SENATE HEALTH, EDUCATION AND SOCIAL SERVICES COMMITTEE April 15, 1998 9:07 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 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 CS FOR HOUSE BILL NO. 459(FIN) am "An Act establishing new eligibility for medical assistance for certain disabled persons and giving their eligibility for services the highest priority among optional services and groups under the medical assistance program; amending the definition of 'personal care services in a recipient's home' as used in the medical assistance program; moving midwife services from being the first to being the 14th service eliminated under the medical assistance program when there is insufficient funding; and adjusting the priority of optional services and optional eligible groups under the medical assistance program in order to reflect the new priorities given to the newly-eligible disabled persons and to midwife services but without otherwise changing the relative order of the other optional services and optional groups." PASSED CSHB 459(HES) FROM COMMITTEE PREVIOUS SENATE COMMITTEE ACTION SB 266 - See HESS minutes dated 4/8/98. HB 459 - No previous Senate committee action. WITNESS REGISTER Jay Livey Deputy Commissioner Department of Health and Social Services P.O. Box 110601 Juneau, Alaska 99811-0601 POSITION STATEMENT: Discussed and supports SB 266 Karen Pearson Health Programs Manager Division of Public Health Department of Health and Social Services P.O. Box 110610 Juneau, Alaska 99811-0610 POSITION STATEMENT: Discussed and supports SB 266 Margo Waring Alaska Mental Health Trust Board 431 N. Franklin St. Juneau, Alaska 99801 POSITION STATEMENT: Supports SB 266 and HB 459 Tana Bulkley 2753 John Street Juneau, Alaska 99801 POSITION STATEMENT: Supports SB 266 Kim Champney Division of Public Health Department of Health and Social Services P.O. Box 110610 Juneau, Alaska 99801-1610 POSITION STATEMENT: Supports SB 266 Representative Con Bunde Alaska State Capitol Juneau, Alaska 99801-1182 POSITION STATEMENT: Sponsor of HB 459 Patti Swenson Staff to Representative Con Bunde Alaska State Capitol Juneau, Alaska 99801-1182 POSITION STATEMENT: Answered questions regarding HB 459 Robert Briggs Disability Law Center 230 South Franklin, Suite 209 Juneau, Alaska 99801 POSITION STATEMENT: Discussed the proposed amendment and supports HB 459 Ronnie Rosenburg Arctic Alliance for People 448 Snow Owl Lane Fairbanks, Alaska 99712 POSITION STATEMENT: Supports HB 459 ACTION NARRATIVE TAPE 98-34, 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 Green, Leman, Ellis, and Chairman Wilken. The order of business before the committee was the completion of the presentation on SB 266, and then the presentation on HB 459. SB 266 - MEDICAID COVER/HEALTHY FAMILIES AK PROGRAM CHAIRMAN WILKEN asked Jay Livey to continue the presentation on SB 266, beginning with page 4, Chapter 19 (Section 9). JAY LIVEY, Deputy Commissioner of the Department of Health and Social Services (DHSS), asked Karen Pearson to address the section on the Healthy Families Alaska Program. KAREN PEARSON, Division of Public Health, DHSS, stated Chapter 19 contains two parts. The first part establishes the Healthy Families Alaska Program in statute and describes the program's operations. SENATOR GREEN asked if the Healthy Families Alaska Program has been a one year program in the past. MS. PEARSON responded the program has existed through appropriations. MS. PEARSON explained the Healthy Families Alaska Program has one main goal: to prevent child abuse and neglect. DHSS knows that most families function at the level they can and nurture and care for their children, but some families have certain stresses that place them at risk for abuse and neglect. Healthy Families, in the geographic areas that it serves, screens families for those risk factors. If a family chooses to accept services from the Healthy Families Program, a worker will discuss with the client the stresses that can lead to abuse and neglect, such as substance abuse, domestic violence in the home, a history of abuse of any kind in the family, and/or financial stresses. If the family chooses to enroll in the program, the family determines its goals and what services and assistance it needs from Healthy Families. Services available include assistance in getting substance abuse treatment, counseling, access to housing services, or a number of other things. Healthy Families Program workers simultaneously teach families appropriate expectations for young children so that parents use appropriate child rearing techniques. The program is geared to the individual family's needs and to help the family develop skills and abilities to deal with crises. The program is available to pregnant women and parents of newborns (AS 47.19.030) who can receive services for up to three to five years. Research has shown that lasting outcomes do not occur when programs are designed to help families deal with an immediate crisis. Families need help dealing with several crises until they develop their own coping mechanisms. MS. PEARSON explained Section 47.19.040 describes the duties of DHSS. It ensures that local agencies get the training and support they need to run a good program. The program is based on service delivery by paraprofessionals with the belief that people respond better to a worker who has the same experiences and cultural background. The most important characteristics of paraprofessionals are empathy and support. The paraprofessionals do not provide specialty counseling; they help the family access the professionals they need. This section also requires DHSS to establish screening and evaluation methods, and to ensure that all service providers work together to prevent duplication of services, to deal with problem resolution within the program, and to monitor and evaluate services for the sake of accountability. Section 47.19.050 pertains to the individualized support plan in which the family sets its own goals. The plan is reviewed and updated with the family on an ongoing basis. Section 47.19.900 addresses confidentiality and mandates that no records on any individual family ever be released. The only types of data that would be compiled by the program are aggregate numbers. Number 167 SENATOR GREEN asked if any place already exists where a person can receive the same services, in whole or in part, as those offered by the Healthy Families Alaska Program. MS. PEARSON replied some similar programs exist. The Head Start Program is a home-visit based program that provides services to children ages birth to three but its focus is on child development and school readiness. Other programs exist but use a different approach. The Healthy Families Alaska Program is specific to child abuse and neglect prevention. Head Start provides services to clients who are low income. The Healthy Families Program is not income based. SENATOR LEMAN asked whether the confidentiality section provisions would preclude a court order to provide records. MS. PEARSON said it would not. SENATOR LEMAN asked if existing DHSS regulation provides for that exception. MS. PEARSON said it does. Number 200 SENATOR GREEN asked if churches and synagogues are considered to be culturally appropriate and community based, and could provide services according to the language on page 5, lines 12 - 15. MS. PEARSON stated if Senator Green was questioning whether DHSS could give a grant to a church or synagogue to provide services, she could not answer at this time. She pointed out that several churches and synagogues have been involved because they are partnered with local agencies. DEPUTY COMMISSIONER LIVEY stated that DHSS does have the ability to give grants to religiously affiliated organizations because it already gives grants to Catholic Community Services in Juneau to provide various kinds of social services. SENATOR GREEN commented that churches were included, in the welfare reform legislation, as entities to provide services in places where no other agencies existed. She noted she would like to see religious organizations included in this bill as well. DEPUTY COMMISSIONER LIVEY responded that DHSS might be constrained by the requirement that the organization receiving the grant must be an organized, non-profit, social service organization. SENATOR GREEN asked Mr. Livey to develop language to provide for that ability. Number 236 CHAIRMAN WILKEN asked for information about the Healthy Families Programs in operation today. MS. PEARSON informed committee members that eight local agencies are operating in Alaska today. Seven of the programs are delivered through local agencies, the Kenai program is operated by DHSS staff. The Juneau program is administered through Catholic Community Services; DHSS funds one staff person in the Southcentral Foundation; there is a program in the Mountainview community of Anchorage, the Mat-Su Valley, Fairbanks; a program in the Bristol Bay area which combines funding with the ICWA program and provides services in some of the villages; and a program in Bethel. CHAIRMAN WILKEN asked the amount of the program's funding. MS. PEARSON replied the amount is $1.4 in grant monies, and about $270,000 for running the Kenai program. CHAIRMAN WILKEN asked if the program leverages any federal money. MS. PEARSON responded it does, but not in terms of the local agencies, except for the Southcentral Foundation. That foundation has a federal grant from the Maternal Child Health Bureau. Number 261 DEPUTY COMMISSIONER LIVEY made the following remarks about SB 266. DHSS's major focus in SB 266 is to ensure that children have good health care. The bill expands medicaid coverage for children whose family's income is up to 200 percent of the poverty level, and maintains the expansion for pregnant women at that same poverty level. DHSS believes that expanding health care coverage to 200 percent of the poverty level will complement the welfare reform program because a lot of welfare recipients returning to the work force will not have health care coverage. DHSS does not want people to quit jobs and apply for public assistance to get medicaid coverage for their children. By providing this program through a medicaid expansion, more federal money will be leveraged. SB 266 is a relatively inexpensive investment on behalf of the state in order to receive a lot of federal money. That money will help to build a health care infrastructure in rural Alaska. Deputy Commissioner Livey reminded committee members that something needs to be done this year or the state will lose its federal allotment of $5.6 million. DHSS believes this program is a good investment in terms of the benefits it will provide in the future. SENATOR GREEN asked what amount 200 percent of the poverty level equals. DEPUTY COMMISSIONER LIVEY replied for a family of three, the level of income would be about $33,000 per year, or about $16 per hour. Number 297 SENATOR GREEN asked if any thought has been given to using the same income guidelines in the eligibility requirements for all programs so that children at age 17 would be eligible at the same income level as children at age 7. DEPUTY COMMISSIONER LIVEY stated that approach makes sense because under the current guidelines, a 14 year in a family might not be covered by medicaid while a younger sibling is. Those eligibility requirements are complicated for the families and for program staff. DHSS wants all programs to set the eligibility requirement at 200 percent of the poverty level, regardless of the child's age. SENATOR GREEN asked if DHSS has determined the number of people who will be eligible at the 200 percent level, 175 percent level, 150 percent level, etc., and whether using the 200 percent income guideline will increase the number of eligible applicants to the point to where services cannot be provided to all. DEPUTY COMMISSIONER LIVEY explained that at the 133 percent level, DHSS could serve about 1600 additional children and no additional pregnant women because that group is already being served at that level. At the 200 percent level, DHSS could serve an additional 4,000 children and 781 pregnant women. At that level, DHSS estimates that coverage could be provided at a cost of $4 million in general funds which would leverage about $11 million in federal funds. Number 315 SENATOR GREEN questioned whether DHSS would eliminate some of its current programs because they will no longer be necessary and whether an overall reduction in costs might occur. DEPUTY COMMISSIONER LIVEY said the different programs are really parts of one program. The difference between them is the level of coverage a person qualifies for depending on his/her income. DHSS would wipe out the different income levels for eligibility determination and use one level. BOB LABBE, Division of Medical Assistance, DHSS, added that the current levels are the federal required minimum levels that all states must have. One of DHSS's goals is to have a common standard which will require a statutory change. DHSS believes that the 200 percent level is the most advantageous to maximize federal funds because Alaska's population is not that large. If any lower level is used, the state will not be taking full advantage of the federal block grant. He noted he provided an analysis of the numbers to Senator Parnell. Number 360 SENATOR GREEN questioned whether it is possible that this program will provide a disincentive to employers to provide health care coverage for employees. DEPUTY COMMISSIONER LIVEY replied that the question of how to prevent employers who are currently providing coverage from discontinuing that coverage has been considered by Congress and by this Legislature. The Robert Wood Johnson Foundation has studied other states who have established similar expansions. The Foundation concluded that if the expansion deals primarily with children then that kind of "crowd out" does not occur, nor does it occur until eligibility includes people above the 200 percent of poverty level. He noted DHSS has also looked at ways to put barriers up to keep individuals from crossing over from employer coverage to medicaid coverage. CHAIRMAN WILKEN welcomed Senator Ward. He then informed committee members that written testimony sent by people from Fairbanks had been placed in committee packets. Number 386 MARGO WARING, staff to the Alaska Mental Health Board, made the following comments. The Board has spent a fair amount of time discussing SB 266 and is very supportive of the expansion of medicaid coverage for children and pregnant women. The Board hears frequently, in discussions with parents, about the difficulty of accessing mental health coverage for children, particularly for low income families. The Board believes that access to early intervention services provided through Medicaid could make significant differences in the lives of children with emotional disturbances. Whatever costs are incurred through medicaid will be offset by preventing children from becoming involved with the state juvenile justice and other systems later on. Regarding the Healthy Families Program, the Board is cognizant of the importance of identifying high risk families and providing them with needed services. Reduction in the rates of abuse and neglect is essential to any kind of prevention and early intervention strategy of serious emotional disturbance in children later in their lives because abuse and neglect are one of the strong environmental factors that create serious emotional disturbances in children. SB 266 is a very cost effective intervention strategy because it targets those at risk families. Intervention will occur at birth, before children experience the traumas that can lead to later psychiatric difficulties. SENATOR GREEN asked whether the Alaska Mental Health Board has given direct grants to the Healthy Families Program from the Mental Health Trust. MS. WARING stated she did not believe so but would defer to someone else from the Trust for that answer. Number 427 TANA BULKLEY, a Healthy Families Alaska Program client, gave the following testimony. She is the mother of four children, ages 15, 13, 7, and a newborn. She was young when she had her first two children and did not have much of a family support system. She had a lot of trouble parenting at that young age, especially with her daughter, who was neglected and has been in treatment for several years. Ms. Bulkley was forced to do a lot of things on her own with her first two children. She finished her GED and returned to school in an attempt to succeed, but it was a struggle. She was not aware of any help available until her children were four or five years old. When her newborn was born, she was given a questionnaire at the hospital that asked her whether she wanted help through the Healthy Families Program. A worker comes to her home, provides her with reading materials, and offers child development tips. She emphasized the most important factor in the success of the Healthy Families Program is that the worker comes to the client's home, which is extremely important to mothers with newborns and infants. KIM CHAMPNEY stated she is completing her MSW by doing field work with the Healthy Families Program in Juneau. She felt strongly about coming to the hearing today because she has seen the impact the program has had on families she has worked with. Ms. Bulkley represents a group of parents who are not receiving home visiting services because the program is full right now but her situation is valuable to share because she has raised children with and without aid from the Healthy Families Program. Had Ms. Bulkley received services from the Healthy Families Program for her first two children, she would have been matched with a home visitor who would have helped her to identify her immediate needs such as adequate housing, child care, job training or employment opportunities among other things. Ms. Bulkley's daughter was involved in a serious accident when she was 18 months old. Had a family support worker been involved, the worker could have advocated for services such as physical therapy or respite care. The family support worker would have helped Ms. Bulkley learn effective parenting skills and the support could have lasted until her children were five years old. Her children entered the state system at about the age of five which could have been avoided had Ms. Bulkley had help from a family services worker. Ms. Bulkley's family is beating the odds and pulling together which is what the program is about. Ms. Champney stated it is important to establish the program in statute so that it can be implemented statewide in a uniform manner and be accountable to the public. CHAIRMAN WILKEN noted no one else was present to testify on SB 266. He informed committee members that a companion bill, HB 369, is moving through the House and he planned to see how the committee can help the efforts of that bill, or vice versa. HB 459 - MEDICAID FOR LOW-INCOME DISABLED REPRESENTATIVE CON BUNDE, sponsor of HB 459, stated he introduced the measure in an effort to resolve a "catch-22" situation. HB 459 pertains to people with disabilities who want to go to work for various reasons, but cannot because the jobs for which they are skilled do not pay enough money in the first year or two of reemployment to cover the costs of their medication nor do they offer affordable health insurance. The only way the disabled worker can get assistance to pay for medication is to quite working to get public assistance and medicaid. HB 459 simply allows people who want to transition back to work to buy into medicaid on a sliding scale so that they have health care coverage until they progress in their careers to a point to where they make enough money to pay for their medications. CHAIRMAN WILKEN asked Robert Briggs of the Disability Law Center to join the committee members at the table. He noted the committee previously heard SB 253, which is similar to HB 459. During that hearing, Senator Leman brought up the issue of a sliding fee scale. Tab number one, in committee packets, is a response to that issue. and tab number two is a response to Senator Green's questions regarding the definition of the word "disability." Number 570 ROBERT BRIGGS, Disability Law Center attorney, stated four issues were raised by committee members during the last hearing on the working draft adopted in lieu of SB 253. The first was in regard to whether a transition provision should be adopted. He urged committee members to leave the language in the bill as is, because the one year transition period will involve insignificant costs. He believes DHSS should be given the discretion to establish a transition provision by written policy; a policy that does not have to go through the notice and comment rule making, but something that DHSS will be required to adhere to. If the committee wants DHSS to charge a premium during the transition period while DHSS is adopting formal regulations, he prepared an amendment. He believed the amendment is fair and will adequately address the committee's concern that DHSS not provide a benefit without some contribution from those who take advantage of it. MR. BRIGGS said turning to the issue of the definition of "disability," he believes it is adequately defined in the context of the present bill which specifically makes this benefit available only to those eligible for supplemental security benefits under 42 USC 1381-1383(c). "Disability" is further defined in two letters from the Health Care Financing Administration, the agency instrumental in the adoption of Section 4733 of the Balanced Budget Act of 1997. That Act initially provided this Medicaid option to the state. The two letters clearly define that a person, to be eligible for this benefit, must meet the disability criteria to be eligible for supplemental security income under present regulations and statutes. The criteria require the person to have a physical or mental impairment severe enough to meet a listing, or a combination of impairments of equivalent severity under Appendix 1 of Subpart (p) of 20 CFR, Part 404, or he/she must have medical limitations that prevent conduct of past relevant work under what is familiarly known as the "grids" located at Appendix 2 of Subpart (p) of 20 CFR, Part 404. Not only do they have to meet that initial eligibility criterion, but their medical condition must have a continuing limitation on their abilities over time. He explained that the eligibility definition for benefits under the supplemental security standard is different from, and more restrictive than, the definition of "disability" under the Americans with Disabilities Act. TAPE 98-34, SIDE B Number 561 SENATOR GREEN noted Mr. Briggs gave her an enlightening explanation of the definition of "disability" prior to the meeting so she will not be offering an amendment. MR. BRIGGS explained the third issue raised by the committee was the definition of personal care attendant services. The current language accomplishes the goal of streamlining medicaid costs in permitting PCA services delivered in the work place and other settings that will expand the population of disabled people who are able to return to work. The House considered this matter and urges the Senate to maintain this provision. MR. BRIGGS stated the fourth issue pertained to the adequacy of the representation of program expenses in the fiscal note. In his April 3 letter, he explained that the fiscal notes show cumulative projected savings, but not cumulative projected expenses. He believes the projections are based on appropriate assumptions but felt DHSS should address the assumptions. He agreed with Representative Bunde that a common refrain within the disability community is that access to health care is one of the biggest obstacles to reemployment, and that when people enter the workforce, they often enter a track that eventually leads to a better job with health care benefits. It is hoped that HB 459 will provide a bridge for people with disabilities, people who want to become self reliant. SENATOR GREEN asked if the "crowd out" scenario, discussed in relation to SB 266, might apply to HB 459. MR. BRIGGS asked Senator Green what she meant by the phrase "crowd out." SENATOR GREEN stated a "crowd out" would occur if an employer stops offering health care coverage to an employee because that employee receives health care coverage under Medicaid. MR. BRIGGS maintained he does not think HB 459 will provide a disincentive because this bill applies to a population of people who find it very difficult to get insurance through the private sector. Number 528 MS. RONNIE ROSENBURG, representing the Arctic Alliance for People, a non-profit consortium of 45 non-profit agencies and individuals who serve low-income people and people with disabilities, gave the following testimony via teleconference from Fairbanks. The Arctic Alliance submitted a resolution to interior delegation legislators in support of HB 459. Because the committee substitute is similar to the original bill she felt sure the Alliance membership would support it. She urged the committee to retain the supplemental security income definition of "disability" because a considerable body of law and understanding exists among people in the field as to what SSI disability is. Changing the definition will only cause confusion and appeals. As the case management director of the Fairbanks Resource Agency for over two years, she had to inform many high functioning clients with development disabilities that they would lose their Medicaid benefits if they became employed and she had to advise them to decline the job offer. Some clients were able to get full-time jobs with health benefits, but many clients are not medically able to work a 40 hour work week. HB 459 will enable those people to work to their maximum potential. The same dilemma occurred for welfare recipients: if they went to work, they often lost the only health care coverage available to them through Medicaid. Ms. Rosenburg emphasized the need for this bill and urged committee members to support HB 459. CHAIRMAN WILKEN thanked Ms. Rosenburg for her work with Arctic Alliance. He commented Arctic Alliance is a wonderful organization that should be mirrored around the state. CHAIRMAN WILKEN noted Mr. Sherwood and Mr. Kreher from DHSS were present and available to answer any questions committee members may have. Number 490 MARGO WARING, representing the Alaska Mental Health Board, stated the Board strongly supports HB 459. Many people with mental illnesses have discussed with the Board their desire to work and be self-reliant, but their inability to do so because of a lack of insurance options. A whole new generation of psychotropic medications is available that enable people to function on much higher levels than previously, however those medications are extremely expensive. Many people find themselves capable of taking on work, but are unable to do so because they will be unable to afford the medications that enable them to work if they no longer receive Medicaid. In addition, some people are working at jobs that do not provide insurance so that when they become ill, they are forced to quit to become eligible for Medicaid to get medication. People who want to work and make a contribution should be able to do so. HB 459 will allow that to happen. CHAIRMAN WILKEN thanked Mr. Briggs for his letter and help on the bill. He noted Senator Leman prepared a proposed amendment regarding the sliding fee scale. SENATOR LEMAN moved to adopt the proposed amendment and then objected for the purpose of making a statement. SENATOR LEMAN explained the amendment will provide for a small co- payment to keep costs down. He stated he likes the formula, but suggested DHSS might want to review and adjust the numbers, especially at the upper income end, for the long term. He felt the formula is a big step in the right direction for use during the transition period. He thanked Mr. Briggs for working on the concept. Senator Leman then removed his objection to the motion. SENATOR ELLIS asked if the formula pertains to a sliding scale co- pay. SENATOR LEMAN said yes, and explained that the maximum co-pay amount is ten percent. He noted he wanted the co-pay amount to be small enough so as not to discourage the program from functioning, but large enough to act as a deterrent to unnecessary services. MR. BRIGGS clarified the initial idea was to use a sliding scale based on a percentage of income. The maximum premium cost would be ten percent of income at the maximum eligibility level of 250 percent of the poverty line, and the minimum premium would be zero when a person's income is at 100 percent of the family line. The premium only buys coverage for the disabled person so a disabled person in a family of four will not pay significantly more than a disabled person living alone. This formula is a function of family size and family income however the premium should not encourage people to expand their definition of family to get the benefit at a lower cost. Mr. Briggs felt his best effort at achieving that goal in the formula is incomplete, and that DHSS's final regulations should address Senator Leman's concerns more thoroughly. He stated he appreciates the generosity of the committee in accepting the formula in its imperfection, and he believes most people do want to contribute and that this co-pay formula will cost buyers a lot less than paying their own medical expenses. Number 411 SENATOR LEMAN said he thinks the formula is a good first shot, but at the upper end the premium starts going the other way which is something that should be looked at later. He noted it is unlikely that many families of seven or eight members will be affected. SENATOR ELLIS questioned the ramifications of adopting into statute this first shot at the formula. He stated he supports the concept but asked if the language is specific to the mathematical formula and not more general language to allow DHSS to take a second shot at the formula. SENATOR LEMAN replied that DHSS will work on the formula and that this amendment only applies to the transition period. SENATOR ELLIS asked for clarification. SENATOR LEMAN clarified the formula will apply until regulations are adopted by DHSS, which should occur within one to two years. Without the amendment, the co-payment would be zero. SENATOR ELLIS asked where that specific language is contained in the bill. SENATOR LEMAN answered on page 4, lines 14-18. Number 387 SENATOR ELLIS asked if this mathematical formula for sliding scale co-pays would be in use for a few years only. SENATOR LEMAN clarified it would be used temporarily. SENATOR ELLIS asked how serious the effect would be on disabled people in larger family groups. MR. BRIGGS referred to his April 3 letter and clarified that the initial proposal was to have a sliding fee scale with a single line which did not take into consideration family size. That meant any individual eligible for this benefit would pay a fixed percentage depending on his/her income. Paying ten percent of the income of a person in a family of four would be a lot more difficult for that family than it would be for a single person paying ten percent of his/her income. SENATOR ELLIS asked Mr. Briggs about his comment that the formula does not completely adjust for family size. MR. BRIGGS stated the defect in the formula is that the lines are parallel on the graph. Ideally, the lines should all converge on a single point at 100, which is something DHSS can work out if it adopts this formula as a permanent approach. DHSS has a July 1, 1999 deadline to establish regulations. Mr. Briggs said if this temporary formula does not work in practice because it is too restrictive or does not provide enough income to the program, DHSS will have the discretion to adjust the sliding fee scale appropriately. He noted he is advocating this formula if it is the will of the committee to adopt some sliding fee scale for the transition period. He indicated he does not think the formula is as generous as having no sliding fee scale at all during the transition period, which is how the bill reads now. SENATOR ELLIS asked Mr. Briggs if the proposed amendment accurately reflects his proposal. MR. BRIGGS indicated he drafted an amendment that he included with his letter of April 3. He stated he has not read the amendment proposed by Senator Leman, but if it is the same as the one he submitted on April 3, he supports it. His amendment basically required that the premium be calculated as a percentage of net income of the person's family according to the mathematical formula. CHAIRMAN WILKEN noted the proposed amendment is a verbatim copy of Mr. Briggs' suggested language. SENATOR ELLIS maintained he agrees with the concept of the proposed amendment but plans to vote against it because it is too speculative at this time. The motion to adopt the proposed amendment carried with Senators Leman, Green, and Wilken voting for its adoption, and Senator Ellis voting against it. SENATOR LEMAN moved SCSHB 459(HES) to its next committee of referral with individual recommendations and accompanying fiscal notes. There being no objection, the motion carried. There being no further business to come before the committee, CHAIRMAN WILKEN adjourned the meeting at 10:15 a.m.