Legislature(2009 - 2010)BUTROVICH 205

02/17/2010 01:30 PM Senate HEALTH & SOCIAL SERVICES

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01:36:17 PM Start
01:37:39 PM SB219
02:29:56 PM Fetal Alcohol Spectrum Disorder
02:58:48 PM Adjourn
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
Bill Previously Heard/Scheduled
Moved CSSB 219(HSS) Out of Committee
+ Presentations: TELECONFERENCED
The AK Mental Health Trust Authority -
"Bring the Kids Home Initiative"
The AK Mental Health Board -
"Fetal Alcohol Spectrum Disorder"
Citizen Review Panel - Update on Office
of Children's Services
+ Bills Previously Heard/Scheduled TELECONFERENCED
         SB 219-TRAUMATIC BRAIN INJURY:PROGRAM/MEDICAID                                                                     
CHAIR DAVIS announced the consideration of SB 219.                                                                              
1:37:39 PM                                                                                                                    
SENATOR MCGUIRE, sponsor  of SB 219, said the  bill establishes a                                                               
program  and  registry  for  traumatic  brain  injury  (TBI)  and                                                               
acquired brain injury  (ABI) within the Department  of Health and                                                               
Social  Services   (DHSS).  Annually,   over  800   Alaskans  are                                                               
hospitalized  with  TBI  due  to  accidents,  domestic  violence,                                                               
shaken baby  syndrome and other  causes.  Approximately  an equal                                                               
number  of Alaskans  suffer  from  ABI as  a  result of  strokes,                                                               
aneurism or tumors.  TBI and ABI affect rural  and urban Alaskans                                                               
and record level of military  members returning from Iraq. SB 219                                                               
will  allow  the state  to  track  the  number of  brain  injured                                                               
Alaskans in hopes  of leveraging much needed  federal dollars and                                                               
for rehabilitation, support and back-to-work programs.                                                                          
Access  to  rehabilitation  has allowed  individuals  with  brain                                                               
injuries to live at home and  return to school or work and engage                                                               
in a  meaningful, productive life.  She emphasized that  T/ABI is                                                               
not a  death sentence  but without  treatment the  statistics are                                                               
grim. People with ABI and TBI  can be a tremendous social cost to                                                               
the state  as they go  on to commit  crimes, live in  poverty and                                                               
homelessness  or  end  up  in   jail.  Service  coordination  and                                                               
rehabilitation may reduce future medical and social costs.                                                                      
1:41:24 PM                                                                                                                    
SENATOR MCGUIRE  said that by trying  to track data with  a brain                                                               
injury  program and  registry can  help  coordinate many  efforts                                                               
made  throughout  the  state  and to  leverage  the  much  needed                                                               
federal dollars. A match of up  to 60 percent federal funds would                                                               
be available through a combination of sources, largely Medicaid.                                                                
She asked that  the committee adopt the  committee substitute and                                                               
noted that Esther Cha has worked with DHSS on the changes.                                                                      
1:43:17 PM                                                                                                                    
CHAIR DAVIS moved  to adopt the proposed  committee substitute to                                                               
SB  219,  labeled Version  R,  as  the  working document  of  the                                                               
committee.  There being no objection, the motion carried.                                                                       
ESTHER CHA,  aide to  Senator McGuire, said  the major  change is                                                               
including "acquired"  along with "traumatic brain  injury" in the                                                               
title.  Also, a  pilot  project in  Section 6  of  Version A  was                                                               
removed because  DHSS thought more  planning would be  needed. On                                                               
page   1,   lines  13-14   establish   the   registry  under   AS                                                               
47.80.500(c)(1).   Many   changes   in  Version   R   relate   to                                                               
establishing the registry  and the program under AS  47, which is                                                               
"persons  with disabilities"  rather than  Title 18,  which deals                                                               
with public health.  This change was recommended  by DHSS because                                                               
the Senior  and Disabilities  Services currently  manage Medicaid                                                               
waivers, case  management, aging and disability  resource centers                                                               
and hospital discharge grants.                                                                                                  
1:45:48 PM                                                                                                                    
ANGELA SALERNO,  health program manager,  Division of  Senior and                                                               
Disabilities Services,  Department of Health and  Social Services                                                               
(DHSS), said her  division is the agency responsible  for the TBI                                                               
program in the  state and would take on these  duties. In Section                                                               
2  [amending AS  47.07.030(b)],  DHSS gets  authority  to seek  a                                                               
Medicaid state plan  amendment to add case  management for people                                                               
with TBI. Targeted  case management is a  straight state Medicaid                                                               
service which  would be  added to the  list of  optional services                                                               
currently in Alaska for Medicaid.                                                                                               
1:47:28 PM                                                                                                                    
MS.  SALERNO said  Section  3 [AS  47.07.030] of  SB  219 adds  a                                                               
definition  for case  management  that the  division believes  is                                                               
problematic  because  it  is  not  consistent  with  the  federal                                                               
definition  of   targeted  case   management.  The   division  is                                                               
concerned that if  the definition goes into  statute, the Centers                                                               
for Medicaid/Medicare may disallow any  claims the state made for                                                               
targeted case management. She suggested  changing SB 219 to refer                                                               
back to the federal definition.                                                                                                 
SB 219  requires DHSS to serve  people with TBI under  a Medicaid                                                               
waiver;  DHSS did  not develop  a fiscal  note for  a new  waiver                                                               
program  because  DHSS already  serves  people  with TBI  on  its                                                               
current  waivers.  Currently,  DHSS  is  serving  102  people  on                                                               
Medicaid waivers  with TBI  because they  meet the  definition of                                                               
nursing  home  level  of  care. DHSS  does  not  feel  developing                                                               
another waiver is necessary.                                                                                                    
1:49:35 PM                                                                                                                    
CHAIR  DAVIS asked  Ms. Salerno  if changing  the definition  for                                                               
case management  in Section 3  back to the federal  definition is                                                               
her only suggested change to SB 219.                                                                                            
MS. SALERNO responded  yes and said DHSS otherwise  has a neutral                                                               
position on SB 219.                                                                                                             
1:50:22 PM                                                                                                                    
MARTHA  MOORE,   chair,  Alaska  Brain  Injury   Network  (ABIN),                                                               
supported  SB 219.  ABIN has  done an  assessment of  the service                                                               
system  across  Alaska  for  TBI survivors.  She  referred  to  a                                                               
document  called,  "Fractured  and Inadequate"  which  shows  the                                                               
continuum of  care for a  TBI survivor. ABIN identified  the gaps                                                               
in  the  system. Case  management  is  needed,  as well  as  data                                                               
recording  and  rehabilitation  after hospitalization.  ABIN  has                                                               
written a 10  year plan and has gathered an  array of partners to                                                               
help accomplish this task, including  the military, Mental Health                                                               
Trust, Alaska Native Medical Center, state and private agencies.                                                                
1:52:56 PM                                                                                                                    
ABIN feels that SB 219 provides  a framework to move forward. The                                                               
TBI  registry will  track  a patient  from  injury to  functional                                                               
outcomes,  showing   treatment  and   rehabilitation  time-tables                                                               
linked  to  the  patient's   recovery,  functional  outcomes  and                                                               
reintegration  into society.  This information  will provide  the                                                               
standards of  care, protocols, recommendations for  treatment and                                                               
the services that  lead to independent living.  The registry will                                                               
also allow a continual reassessment of the gaps in the system.                                                                  
1:54:20 PM                                                                                                                    
JEFF JESSEE, chief executive officer,  Alaska Mental Health Trust                                                               
Authority, said the  Trust supports SB 219. He  stressed the link                                                               
to  veterans   returning  to  Alaska   with  TBI.   Alaska  three                                                               
continuums of  care for people  with TBI: the tribal  system, the                                                               
Department of Defense  and VA system and the  state system. These                                                               
systems need to  be combined to create a  comprehensive and cost-                                                               
effective service  but the state  currently has nothing  to offer                                                               
as a partner. SB 219 starts  a state response and gives the state                                                               
something to offer to the other systems of care.                                                                                
1:56:46 PM                                                                                                                    
SCOTT  HAMMOND,  representing  himself,  Kenai, said  he  is  not                                                               
opposed to  SB 219  but believes  that a  provision in  Version R                                                               
could   have   unintended   consequences:   Article   5(a),   Sec                                                               
47.80.500(3) on page  4. This provision could lead to  a call for                                                               
a mandatory motorcycle helmet law.  He assured the committee that                                                               
Alaska's lack  of requirement for  motorcyclists to  wear helmets                                                               
does not create a problem with TBI for motorcycle riders.                                                                       
He  recommended  that  the  committee  modify  the  provision  by                                                               
removing  the  words  "and  laws"   and  "to  the  prevention  of                                                               
traumatic  or acquired  brain injury".  The provision  would then                                                               
read: "evaluation of standards pertaining  to the treatment, care                                                               
and support of persons with traumatic or acquired brain injury".                                                                
1:59:19 PM                                                                                                                    
CHAIR DAVIS asked if he was reading  from Version R of SB 219 and                                                               
if so, what page.                                                                                                               
MR. HAMMOND replied, yes, he was referring to Version R, page 4.                                                                
1:59:45 PM                                                                                                                    
NANCY MICHAELSON, representing herself,  Palmer, said she and her                                                               
husband care for their 26 year  old son, who lives with them, due                                                               
to a disability  resulting from TBI. SB 219  is comprehensive and                                                               
will be  welcomed by Alaskans affected  by TBI. Her son  has been                                                               
disabled for  seven years. Without  the Medicaid  waiver program,                                                               
her family could not have  managed her son's round-the-clock care                                                               
nor  would he  have the  quality  of life  that he  now has.  The                                                               
services  available  through  the  Medicaid  waiver  program  are                                                               
helping her  son progress  toward more  movement and  speech. She                                                               
listed the  following as  the best  aspects of  SB 219:  One, the                                                               
clarification of the  definition of TBI; two,  assistance to find                                                               
practitioners familiar with TBI who  can be part of a coordinated                                                               
care  team;  and three,  smartly  positioning  Alaska for  future                                                               
funding for brain injury services.                                                                                              
2:03:49 PM                                                                                                                    
MARGARET CARLONI, registered nurse,  Anchorage, supported SB 219.                                                               
She  said  the  inability  to  offer  more  to  TBI  patients  is                                                               
heartbreaking and frustrating.  Acute rehabilitation is available                                                               
in some  locations but  the real  gap is  for cognitive  rehab or                                                               
long-term  housing  for  severely   injured  patients.  About  34                                                               
percent  of TBI's  are Alaska  Native people  and very  little is                                                               
available in small  communities. She hopes that SB  219 will help                                                               
gather more data to consider the gaps around the state.                                                                         
2:05:50 PM                                                                                                                    
JILL HODGES,  director, Alaska  Brain Injury  Network, Anchorage,                                                               
supported SB 219.  She related a story about her  brother and his                                                               
brain  injury five  years ago.  He  and her  family went  through                                                               
intense  brain injury  rehab, a  period of  gratefulness for  his                                                               
life and  then realizing the  difficulty managing his  injury. He                                                               
suffered severe  depression, began drinking and  had run-ins with                                                               
the law.  Now her brother is  in college and understands  his own                                                               
disability. SB 219 gives families more opportunity for support.                                                                 
2:08:29 PM                                                                                                                    
SENATOR MCGUIRE  spoke to DHSS's  concern with the  definition of                                                               
case management  in Version R,  page 2,  section 3, line  21. She                                                               
said DHSS's concerns centered around  the inclusion of housing in                                                               
case management on line 30. She  noted that housing is a big part                                                               
of the equation but eliminating  "including housing", rather than                                                               
incorporation  the  federal  definition,  should  address  DHSS's                                                               
2:10:13 PM                                                                                                                    
CHAIR DAVIS  asked if  Senator McGuire had  spoken to  DHSS about                                                               
this suggested change.                                                                                                          
MS. MICHAELSON said no.                                                                                                         
SENATOR  MCGUIRE said  the committee  can decide  if the  federal                                                               
definition is used or the  words "including housing" are removed.                                                               
Asking DHSS would be the right thing to do.                                                                                     
Regarding  Mr.   Hammond's  testimony  about  helmet   laws,  she                                                               
understood his  concern to be  about the evaluation  of standards                                                               
and law  that pertain to  the prevention  of TBI. She  noted that                                                               
the proposed  statewide committee in  SB 219 is not  a law-making                                                               
committee. Though the  committee will have the  ability to assess                                                               
standards and  laws, changing any  law is  still in the  hands of                                                               
lawmakers  as influenced  by people.  She  proposed keeping  that                                                               
provision the way it is.                                                                                                        
CHAIR  DAVIS  said  she  agrees with  Senator  McGuire  that  the                                                               
language on page 4, lines 7-9, does not need to be changed.                                                                     
2:13:52 PM                                                                                                                    
SENATOR MCGUIRE referred  to the discussion about  whether or not                                                               
a waiver is needed. Although 100  TBI people are now being served                                                               
through various  channels, many more TBI  survivors would benefit                                                               
from the  kind of program laid  out in SB 219.  Having a specific                                                               
waiver is appropriate.                                                                                                          
SENATOR DYSON  noticed that  Version R  has the  phrase "acquired                                                               
brain injuries".  Looking at 47.80.590, which  is the definition,                                                               
he asked Senator McGuire to clarify  whether or not her intent is                                                               
to include brain injuries that are  not as a result of a physical                                                               
trauma, such as a stroke.                                                                                                       
2:16:31 PM                                                                                                                    
SENATOR MCGUIRE  replied that she  believes something  like Fetal                                                               
Alcohol Syndrome (FAS) is an  acquired brain injury. If the brain                                                               
structure  started  out  healthy  and was  exposed  to  drugs  or                                                               
alcohol in the  womb, that person can  go on to live  a life with                                                               
brain  damage. She  believes brain  damage from  a strangling  or                                                               
hypoxia, etc, is also acquired.  DHSS was concerned about opening                                                               
it up to  all congenital brain injuries because  DHSS already has                                                               
places to deal with that. An  acquired brain injury is one that a                                                               
person  did not  start out  with congenitally;  the person  had a                                                               
normal brain structure  at some point. She  envisions things like                                                               
blunt force trauma or deprivation of oxygen to be incorporated.                                                                 
2:18:28 PM                                                                                                                    
MS. HODGES said states began  defining brain injury in statute 30                                                               
years  ago  and  it  was   solely  traumatic.  However,  provider                                                               
services  are  very  similar for  those  with  stroke,  aneurism,                                                               
tumors,  encephalitis,  etc.,  and  providers  cannot  sustain  a                                                               
program  serving  only  those  with   TBI.  Some  states  exclude                                                               
congenital and degenerative brain  injuries, such as Alzheimer's,                                                               
because  they have  very different  service needs.  In Alaska,  a                                                               
person born with a developmental  disability (DD) is served under                                                               
the DD population and services.                                                                                                 
2:20:06 PM                                                                                                                    
SENATOR  DYSON said  other than  physical trauma,  the issue  [of                                                               
brain  injury]  is  blurred. Diagnosing  fetal  alcohol  spectrum                                                               
disorder (FASD)  is difficult. He cautioned  that Senator McGuire                                                               
is introducing a subjective element  that could have major fiscal                                                               
SENATOR MCGUIRE  said that assessments  are not made  through the                                                               
legislature  but   as  part  of   DHSS's  assessments   by  their                                                               
physicians.  She said  she initially  began advocating  for blunt                                                               
force trauma  brain injuries but  Senator Dyson's  leadership has                                                               
brought ABI  issues to light too.  The question is at  what point                                                               
people with  ABI interface  with DHSS to  receive a  waiver under                                                               
another  category. She  is not  prepared to  exclude people  with                                                               
certain types of  brain injury today. She is relying  on the DHSS                                                               
experts  and their  evaluation to  determine  if the  legislation                                                               
needs to be narrowed.                                                                                                           
2:23:15 PM                                                                                                                    
SENATOR  DYSON  encouraged Senator  McGuire  and  the experts  to                                                               
think about  this issue and  make her intention, as  the sponsor,                                                               
very clear because the courts will look at it.                                                                                  
SENATOR  PASKVAN clarified  that  Senator  McGuire is  suggesting                                                               
removing the words  "including housing" from page 2,  line 30, in                                                               
order to avoid jeopardizing future available funding.                                                                           
SENATOR MCGUIRE replied, "yes".                                                                                                 
CHAIR DAVIS clarified that is the only change at this time.                                                                     
2:24:14 PM                                                                                                                    
SENATOR  PASKVAN offered  Conceptual Amendment  1 to  CSSB 219(),                                                               
Version R: He moved to  withdraw "including housing" from page 2,                                                               
line 30. There being no objection, the motion carried.                                                                          
CHAIR DAVIS asked Ms. Solerno to comment on that change.                                                                        
MS. SALERNO said  another item in the  definition is problematic:                                                               
the wording  of strengthening local  capacity [page 2,  line 29].                                                               
She noted that case management  services are for individuals, not                                                               
for  communities  or  localities.   She  believed  removing  that                                                               
wording would make the section work for DHSS.                                                                                   
SENATOR MCGUIRE said  that was acceptable to her.  After the word                                                               
"expand"  the  words  "and  strengthen  the  local  capacity  for                                                               
delivery of needed services, including housing" can be removed.                                                                 
CHAIR  DAVIS said  SB 219  has another  committee to  go through,                                                               
which will allow  DHSS to check with their  attorneys and address                                                               
the issue again if needed.                                                                                                      
2:26:50 PM                                                                                                                    
SENATOR  PASKVAN offered  Conceptual Amendment  2 to  CSSB 219(),                                                               
Version R: He  moved to remove the words from  line 29, after the                                                               
word "expand"  up to the  word "for" on  line 30. There  being no                                                               
objection it was so amended                                                                                                     
2:27:43 PM                                                                                                                    
SENATOR PASKVAN moved  to report the CS for SB  219, version R as                                                               
amended,  from  committee  with  individual  recommendations  and                                                               
attached fiscal note(s).                                                                                                        
CHAIR  DAVIS  announced  that without  objection,  CSSB  219(HSS)                                                               
moved  from  the  Senate  Health  and  Social  Services  Standing                                                               

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