2. The ACE Ledger The Estimated Costs of Adverse Childhood Experiences for Adults in Alaska and What Targeted Reductions in ACEs Could Mean to Alaskans and their Wallets.

3. The economic burden of child maltreatment in the United States and implications for prevention Key findings: The estimated average lifetime cost per victim of nonfatal child maltreatment includes: $32,648 in childhood health care costs +$7,728 in child welfare costs +$7,999 in special education costs $48,375 http://www.cdc.gov/media/releases/2012/p0201_child_abuse.html

4. Three Pronged Approach Primary prevention aims to prevent disease or injury before it ever occurs. Secondary prevention aims to reduce the impact of a disease or injury that has already occurred. Tertiary prevention aims to soften the impact of an ongoing illness or injury that has lasting effects http://www.iwh.on.ca/wrmb/primary-secondary-and-tertiary-prevention

5. A Way to Think about the Three Pronged Approach Population EstimateOutcome Estimate ACE Scores of 2013 Adult Alaska Population Zero194,275 One121,950 Two - Three135,398 Four Plus94,134 Total545,757 Current Smoking 14.4% 18.3% 24.1% 34.5% Primary Secondary Tertiary ACE Scores of 2013 Adult Alaska Population who Currently Smoke Zero27,901 One22,298 Two - Three32,564 Four Plus32,481 Total115,244

6. Population Attributable Risks (PAR) For Alaska Health Behavior or Outcome PAR%* Frequent Mental Distress60.1% Chronic Obstructive Pulmonary Disease, Emphysema or Chronic Bronchitis46.1% Health Insurance: Medicaid40.6% Physical Health Not Good 14+ Days33.2% Current Smoker32.0% Current or Former Asthma30.6% General Health26.8% Non-Gestational Diabetes23.7% Activity Limitation 14+ Days23.7% Heavy Alcohol Consumption20.5% Ever Smoker19.3% Told Have Arthritis15.8% Insufficient Sleep15.5% Obesity14.3% Separated or Divorced13.2% Binge Drinking Risk Factor11.0% No Leisure Time Physical Activity10.2%

7. Prevention What is A Realistic Goal to Reduce ACEs in Alaska?

8. Let’s start with something that’s doable….done somewhere else. Let’s pick a state or two that are lower in ACE scores compared to Alaska. How about two states – Vermont and Arkansas. Should we aim for their level of ACEs?

9. http://healthvermont.gov/research/brfss/documents/2010_data_brief_ace.pdf http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5949a1.htm

10. What is A Realistic Goal to Reduce ACEs in Alaska? All ACEs? One ACE for Everyone? Two ACEs for Everyone? Something Else?

11. http://healthvermont.gov/research/brfss/documents/2010_data_brief_ace.pdf http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5949a1.htm Not very realistic

12. http://healthvermont.gov/research/brfss/documents/2010_data_brief_ace.pdf http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5949a1.htm Maybe someday but still too ambitious

13. http://healthvermont.gov/research/brfss/documents/2010_data_brief_ace.pdf http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5949a1.htm This is really close but let’s stay conservative

14. What about a Reduction in ACEs of one ACE for Half of Alaskan Adults? If half the people with one ACE dropped to zero ACEs and the other half stayed at one…. ……and if half the people with two ACEs dropped to one ACE and the others stayed at two……..etc.

15. http://healthvermont.gov/research/brfss/documents/2010_data_brief_ace.pdf http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5949a1.htm

16. W hat impact on costs might be achieved by a reduction like this?

17. The Alaska ACE Ledger

18. Use of Adult Medicaid Estimated Alaskans adults who have used adult Medicaid Services 2012 – 53,800*  Number taken from DHSS annual Medicaid update (Age 20+) Costs of Age 20 + Adult Medicaid in Alaska are estimated at $860 million in 2012 - based on a DHSS document– Long Term Forecast of Medicaid Enrollment & Spending in Alaska 2012

19. ACE Scores of 2013 Adult Alaska Population who Use Medicaid Zero9,629 One5,956 Two - Three9,059 Four Plus7,410 Total32,055 ACE Scores of 2013 Adult Alaska Population who Use Medicaid Zero7,329 One7,192 Two - Three10,847 Four Plus9,127 Total34,495 ACE Scores of 2013 Adult Alaska Population with Reduction Zero255,250 One101,002 Two - Three113,081 Four Plus76,425 Total545,757 A Reduction, for Half of All Alaskan Adults, of One ACE ACE EstimateAlaskans With Medicaid Adult Medicaid 3.8% 5.9% 8.0% 9.7% In this scenario we would see a reduction of 7.1% of Alaskan adults who use Medicaid This is a reduction of approximately 2,450 people The average annual extra cost per person of have Medicaid is $15,985 The estimated annual savings for Alaska are $39,000,000 ACE Scores of 2013 Adult Alaska Population Zero194,275 One121,950 Two - Three135,398 Four Plus94,134 Total545,757

20. The Alaska ACE Ledger Issue Number of Alaskans Total Costs Average Annual Costs Target ReductionEstimated Savings Medicaid53800$860,000,000$15,9852422$38,715,670

21. Current Smoking Estimated Alaskans Adults who Currently Smoke 2013 – 115,244  Calculate based on 2013 BRFSS Survey Costs of Adult Tobacco Use in Alaska are estimated at $576 million in 2012 - based on a State of Alaska Publication – Alaska Tobacco Facts 2012 Update

22. ACE Scores of 2013 Adult Alaska Population who Currently Smoke Zero36,658 One18,468 Two - Three27,196 Four Plus26,371 Total108,693 ACE Scores of 2013 Adult Alaska Population with Reduction Zero255,250 One101,002 Two - Three113,081 Four Plus76,425 Total545,757 A Reduction, for Half of All Alaskan Adults, of One ACE ACE EstimateAlaskans Who Smoke Current Smoking 14.4% 18.3% 24.1% 34.5% In this scenario we would see a reduction of 5.7% of Alaskan adults who currently smoke This is a reduction of approximately 6,550 people The average annual extra cost per person of Smoking is $5,024 The estimated annual savings for Alaska are $32,300,000 ACE Scores of 2013 Adult Alaska Population Zero194,275 One121,950 Two - Three135,398 Four Plus94,134 Total545,757 ACE Scores of 2013 Adult Alaska Population who Currently Smoke Zero27,901 One22,298 Two - Three32,564 Four Plus32,481 Total115,244

23. The Alaska ACE Ledger

24. Diabetes Estimated Alaskans adults who have a diabetes diagnosis 2013 – 41,160  Calculated based on 2013 BRFSS Survey Costs of Diabetes in Alaska are estimated at $450 million in 2012 - based on the Journal Diabetes Care – The Economic Costs of Diabetes in the U.S. 2012

25. ACE Scores of 2013 Adult Alaska Population with Diabetes Zero15,139 One6,728 Two - Three11,506 Four Plus6,441 Total39,814 ACE Scores of 2013 Adult Alaska Population with Reduction Zero255,250 One101,002 Two - Three113,081 Four Plus76,425 Total545,757 A Reduction, for Half of All Alaskan Adults, of One ACE ACE Scores of 2013 Adult Alaska Population With Diabetes Zero11,522 One8,124 Two - Three13,725 Four Plus7,789 Total41,160 ACE Estimate Alaskans With Diabetes Diabetes 5.9% 6.7% 10.1% 8.3% In this scenario we would see a reduction of 3.3% of Alaskan adults who have diabetes This is a reduction of approximately 1,300 people The average annual extra cost per person with diabetes is $10,933 The estimated annual savings for Alaska are $14,700,0000 ACE Scores of 2013 Adult Alaska Population Zero194,275 One121,950 Two - Three135,398 Four Plus94,134 Total545,757

26. The Alaska ACE Ledger

27. Binge Drinking Estimated Alaskans adults who currently binge drink 2013 – 98,152  Calculated based on 2013 BRFSS Survey Costs of Adult Binge Drinking in Alaska are estimated at $545 million in 2006 - based on a Journal of Preventive Medicine Article – State Costs of Excessive Alcohol Consumption

28. ACE Scores of 2013 Adult Alaska Population with Reduction Zero255,250 One101,002 Two - Three113,081 Four Plus76,425 Total545,757 ACE Scores of 2013 Adult Alaska Population who Binge Drink Zero40,868 One17,294 Two - Three22,138 Four Plus15,961 Total96,260 A Reduction, for Half of All Alaskan Adults, of One ACE ACE Estimate Alaskans Who Binge Drink Binge Drinking 16.0% 17.1% 19.6% 20.9% In this scenario we would see a reduction of 1.9% of Alaskan adults who binge drink This is a reduction of approximately 1,900 people The average annual extra cost per person of binge drinking is $5,553 The estimated annual savings for Alaska are $10,500,000 ACE Scores of 2013 Adult Alaska Population Zero194,275 One121,950 Two - Three135,398 Four Plus94,134 Total545,757 ACE Scores of 2013 Adult Alaska Population who Binge Drink Zero31,105 One20,880 Two - Three26,507 Four Plus19,659 Total98,152

29. The Alaska ACE Ledger

30. Arthritis Estimated Alaskans adults who have a arthritis diagnosis 2013 – 132,136  Calculated based on 2013 BRFSS Survey Costs of Arthritis in Alaska are estimated at $275 million in 2003 - based on a CDC document– National and State Medical Expenditures and Lost Earnings Attributable to Arthritis and Other Rheumatic Conditions U.S. 2003

31. ACE Scores of 2013 Adult Alaska Population who Have Arthritis Zero52,041 One22,594 Two - Three29,333 Four Plus24,457 Total128,425 ACE Scores of 2013 Adult Alaska Population with Reduction Zero255,250 One101,002 Two - Three113,081 Four Plus76,425 Total545,757 A Reduction, for Half of All Alaskan Adults, of One ACE ACE Scores of 2013 Adult Alaska Population who Have Arthritis Zero39,610 One27,280 Two - Three35,122 Four Plus30,125 Total132,136 ACE Estimate Alaskans With Arthritis Arthritis 20.4% 22.4% 25.9% 32.0% In this scenario we would see a reduction of 2.8% of Alaskan adults who have arthritis This is a reduction of approximately 3,700 people The average annual extra cost per person having arthritis is $2,453 The estimated annual savings for Alaska are $9,100,000 ACE Scores of 2013 Adult Alaska Population Zero194,275 One121,950 Two - Three135,398 Four Plus94,134 Total545,757

32. The Alaska ACE Ledger

33. Obesity Estimated Alaskans Adults who are Obese 2013 – 156,660  Calculate based on reported Height, Weight, and Gender - BRFSS 2013 Costs of Adult Obesity in Alaska are estimated at $219 million in 2012 - based on a Institute for Social and Economic Research study published in 2014.

34. ACE Scores of 2013 Adult Alaska Population with Reduction Zero255,250 One101,002 Two - Three113,081 Four Plus76,425 Total545,757 ACE Scores of 2013 Adult Alaska Population who are Obese Zero62,826 One27,195 Two - Three37,183 Four Plus25,559 Total152,763 ACE Scores of 2013 Adult Alaska Population who are Obese Zero47,818 One32,835 Two - Three44,521 Four Plus31,482 Total156,656 A Reduction, for Half of All Alaskan Adults, of One ACE ACE EstimateAlaskans With Obesity Obesity 24.6% 26.9% 32.9% 33.4% In this scenario we would see a reduction of 2.5% of Alaskan adults who are obese This is a reduction of approximately 3,900 people The average annual extra cost per person of being obese is $1,398 The estimated annual savings for Alaska are $5,400,000 ACE Scores of 2013 Adult Alaska Population Zero194,275 One121,950 Two - Three135,398 Four Plus94,134 Total545,757

35. The Alaska ACE Ledger

36. $111,393,551

37. Eliminate Double Counting of Costs Medicaid100.0% Current Smoking93.7% Diabetes63.7% Binge Drinking60.5% Arthritis51.1% Obesity36.6%

38. The Alaska ACE Ledger $89,670,476

39. The Alaska ACE Ledger Eliminating possible double counting of costs we can very conservatively estimate savings to Alaska of $90 million from a reduction of ACEs of to the level of Vermont or Arkansas

40. What Does $90 Million Buy in Alaska? 258 three bedroom homes in Anchorage (average price $347,000) 915 kindergarten teachers (wages only $66,384 + 40%) $97,938 846 police officers (wages only $75,672 + 40%) $105,941 518 mechanical engineers (wages only $123,600 + 40%) $173,040 339 pediatricians (wages only $189,000 + 40%) $264,600 Office of Children’s Services - General Funds 2016 – Operations All of the Behavioral Health State Medicaid Costs + $18 million The General Funds for the Department of Commerce, Community & Economic Development + The Department of Labor & Workforce Development 103,307 Flights from Ketchikan to Barrow in July ($868) Boeing 737-800 + $17 million for fuel and crew. Pick One! http://live.laborstats.alaska.gov/occ/alloccs.cfm#L

41. 8.9%3.5% 5.0% 4.7% 6.6% 4.0% 6.7% 6.0%

42. 3.7%10.4%2.8%10.7%

43. 8.9% 7.0%

44. The Bad Metaphor Section The Balloon Animal Edition

45. The ACEs Risks Balloon

46. Obesity Smoking Asthma Diabetes Substance Abuse Arthritis Medicaid Usage Low Income Other Issues

47. The ACEs Risks Balloon

49. Next Steps What are we already doing? Who is doing it? What works and what does it cost? What doesn’t work? How can we be efficient with what we have? Do we need more resources?

50. To learn more about Adverse Childhood Experiences and what Alaska is doing about them, go to the link at the bottom of this slide. dhss.alaska.gov/abada/ace-ak/Pages/default.aspx Pat Sidmore, Planner patrick.sidmore@alaska.gov