ALASKA STATE LEGISLATURE  SENATE HEALTH, EDUCATION AND SOCIAL SERVICES STANDING COMMITTEE  March 29, 2006 2:03 p.m. MEMBERS PRESENT Senator Fred Dyson, Chair Senator Gary Wilken, Vice Chair Senator Lyda Green Senator Kim Elton Senator Donny Olson MEMBERS ABSENT  All members present OTHER LEGISLATORS PRESENT  Senator Bettye Davis Senator Charlie Huggins  COMMITTEE CALENDAR Overview Update: Avian Flu - Department of Environmental Conservation, Department of Fish and Game, Department of Health and Social Services Overview: Personal Care Attendant Program - Department of Health and Social Services PREVIOUS COMMITTEE ACTION No previous action to record WITNESS REGISTER KARLEEN JACKSON, Commissioner Department of Health & Social Services PO Box 110601 Juneau, AK 99801-0601 POSITION STATEMENT: Commented on Avian Flu issues. DR. RICHARD MANDSAGER, Director Division of Public Health Department of Health & Social Services PO Box 110601 Juneau, AK 99801-0601 POSITION STATEMENT: Commented on Avian Flu issues. MATT ROBUS, Director Division of Wildlife Conservation Department of Fish & Game PO Box 25526 Juneau, AK 99802-5226 POSITION STATEMENT: Commented on Avian Flu issues. DR. ROBERT GERLACH, State Veterinarian Division of Environmental Health Department of Environmental Conservation 410 Willoughby Juneau, AK 99801-1795 POSITION STATEMENT: Commented on Avian Flu issues. JANET CLARKE, Assistant Commissioner Finance and Management Services Department of Health & Social Services PO Box 110601 Juneau, AK 99801-0601 POSITION STATEMENT: Commented on Personal Care Attendant Program. JON SHERWOOD Office of Program Review Department of Health & Social Services PO Box 110601 Juneau, AK 99801-0601 POSITION STATEMENT: Commented on Personal Care Attendant Program. ACTION NARRATIVE CHAIR FRED DYSON called the Senate Health, Education and Social Services Standing Committee meeting to order at 2:03:48 PM. Present were Senators Donny Olson, Kim Elton and Chair Fred Dyson. Senators Gary Wilken and Lyda Green arrived as the meeting was in progress. Also in attendance were Senators Bettye Davis and Charlie Huggins. 2:04:38 PM ^Overview Update: Avian Flu - Department of Environmental  Conservation, Department of Fish and Game, Department of Health  and Social Services  CHAIR FRED DYSON announced that the committee would hear an overview update on avian flu. KARLEEN JACKSON, Commissioner, Department of Health and Social Services (DHSS), reminded members that the Governor through Administrative Order 228 has asked all the state departments to coordinate together to be prepared for the event there is a pandemic influenza. Alaskans need to understand the difference between the two kinds of flu, influenza or the bird flu, and how they might be related. To help with that preparation, three state experts were present - Dr. Richard Mandsager, Director of the Division of Public Health, Matt Robus, Director, Division of Wildlife Conservation, and Dr. Bob Gerlach, State Veterinarian, Department of Environmental Conservation (DEC). 2:06:21 PM DR. RICHARD MANDSAGER, Director, Division of Public Health, Department of Health and Social Services, updated members by setting the stage for them to differentiate human issues from bird issues and why they are connected. He pointed out the websites - AvianFlu.alaska.gov and PandemicFlu.alaska.gov. The website is updated every Monday afternoon and included new reports if worldwide situations change. SENATOR WILKEN arrived at 2:08:57 PM. 2:09:07 PM DR. MANDSAGER related that all the information and frequently asked questions about wild birds and the influenza A, H5N1 virus was on the websites. Transmission of the virus from birds to human has an almost 50 percent mortality rate consistently across countries. 2:10:23 PM DR. MANDSAGER said another reason for concern is that previous pandemics have been caused by influenza A viruses and we should assume there will be three pandemics in this century. H5N1 is a legitimate threat if it develops human-to-human transmission. Last year public health law was updated giving the department significant authority over human health and this year, HB 380, the animal companion gives the appropriate authorities to the department for animal disease control. Many of the new diseases on the human side are zoontic diseases - they either come from animals or they are transmitted back and forth from animals to humans. Both sets of authorities are needed to protect communities. 2:12:23 PM DR. MANDSAGER showed a world map of the spread of the virus dated March 24, 2006. In October, it was confined to Southeast Asia and then moved eastward into Europe. Most of those countries have had the disease in wild birds - a few countries have had it in poultry. Human disease is much more scattered. Southeast countries were filling in rapidly. The question is will Alaska see this virus in birds? He reported that the multi-agency coordinating committee that was created in response to the Governor's administrative order is now functional. Some organizations were meeting every two weeks to drive the planning work. Community outreach visits and working with communities would be launched next week. 2:14:23 PM DR. MANDSAGER said if this becomes a human disease, communities would have to become largely self-reliant. It would become hard to share people between communities where power infrastructure and airplane services are essential to get workers and medicines where they need to go. 2:15:58 PM MATT ROBUS, Director, Division of Wildlife Conservation, Alaska Department of Fish and Game (ADF&G), said his division was becoming more and more involved in the bird issues. He reported that it is still primarily a disease of birds and first developed in the domestic poultry of Southeast Asia. It has moved back into wild bird populations and has caused a fair amount of mortality there. As wildlife managers, the department was very concerned about that. SENATOR GREEN arrived at 2:16:36 PM. 2:16:43 PM MR. ROBUS said the Homeland Security Department has convened a collaborative effort between several different federal departments, including Alaska wildlife managers, to plan for early detection of H5N1. It is not certain that wild birds would bring the virus in, but since Alaska is at the intersection of Asian and North American flyways, and since we send migratory birds throughout all four continental U.S. flyways, if we do get it by wild birds, it would be a national issue in terms of it begin carried elsewhere. 2:17:53 PM MR. ROBUS said they had started sampling for the virus in 1998, though in smaller way. More recently, a University of Alaska study was piggybacked with government divisions to sample 8,000 or 9,000 birds and none has come back positive. This group of agencies put together a national strategic sampling plan for the early detection of the Asian strain of H5N1 and Alaska put its own sampling plan together to gather 15,000 samples from wild birds during the coming season - focused on priority species and habitats. He said the state has been divided up and teams will work in different locations. He said the teams will obtain samples through five basic strategies: 1) catch live birds and doing a tracheal or cloacae swab; 2) collect hunter-killed birds, both subsistence and regular fall season; 3) prepare teams of people ready to respond to reported mortality and morbidity events and do necropsies; 4) sample environment - water and fecal samples, because that is how it would spread between birds; 5) put sentinel birds out in a cage and then test them later to see if they had picked up the disease. 2:21:57 PM MR. ROBUS said in the meantime there is no reason to think it's here and it is highly likely that it will be detected if it gets here. Strategies for avoiding bird flu include wearing rubber gloves when cleaning wild birds or gathering eggs for subsistence, avoiding eating or drinking while cleaning birds or putting fingers in your mouth or on your face and making sure the work surfaces are clean. Meat from birds should be cooked all the way through, which destroys disease organisms. 2:24:11 PM ROBERT GERLACH, DVM, State Veterinarian, Division of Environmental Health, Department of Environmental Conservation (DEC), said that a coordinated, collaborative effort consisting of the state's three agencies and the U.S. Department of Agriculture has organized outreach education, surveillance and response. H5N1 has not been found in North America where there has been previous sampling. No pathogenic avian influenza has been found in Alaska. He mentioned that low-pathogen viruses have been found, but cause very little disease in wild birds. His concern was that migrating wild birds would bring avian influenza into the state where it would infect other wild and domestic birds. When people have been affected by H5N1, it has been through contact with domestic poultry. In Alaska they have focused on educating people about preventing the disease. Alaska has two-dozen or fewer commercial poultry operations and they are not similar to operations in the Lower 48 where people have to scrub in and out, for instance, to avoid disease. Another concern was backyard birds for eating, exhibition or pets. The third population was indoor pets that can be exposed by things that are brought into the home from outside. The virus can be contracted through fecal excretion and brought in on shoes, for example. He has recommended a list of ways to maintain a clean environment for domestic birds by restricting access to wild birds. 2:28:45 PM DR. GERLACH said the state is developing the capacity to test for avian flu at the Environmental Health Lab in Anchorage and the USDA is doing sampling around airports as well. The focus is on interaction of wild with domestic stock. He said it is important to provide the public with a consistent message on this issue. 2:30:42 PM DR. GERLACH said the state's response plan is well coordinated and he exhibited previous outreach materials including a booklet of wildlife diseases that hunters might see. Passage of HB 380 was important because it extends his authority to deal with avian flu in pet birds. 2:31:56 PM SENATOR DONNY OLSON asked what the chances are that other animals like cats and dogs would pick up the virus. DR. GERLACH replied that domestic and exotic cats can be infected by the virus. In Germany, a Stone Martin was affected. In New Zealand, weasels, rabbits and rats have been infected as an experiment in a controlled environment. Pigs are also a susceptible species. So, surveillance is needed in both wild and domestic animals. 2:33:18 PM SENATOR OLSON asked what the chances were of it affecting fish. DR. GERLACH replied that this virus usually affects warm-blooded animals. 2:34:24 PM SENATOR OLSON said that it seemed like a tracheal swab would be difficult to do on birds. DR. MANDSAGER replied that he didn't mean to say that. What he meant to say was that the ability to collect samples from people who might be infected with H5N1 needs to be in place. SENATOR OLSON asked if some birds should not be eaten by people living a subsistence lifestyle. DR. MANDSAGER replied that the birds could be cooked and eaten - so long as the secretions were clear and not bloody. 2:35:46 PM DR. MANDSAGER clicked on birds and animals - hunter safety - on the website to demonstrate where to find safe handling information. 2:36:42 PM MR. ROBUS pointed out the booklet that has the department's safety guidelines. He emphasized that the department needs people's help in observing and reporting sick or dead birds. He said the Fish and Wildlife Service is hosting a toll free line for Alaska calls - 1-866-5BRDFLU. 2:38:01 PM CHAIR DYSON asked if the bird flu has reached the Russian Far East. MR. ROBUS replied that he was not familiar with the exact locations or the extent of the sampling there. He does know that large shorebirds are currently migrating up the eastern coast of Asian and are headed for the western part, the Seward Peninsula and the Yukon Kuskokwim Delta in Alaska. He reiterated there has not been a documented case of a person getting this disease from a wild bird and that it doesn't jump easily from wild birds to humans. 2:39:29 PM CHAIR DYSON asked what birds come to Alaska from the exposed areas. MR. ROBUS replied Curlews and Godwits from the shorebird family. Pacific Black Brant populations have a direct interchange between North America and Asia; the Northern Pintail is a dabbling duck that goes all over the Arctic and hops between continents. A potential problem, if the virus gets here and gets into our water bodies, is that breeding ducks from the Lower 48 could carry it south. 2:40:41 PM SENATOR ELTON asked how long it takes to turn a sample from fieldwork. MR. ROBUS replied there are screening and confirmation steps. The initial screening has a 24-hour result for a presumptive positive for this type of virus. However, to confirm that it is actually H5N1, it has to go to the USDA lab in Ames, Iowa and that test takes up to a week or so. The agency's response would intensify with a positive indication. 2:42:03 PM SENATOR ELTON asked if the presumptive level gets reached in the initial screening, is the agency response more intensive studying or is there a public component. MR. ROBUS replied that in terms of managing wild birds, none of the agencies involved think the spread of the virus would be halted through culling massive populations of wild birds. If it is found in wild birds, the wildlife management part of this is trying to determine the prevalence and monitor it as it moves around the continent. On the public side, the response would be the department modifying its advice on how to use wild birds - possibly through regulatory action on hunts in certain places. Protection of domestic birds and animals and human health would also be a concern. DR. MANDSAGER added that this issue is the subject of much discussion. First they would need to be reasonably sure that the presumptive is probably true through more sampling. A presumptive sample should not be kept a secret while waiting for confirmation. Europe, for instance, notifies the public of presumptive positives and that confirmation is being awaited. He thought one of the things that was done wrong in the 1918 pandemic was that governments didn't tell the truth and lost the confidence of the people. DR. GERLACH added that his response would be different with respect to domestic poultry, because initially, a quarantine would be set up that would halt movement of the animals form the premise. Nothing would be done about eradication until the disease was confirmed. Whether it would be high pathogen H5N1 or the North American version, the low-pathogen H5N1 strain, would be reported. Either would result in a quarantine and hold order on the birds. If it were confirmed, those birds would be depopulated. Once the USDA test is done, it gets reported to the World Animal Health Organization. 2:45:37 PM CHAIR DYSON said that Dr. Gerlach informed him that without HB 380, he would not have authority in the non-domestic animal kingdom, which is one of the reasons it is a priority. DR. GERLACH agreed. 2:45:59 PM SENATOR HUGGINS said he comes from a duck hunting family, a number of whom died in the 1918 pandemic and it appears that the disease shows up more in people that handle poultry and not much in wild birds. DR. MANDSAGER assured him that was correct. The European experience over the last four months confirms that. There have been a lot of positive wild birds scattered across many European countries, but almost no domestic poultry has been affected - most likely because of better practices in taking care of birds in developed countries. There has been no human spread at all in European countries. 2:47:41 PM CHAIR DYSON thanked them for the diligence they are showing in being prepared for what we all hope doesn't happen. 2:47:57 PM ^Overview: Personal Care Attendant Program - Department of  Health and Social Services  CHAIR DYSON announced that the committee would hear an overview on the Personal Care Attendant Program (PCA). 2:48:32 PM JANET CLARKE, Assistant Commissioner, Finance and Management Services, Department of Health and Social Services, and JON SHERWOOD, Office of Program Review, DHSS, said they would give the department's presentation. CHAIR DYSON recapped that from the last meeting it seems that the PCA program has grown far more quickly than others and the cost per client seemed disproportionate. He asked if more people were enrolled and being subsidized through the PCA program than should be. MS. CLARKE answered by providing the committee most recent information from Alaska in 2002 and some analysis that consisted basically of two spreadsheets. Tripling of the average expenditure per recipient from 2001 to 2002 was the largest growth of the program; there has been modest growth since. She also mentioned a letter she sent to the committee on March 21 after the presentation on PCA regulations and that included a legal-sized chart of March 2005 data that shows how the new changes in Alaska regulations compared to what is happening in other states. She explained that before April, one had to have only one daily living activity to qualify for PCA assistance and now you need two. All hours of service now need a prior authorization; other states have caps. 2:53:20 PM MS. CLARKE admitted that the department had not done a good job in projecting this program. It missed the mark in the early years when it was growing so fast. CHAIR DYSON added there were no controls on who could use the program either. MS. CLARKE agreed and said the projected savings in their March 21 memo was very conservative. She said that as regulations were implemented, their effects would be assessed. If individuals were denied any level of service, they would have the right to a fair hearing and an appeal. Services continue until they exhaust those remedies. 2:55:05 PM MS. CLARKE explained they also have to deal with the issue of the growing senior population. Even if some people are dropped off the program, more seniors are coming who would qualify for it. She said it was possible for this program to save more than $17 million, but she wanted to be cautious because of the growing senior population. The newly implemented SB 41 audits have caused a flattening out of expenditures for personal care issues. MS. CLARKE cautioned that she did not want seniors on the older Alaskan waiver to be harmed through implementation of the regulations and that good monitoring was needed. In its memo, the department also recommended providing interim reports to the Legislature - on July 15 and September 30, for instance. She said the regulations have not all gone into effect yet, so she didn't have hard data to do projections with. 2:58:25 P SENATOR WILKEN thanked her for her timely response to the March 2 request. The thing that scares him is that the data they have takes them only to the 2002 chart and that's just when the new program kicked in. So, if we think we haven't even gotten to the expensive part, yet, where we climbed 180 percent a year for five years.... if we look at this chart.... Alaska is spending $13,800 per person before our new program kicks in. So, I looked at other states; I looked at Arizona. They offer much more than what we offer and they are spending $3,300, plus or minus. Idaho is offering much more vision, hearing, brain, HIV, dementia - they're offering a suite of coverage in their state and they're at $6,600. And we're at $13,000, almost $14,000. Montana - they offer about what we offer - they're at $8,000. Washington - close to us - about what we offer - $7,500. The point being, the numbers just don't square on what we're spending. The question is our coverage seems to be about where other people are in our neck of the woods and why does it cost us at least twice as much? And that's before we get to the part where things really took off.... SENATOR WILKEN said he thought the regulations would lower the slope, which they did, but it just flattened out. It didn't go down. 3:01:38 PM MR. SHERWOOD cautioned him about looking at personal care and isolation, because different states use different strategies. Personal care services in Alaska are a state-plan service that is available to everybody that needs it. In some states they limit it to offering it through their home and community based waiver programs where people must be at the institutional level of care. Also, the people who receive it may have access to other supportive services, as well. A lot of other states rely much more heavily on nursing homes to provide this kind of care. Alaska has one of the lowest utilization of nursing homes of any state. He said, "Although $20,000 a year sounds pretty expensive for personal care, it's nothing compared to the cost of nursing homes. It's not a one-for-one trade-off." MR. SHERWOOD explained that the department's strategy is heavily based on home and community-based care. As a result, more people who have serious needs are served through this program than in other states. This is an important component of the answer. He was hopeful that implementing a standard assessment that will be performed by an independent contractor would get them to accurate data that would help their understanding of the numbers. He also said the department didn't want to over-project the possible savings because of the meteoric rise in Alaska's senior population. 3:04:13 PM CHAIR DYSON recalled a few years ago, it seemed that Alaskans were doing what they should with taking care of their aging parents and relatives. Some of those people would do more, but have financial constraints and the state wants to subsidize those folks a bit. However, his sense is that some people are getting paid when they don't really need the money. He didn't know how to sort for that kind of thing. He has talked with Ms. Clarke for years about how foster parents are needed, but he doesn't want people doing it as a moneymaking enterprise. He asked if there was any discussion about this issue on a national level. 3:06:15 PM MR. SHERWOOD replied: The federal government is promoting a program called "Independence Plus," which has a lot of similarities to Alaska's consumer directed personal care program. Most states who participate in that program sort of agree up front to a certain kind of cap - and states calculate them differently - "Basically you agree to less total service, have more flexibility in the way you can spend your money, more control over it. These require the use of waivers, which bring their own administrative overhead. He said the state has looked at those things, but it wants to get control of the program it has now without throwing another piece into the mix. 3:07:33 PM CHAIR DYSON suggested that their funding may get capped at some point and also encouraged them to continue looking for fraud. MS. CLARKE recapped that SB 41 did a lot for the department as far as requiring audits and those are an integral part of the program. Better communication has been established within the department, it has an audit committee, procedures and practices are being set up and the Department of Law is helping them developing sanctions. The department is doing significantly more in that area than in the past. 3:09:52 PM SENATOR ELTON said he was intrigued by comments about the expanding senior population. He has heard it was growing six times the rate of the younger population and he wanted a better idea of the demographic changes that are coming up, because it has huge implications to the state and how services will be provided to that group of people. He also asked for a tracking of the history of nursing home beds and the communities they are in - to get some perspective on the issue. He also wanted to know how nursing homes work in Juneau in relation to servicing communities that don't have any, like Hoonah. MS. CLARKE responded that she did a presentation for the Senate Finance Committee and would be happy to meet with him and his staff to go over the study that has a 20-year horizon. CHAIR DYSON said that Dr. Mandsager reminded him that while the population is growing older, it is also living healthier and more competent for a longer period of time. The justification for helping seniors should not lock-step with progression in age. He asked them for any information they would have on that issue. 3:12:49 PM SENATOR WILKEN urged that this report needed to be updated next year to keep things going forward. CHAIR DYSON said the committee would write a letter for everyone to sign asking for that updated report. There were no objections. There being no further business to come before the committee, Chair Dyson adjourned the Senate Health, Education and Social Services Standing Committee meeting at 3:14:04 PM.