Remarks: Medicaid Expansion Press Conference March 17, 2015 Governor: Thank you very much for begin here. This is an exciting day for Alaska. This is an exciting day for this administration. My only regret is that Byron Mallott is not standing next to me. He is out of state on an Alaska commitment. Otherwise he would be here as well. We are excited to say that today we have transmitted legislation for Medicaid expansion and Medicaid reform. It has been something we have talked about for a long, long time. So it’s nice to be talking about it in the past tense. It is something that we have received lots of support for from across the state. Not just today, but for the past several years, we have received that kind of support. We’ll talk about that in a little bit. We’re doing this for a many reasons. The number one reason is for healthy Alaskans. Any time you can provide health care opportunities for over 40,000 Alaskans, that’s a good thing, it’s a good day to do that, it’s the right thing to do. That’s why we’re doing it. It’s healthy for the economy. Anytime you can bring in $146 Million in federal dollars into our state when our economy is such that . . . we would lobby and fight hard for that to happen. We’re proud to be able to have that come into our state. And that will be coming in, it’s not as a one-time payment, it’s on an on-going basis. It’s healthy for the general fund. Lots of dollars out of the general fund for health care that will not have to be now as a result of the, once this is in place to receive federal funding to replace general fund dollars. It is the catalyst for reform. We’ve heard a lot about reform and we are in the process of reforming, it has been ongoing. We will continue that on. Reform is part of this legislation. Reform isn’t something you start on one day and stop on another day. It’s an on-going process. This will be the catalyst for that. It’s what the legislature has asked for that. We have responded with the reform measures. You know the support from Alaskans has been overwhelming. When Byron and I were on the campaign trail, there was never a time that we didn’t bring this up that there wasn’t instantaneous applause. There was not one time – I mean immediately there was applause. Whereever we were talking – if I was standing in front of the Anchorage Chamber of Commerce, we got a round of applause when we talked about expanding Medicaid. So it wasn’t a regional issue, it wasn’t a special interest group issue, it was an Alaskan issue. So that became loud and clear during the campaign process. Since then, in my travels, I’m in a restaurant, I’m in an airport, you know, it’s not a scientific poll I do, but you know, people come up to me, and are bold enough to kind of interrupt whatever I’m doing or step up and say, introduce themselves, this is the number one issue that is talked about. They talk about other issues as well. But this is the one that stands out to me – they’ll come up. One was a physician from Fairbanks that came up and said thank you very much for that. I’ve heard from a number of people that otherwise wouldn’t have had coverage. Some don’t have coverage, but will under the Medicaid expansion. So it’s sort of been across the board. So the number one issue that has been brought to my attention by the Alaskans that I run into. You know on the federal funding side, we don’t receive about $400,000 a day as a result of not having this coverage. That’s about what it would equate to as far as coming into our economy. So it’s a big ticket item. Another way of looking at it is $146 Million – well that’s pretty much what our capital budget, our state contribution to the capital budget this year, it’s about $150 million. So it’s of that magnitude. It’s a big deal. It’s a lot of revenue to Alaska, but it’s a lot of benefit to Alaska. And I don’t just look at it as wearing a chamber of commerce hat, or trying to develop, bring in revenue. Yes it does, yes it creates additional jobs. I think the number is about 4,000 jobs that we estimate. I’ve heard from other governors around the country that what they have estimated became significantly greater once it was actually implemented. So we’ll see that after implementation. There has been some concern about whether or not, you know what happens if the federal government does this or the federal government does that, remember, this is the law of the land. In order for that to change, and go below 90%, it’s going to take an act of congress. It’s going to take a president to sign off on that act of congress. So it won’t be all of a sudden someone flips a switch and says we’re not going to fund this anymore. It’s the law of the land. We do have a letter, since there was some concern about whether or not we would be able to withdraw. We did get a letter from the Secretary that she said, Secretary Burwell said if Alaska ever goes below 90% and you want to make a modification, you can certainly, if you want to withdraw, we can certainly do that. There is a process to do that. So we’re not locked in. We have the ability to withdraw if necessary. So I’m just very excited about it. About what it’s going to do for Alaska. I think they have responded to what we’ve asked for by Alaskans in general across the state. I think the legislature asked for reform, we brought forth a bill, transmitted today, a bill that provides for both, for reform as well as the expansion. So the savings of the first year, net savings of $6.5 / $7 million dollars is what we’re looking at. And it grows. It’s going to grow significantly from there. There are just so many good, positive reasons why this should be accepted. There is plenty of states across the land have accepted it. Republican governors, Democratic governors, Governor Christie has accepted it in New Jersey. Certainly there is no question about the party he is affiliated with. So to me this is not a partisan issue. For us this is not a partisan issue, it’s an Alaskan issue. We are excited about today. You might notice we’ve got some pins on. It’s the right thing to do. It is the right thing to do. So I’m pretty excited about it. I’m very excited about the kind of support. Our written support – we’ve got resolutions of support from chambers of commerce, the Municipality of Anchorage, other municipalities across the state, the YMCA, Boys & Girls’ Clubs, faith based organizations, Alaska native corporations, different tribes across the state, it’s just wide spread. And so we will make that public, as part of our whole transparency concept. We’ll make that public. We do have commissioners here today to answer specific questions that come up on technical issues. I am certainly happy to answer questions right now. Jennifer Canfield, Alaska Budget Report: Are you submitting a bill, is that what you’re saying? Governor: Yes. We have transmitted a bill already today. We don’t have a bill number. That will be tomorrow. Alexandra Gutierrez, APRN: We’ve heard a lot of people say that we want reform, about defining what reform means. What does reform mean to you, what reforms are we seeing in the bill? Can we get some specifics? Governor: And that’s exactly what Commissioner Davidson is going to talk to you about. As far as what I’ve done, as far as specifics in the bill, that shows exactly what the statements will be. Gutierrez: Well for you, which one is the most important reform? Governor: Well, reform where there’s cost savings. There is a savings and there is also a reform associated with the audit provisions that are important to me as well. To make sure that what we receive is done properly. Gutierrez: I was wondering also, it’s day 57 of the legislature, obviously you know things can move slowly here sometimes. Do you think there is enough time for the legislature to properly vet the bill and could pass before adjournment in April, and if not, would you keep the legislature here to see that it is passed? Governor: We are optimistic that it will pass during the legislative session. We will just keep our eyes focused on the last day to make sure that it’s passed by then. Nat Herz, Alaska Dispatch News: Do you regret in retrospect not offering the administration’s own bill earlier and can you explain why you didn’t do this earlier. Governor: Sure. We put it in our budget. We approached the Medicaid expansion in our budget. It was in our budget. When it looked like it wasn’t going to stay in the budget, Senator Kelly was working on a bill, we knew that. We thought that might be a vehicle that we could use for that. When his bill came out and did not have the expansion, you know one was in the House that had expansion without reform. There was one in the Senate which had reform without expansion. So we said well, I think we might need to do a bill. So that’s what we did. Once we saw there wasn’t a vehicle available, we did start the process with it being in our budget of course. And then after different bills moved, that were introduced that didn’t match up with what we were hearing, we said let’s do a bill and that’s what we did. Rhonda McBride, KTVA: There’s been a lot of butting of heads between you and the majority leaders in the advancement of the bill first, in the budget. What kind of broke the lock there and gave you the sense that there was enough trust to go forward with a bill? Governor: Well, I think seeing that Senator Kelly’s bill didn’t have the expansion in there. That was the next logical thing for us to do, we said, okay let’s put that together. We anticipated that and he chose not to for whatever reason, that’s fine. So we decided it was time for us to sort of close the loop and put out there exactly what was being asked for. You have a follow up? Rhonda McBride, KTVA: Can you be specific about sort of had Senator Kelly specifically promised to include Medicaid expansion in his bill and then he didn’t? Governor: Oh No. I don’t think there were any commitments made to us from Senator Kelly. I think that was perhaps his intention, that was somewhat understood. But there was no commitment that we were uncomfortable about. Matt Buxton, Fairbanks Daily News Miner: You know, you’ve introduced a number of bills this session, some of them are locked up. For example, maybe the Fairbanks Energy Project bill. It’s gotten 4 committee referrals. It’s sort of stuck where it is. How are you going to make sure this gets its hearings? And move forward as it should? Governor: Well, I, we understand, it’ll get two assignments, HSS and Finance and if it gets two on each there should be plenty of time to go through that. Becky Bohrer, Associated Press: Is there recourse for the administration outside the legislative process to accept expansion? Do you need for the legislature’s explicit blessing or can you in the administration do something else? Governor: This is the best way to do it, do it through the legislative process. So it has the collaborative process. So this is our preferred option by all means. Dorene Lorenz, ABC/ Fox: Senator Dunleavy suggested that we hadn’t heard from every day Alaskans that they wanted Medicaid expansion. Is that why this room is filled with every day Alaskans? Governor: You know, it is filled with every day Alaskans and it’s not for that particular reason, but it’s just it impacts every day Alaskans and we’ve heard from every day Alaskans. So I think there will be no lack of input from every day Alaskans. That’s what I hear from when I’m in a restaurant or traveling and what not. I think they won’t be bashful. Actually that’s what we’re going to need. People need to make sure that legislators are aware of their position, either side of the position. There are certainly two sides to that. Alexandra Gutierrez, APRN: Following up on the Becky’s question, when you say this is the best way to do it that implies that there might be other ways to do it. Is there a way for you guys to do it unilaterally if the legislature does not advance this? Governor: There are other options, but none that we are exploring at this point, because we have a faith in the legislative process that they’re going to move this through. Question: And are you concerned that the disagreements over the gasline could have any effect over getting Medicaid expansion through the legislature? Governor: Boy, I sure hope not. I’m having a hard time connecting the dots on that. But I don’t think so. I have not heard anything that would lead me to believe that one would impact the other one. Nat Herz, Alaska Dispatch News: Your talk, sort of head butting between you guys and the House majority, has sort of been over process I think, you know the Pt. Thomson settlement, for example. You guys were pretty much in line on that on the outcome of that, as far as dropping the law suit. Could you talk a little bit about the process of introducing this bill, did they get to see it in advance, do you have, you said you have understanding it will get two committee assignments, you have plans for hearings, that kind of stuff? Governor: You must have missed the golf thing this weekend, because you know we’re getting along really well. We had a great three some and that was fun. It’s no surprise they’ve asked for the legislation. So we’re providing in that form. We have provided that to them today, distributed prior to this press conference today. So it’s something they’ve asked for and now we’ll go through the process and see if there are other adjustments that we’re going to make on that. Rhonda McBride, KTVA: I understand that you met with the House speaker and the Senate president after that golf game. Is this sort of where this agreement was made? Governor: Well, you know they say a lot of work gets done on the golf course, and so I guess that would be true even when the golf course is here in the capital building. It was an opportunity to discuss it with them. But no body’s asked me any questions about my new grandson yet. You know. He was born yesterday. Nat Herz, Alaska Dispatch News: Have you been told there’s a quid-pro-quo reform for expansion or do you assume there’s a quid-pro-quo? Governor: No, I have not been in discussions about any quid-pro-quo at all. It is what it is. Question: I just want to follow up Governor. You talked about how the Federal secretary of Health and Human Services said that there had to be, there would be assurances they wouldn’t just drop the program below 100% federal match. If – Governor: 90% Question: 90% I’m sorry, is there a threat that folks could lose their insurance if Congress voted to lower that below 90%. I mean folks who are already insured under this expansion end up left high and dry should the worse happen? Governor: I don’t know, that’s a technical question that Commissioner Davidson may be able to answer when I step away for something else. It’s a good question. Becky Bohrer, Associated Press: The Obama administration has support of expansion obviously in the states. Have you guys heard anything from the administration in terms of would it be easier to get waivers approved if you have an expansion element verses if you just tried to do reform and get waivers for reform? Governor: I know that Val is going to have answers for you, I’m sorry Commissioner Davidson will have a good answer for you on that. Question: Any concessions you’re willing to make on perhaps other issues to get this passed through? How much of a priority is it for you over other things? Governor: Concessions on other issues? Question: Maybe a little give and take, you might want to change your stance on a few things or give up on . . . speaking of gasline? I don’t know. Governor: No, I don’t think we’re at that stage at all that we’re going to trade. We’re talking about the health care of thousands of Alaskans. And boy that’s a pretty, that’s such a high priority. I don’t know who you trade that away. Question: The majority is not really excited about expansion, so what are you going to do to get them excited about this? Governor: Well, we’re going to present this bill, which we have. We will present it in committee as well. And we expect that we will be able to convince, to meet with the legislators on a one-on-one basis, or however they want to discuss this, to convince them that it’s the best thing for Alaska. I know it’s really kind of an old fashion way of doing it, but I think we can do it one vote at a time. Alexandra Gutierrez, APRN: At the last press availability you had on the subject, you were very adamant that the bill that had been introduced by the House minority would be sufficient and that they should hear that. And you kind of spoke as to why you changed your mind in terms of why Senator Kelly’s bill might not be a vehicle. But why did you change your mind on Representative’s Josephson’s bill on being a vehicle? Governor: Well, at the time we thought there was something coming from the Senate as well. And so we’d see if the senate bill was sufficient, we would work with that and then perhaps it would be amended in the House. Perhaps we could adopt what the Senate had. . . You know we still have process in our budget that we submitted, on the operating budget, and then we let that legislative process work for a bit on the House and the Senate, and they both match, so it was time to put something together. Question: So then Representative Josephson’s bill was not ever really seen as a vehicle then? If you were waiting on something from the Senate side. Governor: We saw it as a vehicle from the House side. It depends on what comes on the Senate side. The Senate side came on something that was close to what we were looking for. Then there was some confirmation on the House side as well. So once both those options played out, it was time to put together a bill. Nat Herz, Alaska Dispatch News: I guess I’m wondering is there any new savings or new reform elements in this bill that haven’t already been presented. Is it your understanding that that is necessary to get a bill through to the legislature, or is it more of a question of packaging everything that already exists that you’ve presented into one bill? Governor: Well, I think it’s largely packaging what has already been talked about and discussed. And putting it all into one bill. Putting all the pieces together into one piece of legislation. Again Commissioner Davidson will talk more specifically about that. Nat Herz, Alaska Dispatch News: Do you feel like you need to present more savings and more reform for the legislature to go along with expansion? Governor: I don’t think so. I think this goes far enough. Again, remember, it’s not a light switch when we turn on reform once the bill is passed. It’s an ongoing process. There are some things you can’t do, that you can’t just do over night. You have to begin with, it takes a process associated with that. So there is some of that in there as well. Again, it’s not a simple as sort of just crossing this out, adding this in. It’s a lot of moving parts to make the reform work. But it’s a great catalyst for it. We have actually already started the reform, you know, without this. We’re just continuing on. Commissioner Davidson. Val Davidson, HSS Commissioner: Quyana Governor Walker for you incredible leadership to the state on the issue of Medicaid expansion. I think we’ve said before that you know when things are really difficult and things are really tough, it would be really easy for somebody to take a step back. But in tough times in Alaska certainly when things are tough, a real leader steps forward and Governor Walker you have done that for Alaska time and time again on Medicaid expansion. And you know when Alaskans are having a difficult time, we don’t turn our backs on each other. We turn towards each other. We extend a hand of friendship and we help each other. And that’s what this bill is really all about. So just to recap for folks who may not necessarily remember all of the details about Medicaid expansion. It provides coverage for adults without dependent children with income up to 138% of the federal poverty level. Which is a single adult earning $20,314 a year or a person that earns about $9.76 an hour. Or a married couple who earns a combined income of about $27,500 a year. In terms of the reform package, these are not new concepts. As Governor Walker indicated, these are issues that we have discussed in every budget presentation that we have presented as a part of the department’s budget process. Governor Walker introduced Medicaid expansion and reform opportunities as a part of his budget from the very first day. We had a number of hearings in the House Finance HSS Budget Subcommittee specifically to Medicaid expansion and on-going reform efforts as well as new reform efforts. We started that process also in the Senate Finance HSS Budget subcommittee. In fact, last week had a hearing on Medicaid expansion in full Senate Finance, although that was last week, it might have been Monday. My days are all going together here, I apologize. In terms of the reform package, what we’re looking at are really building upon the reforms that the department has quite frankly already undertaken. And so they include things like maximizing existing 100% federal match opportunities. For example, by working with our tribal partners to increase the number of IHS beneficiaries or Indian Health Service beneficiaries, who receive services from tribal providers through an 1115 waiver, that allows us to realize a potential savings between $80 and $150 million, which is a significant savings to our state general fund. Again, as Governor Walker indicated, that isn’t on day one. That’s a process that will take some time. Other options are really refinancing the way that we deliver health care. So for example, for home and community based services, right now we pay for some services for Alaskans who don’t meet their nursing level of care, but meet other criteria. Perhaps they have Alzheimer’s, perhaps they have they are suffering from a traumatic brain injury, or maybe they have a severe mental illness. Right now we pay for those services with 100% state general fund dollars. But we have the opportunity, by exercising an option, a 1915(i) option with the Centers for Medicaid and Medicare Services, that allows us instead of that being 100% state match, to 50% state match. Another option is 1915 (k) option to replace existing home and community based services where we see an increase of an additional 6% federal match. Those two issues combined, those to reforms combined, have the potential for $24 million in savings we estimate in about 2 or 3 years out. Other opportunities, we know there are tremendous opportunities in a state as geographically large as ours, where not every community has the benefit of having a specialist. There are opportunities for tele-health enhancement. Also looking at broad demonstration authority and payment reform and innovation reform authority. So that as we move forward, we recognize that we may not have all of the answers today. And working with the public, we actually have an RFP on the street, requests for proposals are due this week. To be able to work with stake holders, look at reforms that other states are doing, not just on expansion but for regular Medicaid. And looking at ways that we can deliver health care more efficiently while realizing savings but still being able to sustain our Medicaid program that will allow us to provide services in the future. The other thing the bill does is, it also as Governor Walker mentioned, includes a provision making Alaska’s continued participation in Medicaid expansion continued on the federal match remaining at or above 90%. The bill also directs the department to submit to the legislature January of 2016 a proposal to authorize a provider tax to offset some of the costs of expansion. But I guess in a nutshell, this is really a tremendous opportunity that Alaska has to be able to leverage a small amount of state resources to be able to leverage significant federal resources into the delivery of our health care system. We have the opportunity as Governor Walker mentioned, to improve the health of Alaskans; to improve the health of our economy, to be able to deliver health care services and quite frankly at a time we are experiencing budget challenges, our state could really use those federal dollars, all at a net savings to our state budget. But I think I might be getting into dangerous territory here in terms of the financing of it. But I guess going back to a question that was asked earlier by you, Nat, you asked a question about whether we really had enough time to be able to vet these ideas. There ideas have been vetted already before committees and finance committees. These are issues that we have mentioned before. Governor Walker heard the legislators say they wanted a stand-alone bill. And that is what Governor Walker has delivered today. Governor: This is how it works. You’ve said all these wonderful things. So you just call on whoever you wanna call on. Davidson: Ok (laughter) Thank you. I learn new things from you every day. Governor: That’s right. That’s the way we work. Adam Pinsker, KTUU: First assuming if this bill passes this session, when is the soonest you can implement Medicaid expansion? And you mentioned obviously the agreement Alaska has with the federal government if it drops below was 90% the state would withdraw. But what would happen to people that were already on expansion if unfortunately that were to occur? Davidson: In terms of eligibility for to be able to receive services, our target date is July 1st. In terms of if our state decided that we don’t want, we want to pull out of Medicaid expansion, Secretary Burwell’s letter indicated to Governor Walker, that of course Alaska can discontinue their participation but they would appreciate a transition period so that people have the opportunity to receive adequate notice and so that there is a period of transition so that people have the opportunity to find additional coverage. Adam Pinsker, KTUU: Real quickly, I’ve heard 40,000 Alaskan’s could be eligible, I’ve heard that number thrown out for a couple of years. Is that still an accurate number for folks who would be interested in, are they aware even they are even, maybe some people don’t even realize they are eligible for it? Davidson: Well, up to 42,000 people would be eligible for expansion. We anticipate that probably about 20,000 people would enroll in the first year. That’s based upon the information from Evergreen Economics, a firm that has been doing our analyzing on Medicaid date for the department for about a decade. Nat Herz, ADN: Senator Kelly’s reform bill that he introduced last week it includes some like broader or more extensive changes to the Medicaid program, like there’s a managed care demonstration program, there’s a study on whether you can privatize some of the services that are offered at places like the pioneer home. Can you explain why those concepts aren’t elements of what you guys are proposing now and could people see them from you guys later? Davidson: So a couple of things. One is that the reform package that we have included in this bill is what we thought we would be able to accomplish within this timeframe. As Governor Walker mentioned, reform is not something that starts today and then ends tomorrow. It is a process that continues over time. But because of the questions that you raised in terms of other reform opportunities, the Governor also included broad reform authority within the bill to be able to capture those other kinds of opportunities should they arise. And we also know, that the Centers for Medicare and Medicaid Services certainly through their innovation center and other opportunities, they make new opportunities, make available to states every year and we don’t know what those new opportunities might be in the future. But we do see some opportunities for payment reform etc. Becky Bohrer, Associated Press: Commissioner, you said something that you felt we could do in this timeframe, do you mean within this session or within the fiscal year. Can you talk a little bit about the lead time that would be required for this and if you could explain what a provider tax is. Davidson: Sure. So in terms of timeframe, I believe the fiscal note is a 5 year timeframe which is a standard fiscal note cycle for this. So we identified reform efforts that we thought we could identify today that we would be able to accomplish during that time frame. Recognizing though, again leaving some flexibility for things, other opportunities that may arise as we move forward in the process. And then in terms of provider tax. Alaska is one of the few states that doesn’t have a provider tax. What other states have done, is they tax certain providers, it doesn’t have to be all of them. Typically they tax hospitals as a way to be able to pay for some of the services that people receive. But there is a limitation on the amount under federal rules as well. But we recognize that implementing something like that is something that we can’t do by ourselves. We are working with stakeholders, again, over until January when we will submit a proposal to the legislature that really talks about the best path forward. Quite frankly, we recognize that we don’t have all of the answers. We want to make sure that as we move forward with these reform efforts, that we do it responsibly. Because, quite frankly, we have to make sure that we have people on board, it’s in a timeframe that they can live with, and on a timeframe that people can absorb. Alexandra Gutierrez, APRN: You said that the provider tax would be to offset the costs of expansion. I guess can you give us some numbers on how big that tax would be and what those costs of expansion are? Governor: We might call on OMB Director, Pat Pitney on that. Pitney: So the provider tax isn’t factored into the fiscal note at this point. And I think the maximum federal amount could be 6% and it can’t tie directly, so it would be similar to other fees that go into the general fund. It doesn’t tie directly to this particular program, but that money could then of course go into the general fund, that would be an offset. So the bill allows for up to the federal maximum tax up to, not demanding that. But it is not right now a component of the fiscal notes but there still is some savings. Question: And that’s when you say up to 6% that’s of the cost of the state’s share of the Medicaid program, or that’s 6% of ? Pitney: Of hospital activity. I can’t image it would go that far, but that’s the federal; there’s a federal limit. And the bill says up to the federal limit if you chose to. Question: Do you have sort of any sense of total hospital activity, like are we talking single digit millions, tens of millions, hundreds of millions? Pitney: Well, right now just based on the corporate income tax, the additional activity would bring in, in this current year, 2016, like $1.6 million and up to $3 million across the time period. So just from the additional activity and our current corporate tax, you’d see a small balance. Question: Do you know what the current tax is for hospitals? Pitney: Well the corporate tax is what the corporate tax is for all corporations in the state. I think it’s very small. In total it’s not a big number. Question: So the, I’m just still trying to get clear, is it, would the provider tax presumably be a little bit larger in scale than that for hospitals? Pitney: The provider taxes would bring in more than the corporate tax for health providers, yes. If one was implemented. Even though this allows for it, that would still have to go through the legislative process. So there would be plenty of hearings and that’s why we didn’t get, the other pieces are ones that we are more sure of, that we would receive the savings for than this one because it would be contingent on more legislation. Governor: Let me clarify on that. The $6.5 million savings, takes into consideration the cost of implementation. So that’s after the cost of implementation. That’s sort of a net savings. Question: When you’re looking at a provider tax specifically on hospitals, in Anchorage for example, it is my understanding that hospitals like the native hospital and Providence don’t pay the corporate tax because they are non-profits. Are we basically just selecting that number of 1.6 off of what we’re getting from Alaska Regional and the small hospitals? Pitney: It is only the hospitals that currently pay under the corporate tax rules. Davidson: If I may just add to that. One of the reasons, just to recap what Pat said and also what the Governor has said, is that one of the reasons that we don’t have that level of specificity is because we have committed to being able to sit down with providers and stakeholders and arrive at what works for Alaska. I mean we have said repeatedly that in Alaska we don’t want the Arkansas plan, we don’t want the Indiana plan, we don’t want another state’s plan. We’re taking the time to design an Alaska plan that works for Alaska and works for Alaskans. And that’s going to take some time. Rhonda McBride, KTVA: Two questions: who came up with the slogan “it’s the right thing to do” and why that theme. And the second thing is there any specific mechanism in the bill that allows for ongoing reform that sets the stage for that? Governor: I think Alaskans came up with the slogan, as far as I’m concerned. So many people came up and said hey, let’s do it, it’s just the right thing to do. I honestly don’t know where that came from. Maybe somebody else does. Davidson: I don’t believe it’s trademarked or copyrighted or anything. And I think that’s one of the things that so I appreciate about working with Governor Walker and working with Alaskans is that people are really practical. And that we faced really tough challenges before as a state, whether it’s the budget, whether it’s designing a health care system, but you know what, when Alaskans come together to have those candid conversations, we arrive at a really good place every time. And that is a really good thing for us to be able to do. And in terms of your second question on the mechanism for reform opportunities, there is actually a section in the bill that specifically talks about reform opportunities. Pat Forgey, Alaska Dispatch News: Question for, maybe for Darwin. If the provider tax is such a good idea, why wasn’t it done earlier in a separate bill because that can’t be done through the budget, can it? Pitney: Sure the bill provides for it. It would take separate legislation to actually implement that tax. Pat Forgey, Alaska Dispatch News: But why wasn’t it done before now? Pitney: Because it requires an open dialogue with providers. We don’t want to impose something without having time to discuss that. And with the new administration, it’s not what we want to lead with. We want to lead with expansion and doing what’s right and then we can pick up the provider tax because I believe the providers also see the benefit of participating in the overall solution. That’s not what we wanted to lead with; we want to lead with expansion. And that can come on; there will be savings to the state prior to that. Question: (inaudible) section authorizing it before today . . . Governor: This is our first piece of legislation on this so we had no. . . we would have worked with somebody else’s piece of legislation with this and that opportunity didn’t presented itself, so we presented with this legislation. Question: Just to take a step back, in terms of the reforms that you are proposing, can you explain the process? Does everyone need a detailed plan that you submit to CMS or someone else? I mean, can you talk about the process that’s necessary to get approval of that. Davidson: Sure. So the processes are different depending on which reform option that we’re talking about. So that for example, the tribal health option that we’re talking about is actually a waiver. It’s an 1115 waiver that we are negotiating with tribal health organizations and with the Centers for Medicare and Medicaid Services. The 1915(i) and (k) options are, again, things that we negotiate with providers and that we also negotiate with CMS. But those are options that are available to us. One of the things I didn’t mention earlier, I’m sorry Governor, is that we have certainly heard from providers over the last couple of years that a lot of our audits were just killing providers. We’ve had audits on the book for some time, for very good reason. But as the federal government has increased its requirements for audits, those have really, providers have really felt like they’ve been doubled up on audits and we think historically haven’t necessarily coordinated very well. And so part of the bill includes streamlined audit requirements to better coordinate those federal and state audits as required. In terms of some of the other reforms, some of those we think we can get done just by demonstration projects. As I mentioned before, that broad authority, but some of those, clearly we would want to make sure that we work with providers so that we’re clear on what it is that we’re trying to accomplish. We recognize that this is not something that we can do alone. We need to have stakeholders on board to be able to help us develop a path forward. But some things may require some approval by CMS, the Centers for Medicare and Medicaid Services. They have been really great partners in this effort of providing more coverage to Alaskans. Alexandra Gutierrez, APRN: It seems like a lot of the reform components that you mention have to do with the accounting, is there kind of a conscience choice of because of the timeline to focus on the accounting verses delivery of Medicaid? And are there delivery aspects to this reform package that we’re missing right now? Davidson: So it’s both. One is we recognize that one of the best things that we can do quickly in terms of reform efforts is really refinance our program given our current budget situation. We are doing that not only in health care. We’re doing that in other areas as a state. Certainly as the House and Senate finance committees are looking at opportunities for savings, they’re doing that as well. But in terms of other reform opportunities, like payment reform, those are things that take time. And so I mentioned earlier the RFP being able to work with stakeholders, work with providers, to be able to develop a longer term reform package that works for Alaskans. Question: and has Xerox demonstrated over the last several months that it made substantial changes that would cause you to believe that July 1 remains realist? Governor: They have. Of the new bills that have come in, 90% of them have been paid within the time frame. So there is a significant improvement on the new bills that are coming in. So we believe that reform is on the right direction or that the process is improving significantly. . .that by July 1 things should be fine. Alexandra Gutierrez, APRN: Can you just tell us who these people are behind you and why they were invited. Governor: We have commissioners here. Ron Taylor, the Commissioner of the Department of Corrections is here. Corrections is a big part of what we, the savings itself. We have groups that have been reaching out to us across the state. Jeff Jesse from the Alaska Mental Health Trust, they have stepped up and offered to participate financially in the implementation the first year. You know, we’ve just had . . . I can’t go through every single individual that’s here. Davidson: Wonder if maybe, Governor I’m sorry for interrupting, maybe they might have the opportunity to introduce themselves. Governor: That would be awesome. And also not just, also why they are here. I think that would be helpful. Anybody that feels comfortable enough can step up. My name is (inaudible) of the Filipino Community of Juneau. I’m in favor of the expansion of this Medicaid thing. The only thing that worries me is the there is a pending case at the U.S. Supreme Court and that would affect you know regarding the subsidy. We hope that it could not be declared unconstitutional by the U.S. Supreme Court because it has an effect on this expansion thing. But we are all in favor of this expansion of Medicaid. Governor: I’m going to have to run for another commitment. But again, thank you all very much for being here. Strong: Thank you Governor Walker, I’m Kimberly Strong. I’m with the Southeast Alaska Regional Health Consortium, I’m the chairman of the board and I’m here in support of the expansion. Medicaid expansion will greatly increase our abilities in the native health field to provide better services. And as we expand out and provide services to people who are not natives in the communities that we serve, it will be a great thing for the underserved in our rural communities. Thank you. Johnson: Hi, my name is Stephanie Johnson. I’m here on behalf of the National Association of Social Workers and the Social Action Committees. These are our board members, Robin, Cam and DeAn. And we are here on behalf of all of our social work members as well. The Medicaid expansion was our number one priority so we are really excited to see this go through. And I appreciate all of your guy’s support. Thank you. Fuhrer: My name is Ron Fuhrer, NEA Alaska President. I represent 13,000 teachers, educational support professionals and above all 130,000 students in the State of Alaska. We believe that a healthier Alaska will make healthier students and our students’ learning will improve. Thank you. Jesse: I’m Jeff Jesse, I’m the CEO of the Alaska Mental Health Trust Authority and Medicaid expansion is critical for our beneficiaries, particularly single individuals between 18 and 65 that need substance abuse treatment that aren’t eligible for Medicaid now. This is huge in terms of addressing issues of alcohol and substance abuse in the state. Also, as we look at trying to control the corrections population. And looking at support for recovery in the community, having access to health care and substance abuse and mental health treatment would be absolutely critical to getting that job done. That’s why the Trust has stepped up and agreed to provide some of these initial administrative expenses. Brown: I’m George Brown, a pediatrician, my wife, Carolyn, is a physician also. We have been here in Alaska since 1965. We’ve been promoting the idea of that it’s is correct and right for everybody to have access to health care. To answer the question about where the slogan might have come from, the 19th amendment of the U.S. Constitution was passed in August of 1920. The Tennessee House of Representatives member, I’m sorry I can’t remember his name, was gonna vote no. The night before he got a note from his mother. And he read it. And the note said “do the right thing”. And now women vote. Thank you. Kueffner: My name is Eric Kueffner and I’m an everyday Alaska. I also happen to be the President of the Juneau Community Foundation. I’m here because I think this is a good idea and I have no technical expertise on this but seems like an obvious choice to do to help the health of Alaskans. Thanks. Ciambor: Good afternoon, I’m Scott Ciambor. I’m the chair of the Alaska Coalition on Housing and Homelessness. Homeless individuals, the working poor, folks on the verge of becoming homeless, tend to benefit from Medicaid expansion. So we’re in support of this bill. Thank you. Escalante: I would benefit from the expansion. My 20 year old daughter would benefit. She is fighting a rare disease called vasculitis. She wants to work and was actually told to apply for disability at 18. In order to get insurance. She did not do that and she could die if she does not get medical treatment. It’s as serious as cancer. I think it’s important that Alaska takes care of its people. That no one should go without insurance or risk of dying because they don’t have insurance. I support the expansion of Medicaid. Thank you. (applause) My name is Tiana Escalante. Thank you. (applause) Grunstein: My name is Steven Grunstein. And I find myself in the healthcare gap. Through no fault of my own. There is nothing in my power that I could have done that would have prevented that. I’m also dealing with a terminal kidney disease. Where I’ll be on dialysis probably before August. And right now trying to get health care is like running a gauntlet. It is nearly impossible. You go from one agency to another to another to another and everybody’s passes you around like a football. I believe that if this health care expansion goes as intended, it will be a wonderful thing. But I am also aware that in politics things go bad. I’ve seen too many bills start out with really intentions go horribly wrong. Let’s try not to let the horribly wrong happen here and make it awfully good. Not just for myself, but for all the other people out there who I’ve dealt with and talked with who’ve been without health care because they are in the gap as well. Thank you. (applause) Jang: Any more questions? Jennifer. Jennifer Canfield, Alaska Budget Report: I have a question for the Commissioner and perhaps Miss Kimberly Strong. I heard her mention something about some of the search clinics here in Southeast Alaska, perhaps extending services to even non-native patients and that’s something they’ve done a lot of, well not a lot of but at least in some rural communities down in the states. And there is usually some state or federal support for it. Is there any discussion when we’re talking about reform efforts in Medicaid between the state and tribal health consortiums to push for that idea – tribal clinics serving everyone in a community? Davidson: So, I certainly don’t want to speak for tribal health, but I can speak from 15 years of experience in tribal health. That tribal health organizations in our state are more than just IHS beneficiaries. (coughing). I think my voice finally just gave out. On the worse possible day. Strong: Our president was sitting in here a moment ago and for Southeast Alaska Regional Health Consortium we have been providing health care to non-natives in some of the rural communities. For instance in Klawock, we provide services to non-natives there. A lot of times, we’re the only. . . and in Haines, where we’ve been providing services for non-natives through the requests of the City who is running the medical services prior to that weren’t able to keep the facility open and occupied with providers. We also receive HRSA funds which were federal funds for helping underserved people. Those are some of the areas that we’ve been . . . Question: Let me help clarify, I’m sorry. If we’re looking in Southeast, we have some struggling city owned hospitals, like in Wrangell, is there any discussion talking about reform, expanding something like an HRSA availability (inaudible) Strong: You know, I’m not really the person. I think, Valerie with her 15 years of experience would be able to answer the question better than I would. I’m the chairman of the board and we are trying to provide the best serves that we can for all the people that we serve. But I don’t have the detailed information that Valerie had been working with at AHTNC. If you could help with that. Davidson: Let me try this one more time with the aid of a cough drop. Speaking about the need for health care . . . (laughter). I apologize. As was mentioned before. Many communities, certainly in rural communities, tribal health is often the only provider of care. And so tribal health care organizations have long provided health care to beyond just IHS beneficiaries. They are required by the federal government to bill third party insurance, whether that’s Medicaid, Medicare, or a third party insurance most recently over the last couple of year. The tribal health system actually negotiated agreements with the veterans administration that allow veterans regardless of whether they are an IHS beneficiary or not to be able to receive health care services in their home community without having to travel to Anchorage, or Fairbanks or Juneau for their services. I think one of the things that I so appreciate about Governor Walker is his commitment to work with everybody. To be able to work with tribal organizations, to be able to work with the federal government, to really bring all of our resources to the table. To have a conversation about what works for Alaska; who’s doing what with limited resources and how we can move forward. In regards to those specific instances, that isn’t a part of this plan. I would certainly have to learn more about those opportunities for those specific communities. We are certainly not in the business of going into communities to dictate how why should provide services in their communities. But, you know, if folks are having challenges, we certainly would like to be able to have a conversation with them and help them to develop a path forward. Question: Valerie, you identified some basic kinds of reforms. For example, in Senator Kelly’s bill there’s privatization, there’s also a provision to bring managed care where beneficiaries would have an opportunity to remain with one doctor. Kind of similar to what native health care has offered. Some of their innovations. So where in this bill is there room for that discussion, those kinds of reform efforts? Davidson: So those broad sweeping reform efforts are included in Section (look at my handy-dandy list here) . . . are included in Section 10 of the bill. It talks not only about specific opportunities, reforms that I mentioned earlier, but it also includes broad authority for us to be able to move forward. So payment reform and those types of things are all included there.