Legislature(2019 - 2020)CAPITOL 106
04/18/2019 03:00 PM HEALTH & SOCIAL SERVICES
Note: the audio and video recordings are distinct records and are obtained from different sources. As such there may be key differences between the two. The audio recordings are captured by our records offices as the official record of the meeting and will have more accurate timestamps. Use the icons to switch between them.
Download Mp3. <- Right click and save file as
Download Video part 1. <- Right click and save file as
* first hearing in first committee of referral
= bill was previously heard/scheduled
= bill was previously heard/scheduled
SB 37-RENEWAL OF VACCINE ASSESSMENT PROGRAM 4:47:49 PM CO-CHAIR ZULKOSKY announced that the final order of business would be CS FOR SENATE BILL NO. 37(FIN), "An Act relating to the statewide immunization program; and providing for an effective date." 4:48:40 PM The committee took a brief at-ease. 4:49:49 PM SENATOR CATHY GIESSEL, Alaska State Legislature, as prime sponsor, introduced CSSB 37(FIN). She explained the bill would renew the Alaska Vaccine Assessment Program (AVAP) that was established in 2014. The bill would authorize a statewide vaccine program in the Department of Health and Social Services (DHSS). Because it is scheduled for repeal in 2021, the bill is a proactive action to extend it. This was a bill in 2014 that she sponsored. It monitors, purchases, and distributes all childhood vaccines and some adult vaccines to health care providers, allowing more access for Alaskans. SENATOR GIESSEL stated the bill is an innovative solution to a challenging problem. She related that before this program was in play many health care providers had to buy two supplies of vaccines. One supply was for those people who had private insurance or cash pay. The other supply was for folks who were Medicaid beneficiaries or beneficiaries of some government program such as Vaccines for Children. The reason for these two supplies is that the private pay vaccines had to be purchased by the providers themselves at the full retail prices. The two supplies could not be interchanged because the government supply was obtained by the state using bulk pricing at a much lower price. The two supplies had to be kept separate in separate refrigerators and the nurses had to keep track of the insurance and which supply of vaccine to use. If a provider had purchased its own supply for private payers and if out of a box of 10 vaccines only 9 were used and then the last one then expired, it had to be thrown away. Providers had to manage their supply and the expiration dates so there was full utilization. This program eliminates that confusion and duplication. SENATOR GIESSEL noted the program is a private-public partnership that is funded by the insurers and the government programs. Everyone pools their money and uses the state's ability to buy at bulk prices, which results in lower cost for the vaccines. The program helps the insurance companies because it allows them to maximize the bulk buying potential that the state has, thereby keeping costs down for them, and they in turn supply the vaccine for their subscribers with just the charge of the injection fee or clinic visit fee. The state asks [the insurers] how many vaccines for, say, measles are needed, they estimate that, the state assesses them that amount of money, and then the state makes a big purchase and stores the vaccines in a central location in Anchorage. For more distant clinics in places like Bethel, Nome, or Kotzebue the manufacturer may ship directly to those locations versus the central location. SENATOR GIESSEL reported the program has been wildly successful and has reduced costs, but more importantly it has increased vaccine rates. [The state] has gotten some awards for increased vaccination rates over the years that this program has been in place. The bill would simply renew that, as well as provide a funding mechanism. 4:54:16 PM JANE CONWAY, Staff, Senator Cathy Giessel, Alaska State Legislature, on behalf of Senator Giessel, sponsor, paraphrased from the written sectional analysis of [CSSB 37(FIN)] included in the committee packets, which read [original punctuation provided]: Section 1: Amends AS 18.09.200(b)(1) by removing the "phase in" language from statute as the Alaska Vaccine Assessment Program is now fully implemented. Section 2: Amends AS 18.09.220(a) by removing the "phase in" language from statute as the Alaska Vaccine Assessment Program is now fully implemented. Section 3: Amends 18.09.230 by creating the vaccine assessment "fund" in the general fund for the purpose of providing funds for the program that will be appropriated by the legislature, that can also include program receipts, penalties, money from other sources along with interest earned from the fund. These appropriations to the fund will not lapse. Section 4: Repeals and reenacts AS.18.09.230 allowing the commissioner to administer the fund in accordance to the provisions of the statewide immunization program. Section 5: Amends 37.05.146(c)(75) changing the word "account" to "fund" Section 6: Repeals AS 18.09.220(e) by removing the "opt out" option for assessees since the program is no longer in the "phase-in" stage. Section 7: Repeals the sunset provisions (to repeal the program in 2021) that were in section 5 of the original bill, [Senate Bill] 169 in 2014. Section 8: Sets effective date for July 1, 2019. 4:57:03 PM CO-CHAIR ZULKOSKY passed the gavel to Co-Chair Spohnholz. CO-CHAIR SPOHNHOLZ invited Dr. Lou to continue the introduction of CSSB 37(FIN). 4:57:48 PM LILY LOU, MD, Chief Medical Officer, Central Office, Division of Public Health, Department of Health and Social Services (DHSS), stated she served on the Alaska Vaccine Assessment Council for the first three years. She is a pediatrician and is president of the American Academy of Pediatrics, Alaska Chapter. She said she is disclosing this because there is a letter in the committee packet in support of the bill that was signed by her as the chapter president a few days before she took her current position with the State of Alaska. DR. LOU explained the bill would reauthorize the Alaska Vaccine Assessment Program (AVAP), a program that makes access to vaccines universal for all Alaskans. It expands coverage from the subset of children who are covered by Vaccines for Children to all children and it also covers some adults. The program more than pays for itself, it allows for Alaska to get a 20-30 percent discount in the cost of vaccines. She brought attention to a graph in the committee packet, which shows that over the three to four years that this program has been in effect Alaska has saved $11 million in the cost of vaccines. 4:59:44 PM REPRESENTATIVE TARR surmised the savings is because the state would otherwise be responsible for the cost of the vaccines for the beneficiaries under state-run health programs. By doing bulk purchasing the state is realizing those savings on those individual vaccinations. DR. LOU replied it is a volume discount because the state is purchasing vaccines for all Alaskans rather than piecemeal, including some retail pricing. The payers, the insurance companies who pay into the program, have realized savings by doing it this way. CO-CHAIR SPOHNHOLZ asked which adult populations this would apply to. DR. LOU responded that the unique part of Alaska's program is that the state offers payers and practitioners to opt in to cover vaccines for uninsured adults. Also doing this are the states of Vermont and Rhode Island. DR. LOU continued her presentation on CSSB 37(FIN). She pointed out that this bill and this program would [continue to] streamline the process of giving immunizations into a single system. Pediatricians would [continue with not needing] to have two refrigerators, two log systems, and two completely separated bookkeeping systems. The program was created in 2015 and is due to sunset in 2021. In 2018 the program covered 366,000 people, 50 percent of Alaskans. [The state] has demonstrated a trend of improving its vaccination rates through this system. She drew attention to a document in the committee packet and said the left half of the graph is pretty flat for these vaccines, but after the start of AVAP there is an increase. She noted the graph doesn't show all of the types of vaccines. CO-CHAIR SPOHNHOLZ offered her understanding that it was stated during a hearing before the House Finance Standing Committee, Health & Social Services Finance Subcommittee, that some of the vaccination rates had gone down and subsequently Alaska had higher influenza rates. She asked whether the graph includes influenza vaccine. 5:02:27 PM JILL LEWIS, Deputy Director (Juneau), Central Office, Division of Public Health, Department of Health and Social Services, replied that the graph includes some of the selected vaccines, but does not include the flu [vaccine] for which the rate has not gone up. CO-CHAIR SPOHNHOLZ asked whether this program would allow the state to increase flu vaccination. MS. LEWIS responded yes it would but noted it doesn't happen to show on the chart. DR. LOU added that flu vaccination tends to fluctuate depending on the vaccine for the year and how people feel about it. She confirmed it is one of the covered vaccinations in the Alaska Vaccination Assessment Program. DR. LOU pointed out that Alaska was recognized by the Centers for Disease Control and Prevention (CDC) for increases in both teen vaccines and pneumococcal vaccine for the population over 65. She said both are important populations and they demonstrate that when something new comes along this program is nimble enough to do something like the human papilloma virus (HPV) vaccine that prevents cancer. The department has seen the benefits of this program and that it is proven to be effective. DR. LOU recapped that CSSB 37(FIN) would reauthorize the Alaska Vaccine Assessment Program to remove the phase-in language, including the opt-in language, and to remove the sunset language. It would not impact any regulations about exemptions, so it is only the provision of vaccinations. Alaskans will gain the following from reauthorization: 1) Improves access to vaccines, one of the few absolutely proven effective health interventions; 2) Removes the barriers, particularly for small practices that would have to buy a box of ten to give eight vaccinations; 3) Allows [the state] to take advantage of discounted volume vaccine pricing; 4) Allows the use of a unified inventory system, allowing [the state] to redistribute according to need and not according to box number; and 5) Decreases the cost as well as the pain and suffering of vaccine preventable diseases. DR. LOU closed by reiterating that this program has proven itself since it began in January 2015. It has been a great public-private partnership. The training wheels can be taken off and [the program] continued into the future with greater health for all Alaskans. 5:05:52 PM MS. LEWIS provided a PowerPoint presentation, entitled "SB 37 Renewal of Alaska Vaccine Assessment Program," to explain how the program operates. She brought attention to slide 2, entitled "SB 37," and stated the bill would reauthorize the program, would take out from the new language the temporary phase-in period that has already ended, would not use state general funds, and would restructure the vaccine assessment account. MS. LEWIS turned to slide 3, entitled "What is the Alaska Vaccine Assessment Program?" She said the program provides all childhood and certain adult vaccines for privately insured children, which does not exclude the uninsured children as they are covered under a different program that is a federal program. The program also covers the majority of adults. CO-CHAIR SPOHNHOLZ recalled that earlier it was described that this covers uninsured adults. She asked which adult vaccines are not included. MS. LEWIS answered that the formulary of what vaccines are covered is provided in the committee packet. She said [the program] covers the vaccines that are recommended by the national committee that makes vaccine recommendations. DR. LOU added that the program follows the recommendations of the [Advisory Committee on Immunization Practices (ACIP)]. There are some vaccines [the program] likes, for example the human papilloma virus vaccine that is provided to young adults. Part of that is because the vaccines are felt to be most effective when they are given as soon as they can be in young adulthood. She referred members to the information in their packet for the specific details. Things like SHINGRIX [shingles vaccine] are covered, so the program is nimble enough to bring new vaccines on board and the assessment is just adjusted according to what is available and what is recommended by scientific evidence as effective. 5:08:34 PM MS. LEWIS resumed her discussion of slide 3. She explained the program collects money by assessing health plans, health insurers, as well as other program participants. The state pools that money together and buys vaccines at the wholesale [price] at a greatly discounted rate off of a federal contract. It is a price that the private sector cannot achieve on its own. The state is in a unique position to provide this benefit. The state purchases and then distributes the vaccine. So really the bill is about vaccine purchasing and distribution. MS. LEWIS moved to slide 4, entitled "What is the Alaska Vaccine Assessment Program?" She said Alaska is the only state that gives the providers the option to cover their uninsured adults. Two other states cover adults, but only for the insured population, the reason being that there is no assessment to be paid if there is no insurance coverage to provide the funds. In Alaska there is an option that if a provider has a large number of uninsured patients they can choose to opt in and pay the assessment, which allows them to get that same price break. Health plans are mandated to participate, but providers that want to get this price point for their uninsured adults can volunteer and then pay that. About 9 percent of what [the program] covers is related to the uninsured adults. About 32,000 lives are covered under the program, so this is an important option. Alaska is the only state able to offer that. DR. LOU pointed out that the options for providers that don't opt-in to the uninsured adult coverage are that they pay full price for vaccine or they don't vaccinate those patients. CO-CHAIR SPOHNHOLZ commented that given what is known about the "herd protection factor" and how important it is to get the maximum amount of people vaccinated; she thinks most people would support getting the maximum number of people vaccinated. 5:11:28 PM MS. LEWIS addressed slide 5, entitled "AVAP." She explained the Vaccine Assessment Council sets the assessment rate once a year. The current rate is $8.61 per member per month for children and 88 cents for adults per member per month. That rate is going to decrease for 2019 it will go down to $7.44 and 53 cents. Those rates are adjusted each year and are prospective, so if the vaccines didn't cost as much as was thought then that amount is factored into the next year's rate. Every quarter the assessed entities, the payers, pay their assessment based on the amount of covered lives they have for that quarter. This allows the payers to adjust their numbers during the year if they have a change in the number of members participating. The Division of Public Health pools that money and then uses it to buy off of a federal contract at a discounted price. Either [the division] ships the vaccine to the providers or it is shipped directly to them. [The division] does not charge the providers for the vaccine because the insurance plans have already paid for it upfront. Providers then cover their patients and provide the vaccines and the only thing they can bill for is the office visit, the charge to administer the vaccine, because that is not part of what this program is collecting assessments for. Every quarter the providers are required to report their vaccine usage to the department so it is known how much has been used and the inventories can be monitored and then [the department] uses that information to provide information back to the council for setting the next year's rate. 5:13:57 PM MS. LEWIS displayed slide 6, entitled "Vaccine Cost," and related that the state is able to achieve a vaccine cost that is about 20-30 percent lower. She explained the slide shows how much just for the cost to vaccinate a person through age 18 and the difference in the cost between the Vaccine Assessment Program and the private sector. MS. LEWIS turned to slide 7, entitled "Vaccine Coverage," and said that in regard to the state's increase in vaccination rates, the program already covers about 50 percent of the population, 44 percent of the children, and 52 percent of the adults. Uninsured children are covered under a different program and are not represented on the slide. MS. LEWIS moved to slide 8, entitled "Successes," and stated that overall it is a win for everyone. The Division of Public Health benefits because it gets to reduce vaccine preventable disease, which is one of the division's main objectives. Providers get improved health outcomes for their vaccinated individuals and they also have a lot easier stock management of their vaccine. The health insurance industry pays less overall for the cost to vaccinate. All Alaskans save money in the long run due to fewer medical costs and secondary costs from vaccine preventable diseases. MS. LEWIS skipped slide 9 and went on to slide 10, entitled "For every $1 spent on a vaccine in the US...." She stated that the slide shows how much can be saved for every $1 spent on the individual types of vaccines in the U.S. For example, for every $1 spent on the measles, mumps, and rubella (MMR) vaccine, $26 is saved. MS. LEWIS concluded with slide 11, entitled "In Closing...." She said reauthorizing this program ensures a healthier future for all Alaskans at a lower cost, plus no state general fund involved. 5:16:20 PM REPRESENTATIVE TARR referred to the nationwide discussion that is going on about vaccination and some people being anti- vaccination with subsequent outbreaks. She inquired whether this discussion is being seen in Alaska or is influencing anything in Alaska. She further inquired whether the division is doing anything to overcome that to ensure participation. DR. LOU stressed that this is an important issue across the country. However, she continued, vaccine hesitancy is quite separate from this bill, which is only about vaccine purchase. In regard to vaccine hesitancy, she said Alaska does have vaccine rates that are close to the borderline and for each vaccine there is a different percentage that confers herd immunity. It is not just the overall immunization rate that matters, but that collections of people who have a large number of unvaccinated people are where outbreaks can start. REPRESENTATIVE TARR concurred it isn't one of the technical details of the bill. But, she noted, one of the overall goals of having AVAP is to increase participation by Alaskans. For example, when HPV first came out there was some hesitancy by parents around that vaccine, so she is inquiring about whether these kinds of things influence participation in the program. DR. LOU replied that as a pediatrician, what she and her colleagues do every day is try to answer people's questions so they can make those decisions. This bill, in terms of vaccination rates, would remove barriers to people who have decided to get vaccinated and the bill would mean more offices, even small ones, are able to provide that. Some doctors might not vaccinate because they cannot afford to keep a stock and patients might not go somewhere else that does provide vaccines. The bill would impact that by making it less difficult and less expensive for people to get immunized. She said she believes the increase in vaccination rates is from removing barriers. 5:20:23 PM REPRESENTATIVE PRUITT requested clarification on provider opt-in payments. He offered his understanding that the state assesses a fee on [opt-in] providers to cover the cost of the program. He asked whether there are people on the outside of this who might seek to be a part of it, such as individual doctors. MS. LEWIS explained the program mandates that the insurers, the health plans, pay the assessment, but it is voluntary for a provider or a clinic to join. So, a provider's office is not assessed, but the health insurance industry is. Providers can opt in because that way they can also get 20-30 percent off of their vaccine cost, which otherwise they wouldn't be able to do. The most likely types of provider offices that are interested are the ones that see a large proportion of the uninsured. Quite a few that have opted in are in the tribal system or the Federally Qualified Health Centers (FQHCs) because they have to see everyone who comes to them whether or not they are insured. The providers all have to look at that and see if it costs out for them given the amount of the uninsured population that they see. REPRESENTATIVE PRUITT offered his understanding that he cannot look at the financials and determine that that is the amount of actual usage. He asked how many providers have chosen to opt-in to the program. He further asked whether the limitation is just the cost aspect of it, or if in some cases smaller providers don't have the personnel to look at this and determine whether it makes sense. He also asked whether there could be a greater participation in the program by providers who may not be utilizing it. MS. LEWIS responded she does not have the number of the actual providers that are paying in at the moment, but it amounts to about 32,000 lives that they cover. That will be looked at as the program continues and more outreach will be done to the provider community to let them know about the program and the opportunity. Until now most of the outreach has been focused on the payer community, the health plans and those mandated to pay the assessments, because there was that phase-in period that allowed it to be optional, so it was important that all the mandated assessment payers were brought on board. DR. LOU offered her belief that there is information about the opt-in providers, but that it doesn't really reflect what she believes Representative Pruitt's question is trying to get at. There could be providers that don't take care of kids or that only have two uninsured patients and so it may not be worth joining the program. But if a provider has 100 patients then it becomes worthwhile for them to engage with the program. So just looking at the percentage of providers wouldn't represent the distribution of uninsured adults. 5:25:30 PM CO-CHAIR SPOHNHOLZ inquired about the mechanism that requires insurers to participate. MS. LEWIS answered that the current statute requires the payers to participate. CO-CHAIR SPOHNHOLZ further asked what the authorizing mechanism is that says insurers must do this. For example, whether the statute says that anybody who provides insurance in the state of Alaska must do this. DR. LOU replied that in 2014 [the division] asked for everyone to be required to participate, but the bill was initially written to allow for payers to opt out for the first three years. During that period, she served on the council and a growing number of participants was seen because they knew they would be required to after three years anyway. That gave payers the opportunity to see how the program worked and to join on. Essentially all of the payers participate now, including TRICARE participation. CO-CHAIR SPOHNHOLZ offered her belief that there is an incentive to the payers to participate but that she wanted to know about the rule. DR. LOU added that [in 2014] it was a new program and now that the program has proven itself [CSSB 37(FIN)] would remove the sunset. She offered her belief that the program has also proven itself in the minds of the payers. MS. LEWIS noted the mechanism is in AS 18.09.240. She said a penalty could be assessed for non-compliance. She offered her belief that some interest has been assessed, but not any penalties for non-compliance because the phase-in period was open for a duration. CO-CHAIR SPOHNHOLZ asked what the penalty is. MS. LEWIS responded she would get back to the committee with an answer. 5:29:22 PM DAVID TEAL, Legislative Fiscal Analyst, Director, Legislative Finance Division, Legislative Agencies and Offices, stated that CSSB 37(FIN) is a short and simple bill that extends a program that has been proven successful at both reducing cost and increasing the availability of vaccines. Although the program operates at no net cost to the state, there are three fiscal notes. In February when reviewing the bill in the Senate, his division suggested the program be re-established as a fund capitalization rather than as a fund transfer. The existing financing mechanism is a fund transfer method, which requires money to be transferred, or appropriated, into the fund and then appropriated out of the fund. That meant double counting the money and a fixed appropriation available to the department. That is because in the appropriation bill simply said the sum of $10 million is appropriated to the department, the $10 million being a surmised assessment. MR. TEAL explained that a fund capitalization differs in that money only needs to be appropriated into the fund but not out of the fund. On the way out in Section 4 of the bill it says that the commissioner can spend the money without further appropriation. The constitution only requires that money be appropriated once, not twice. A fund capitalization methodology provides increased flexibility. If more providers sign on to the program, or a new vaccine is added, or there is an outbreak of flu or measles, or other illness, the department can immediately increase its expenditures without legislative action, so it is more flexible. If there is not enough money in the fund, more assessments can come in without appropriation; whatever amount is collected is appropriated to the fund and there is no legislative action required to have the department then respond to the outbreak. It also eliminates double accounting. By permitting money in the fund to be spent with no further appropriation, the fund isn't subject to the annual sweep of sub-funds into the constitutional budget reserve (CBR) fund. That may not be important, it hasn't been in the past because there has always been a vote to reverse the sweep, but if there isn't at some point, that constitutional sweep into the CBR could end the program if health care insurers refuse to pay an assessment that didn't get used for vaccine purposes. Any money that is left in the fund carrying over from one year to the next would be swept into the CBR. MR TEAL added that he doesn't see any disadvantage to moving to a fund capitalization because of the increased flexibility. He doesn't think that there is a fiscal problem with it. There are lots of fund capitalizations out there. It is a simpler, more direct, less double counting method, which is why his division recommended it. CO-CHAIR SPOHNHOLZ commented that it is very practical. 5:33:51 PM REPRESENTATIVE PRUITT offered his understanding that revenues generated in a particular year would have carry forward ability to the next year if all of them were not needed and the assessments would be adjusted based on that. MR. TEAL replied the fund would be non-lapsing, so money in it would carry forward from year to year. REPRESENTATIVE PRUITT recognized that Mr. Teal is explaining it would go from the vaccine assessment account to the vaccine assessment fund. He offered his understanding that currently in an account it doesn't lapse and because it is an account within the sub-fund the legislature must appropriate the money into that account and then subsequently the legislature must appropriate that money to the actual program. MR. TEAL responded correct. REPRESENTATIVE PRUITT surmised it is just like forward funding education, where the legislature funds the fund and it would automatically pay for it the next year as the legislature then put money into the public education fund. MR. TEAL answered correct and said that the public education fund is a good example of an appropriation that goes in and doesn't lapse and then it flows to school districts without further appropriation per a formula. In this case it would simply flow without further appropriations as needed to purchase vaccines. CO-CHAIR SPOHNHOLZ stated that an important element of using [the proposed] model is that it would allow for responding to health challenges in the community. So, if there were a need to dramatically increase the number of immunizations for a particular health crisis [the state] would be able to respond by utilizing the funds already on hand, eliminating the need for having to come back for an emergency supplemental, which would be important in an emergency situation. 5:36:29 PM CO-CHAIR SPOHNHOLZ opened public testimony on CSSB 37(FIN). 5:36:45 PM NANCY MERRIMAN, Executive Director, Alaska Primary Care Association (Alaska PCA), testified in support of CSSB 37(FIN). She spoke as follows: The Alaska Primary Care Association supports the operations and the development of Alaska's 27 community health center organizations. And together with the leaders of the community health centers in this state, we strongly support SB 37 to reauthorize the Vaccine Assessment Program. Alaska's 27 community health centers are committed to community health and have as one of their primary and reportable measurable objectives to promote immunization for infants, children, and adults. In 2014, when the Alaska [Vaccine] Assessment Program legislation was passed, health centers were among the strongest of supporters. And a quick review of participating providers today shows that 26 of the 27 community health center organizations actively rely on this program as a reliable source for their immunizations. This program allows these nonprofit practices a streamlined and cost-effective way to purchase, manage, and administer vaccinations to their patients. The assembly of private and public dollars to purchase vaccine through the AVAP eliminates the need for health centers to manage and maintain two separate stores of vaccine. Very importantly for health centers who serve all patients who walk through their doors regardless of their ability to pay, it also affords them a way to provide vaccination to lower income and uninsured adults, preventing them from contracting debilitating infectious diseases. The measles outbreak in the Lower 48, now having affected 555 children and adults reminds us of the toll of preventable infectious disease on an economy and the public health infrastructure. We should want to do everything we can to make immunizations easily accessible and affordable. This innovative program has succeeded in making both procurement and distribution of vaccine efficient and effective for the State of Alaska, payers, and health care providers across Alaska. Alaska community health centers work every day to improve the immunization rates of all children and adults regardless of their ability to pay and the AVAP gives them the framework and cost savings to do this. Alaska PCA strongly supports the reauthorization of the Alaska [Vaccine] Assessment Program through passage of SB 37. 5:40:02 PM PATTY OWEN, Director, Board of Directors, Alaska Public Health Association, testified in support of CSSB 37(FIN). She said the Alaska Public Health Association would be remiss if it weren't here today because of the connection between public health and immunizations. Immunizations are one of the main pillars of public health. An affiliate of the American Public Health Association, the Alaska association has about 150 members statewide of public health professionals and other community members dedicated to improving the health and wellbeing of Alaskans. The association strongly supports the bill's passage. This innovative public partnership will make vaccinations more accessible to more Alaskans. Thanks to immunizations in general, particularly childhood immunizations, [Alaskans] are benefitting from increased life expectancy largely due to the prevention of infectious diseases. Immunizations have become so successful in preventing diseases that people have become complacent and resurgence of outbreaks is being seen, so vigilance is needed. Vaccines are among the most cost effective clinical preventive service and core component of preventative service that can be offered. A strong immunization program is essential to public health infrastructure. 5:42:27 PM CO-CHAIR SPOHNHOLZ left public testimony open. CO-CHAIR SPOHNHOLZ announced that CSSB 37(FIN) was held over.