Interview with Hollis French
|
During
the 25th Alaska State Legislature, Hollis French, who represents Alaska
Senate District M, sponsored Senate Bill 160 Mandatory Universal Health
Care. This legislation, which aimed to establish an Alaska health care
program that ensures insurance coverage and provides essential health
services for all state residents, failed to pass. In this interview,
find out why the bill failed, what future action Senator French will
take, and whose support might make major health care reform a reality.
Among the many positions he has held, he has served as chair of the
Senate Judiciary Committee and as the assistant district attorney. This
interview was recorded November 20, 2008. It has been edited for length
and clarity.
AHPR:
Jumping right into the questions: How would you characterize -- or
summarize -- the progress of Senate Bill 160 in particular, and the
question of wide-ranging health reform in Alaska during the past year?
French:
We had good success. We got the bill through two major committees, and
all the way to the Finance Committee. That was my goal ultimately: to
get a hearing on the bill in the Finance Committee. Ultimately, that's
where the big decisions on this issue will be made -- at the table
where the money pile is. You've got to get the people that control the
money pile to decide to push some of that across the table towards
universal health insurance. In order to do that, you have to educate
them as to what the plan does. The only way to do that is to get a
hearing. We just set that as a goal, to get to the Finance Committee.
We made a 20-minute presentation towards the end of the session. It
wasn't as in-depth as I wanted, but the only way you ever get a bill to
the floor is to get to the Finance Committee. So we got there and began
to educate those members.
AHPR: Why did it fail to become law in the last session?
French:
Insufficient knowledge from the members of the committee and the other
members of the body about how the bill actually works. It didn't fall
high enough on anybody's set of session priorities in a session
dominated by the gas pipeline and a capital budget that was about
trying to catch up on much-needed infrastructure investments. Universal
health care is one of those issues that takes several years to rise to
the top, and there wasn't much support from the governor and the
administration.
AHPR: When you said "the committee," is that Senate Finance Committee?
French: Yes.
AHPR: Were you surprised by the level of interest in Senate Bill 160 and/or the question of health reform in general?
French:
No, I think it was about where I expected it to be. We got good
interest from our side of the aisle from the Democrats, and where I
tried to specifically to make inroads was with the business community.
I went to speak to the Chamber of Commerce, to the National Federation
of Independent Businesses, and spend some time with their members.
They're
very suspicious of this idea. They believe -- without evidence -- that
they are somehow going to wind up paying for this. You try as hard as
you can to convince these folks that for many of the smallest employers
it's going to cost you nothing. Suddenly you have three, four, five
employees who don't have health insurance that are going to be eligible
for health insurance through the state at no cost to you. They just
know that's not true, they believe it's not true. They believe that the
1% or 2% employer levy that is in the bill is going to quadruple or
worse as soon as you pass the bill into law.
"You dispel the fear that this is government-run health care. You dispel
the fear that there is an enormous tax increase behind the proposal.
All you can do is just keep telling people over and over."
AHPR: And you clearly don't believe that will happen?
French:
No, I don't. That's why I'm trying to talk to them as much as I can.
You just sort of dispel the fear that this is socialized medicine. You
dispel the fear that this is government-run health care. You dispel the
fear that there is an enormous tax increase behind the proposal. All
you can do is just keep telling people over and over.
AHPR: Was your experience with Senate Bill 160 a learning experience for you, and if so, in what ways?
French:
Two yeses to that [in] two different phases. One: a personal sort of
learning curve of this highly complex area. Every time I work in the
area, I learn how much I don't know. Last night in a room full of
educated citizens [a public forum on Senator French's health reform
bill] -- it takes an educated person to want to come to a meeting like
that -- you get questions and comments that are right at the edge of
your ability to understand the subject. So I come back to Andy [Andy
Moderow, legislative aide] with a list of questions and say, "OK,
you've got to educate me on this and this and this."
More
generically, you're just trying to get the word out. Probably the
hardest thing in this endeavor is just getting press coverage -- simple
press coverage. I've gotten good support from the [Anchorage] Daily News editorial board, [and] one or two very small stories on Channel 2. I don't think the Daily News has run a news story on this bill yet. I'm still waiting to break into the news column.
Like
I said, the editorial board -- I get good support from on that one
little page of the paper. But as far as it being a front page or a back
page story in the Daily News,
it hasn't happened. And that's frustrating to me, because you've got to
tell people what you're doing in order to generate public interest in
putting pressure back on their representatives to create legislative
power.
AHPR: You
mentioned something like this before. Do you think the lack of press or
media coverage is because of competing issues that we've had recently?
We've had quite a few.
French:
The short answer is: yes. The long answer is that the day that we
debuted this bill was the day that Bruce Weyrauch washed up ashore on
an island in Southeast Alaska, and that was just far more of an
interesting story than my role with this bill. When the FBI is raiding
legislative offices, you can sort of guess who the good guys and bad
guys are pretty quickly. The public gravitates towards those kinds of
stories.
AHPR: Based on
feedback from the public -- perhaps you've addressed this already, but
I'd like to ask anyway -- based on feedback from the public, what parts
of Senate Bill 160 were of most concern to the public and perhaps
required the most explanation from you?
French:
From the public, two parts. One, the fact that we're maintaining
private insurance companies in plural, sort of in the health
care-landscape. I think the public would like to see single payer, so
you have to sort of explain to the public that single payer is not
viable politically.
"The other topic that gets a lot of public pressure or resistance is the
individual mandate, the part of the bill that says everybody has to
acquire a health insurance policy. People just resist that, I think by
nature, and Alaskans maybe resist that by more nature, by a stronger
nature."
AHPR: Even though it seems to you that the public in general would be supportive?
French:
Yes, the people that I talk to typically are sort of more to the left
end of the spectrum. They're more interested in this as a topic -- and
they're educated enough on the topic to know or at least to believe --
that single payer is far superior to the multiple insurance company
landscape that we find ourselves in now. So the first thing that I had
to do -- you know they're sort of disappointed and they get a lot of
pushback from the left. I go on KUDO radio, and I get beaten up because
it's not sufficiently progressive an idea.
The other topic
that gets a lot of public pressure or resistance is the individual
mandate, the part of the bill that says everybody has to acquire a
health insurance policy. People just resist that, I think by nature,
and Alaskans maybe resist that by more nature, by a stronger nature.
They just resist the idea that the government is going to force you to
buy a health insurance policy. I've debated whether I should drop that
part of the bill just to try to ease its passage. I just think it makes
the economic model much, much weaker.
AHPR:
I understand that you will be submitting a new draft of the universal
health coverage legislation in the coming session of the Alaska State
Legislature. What will be similar and what will be different compared
to SB160 from the last session?
French:
The basic structure will be very similar. You know, the Massachusetts
model at its very, very simplest -- some government help, some
government subsidy to a consumer, to help that consumer buy a private
insurance policy -- that's basically what it is. There's lots of bells
and whistles on it, but that's sort of fundamentally what it boils down
to: to keep the insurance companies that are presently in this system,
keep them alive, and you just help customers, consumers, afford one of
those policies. So, that's the basic structure. We're looking at
lots of little tweaks. Maybe I'll turn to Andy to have him run down
some of the potential amendments that we're going to put in the revised
bill that we're preparing now.
Moderow:
During the past few months, I've been trying to learn as much as
possible from Massachusetts, so that when ideas come in from the public
or other sources, we can consider them for the bill. I'll put them in
front of Senator French and we'll discuss them and come up with
options. Some of the things that I've looked into ... when
Massachusetts had their bill implemented, the amount of primary care
seekers increased, which you would predict when people can afford to
seek primary care. They would want to go ahead and go see a doctor.
The
result of that was pressure on their medical system. One thing the
senator has expressed concern to me about is making certain that we
have adequate primary care physicians and other medical professionals
to deal with that increase. Massachusetts has different regulations
than Alaska when it comes to insurance. I don't know where that will
end up being, in terms of the policy call, but it's something that I
hope to provide the senator, so that we can go through and help answer
some of the public's questions [from the forum last night] in terms of
which way and how the bill is shaped.
AHPR:
I would like to return to what you were addressing previously for a
moment. Why is it in your assessment that politically single payer in
Alaska would not be feasible?
French:
Because you just run into a brick wall of the insurance industry
feeling threatened by the fact that it's a winner take all system, or
for them there is just going to be one insurance company left --
possibly even a government-run one at that. Why employ some private
person to pay claims when you can just do it yourself in-house? You've
gone too far in the direction of socialized medicine, I believe, for
what you can achieve in this landscape. I mean Massachusetts is the
perfect example. It's an extremely blue state and an extremely blue
legislature. They've never been able to implement single payer. They
had to compromise with the business community through the Romney
approach of keeping individual companies alive.
"We were just talking about maybe doing a pilot project of two new
community health clinics in Anchorage, one in Midtown and one in South
Anchorage. They would have three primary care docs in each, six nurses."
AHPR:
In the past, much earlier this year, I had criticized some of the
discussion around SB160 because it didn't seem to be based on research,
analysis, solid projections. I wonder if we can expect more of that
with your new draft?
French:
One of the things we're focusing on is the fiscal note. Frankly, if we
were a little weak on our analysis, the administration was far weaker.
The fiscal note we got from them overlooked some of the obvious
components of the bill. For instance, it's an option for Native people
to seek a voucher under this program; it's not mandatory. Anyone who's
covered by an Indian Health Service plan or Indian Health Service
coverage through a clinic doesn't have to seek a voucher yet the
administration's fiscal note supposed that we'd be covering all
Natives. Their fiscal note also supposed that we would cover each
individual as if they were sort of add-ons in the landscape instead of
being part of a family unit. So each person got assigned a full value
policy. So there was that weakness in their analysis.
One of the
legitimate criticisms goes back to what Andy was talking about -- about
primary care. You can give everybody a health insurance policy with
absolutely no value if you can't find someone to treat you. The policy
doesn't do anything for you, so we've looked at expanding. We were just
talking about maybe doing a pilot project of two new community health
clinics in Anchorage, one in Midtown and one in South Anchorage. They
would have three primary care docs in each, six nurses.
Apparently
you can offer better Medicare reimbursement rates at those centers than
you can get through Washington, D.C. So maybe using that model, we can
jump over the insurance turnstile, if you will, and just go straight to
a [model of directly funding the provider]. We're starting to look at
it as, if not the solution, a component of the solution, which is
getting more primary care doctors in the community.
AHPR:
Great. Music to my ears, if I may say so. Regarding financing, could
you go into that a little more? How is this going to be paid for?
French:
The vast majority of the money will come from the state general fund.
There's just no way around that. Unless, of course, you see a federal
solution come out of the new Obama administration and the new
Democratic Congress. My concern is that the financial meltdown
happening worldwide right now will prevent them from taking on bold new
initiatives at least on this front. I think they're likely going to be
concerned with shoring up the economic system, the financial system,
and maybe doing public works infrastructure investments in highways,
roads, bridges, and so forth before they get to universal health care,
although President-elect Obama said it was a big priority. So that
remains to be seen.
Maybe they pass something that requires
state participation, which is far more likely. Are they going to pick
up the whole bill, or say to the states that you've got to buy into
this with some of your own money, which makes as much sense to me as
anything else? So, the financing is likely going to be a combination of
fed and state. It is hard to say what the bottom line is. I think we
should be prepared to pay for most of our own way, given our own
natural resource wealth. That's why you've got to get the bill up to
the Finance Committee, because my views will go away at that point and
their views will be superimposed on mine.
"At some point, you say, "I've got to spend money on bread, shoes, and
airplane tickets." You just can't spend all your money on medicine and
medical care."
AHPR:
Let me just posit something and see your reaction. I interviewed Neal
Fried [Department of Labor economist] just a few days ago, and what he
told me was very interesting, and I had not fully understood this
before. If you go back 15 years, maybe longer, the health care industry
in Alaska has been growing at an extraordinary rate, adding a lot of
jobs on every year, bringing a lot of money into the state. It's been a
big major growth industry. According to Neal, in the last year or two,
that growth rate has slowed way down. He believes that there is a
possibility that the health care industry in Alaska has reached a
saturation point.
French:
Doesn't that sort of make sense? Medical costs in the medical industry
can't continue to rise. I guess I'm just extrapolating the cost. They
just can't become 50 percent of the GDP [gross domestic product]. At
some point, you say, "I've got to spend money on bread, shoes, and
airplane tickets." You just can't spend all your money on medicine and
medical care.
AHPR:
That's true, and I think that's part of it. In terms of saturation, he
was looking at it from a little different angle, I believe. He was
saying that, if you look at other states, maybe 9 percent or 10 percent
of the total expenditures are in the health industry, and we are at 8
percent. We've come up to eight over these last number of years, so
we're beginning to level out. We're beginning to approach that national
average.
One could begin to imagine what the consequences for
the state will be when one of the major growth industries has flattened
out and reached saturation and isn't that mighty engine that it has
been. I wonder if you could make the case that if your bill passed, it
would actually contribute to extending growth of the health care
industry in the state?
French:
Oh sure, you would have basically a hundred thousand new customers for
the medical facilities in the state -- the uninsured. Actually 109,000
new customers. That's a lot of new business. That's a good way of
thinking about it.
AHPR:
Will the new draft [of SB160] have a greater focus on the potential
contribution of the Community Health Centers in Alaska in terms of
increasing access to health care? It sounds like you're contemplating
something like this.
French:
It actually may be a separate effort. They go together in sort of a
holistic sense, but, as far as the bill goes, we may just try to do a
separate appropriation in the budget bill for a Community Health
Center. It's probably less laborious getting that through the system.
You just have to convince 11 senators to vote for it, and you don't
have to change their minds about the way they see the operation of the
insurance industry.
AHPR: And there is precedent from earlier this year.
French: Right. Even though that's not my first choice, maybe that's more [achievable] in Juneau.
AHPR:
Will the new draft [of SB160], or any other associated legislation you
might sponsor, deal in any way with the question of assessing or
increasing the quality of health care in Alaska?
French:
That's a great question, and I hate to say "no." At the same time,
that's an extremely hard thing to quantify. That's just something
that's maybe more appropriate for the medical profession itself to be
looking after rather than someone in Juneau saying, "I want to stop
filling out so many paper forms when I go to a medical office." That
drives me personally insane. But whether I can pass a law that requires
those doctors in Anchorage or statewide to start using electronic forms
may be more trouble than it's worth.
AHPR: Paranthetically, we at the Alaska Center for Public Policy have an interest in the question of quality of health care.
French:
It will be fascinating to see if there are any sorts of law changes
that can help enhance that. Certainly bring them to us. But it just
seems then like you're trying to affect the system from the wrong place
-- from outside rather than from inside.
AHPR: There are plenty of precedents in other states that we are starting to look at.
French: Sort of like a patient bill of rights or is it more sophisticated than that?
AHPR: It has to do with statistics that are generated and made public. It is in part the transparency issue.
French: So, you share information about where customers are happy or where they're unhappy, and let the public follow?
AHPR: Yes, and it may be more than a happiness quotient. It may be things like best practices for chronic diseases.
French: That's a good idea.
" ... I don't think that's really the focus of your question. It's, "Are you
going to be able to bring down the cost of a knee replacement in
Anchorage through this particular bill?" And I guess the really short
brutal answer is "no." That's a separate effort."
AHPR: Will the new draft [of SB160] have mechanisms in it to monitor, reduce, and/or control costs?
French:
That's another very difficult area to address. Of course you get a
reduction in the price of insurance if everybody jumps in the pool. So
there's the price of insurance but I don't think that's really the
focus of your question. It's, "Are you going to be able to bring down
the cost of a knee replacement in Anchorage through this particular
bill?" And I guess the really short brutal answer is "no." That's a
separate effort.
AHPR:
Since you brought it up as a separate effort, will you be working on
some separate legislation or concept to ultimately reduce costs?
French:
It's not on my landscape right now. I'm open to suggestions. It's
another area. There's probably four or five big pieces of the puzzle,
and I don't even know if I've given names to all them yet. But that's
certainly one of them. Primary care, insurance policies, quality, costs
-- they all go together. Right now I'm focused on one and maybe two.
AHPR: Nevertheless,
I feel compelled to ask you about some of the others. You did mention
this, but maybe you could address it a little more fully: Will the new
draft [of SB160] address the chronic and growing shortage of health
care providers in Alaska, particularly primary care providers? In other
words, will it include features such as a loan forgiveness program,
more support for WWAMI, nursing, the PA programs, that kind of thing?
Is that a part of it, or are you dealing with those separately?
French:
It's part of it. We will deal with it, probably in a separate bill or
separate appropriation. You really can't do one without the other; it
is just too foreseeable. When you think about increasing the access to
health care, we've approached it through an insurance model. But
ultimately, if we're successful, you going to have 100,000 new people
out there that suddenly want to go see the doctor when they have a sore
throat. Instead of going to Carrs and getting a bottle of Nyquil, they
may decide to actually get a culture on that sore throat. There's got
to be a nurse there to take the culture, and a lab to analyze it. So,
we've begun to try to put a number to that, and to think about trying a
pilot project here in Anchorage, so we don't have the pig and the
python problem that they had in Massachusetts, where they had an
overwhelming number of sick people going to see doctors.
"What I'm really hoping for is some more overt support from the
administration ... What
this needs is some sort of push from the enormous media and political
powerhouse that is Sarah Palin."
AHPR: Do you think there will be bipartisan interest in the new draft [of SB160]?
French:
There was before. I expect there to be so again. I can't put any names
on it. What I'm really hoping for is some more overt support from the
administration. Last night at the [public forum on health reform], Dr.
Jay Butler [chief medical officer for Alaska] was there ... Linda Hall
[director of Division of Insurance] has been very involved ... other
members of the administration have been keeping an eye on this. What
this needs is some sort of push from the enormous media and political
powerhouse that is Sarah Palin.
AHPR: Do you anticipate that it might be especially difficult to move out of any particular committees?
French:
It will always come down to the Finance Committee. It's sort of easy
for this bill to get moved out of committees because every committee
knows it's ultimately going to go there, and that's where the hard
decisions are going to get made. This bill will always have its
greatest and longest battles in the Finance Committee.
AHPR: On the other hand, do you see any new or emerging sources of support from particular groups or organizations?
French:
The League of Women Voters was a new sort of entity that got on the
bandwagon by bringing me to [the public forum] last night, and I think
we're going to see more of that. AARP has been fantastically helpful in
spreading the word. We're getting a little more sophisticated in our
Internet approach. The unions are also groups that have been very much
on board with this idea, and they have workers that hop from job to job
and don't always get health care coverage. As far as brand new -- I
think we're trying to build on what we have, with the biggest hope
being for the administration.
AHPR:
President-elect Obama seems to have pretty clear ideas about
significant and far reaching health reform for the United States as a
whole. Is it too soon to ask about the implications for your
legislation in particular, and/or the question of health care reform in
Alaska in general?
French:
I think the answer is: no. As you asked me the question, I thought, we
ought to dash off a letter to Tom Daschle who's coming in as the
secretary of health. He's a person who has a long history of being a
reformer. He's an incredibly dynamic individual, and it may be that he
is sort of surveying the states' landscape to see what's happening
there. We should let him know of our efforts, and at least express some
support for a fix from the feds.
AHPR: Yes, I suspect he'd be interested. Is there anything else you would like to tell the readers of Alaska Health Policy Review?
French:
Only that it's a symbiotic relationship we have going here. I'm sort of
the figurehead of a legislative effort to change the health insurance
and healthcare landscape, but I can't do it without the support of the
people that are going to read this article because they can write
letters to the editor. They can call their representatives. They can go
to our website. It takes thousands of people to make this happen, and
I'm just one of them. So I encourage your listeners and your readers to
take a small step in the right direction, and help us get there.
AHPR: Thanks so much for taking the time to interview with Alaska Health Policy Review.
Back to top
|
| Please Respect Our Copyright |
|
|
Interview with Jim Gottstein
|
Jim
Gottstein is the founder of The Law Project for Psychiatric Rights and
the lead lawyer in the PsychRights effort to stop forced psychiatric
drugging in both Alaska and the United States. In this interview, he
discusses his key role in important litigation involving the
establishment of the Alaska Mental Health Trust Authority and the
protection of patients' rights. You will read about his attempts to
stop the forced drugging of children and youth in the state's foster
care system, and his legal encounter with the pharmaceutical company
Eli Lilly over the Zyprexa Papers. Jim Gottstein is a graduate of
Harvard Law School. He has practiced law in Anchorage for over twenty
years and appeared before the Alaska Supreme Court numerous times. This
interview was recorded November 29, 2008. It has been edited for length
and clarity.
AHPR: Jumping right into it, how would you currently describe your law practice?
Gottstein:
I'm devoting substantial time to a PsychRights mission of mounting a
strategic litigation campaign against forced psychiatric drugging and
electric shock, not only here in Alaska but around the country. In
Alaska, we don't do forced electric shock but they do in other places.
In the last couple of years, we've really become alarmed at the rate at
which children are being drugged with these most powerful psychiatric
drugs, including neuroleptics such as Risperdal, especially children
and youth in state custody -- mostly foster care --where a very large
percentage of them are given these drugs when there is no evidence that
they help, and it's absolutely clear that they're very harmful.
AHPR: I'm going to ask you about several specific cases I know you've been involved with.
Gottstein:
You bet. There was just a decision two days ago, on Tuesday, in a
forced drugging case. Probably one of the clients that you will
mention. It was very interesting and very disturbing in many ways. It
will likely -- inevitably -- be heading to the Alaska Supreme Court.
AHPR: I noticed that several of your cases have gone there.
Gottstein:
May I add one other thing, which is that in addition to the litigation
campaign -- the strategic litigation campaign -- I believe it's
essential that two other things occur. One is that we need to try to
educate the public that the story that's been sold about these drugs,
and electroshock for that matter, is not the truth. And we need to
offer other approaches that have been shown to work. In other words,
have a solution as well as just having a complaint. So I spend a fair
amount of time on those two aspects as well. In fact, this interview is
part of that. I accept all speaking invitations.
AHPR:
Again, just to lay a little bit of the groundwork of your background
and interests, would you describe your historical relationship with the
Alaska Mental Health Trust Lands Litigation?
Gottstein:
I was one of the four or five lawyers involved in that case. I think
most people considered me the main lawyer in the Mental Health Trust
case until the very end. I was the only one who really had familiarity
with land issues. I was pretty much the only one who focused on that as
well as the mental health issues.
AHPR: Maybe you could help us recap that case?
Gottstein:
In 1956, the United States Congress granted Alaska, which was a
territory at the time, the right to select a million acres of land to
be used first for the necessary expenses of a mental health program.
That was before statehood and before Alaska knew it was going to get
any other land, so it selected the absolute best land in the state.
For
example, there were 2,000 or 3,000 acres in Anchorage, a lot it in the
Mat-Su Valley and Southeast. Forestlands -- most of the state
forestlands and parklands in Southeast were Mental Health Trust lands,
the Chilkat Eagle Preserve for example. Coal lands, oil and gas lands,
mineral lands -- it was absolutely the best lands that they could
select at the time.
The territory and the trust never actually
managed it as a trust. They gave a little of it away and this and that.
Finally, in 1978, the legislature -- basically at Governor Hammond's
administration's urging -- passed a statute that said: "We hereby
re-designate Mental Health Trust lands as our land." In other words,
they stole it.
My mother worked for the Alaska Mental Health
Association at that time as the executive director. Lidia Selkregg was
kind of her mentor -- many people know her as a real land expert.
So
the Mental Health Association went down to the legislature and said,
"You can't do this. This is illegal." And the response was basically:
"We don't care if it's illegal. Sue us." So we did. To make a long
story short, after three settlements that the state reneged on and one
really good one that the plaintiffs didn't accept against my advice, a
settlement was reached.
The Alaska Mental Health Trust
Authority was created to have a very big role in shaping Alaska's
mental health program. The trust was reconstituted to consist of land
and money. It got about half a million acres of the original land -- I
would say the worst half. And then it got another almost half million
acres of replacement land. In both cases, some of it was just
subsurface or mineral lands.
The trust authority was allowed
to spend the income from that without the legislature having any say in
it. The trust authority also formally recommends to the legislature
what it should spend on the mental health program. And the legislature
and the governor are supposed to explain the reasons why if they don't
go along with it.
I would say that I actually opposed this
settlement for structural reasons, and because it wasn't really fair
compensation, the structural reasons being the stronger in my mind. I
would say that this settlement has worked out fabulously well with the
trust authority having influence far beyond the money that it is able
to spend, and the money that it does spend, it does so very well with.
I
think the main difference is that the trust authority looks at its
beneficiaries and what it's doing, and asks, "Are our beneficiaries'
lives better as a result of what we're doing?" Whereas, the state
mental health system -- and I think this is true generally of mental
health systems and bureaucracy -- they ask the question: "How many
services are we providing?"
Those are entirely different
questions. Providing services is not necessarily improving people's
lives. In fact, a good argument can be made that the system tracks
people into permanent disability and poverty. That's just the way that
it's set up.
"The Law Project for Psychiatric Rights is a public interest law firm ... I mentioned before that its mission
is to mount a strategic litigation campaign against forced psychiatric
drugging and electroshock around the country."
AHPR:
Thanks very much. That's just the background I was hoping for. Now I'm
going to ask you some more specific questions about your involvements,
as I understand them. What is the Law Project for Psychiatric Rights,
and what is your relationship with it?
Gottstein:
The Law Project for Psychiatric Rights is a public interest law firm.
Technically, it's a nonprofit corporation under Alaska law. It's
tax-exempt under the Internal Revenue Service code, which means that
donations to it are tax deductible. I mentioned before that its mission
is to mount a strategic litigation campaign against forced psychiatric
drugging and electroshock around the country.
We've really
started focusing on children and youth, because they are essentially
always forced. It's the adults in their lives that are making that
decision. I was a founder of the Law Project for Psychiatric Rights,
which we call PsychRights. I am currently on the board, its president
and CEO.
AHPR: So it's a nonprofit founded in Alaska, but it has a national mission?
Gottstein:
Yes. It has proven harder to mount strategic litigation campaigns in
other states because I'm not licensed to practice there. Even if I
were, logistically, it would be harder. It's fair to say that we're far
ahead in what we've been able to do in Alaska. And it's also fair to
say that we're starting to gain some traction in other states as well.
AHPR: One follow-up question on that. Where does the funding come from for PsychRights?
Gottstein:
I've donated all my time pro bono. I'm lucky that I'm in a position
where I can afford to do that -- although, that may not be able to
happen indefinitely. So that really helps with the funding -- not
having to pay staff. We don't really have any real paid staff, although
we have one very part time contract with [our] Northeast coordinator.
We
get donations from the public. We generally will not take government
grants, because we don't think you can really sue them seriously if
you're taking their money. We've made an exception for a couple of
relatively small grants from the Alaska Mental Health Trust Authority
because we think it's a different type of agency.
We've taken
money to put on a couple of conferences. Our finances are completely
transparent. We post all that on our website. We tend to take in
between $15,000 and $30,000 a year in donations. We've gotten some
attorney fee awards out of the litigation that we've done.
AHPR: Now let's jump into some specific litigation. In terms of policy, please describe the significance of the Myers v. Alaska Psychiatric Institute case decided by the Alaska Supreme Court in 2006.
Gottstein:
The Alaska Statutes provide that if some one is in the hospital and the
hospital wants to give them psychotropic medication, and if the person
is incompetent to make a decision to decline the medication, the
hospital gets to do whatever it wants. We went to the Supreme Court and
said that's unconstitutional.
When you are invading someone's
body and mind that way, that's an invasion of a fundamental
constitutional right or a deprivation of a fundamental constitutional
right. The state can only be allowed to do that if it proves that the
medication is in the person's best interest and there are no less
intrusive alternatives. That's basic constitutional doctrine when
you're talking about fundamental constitutional rights. The Supreme
Court agreed with us on that. That was key.
The other really
key thing is that these drugs are counterproductive for a very large
percentage of people. What you find is that they are preventing people
from recovering, and they are shortening people's lives by 25 years on
average. If you look, for example, at the affidavit of Robert Whitaker
that I've been filing in cases, it goes through this chapter and verse
-- how this myth developed that the drugs work.
This is
further buttressed by some written testimony and oral testimony by Dr.
Grace E. Jackson. She's maybe the most preeminent expert on
psychopharmacology in the United States -- on this and, especially,
she's really focused on the brain damage and other damage these drugs
do.
A recent study showed that people who were allowed or
managed not to take the drugs had an eight times greater recovery rate
than those that did. I have no problem with people that decide to take
the drugs. I think they should be told the truth about them, including
that there are other approaches that really have been shown to work far
better and be far less harmful. I know people that find the drugs
helpful, and I think that they should have access to them.
It's
a very difficult thing to be facing these kinds of psychiatric
symptoms. So I have no problem with that, but I have a very serious
problem with the courts ordering people to take these drugs when they
don't want to, when the evidence shows that for many, many people they
are counterproductive and very harmful. The courts do so based
essentially on untrue testimony by the psychiatrists at the Alaska
Psychiatric Institute (API).
To be fair to them, part of the
reason why the testimony is untrue is because they've been sold a bill
of goods by the pharmaceutical companies. Just in the last few weeks
there's been revelations about how what are called "key opinion
leaders" have essentially been corrupted by the pharmaceutical
companies -- and their influence is everywhere. The research that has
been published in even the most prestigious journals really has been
corrupted by pharmaceutical money.
So the psychiatrists are
not getting reliable information, and I think they should be in an
uproar about this. Five years ago, I think they could've had plausible
deniability about that, but now I think they're just basically hiding
their head in the sand when they continue business as usual.
"It's interesting, there is a great lawyer at Golden Gate University,
Mort Cohen ... He says, first you win a case like Myers, and then you
spend the next 10 years getting the state to follow. So it's not an
unexpected process, but I don't think it's fair to say that it's
changed anything frankly. Yet."
AHPR: Did this case result in the change of policy relating to these matters in Alaska?
Gottstein:
No, because API has ignored it. I wrote a law review article that got
published in June. My biggest complaint is with the Public Defender
Agency for failing to adequately represent its clients coming in and
resisting these. So even to this day, they don't come in with any of
this evidence about the drugs.
For example, I mentioned that Myers v.
requires the state to prove that the forced drugging is in the person's
best interest and that there is no less intrusive alternative -- API
has not even changed its petition to reflect that. They've essentially
just ignored it, and that's what my follow-up litigation is trying to
get them to follow.
It's interesting, there is a great lawyer
at Golden Gate University, Mort Cohen, who I think represented
prisoners at Attica. He's a public interest lawyer. He says, first you
win a case like Myers, and then you spend the next 10 years getting the
state to follow. So it's not an unexpected process, but I don't think
it's fair to say that it's changed anything frankly. Yet.
AHPR: We'll, that's distressing.
Gottstein:
Yes, I think it is. From my perspective, the forced drugging apparatus
operates essentially illegally. I think the most important policy issue
is that, if the state adopted what I am suggesting, the number of
people that are put on the disability rolls and permanently given
medical insurance, and permanently given disability payments, would be
at least half.
So there's a tremendous amount of costs that
would be avoided if we didn't have a system that unnecessarily tracked
people into permanent poverty and disability, placing them on welfare
rolls. I think that's the most fundamental policy issue involved. It's
distressing to me that the policymakers will not look at that, even
though I've been raising this point for years.
AHPR:
You're implying or saying that the scientific evidence bears this out
-- that the administration of these drugs results in these consequences
for people?
Gottstein: Yes,
and I've been presenting the evidence in varying forms and increasing
detail, updated, since the Myers case in 2003. The state has never even
attempted to refute it. No one has ever really refuted it. It's just
ignored, then bladed over by the billions of dollars of pharmaceutical
money that is used to perpetuate and expand the number of people being
placed on these drugs.
AHPR: Could you just go over it a little more, because I don't really know the details of that case or the implications?
Gottstein:
The Alaska Statutes provide that people can be involuntarily committed,
which, if you were to use a less euphemistic phrase, would more
appropriately be called psychiatric imprisonment. The Court has
acknowledged this is a massive curtailment of liberty. It's like being
locked up as a criminal, except you haven't been charged with a crime.
In
order to do that constitutionally, the states can do that only if, in
addition to someone being found mentally ill, a person is proven to be
a danger to themselves or others -- and it's got to be a pretty serious
danger. Then there is this concept of being gravely disabled, which is
the idea that someone can't take care of themselves.
There are
two prongs to what the Alaska Statute says about it. One -- and I'm
going from memory -- one prong says that serious illness or death is
highly probable. I buy that. I think that satisfies the concept of
serious injury to self. But the second prong says that the person's
ability to function in the community would deteriorate if he's not
locked up. And I didn't buy that. That's such an amorphous standard.
Anybody could deteriorate -- don't you need to get to a level of deterioration before you can be locked up? So what we said in Wetherhorn
was that it's unconstitutional to do that unless it means that the
person is unable to survive safely in freedom, which is what the United
States Supreme Court said in the case -- I think it's called O'Connor v. Donaldson. The Alaska Supreme Court ruled that, not surprisingly, based on the Alaska Constitution.
The
real policy implication is that the system has gotten out of whack. It
takes a fundamentally wrong direction in using coercion as a way of
administering its psychiatric program. Even though the preamble to the
statutes say we want to make things as voluntary as possible, the
system will operate essentially under the catch-22 principle.
They
will not help anybody unless they meet commitment criteria. All the
evidence shows that coercion itself is very harmful. So a lot of what
we're trying to do with our strategic campaign is to get the system to
back away from all the coercion and into more cooperative relationships
with its patients, its clients.
Dr. Loren Mosher, who
testified in the Myers case, who has since passed away, was a former
chief of schizophrenia research at the National Institute of Mental
Health. In addition to talking about the drugs being based on
fraudulent misrepresentations by the drug companies, he pointed out
that the therapeutic relationship is the most important thing for
someone getting better. When you enter into a situation where a
psychiatrist or whoever else is forcing someone, that is very
counter-therapeutic.
I asked him if he had much experience
with psychotic people not on drugs, and he said, "Oh, my lord, I'm
probably the person alive today that's been with more non-medicated
psychotics than anyone, and I find them among my most interesting
customers." That's an attitude I think people really need to have.
So
what if people believe whatever it is that they believe? That's not
really that harmful. The harmful behavior is what really needs to be
focused on rather than the beliefs. The other thing he said that I
think is so critically important is that, in his 35 or 40 years of
practice, he had never committed anybody involuntarily. He had always
been able to form a relationship. Whatever needed to be done, he could
get the person to agree to because he formed a relationship. He said
that if he ever ran into a situation where he needed to prevent
grievous harm he would do it, but that he had never had to do it. That
is 180° from the way the system now operates.
"One of the ways that they really get away with it is that when the
patients complain ... the response of the psychiatrist in the system generally
is: "Oh, you're crazy. We don't need to pay any attention to anything
that you say.""
AHPR:
You've discussed the role of the drug companies in terms of corruption
and influence with their money and so forth. This issue of coercion,
does it trace back in part or in whole to the drug companies, or is it
a different issue?
Gottstein:
I think that in some ways it's different, and in other ways it's not.
One of the ways that they really get away with it is that when the
patients complain that it's not doing any good, that it's making them
have psychotic reactions -- which they do -- when they say that it's
harming them, the response of the psychiatrist in the system generally
is: "Oh, you're crazy. We don't need to pay any attention to anything
that you say."
Therefore, it's been easier for the drug
companies to get away with it because the patients have been so
marginalized at best, in terms of having any power over what's being
done to them. Does that respond to your question?
AHPR:
Yes. It sounds like you're saying that the drug companies may not have
any direct influence, but indirectly they're sort of setting an
environment where coercion becomes more acceptable.
Gottstein:
Now that I think about it, you could even say that it's more direct.
For example, the neuroleptics -- which are the worst ones -- the older
ones were Thorazine and Haldol. They're the ones that are still used
today the most. The newer ones are Zyprexa or Risperdal, Seroquel,
Abilify. I think Geodon is one. They have targeted the elderly in
nursing homes -- illegally by the way -- who are similarly
disempowered.
There is a black box warning on these drugs,
saying it kills the elderly. It doubles the death rate in the elderly.
What they do for the nursing home industry is they keep their residents
or patients from being able to complain. A lot of them make it so that
they can't get out of bed -- making them very easy to deal with. Then
when they die they go and tell the family members, "Oh, well you know,
your mother was old. She just died." That's an instance where they
really have targeted, and I think it really is a coercive situation.
Another
one, which is even more tragic, is the targeting of children,
especially children in foster care. Around the country, you see figures
where 60 percent to 80 percent of the children in foster care have been
given these drugs. Recently, Joseph Biederman, from Harvard, has been
exposed for taking millions of dollars to promote the diagnosing of
children and youth with bipolar disorder, which then justifies them
being given these stronger drugs called mood stabilizers -- and they
aren't mood stabilizers.
What they are are anti-seizure
medications, and neuroleptics. Since he started doing this, the rate of
diagnosing children and youth with bipolar disorder has gone up 40
times. The diagnosis then becomes a justification for giving them these
drugs.
I met with this marvelous group of foster youth and
alumni called Facing Foster Care in Alaska. They've been in the paper
recently, which is how I found out about them. I went to their retreat,
and we talked about this issue because it's on their policy agenda that
they formulated -- without even talking to me. I took kind of an
informal poll: "How many of you were put on psychotropic drugs?" 80
percent of them had been.
We've got these kid-drugging prisons
that we're sending children to. They're called residential treatment
centers. They're all being drugged. That's why they're being sent
there, and they're being given multiple drugs -- four, five, even up to
a dozen. These kids -- children and youth -- in foster care really
don't have anyone to speak up for them. Their parents have been
disempowered, and the bureaucrats are in charge of it.
When
whoever says this person should be given a drug, they just go along
with it. That's the most important thing that we're doing right now. We
filed a lawsuit at the very beginning of September, or the end of
August, against the state of Alaska to stop that practice unless it can
be justified.
"The question is: Why is the state resisting it? I am somewhat
encouraged that the state is maybe willing to look at what it's doing."
AHPR: What's the name of that suit?
Gottstein: It's called the Law Project for Psychiatric Rights v. State of Alaska, et al.
I think it was filed August 29. There's a link to it on our website.
It's worthwhile to read what the lawsuit asks for. It asks for
declaratory and injunctive relief that Alaskan children and youth have
the right not to be administered psychotropic drugs -- and to prevent
the state from getting them these drugs -- unless and until: 1)
evidence-based psychosocial interventions have been exhausted; 2)
rationally anticipated benefits of psychotropic drug treatment outweigh
the risks; 3) the person or entity authorizing administration of the
drug(s) is fully informed; and 4) close monitoring of, and appropriate
means of responding to, treatment emergent effects are in place.
It's
a 55-page complaint, and it goes through all the stuff chapter and
verse. It's based on a curriculum put together by this project called
Critical Think RX. It's found at CriticalThinkRX.org, which was funded
by a settlement of a fraud lawsuit against the manufacturer of
Neurontin, which is one of these anti-seizure drugs that have been
marketed.
They went through and put together this whole
curriculum, going through the scientific evidence, including the types
of non-drug approaches that have been shown to be very helpful to
children and youth -- including children and youth in state custody,
i.e. foster care. One of the key components is that you shouldn't even
consider giving the drugs until you've tried other things. That's the
number one.
The number two is that one has to actually look at
the science and say, "Does the science support it?" The decision-maker
should be informed that these drugs have very serious side effects. You
need to have a program in place that checks on the children and youth
if they're getting them, and to have an appropriate response if they
do.
It's pretty hard for me to see how that kind of approach
is or would be objectionable to anybody. The question is: Why is the
state resisting it? I am somewhat encouraged that the state is maybe
willing to look at what it's doing.
AHPR:
When you say, "the state," apparently that's not the Alaska Mental
Health Trust Authority, but the Department of Health and Social
Services (DHSS) for example?
Gottstein:
The actual defendants are the state of Alaska; Governor Palin --
because she's responsible for everything; commissioner of the DHSS,
Bill Hogan, because he's in charge of the DHSS; the director of the
Division of Children's Services; the director of the Division of
Behavioral Health; the director of the Division of Juvenile Justice;
the CEO of API; the director of Health Care Services -- the person who
manages Medicaid. You have to sue people rather than the state, because
of what's called "sovereign immunity." You can't sue the king. I'm not
sure that's really true in Alaska, but I had a case dismissed on that.
So you're forced to sue the actual people.
AHPR: How does the Wayne B. v. Alaska Psychiatric Institute case, which was just decided this year by the Alaska Supreme Court, fit into this?
Gottstein:
What's happened is that for the convenience of the court system, for
the hospitals, for the lawyers -- including the public defenders in the
attorney general's office -- there have been all these shortcuts taken
to the detriment of the rights of the patients.
What happens
in Anchorage is that all of these cases are "referred" to the probate
master to hear. The probate masters only have the right to make
recommendations. There is a court rule that says that when the probate
master makes a recommendation, they've got to give a Superior Court
judge a transcript of the hearing.
The reason for that is that
it's a Superior Court judge that's actually making the decision. A
Superior Court judge cannot actually review and determine whether or
not the recommendation should be followed without seeing the evidence.
Those transcripts were never prepared. These were all done very
quickly, and the recommendations have been basically approved as a
ministerial act. I said you can't do that: you've got to have these
transcripts.
In some ways it might be thought of as a minor
procedural issue, but it's interesting. There's a law professor by the
name of Michael Perlin at New York Law School who Judge [Stephanie]
Rhoades here calls the icon of mental health law.
When Myers came out, he said that it was perhaps the most important state court decision in the last 20 years. When Wetherhorn came out, he said -- this is in the forward to his treatise, his annual pocket part -- Wetherhorn shows again how the Alaska Supreme Court takes these issues seriously.
I saw him in November at a conference, and he said there that he thought Wayne B.
was even more important than either of those other ones because it
demonstrated that the Alaska Supreme Court was very serious and that
people's rights need to be respected. These are very serious
deprivations of liberty and fundamental rights. Shortcuts should not be
taken.
AHPR: Has the implied policy change been implemented, or will it?
Gottstein: Well,
this one is fairly interesting because it's really thrown the court
system into a tizzy because they haven't been doing it. They haven't
been doing it not only for these mental health proceedings but for all
the other referrals to the probate masters. The court said in Wayne B. that the judges could listen to recordings as a substitute for having a transcript.
But
they actually have to listen to them, which is a very inefficient. It's
much faster to be able look at a transcript if you want to go back and
so forth. That's what they've been doing now, listening to the
recordings. And it really has thrown the court system into a little bit
of a tizzy trying to deal with it.
My view is that the probate
masters cannot really hear the involuntary commitments, because of the
timing and such -- they need to be properly decided fairly quickly.
There's just not enough time to put a probate master in the middle of
that process.
Now, API insists that the forced drugging
hearings have to be done very quickly too, but the Alaska Supreme Court
has rejected that. That's also something that's not been implemented.
In fact, the Superior Court judges have tended not to follow the
Supreme Court's guidance on that.
In other words, what the
Supreme Court said is that when someone is being locked up, that is a
deprivation of their liberty interest and they have the right to have
that determined quickly -- whether or not it's proper for them to be
locked up. So that should happen fast.
In contrast to that,
they said -- talking about forced drugging -- that their deprivation of
liberty interests only occurs after the forced drugging starts or if it
starts; therefore, there is no reason to sacrifice proper procedures
and proper consideration in the interest of speed. I'd say the court
system in Anchorage has it backwards.
When I'm in cases, they
tend to have the involuntary commitments done by the probate masters.
Then the forced drugging ones, because they're not going to take up the
15 minutes the probate masters have available to do it, they bump to
the Superior Court. I think that's really backwards. I'm not a fan of
the probate masters doing it because I think that the patient's
responses are not getting a fair shake.
"There were a couple of mistakes I made, but, fundamentally, I don't
believe I did anything wrong. It's on appeal. Eli Lilly is threatening
me with civil and criminal contempt charges and going after my license
to practice law."
AHPR:
Moving on to yet another big case you've been involved with, or a high
profile situation in any case, I believe it was just last year that you
successfully subpoenaed and then released what have become known as the
Zyprexa Papers. Why are these documents important, and what are the
policy implications of these documents and the issues surrounding them?
Gottstein:
It was just about two years ago. And I have to be really careful about
this, because the federal judge in Brooklyn (this is on appeal)
enjoined me from further dissemination of these documents. Eli Lilly,
the manufacturer of Zyprexa, takes the position that if I even say what
the New York Times said about
them, then I'm further disseminating. I think that's horse hockey,
frankly. But do I really want to poke the dragon?
What I will
say is that I still do not believe that I did anything improper. What
happened was that Eli Lilly abused its huge financial advantage to come
into court and get the Eastern District of New York Court to rule
against me. These documents were under what's called a protective order
in the Zyprexa products liability case, multi-district litigation.
People think of it as a class action, but it's not technically a class
action. It was the consolidation of 30,000 separate lawsuits against
Lilly for causing diabetes and other metabolic problems into one court,
for discovery and settlement purposes.
A couple things about
that. First, Eli Lilly produced some 15 million pages of documents
under a protective order. They were allowed to mark documents
confidential if in good faith they thought they were confidential.
Well, they marked everything confidential, including press releases,
annual reports, newspaper articles. They just marked everything. It was
clearly not in good faith.
There was a provision in that
protective order that said, if someone like myself subpoenaed the
documents, Lilly had to be given notice of the subpoena and a
reasonable opportunity to object. Interestingly, a prior version of
that protective order said they had to be given 10 days notice. That
got changed to reasonable opportunity, which then gave them the ability
to say -- no matter how much notice they got -- that the notice wasn't
reasonable.
So I subpoenaed the documents. They got notice.
They waited almost a week. I expected them to object immediately, and
that then I would be in front of the court here saying I am entitled to
these documents because you, your honor, cannot possibly properly
decide that forcing my client to take Zyprexa or any of these drugs for
that matter is in his best interest while the drug companies are hiding
negative data; therefore, I'm entitled to get it. That's what I
expected to happen.
Well, they didn't do it. The guy I
subpoenaed, Dr. David Egilman, it was his obligation to comply with the
protective order. He decided enough time had passed and he sent me the
documents. I basically knew that even though Lilly was slow getting
going, that once they got going they'd be big and fast. And even though
I had every right to get them out, they could bottle it up in
litigation if I didn't get them out.
So I got them out right away to a bunch of people, including the New York Times.
There were a couple of mistakes I made, but, fundamentally, I don't
believe I did anything wrong. It's on appeal. Eli Lilly is threatening
me with civil and criminal contempt charges and going after my license
to practice law. And they still are. Theoretically, we're in
negotiations, and hopefully it will be resolved.
AHPR: I think we can refer people to web sites that have more details.
Gottstein: Yes, I didn't say anything that I thought was improper.
AHPR:
Moving on to a different type of question, is there any legislation
that may come up in the 2009 legislative session here in Alaska -- or
any that you think should be thrown into the hopper for consideration
-- on these issues of interest to you?
Gottstein:
First off, I think the big problem is that the laws aren't being
followed. If the laws were being followed, then 90 percent of the
problem would go away. In my mind, in a broad-brush approach, I think
that passing new laws that will be ignored is not the answer. Having
said that, I think that the statutes that the last Supreme Court has
ruled unconstitutional, they ought to change to comply with the
Constitution, so when someone reads the statute, it actually follows
what the courts require.
Otherwise, I think people can be
misled by just looking at the statute. If your lawyer, [or if] you have
an annotated set of statutes, you can look and see that Myers declared this statute unconstitutional; Wetherhorn
declared this statute unconstitutional. The statutes should be amended
so that anybody who reads straight from the statute will actually get
an accurate view of what the law requires.
I don't know about
any specific legislation, but the legislature should get involved in
stopping this massive over-drugging of children and youth in state
custody. It should get involved in trying to implement a more voluntary
mental health system. I think the former is something that is pretty
susceptible to statute change. The latter, I think the statutes aren't
that bad.
Having said that, I think that there is one statute
that is unconstitutional, AS 47.37.05 or .10, I think, where it says
that if a police officer has brought someone to the hospital -- and
they have the right to do that. Any police officer -- or physician for
that matter -- can take someone to the psychiatric hospital or to some
other evaluation facility for an evaluation. The statute says that they
can then go ahead and apply for an ex parte order.
What an ex parte
order means is that only one side goes to the judge. That's very rarely
allowed because the fundamental principle of due process is notice and
an opportunity to be heard, a meaningful notice and a meaningful
opportunity to be heard. There are some exceptions to that. The easiest
to understand is probably the search warrant situation where, if you
told the person that you're going for a search warrant ahead of time,
whatever it is the police wanted to search for would disappear.
So
there's an exigency and a reason why that person doesn't get notice.
But when that happens, the police have to come in to the judge and tell
him, give him enough facts, to justify that. Once someone is already in
the hospital, I can't see any scenario where it's permissible
constitutionally not to give someone notice. What's the exigency then?
So I think the involuntary commitment statutes, with that exception,
are really quite good. They're just not being followed.
AHPR: Are there any legislators that you think are particularly good on these issues?
Gottstein: I
think Senator Davis is good. Johnny Ellis is pretty good. I'm going to
get in trouble for not mentioning some one. Representative Gardener,
Gruenberg, and Gara ... they're all supportive. Of course, especially
in the House, they're not in power. I'm sure there are others.
"I think [we should address] the rate at which Alaska Natives are put in
API, corrections, or otherwise. Fundamentally, I think it's a mental
health issue."
AHPR: Are there key pressing mental health issues in Alaska at this time that perhaps we haven't addressed?
Gottstein:
I think [we should address] the rate at which Alaska Natives are put in
API, corrections, or otherwise. Fundamentally, I think it's a mental
health issue. We need to do a far better job of addressing the
cataclysmic change in their culture that has resulted in these
problems. We're just not doing a very good job of that. And I think
frankly that the Native medical community has abandoned its people.
For
example, they won't provide any inpatient mental health services. So
they all end up going to API rather than an Alaskan Native medical
center. I think that that's pretty terrible. They ought to fashion
programs, culturally relevant programs, and really help the younger
generation deal with this culture change that's caused so many
problems.
When you think about it, white man came and totally
disrupted their culture. Then [he] said you're no good because you
aren't educated or you don't work an eight-to-five job or whatever it
is, without really understanding their culture and trying to ease the
transition from the old ways to the new ways.
AHPR: Is there anything else you would like to say to the readers of Alaska Health Policy Review?
Gottstein:
I think everyone should really advocate for these changes. I think
Governor Palin should look at it. She told the nation that she was
going to be an advocate for special needs children, and here in Alaska
she's basically in charge of a program that is giving these deleterious
drugs to almost all the children for whom the state assumes custody.
I
think she should look at that. I think that up and down the
bureaucracy, especially up, the commissioner and the division directors
-- your readers should urge them to not just have a knee-jerk reaction
to resist what I'm trying to do, but to honestly look at what I'm
saying and what the evidence says, and do the right thing.
AHPR: Thank you so much, Mr. Gottstein, for taking the time to interview with Alaska Health Policy Review.
Back to top
|
| New From ASHNHA: Guiding Principles for Health Care Reform 2009 |
Foreword:
Access
to quality, affordable health care for all is vital to Alaska's social
and economic future. That is why the Alaska State Hospital and Nursing
Home Association (ASHNHA) is committed to health care reform in Alaska.
ASHNHA, in conjunction with key hospital personnel and community
stakeholders from across the state, has initiated the
identification of health care reform issues most important to the continued and improved health of our communities.
As
providers of medical services, hospitals are well positioned to
designate reform priorities which will have the maximum impact on the
future of Alaska's health care industry and on the health care status
of our residents. As consumers of medical services, community
stakeholders offer a critical patient-centered approach to potential
reform and assure that identified priorities ultimately serve the best
interests of our communities. For the benefit of the uninsured, the
underinsured, our businesses, employees and society as a whole, we have
an obligation to address health care reform now.
This
document is the foundation of our efforts to become discussion leaders
in our communities and to develop community consensus on what elements
of health care reform the public supports.
The following
principles have been identified in a collaborative effort between
ASHNHA, Alaska hospitals and community stakeholders, and will guide the
organization's health care reform efforts in 2009:
- Continue to improve health care quality and efficiency
- Establish health care accountability
- Improve and expand health care coverage and access
- Strengthen public and private health care programs
A
vital component to advancing the reform discussion and drafting
proposed changes to our existing health care system is the
establishment of a Statewide Health Care Commission. The commission,
comprised of health care leaders from across the state, will be tasked
with reviewing these and other reform issues to assess the viability of
positive long-term solutions. Ultimately, this body will be responsible
for implementing reform priorities supported by Alaskans in order to
define the roles of the state, businesses, providers and individuals
regarding future health care funding and delivery.
Principle 1: Continue to improve health care quality and efficiency.
As
health care providers, we must ensure that consumers have access to
critical information when choosing their medical provider. Under this
principle, the following actions should be considered in an effort to
improve health care quality and efficiency, and to make information
available to the ultimate consumer of health care services.
Quality and efficiency in health care:
- Define "quality" and "efficiency" and what constitutes best practices.
- Develop relevant quality and efficiency measures which appropriately reflect Alaska's uniqueness.
- Develop a system to capture the data.
- Develop a system to analyze the data against previously identified quality and efficiency measures.
- Develop a system to report the data and make it available to the consumer.
Mandates and incentives:
- Consider a statewide mandate for reporting health care acquired infection incidents.
- Consider a statewide mandate for reporting incidents of serious medical error ("never events").
- Detail the cost of quality initiative implementation and the financial impact of data reporting.
- Consider potential incentives rewarding facilities for improved quality over the short and long term.
- Outline
potential incentives for voluntary participation in programs such as
the 5 Million Lives Campaign and other quality-driven improvement
programs.
Efficiency considerations:
- Develop
a uniform billing process with coordination of benefits between payors
in order to reduce consumer confusion and provider/insurer
administrative costs.
- Establish an Electronic Health Record (EHR) data standard and implementation timeline.
- Detail
the potential role of telemedicine in Alaska and how the state could
leverage improved efficiency and accessibility as a result.
Shortage of health care providers:
- Address the shortage of health care professionals and its effect on quality and efficiency.
- How would expediting licensure of health care providers impact quality and efficiency?
- Develop a plan of action to close the workforce gaps. Some considerations:
- Recruitment and retention
- Relocation costs
- Incentives
- Rural Alaska
- Lack of instructors/training facilities
Other important factors critical to quality and efficiency:
- Develop
a program similar to the Mayo Clinic in order to acquire valuable
consumer input and two-way communication between provider and patient.
- Refine Alaska's Certificate of Need program to improve overall health care quality and efficiency.
Principle 2: Establish health care accountability.
Health
care providers must be transparent about their cost and quality, giving
patients information to empower them to make informed health care
decisions. The following recommendations constitute measures identified
to increase health care accountability and openness with regard to
these attributes.
Price and quality reporting:
- Adopt a uniform, statewide reporting of price and quality data for inpatient and outpatient procedures.
- Adopt a set of measures that are applicable to urban and rural Alaska
- Ensure integrity and comparability of data
- Involve payors to acquire cost data
- Quality measures should focus on patient outcomes
- Outline who should be required to report
- Outline what data should be reported
- Develop a system for data collection
- Develop a system for making the information available to the consumer
- Develop educational material and communication plans about the availability of information resources
- Adopt a uniform pricing estimate system for all services and providers.
Incentives and non-reimbursable services:
- Develop modified pay for performance reimbursement incentives.
- Adopt a non-reimbursement policy for incidents of serious medical error ("never events").
Other considerations:
- Should facilities receive a financial offset for uncompensated care?
While
consumers should have the option to purchase additional coverage, a
basic plan should include preventative services that encourage good
health management and consumer financial involvement. This principle
focuses on consumer wellness and prevention, incentive programs that
encourage businesses to offer health care coverage, and potential state
subsidies to make health care affordable to the uninsured.
Patient cost savings incentive:
- Develop a proposed cost savings incentive program for consumers who live a healthy lifestyle.
- Define "healthy lifestyle"
- Outline parameters for eligibilityDevelop a plan to educate consumers on the importance of wellness and prevention
- Design a system to track healthy lifestyle factors
- What will the incentive consist of? Lower insurance cost? Improved benefits? Lower co-pays/deductibles?
- Who will pay to offset the incentives?
Employer cost savings incentive:
- Develop a proposed cost savings incentive program for small employers to offer health care insurance.
- Design a program conducive to provider collaboration
- What will the incentive consist of? Lower insurance cost? Improved benefits? Lower co-pays/deductibles?
- Who will pay to offset the incentives?
Mandate considerations:
- Research the political viability of an individual mandate to carry basic insurance coverage.
- Research the political viability of an employer mandate to offer a basic benefit package to employees.
- Adopt a uniform definition of a "basic benefits" package for employers and insurers
State intervention considerations:
- Develop state subsidies to make health insurance affordable for low-income families.
- Discuss the viability of state funding for loan repayment programs.
Other important factors critical to expanding coverage and access:
- Adopt mechanisms to more equitably spread the burden of cost shifting across all purchasers.
- Adopt mental health parity legislation.
- Propose a program providing for dependent coverage to those age 26 and younger on their parents' policy.
Principle 4: Strengthen public and private health care programs.
Government
funded health insurance programs play a large role in the health status
of seniors, children and low-income families. Those programs, including
Medicare and Medicaid, must become more patient-centered and focus on
meeting consumers' medical needs, whatever their stage in life.
Inherent
to this principle is the role that uncompensated care plays in the cost
of health coverage, and employers' inability to offer health insurance
as a result. One important component of the cost of commercial premiums
is the extent to which these premiums are used to pay for care that is
provided to uninsured (or underinsured) individuals who cannot or do
not pay their bills. This uncompensated care is ultimately paid for by
those with private commercial insurance in the form of higher premium
rates.
Seniors, Medicare and Medicaid:
- Assess
the full range of long-term care services needed by Alaska's elderly
through 2025 (including, but not limited to, Alaska's Medicaid program).
- Develop strategies for improving access to Medicare for the eligible population.
- Design a plan to better facilitate coordination between Medicaid and the Tribal Health programs.
- Expand the public health nurse program to promote prevention and early diagnosis.
Alaska's Denali Kid Care program (Alaska's SCHIP program):
- Develop a program expanding the reach of the Denali Kid Care program by increasing the age threshold for eligibility.
- What should the age threshold be?
- Should all children have access to health care regardless of family income?
- Design a plan to educate the legislature about the importance of supporting change to the program
- What type of budget increase would this program require and does the state have the ability and willingness to fund it?
- Streamline the application process by reducing barriers in order to encourage more eligible people to apply.
Uncompensated care and cost shifting:
- Discuss state funding to help support uncompensated care and reduce the cost shifting to employers.
- Define "uncompensated care"
- An emphasis should be placed on long-term program sustainability
- What would a state-funded program for uncompensated care look like?
- How do you ensure a balanced system?
- How would state funding be distributed?
- Consider the true cost of uncompensated care as opposed to charges, which increase annually
- Design a plan to educate the legislature about the importance of supporting change
- What type of budget increase would this program require and does the state have the ability and willingness to fund it?
Conclusion:
Alaska
has the nation's highest health care costs, most expensive insurance
and ranks 49th among states in availability of medical services.
Meanwhile, Alaskans post staggering statistics regarding heart disease
and stroke, cancer and diabetes -- tens of thousands of Alaskans
currently suffer from these diseases and the state's death rates rank
above the national average. These factors are hurting Alaska families,
putting health care insurance out of economic range for individuals and
businesses, and threatening the effectiveness and sustainability of our
health care system.
ASHNHA, in collaboration with Alaska
communities and hospitals, supports the development of a Statewide
Health Care Commission that is willing, able and ready to take a
leadership role in developing innovative improvements to the state's
health care system.
Less than half of Alaska's private employers
offer health insurance, and more than 123,000 residents (including
21,000 children) are without ongoing health care coverage. These are
signs that Alaska is not gaining ground in assuring that its residents
have access to affordable and appropriate medical services. Alaska's
ability to recruit and retain physicians is inadequate and the lack of
cost and quality data available to consumers prevents them from making
informed health care decisions.
The Statewide Health Care
Commission, comprised of industry leaders with experience and an
understanding of the current health care structure, will be designed to
most effectively promote enduring change beginning with the identified
reform principles summarized in this document. They will be tasked with
developing feasible and sustainable legislative proposals that support
quality and access improvements while producing a more efficient health
care delivery system for Alaska.
It's imperative that we plan
for future health system needs by continuing to improve health care
quality and efficiency; establishing health care accountability;
improving and expanding coverage and access; and strengthening public
and private health care programs. These are complex issues that should
be addressed by those who can most appropriately recommend adaptive
solutions. The commission will be well-positioned to identify, analyze
and recommend viable changes to our existing system and lay the
foundation upon which positive health care reform can be built.
We
have an obligation to address health care reform now. States with far
less resources have instituted health care commissions with great
success and achieved measurable reform results. A similar body to
represent Alaska's best interests is vital to the sustainability and
future advancement of our health care system, and to the health care
status of our residents.
www.ashnha.com
Main Office
426 Main Street
Juneau, AK 99801
Phone: 907-586-1790
Fax: 907-463-3573
Anchorage Office
943 West 6th Ave #120
Anchorage, AK 99501
Phone: 907-646-1444
Fax: 907-646-3964
Back to top
|
Alaska Health Policy Review Staff and Contributors
|
Lawrence D. Weiss, PhD, MS, Editor
Kelby Murphy, Associate Policy Analyst
Keith Liles, Project Coordinator
Jacqueline Yeagle, Newsletter design and editing
|
| Subscribe now to the Alaska Health Policy Review! |
|
The Review is issued electronically, weekly during the regular legislative session and monthly the rest of the year.
A standard 12-month subscription to Alaska Health Policy Review
is available for $850. Please inquire about discount rates for multiple
recipients in the same organization, legislators, and small nonprofit
organizations. There is a separate pricing schedule for large
corporations.
| |
