improving their job skills and prospects. DHSS does not want people to quit their jobs just to go back on public assistance to get health care coverage. Second, DHSS thinks the child health program is associated with the federal matching assistance percentage change. Last year, Congress changed Alaska's federal matching assistance percentage rate for medicaid which allows the state to collect more federal dollars for the medicaid program. That action freed up a lot of general fund monies in the budget. The federal matching assistance percentage rate change will be reviewed by Congress in three years. One of the cases made when Senator Murkowski got the bill through was that Alaska would use some of that money to expand health care coverage. DHSS was previously unable to do because of the expense. When the rate change comes up for reauthorization in three years, DHSS believes having health care expansion on the books will help the reauthorization effort. Third, DHSS chose to expand coverage for pregnant women in SB 272 at up to 200 percent of the poverty level for a couple of reasons. First, research has shown that prenatal care results in better birth outcomes. Second, it makes sense to insure the children before birth if coverage is going to continue afterward so that the children are healthy starting out. A state plan must be approved by the federal government by September 30 to guarantee the state's allotment of $5.6 million for this year. The federal government told DHSS the state plan must be submitted by July 1 so that it can be reviewed and enacted on by September 30, therefore legislation needs to pass during this session to give DHSS adequate time to prepare the plan. Number 029 MR. LABBE gave the following explanation of the sections of the bill, and action taken by the House HESS committee. The same bill was introduced in both bodies. Section 1 expands coverage under the medicaid program for children under age 19, and pregnant women, at up to 200 percent of the federal poverty level. Currently the state is providing coverage mandated under the federal program for pregnant women and children up to age 6, whose income is up to 133 percent of the poverty level, to children ages 6 to 14 living at up to 100 percent of the poverty level, and to children over 14 if their family receives cash assistance, which is at about 70 percent of the poverty level. TAPE 98-33, SIDE A MR. LABBE continued. DHSS had a choice of going with the private model or the medicaid model. If DHSS used the private model, it would have screened children first for medicaid eligibility. If eligible, those children would be placed on the medicaid program. DHSS's reason for choosing the medicaid model was largely influenced by the fact that more children could be served. Under the medicaid program and new child health block grant, American Indians and Alaska Natives can be eligible for medicaid, and medicaid will be the primary payer rather than IHS. SB 272 will allow IHS providers to bill the medicaid program for services to clients who are eligible for medicaid. The federal government will reimburse the state for 100 percent of those medicaid costs, so no general fund money will be involved. DHSS estimates that anywhere from 25 to 40 percent of the children who will be covered in this expansion will be Alaska Natives. If DHSS chose the private option, it would not get the 100 percent reimbursement, so state funds would have to be used. DHSS also looked at the fact that the child health program will serve a relatively small group and Alaska already has a large medicaid population so there will be some efficiency in pooling. Other provisions were added to the child health program to allow for continuous health care coverage for children for up to 12 months a year. Currently, medicaid eligibility is on a month to month basis which causes a certain amount of administrative confusion and interrupts treatment. DHSS has proposed up to six months of continuous eligibility so that if a child qualifies at the month of application, he/she would be covered for six months. That provision applies not only to the new group but to the entire child medicaid population. MR. LABBE stated the third section of the bill contains language to allow the state to cover, as a medicaid service, targeted case management, a service for pregnant women and children under age 5, in an effort to support the Healthy Families Program. DHSS does not plan to provide that service in the short run but it wants to have the authority to reimburse the Healthy Families Program for medicaid eligible children that it serves. A number of states have used a similar provision as a refinancing vehicle. DHSS also added a section for comprehensive pregnancy related services in an effort to help cover services of direct entry midwives which has been taken care of in another bill. Section 4 amends the current statute to allow DHSS to do managed care without getting a federal waiver. DHSS has had authority to do a managed care model since the Balanced Budget Act passed Congress last year, but it has not implemented anything yet. Section 5 contains a technical change. Section 6 is tied to the child health program. Under the block grant, states are able to charge premiums for pregnant women and children between the 150 and 200 percent poverty level. DHSS has been advised, however, that if it does a medicaid expansion, it cannot charge premiums. DHSS felt cost sharing on a sliding fee basis was reasonable so it is included in the bill in case Congress revisits this issue. CHAIRMAN WILKEN asked Mr. Labbe to return on Wednesday morning at 9:00 a.m. to finish the sectional analysis. MR. LABBE agreed. CHAIRMAN WILKEN adjourned the meeting at 10:50 a.m.