Q&A: Rep. Geran Tarr talks about health care policy in Alaska, systems level thinking, and preventive care.

As a member of the House Health and Social Services Committee, Rep. Geran Tarr has been a strong voice for preventive care and the expansion of coverage. With the legislative session fast approaching, I caught up with Rep. Tarr to ask about how she plans to approach health legislation in response to recent cuts, the ideological divisions that pervade health care policy both at the state and national level, and the market conditions that make Alaska unique. 

 

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Michael Goldberg: Let me just start by asking where, from your perspective, did things leave off last session on health care policy and where do you see it going this session in terms of new legislation?

Rep. Geran Tarr: Right now, we have to really think at a systems level, and recognize that what happened last year was arbitrary cuts to services without any kind of plan for meeting the unmet health care needs resulting from those cuts. It was an ideologically driven agenda and really dangerous at a time when you have to be as effective as possible with your spending. I’m trying to push the conversation toward a public health model. We know in a public health model, you want to get as far upstream to the problem as possible. We know there is tremendous benefit to spending on prevention, whether it be on prevention related to interpersonal violence, or prevention as it relates to substance abuse, we know there are huge returns. 

So again, I’m trying to push us to think about what kind of model we’re using and to remind people about the danger of pushing an ideologically driven agenda. Because as we saw last session, making arbitrary cuts did not reduce demand for those services. It’s not as if overnight, the Alaskans that needed Medicaid dental health care didn’t need it the next day. But if you use a public health model that is prevention oriented, you can actually save money. You save because you prevent the need for services or you use the earliest intervention possible which is generally the least costly as well.

This session, I’ll be focused on getting people to understand that if we want to reduce the budget as it relates to health care, we need to reduce the demand for services. And there’s a lot of opportunities where we can have healthier Alaskans, healthier communities and have a reduced demand for services that will cost the state less.”

MG: On the consequences of an ideologically driven agenda, I recently spoke with Rep. Andy Josephson about the cuts to adult dental Medicaid and the marginal returns they delivered. The figure he came up with was something close to $35 per Alaskan. What set of objectives do think underlay the more ideologically driven parts of the administration’s agenda?

GT: Their message was that we need drastic reductions in state government. As it relates to health care, any of these cuts are going to have drastic impacts on a large number of Alaskans. I think among the “optional services”, they were looking for something that was a pretty substantial number in terms of the monetary value of that service and one that affected a discrete number of Alaskans. What to me is really shortsighted is, without that service, individuals will not get preventive care. Instead, they will show up at an emergency room and then they will not be turned away. Hospitals will have to provide emergency dental care, which is the most expensive. You may delay the costs this year or next year, only to double or triple the costs the year after.”  

MG: As you know, health care costs in Alaska are among the highest in the country. Some estimates have price levels in Anchorage at 65% above the national average. Before insurance, about 10.4% of Alaska’s median income goes toward health care and about 14% of Alaskans are uninsured. There are many explanations that have been offered for Alaska’s high costs but I’m curious to hear your diagnosis as to what reforms lawmakers should direct their focus toward?

GT: A couple of things make the Alaska market unique. Overall, we are very small. That’s becoming increasingly true as there’s more growth in the lower-48 states and we’re actually having a reduction in population. So you have this giant state geographically, with very limited infrastructure and very limited connectivity. Modes of transportation are limited in many places. The combination between our geographic size and small population is not found anywhere else. 

Secondly, when you look at the way Alaskans are covered, a third of Alaskans are covered under TRICARE because they are active military dependent or veterans. When you take those people out, you have another large group of individuals under Indian Health Services (IHS), then you have over 215,000 Alaska that receive Medicaid, you also have Medicare and you have public employees. When all is said and done, there’s only 15,000 to 20,000 Alaskans left for the individual health care market. That’s so small as to be impossible to provide reasonable cost insurance. As a result, the legislature had to pull the high-risk individuals out of that group and do a set-aside for them so that there would still be a company that offers individual health care plans in the Alaska market.  

I think we missed an opportunity when the Affordable Care Act passed to join the national marketplace and be locked in among that huge group of people. Not every state did of course, but because so many other states did, we probably could have benefited from that. 

I think one topic that will come up this year is a certificate of need. It’s an idea that is supposed to regulate the market in a way that is good for pricing, so that you don’t have an excess of one type of facility or an imbalance in terms of things like specialty care which could influence prices. But it’s very controversial and there have been big legislative battles over it. I think Senator Wilson actually has a bill to repeal the requirement for a certificate of need. 

We are also at the point where we should start to hear back from some of the pilot projects that were started as a result of our Medicaid reform bill about managed care. There could also be potential there for looking at costs.” 

MG: What are you thoughts on the Democratic debates over health care?

GT: Well, I think there is one point we really need to educate people about. When the Affordable Care Act came about and we had conversations at the state level, there was this expectation, because there was ‘pent up need’, you were going to have through expansion over 40,000 more people in Alaska that were going to go to the doctor for the first time in a number of years. When they went to that appointment, they were going to find that they had some unmet health care needs. Treating these needs can get very costly very quickly.

So the expectation was that there was going to be a period where there would be an uptick in the costs as those issues were worked through. That to me made a lot of sense in terms of how the system was going to evolve. But that never really become a part of the larger conversation. Instead it was, as soon as the law passed, ‘overnight things will be less expensive.’ It just didn’t evolve quickly enough to meet that expectation. 

All of these efforts need to recognize both where you are today and where you are trying to go. Today, Alaska’s number of uninsured people is growing. What that means is that people aren’t seeing a doctor until their condition gets really bad, and that’s always going to be the most expensive way to address the issue. 

As we look at how systems can evolve and what’s going on in the national conversation in terms of Medicare For All, I can understand why people may not be 100 percent enthusiastic about it. On the consumer side, are the current beneficiaries of these programs singing their praises and saying it’s always easy to find a doctor? No. In Alaska there was a period where we didn’t have any doctors who accepted Medicare until we bumped up some of the reimbursement rates. So I can understand some of the apprehension around that. 

But I think that conversation does have to include thoughts about how systems can evolve. 

This interview has been edited for clarity and length.