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December 2008 Vol 2, Issue 23
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Interview with Hollis French
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Interview with Jim Gottstein
ASHNHA: Guiding Principles for Health Care Reform 2009
Alaska Health Policy Review Staff and Contributors
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From The Editor  
Dear Reader,
In light of national efforts on health reform, this interview is of particular interest. During the 25th Alaska State Legislature, Senator Hollis French 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. This month we interviewed Senator French and encouraged him to talk about why the bill failed, what future action he will take, and whose support might make major health care reform a reality.
Our next interview is with Jim Gottstein, 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 candid and fascinating 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.
In addition, he discusses 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 has appeared before the Alaska Supreme Court numerous times.
Finally, we are very pleased to present a brand new document hot off the presses from the politically influential Alaska State Hospital and Nursing Home Association (ASHNHA), Guiding Principles for Health Care Reform. ASHNHA considers this document "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."  It is certain to play a major role in the ongoing health care reform discussions in Alaska, particularly in the upcoming legislative session.
Your comments on current and potential content, and on the Review format appreciated. Thanks so much for your support of Alaska Health Policy Review.

Lawrence D. Weiss PhD, MS
Editor, Alaska Health Policy Review
Office: 907.276.2277

Interview with Hollis French
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.

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Interview with Jim Gottstein
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, 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.

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New From ASHNHA: Guiding Principles for Health Care Reform 2009


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?
Principle 3: Improve and expand health care coverage and access.

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?

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.
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

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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

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