Legislature(2023 - 2024)ADAMS 519
03/22/2024 01:30 PM House FINANCE
| Audio | Topic |
|---|---|
| Start | |
| HB219 | |
| HB115 | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| += | HB 115 | TELECONFERENCED | |
| *+ | HB 219 | TELECONFERENCED | |
| + | TELECONFERENCED |
HOUSE FINANCE COMMITTEE
March 22, 2024
1:35 p.m.
1:35:26 PM
CALL TO ORDER
Co-Chair Foster called the House Finance Committee meeting
to order at 1:35 p.m.
MEMBERS PRESENT
Representative Neal Foster, Co-Chair
Representative DeLena Johnson, Co-Chair
Representative Julie Coulombe
Representative Mike Cronk
Representative Alyse Galvin
Representative Sara Hannan
Representative Andy Josephson
Representative Dan Ortiz
Representative Frank Tomaszewski
MEMBERS ABSENT
Representative Bryce Edgmon, Co-Chair
Representative Will Stapp
ALSO PRESENT
Representative Dan Saddler, Sponsor; Representative Mike
Prax, Sponsor; Dr. Natalie Wiggins, Alaska Association of
Naturopathic Doctors; Representative Justin Ruffridge.
PRESENT VIA TELECONFERENCE
Melodie Wilterdink, Staff, Representative Saddler,
Anchorage; Duane Mayes, Director, Division of Vocational
Rehabilitation, Department of Labor and Workforce
Development; Mystie Rail, Executive Director, Assistive
Technology of Alaska, Anchorage; Dr. Carrie Baldwin-Sayre,
Associate Vice President, Advancement and Community
Engagement, National University of Natural Medicine,
Portland, Oregon; Dr. Sean Higgins, Emergency Room Doctor,
Anchorage; Dr. Clyde Jensen, Professor of Pharmacology,
College of Osteopathic Medicine, Rocky Vista University,
St. George, Utah; Dr. Robert Downey, Family Practice
Physician, South Peninsula Hospital, Homer; Dr. Roxanne
Jones, Alaska Academy of Family Physicians, Anchorage; Dr.
Hillary Johnson-Jahngir, American Society for Dermatologic
Surgery, Iowa; Dr. Kristin Mitchell, President Elect,
Alaska State Medical Association, Soldotna; Dr. Scott
Ferguson, Board of Trustees, American Medical Association,
West Memphis, Arkansas; Bruce Campbell, Self, Fairbanks;
Bart Grabman, Self, Anchorage; Karen Gonne-Harrell, Self,
Anchorage; Dr. Tim Birdsall, Alaska Association of
Naturopathic Doctors, Anchorage; Pam Ventgen, Executive
Director, Alaska State Medical Association, Anchorage.
SUMMARY
HB 219 REPEAL ASSISTIVE TECHNOLOGY LOAN PROGRAM
HB 219 was HEARD and HELD in committee for further
consideration.
HB 115 NATUROPATHS: LICENSING; PRACTICE
HB 115 was HEARD and HELD in committee for further
consideration.
Co-Chair Foster reviewed the meeting agenda.
HOUSE BILL NO. 219
"An Act repealing the assistive technology loan
guarantee and interest subsidy program; and providing
for an effective date."
1:38:00 PM
REPRESENTATIVE DAN SADDLER, SPONSOR, introduced the bill.
He stated that one of the best things about living in
Alaska were the great people who had big hearts and a
willingness to help every Alaskan enjoy life in the state
to the maximum, including individuals experiencing physical
or mental disabilities. For example, in 1995 the state
sought and received a $500,000 grant aimed at backing loans
for individuals with disabilities. He detailed that the
loans helped people buy assistive technology (AT) to help
them get or keep a job, attend school, or live more
independently. He provided examples of AT including
wheelchairs, computers, sleep synthesizers, prosthetics,
hearing aids, and other communication devices. The
legislature had established the Assistive Technology Loan
Guarantee Fund intended to guarantee the principal amount
of the loans to Alaskans in order to purchase AT. He noted
the funds could also be used to subsidize interest rates.
He relayed that despite the legislature's good intentions,
few people had taken advantage of the program. The intent
of HB 219 was to repeal the grant fund and direct the fund
balance of approximately $460,000 to the Assistive
Technology of Alaska (ATLA), a nonprofit empowered to
administer the grants. He explained that the repeal of the
underlying statute would only happen if the legislature
reappropriated the funds through separate legislation. He
believed members' bill packets included the draft language.
He elaborated that passing HB 219 to repeal AS 23.15.125
would remove outdated statutory barriers that were keeping
Alaskans with disabilities from taking advantage of the
funds. He noted his staff was available to review the
sectional analysis.
Co-Chair Foster asked to hear from Representative Saddler's
staff.
1:40:22 PM
MELODIE WILTERDINK, STAFF, REPRESENTATIVE SADDLER,
ANCHORAGE (via teleconference), offered the sectional
analysis of the bill (copy on file):
Section 1 Page 1, Line 4
Section 1 repeals AS 23.15.125 the assistive
technology loan guarantee and interest subsidy program
which established the "assistive technology loan
guarantee fund." The fund can be used to guarantee the
principal amount or subsidize the interest rate of a
loan for purchasing assistive technology that enables
an individual to obtain or maintain employment or live
more independently.
Section 2 Page 1, Lines 5-9
Section 2 adds conditional language to Alaska's
uncodified law stipulating that this act only takes
effect if the Legislature reappropriates the balance
of the assistive technology loan fund for the purpose
of improving access to assistive technology.
Section 3 Page 1, Line 10
Section 3 provides for an immediate effective date.
Co-Chair Foster observed that the law would only take
effect if the legislature reappropriated the balance of the
AT fund. He asked if the adjustment was something that
would happen at the very end of session when bills were
rolled into the conference committee. Alternatively, he
wondered if the operating budget co-chair needed to do
something in the meantime.
Ms. Wilterdink responded that there was drafted language
and the amendment to the operating budget could happen in
the House Finance Committee during the budget amendment
process, on the House floor, or at a later time during
conference committee. She noted that ideally the change
would take place prior to conference committee.
1:43:16 PM
Representative Josephson asked how the fund avoided being
swept over the past several years.
Representative Saddler deferred the question to the
Department of Labor and Workforce Development (DLWD).
DUANE MAYES, DIRECTOR, DIVISION OF VOCATIONAL
REHABILITATION, DEPARTMENT OF LABOR AND WORKFORCE
DEVELOPMENT (via teleconference), replied that he did not
have the details to answer the question. He relayed that
the funding had been a one-time allocation to the Division
of Vocational Rehabilitation (DVR) in 1995. He offered to
follow up with the information.
Representative Saddler speculated that the fact that the
funding was still available 30 years after the
establishment of the fund was some indication it had found
a niche to be safe from the sweep.
Co-Chair Foster suggested a follow-up on the question with
the information to be provided at the next hearing on the
bill.
Representative Hannan asked how much money was available in
the fund. She understood the fund had initially been
capitalized with federal money and $100,000 had been put in
a couple of years later. She remarked that the fiscal note
did not address how much money would be reappropriated. She
asked if none of the money had ever been spent and if it
earned interest in the fund.
Representative Saddler deferred to Mr. Mayes.
Mr. Mayes responded that the current balance of the fund
was $447,000. He estimated that over the 30-year life of
the fund, around 10 loans had been provided. He relayed
that there had been no loans in the past six years.
Representative Saddler added that there had been a period
of very low interest rates and because part of the aim of
the federal grant money was to subside loans it was rather
difficult to find a way in which a subsidy was much of a
benefit. He stated it was one of the reasons the loan
program had been moribund.
Representative Hannan asked if there were any restrictions
on reappropriation tied to the initial $291,000 in federal
funds.
Representative Saddler deferred the question to Mr. Mayes.
He believed there were some restrictions.
Mr. Mayes answered that ATLA was the implementing agency
and store front in terms of technology. There were no
restrictions on the funds. The change in statute would
enable the state to allocate the funding to ATLA, which was
better positioned to promote the program and the funds. The
department had been talking with its federal funding
partner and there were many other states that had done the
same thing because they were experiencing the same thing as
Alaska.
1:49:09 PM
Representative Hannan provided a hypothetical scenario
where the legislature wanted to move the initial amount
that was capitalized and to reappropriate $100,000 to
senior and disability services technology. She asked if the
scenario would be allowed. She noted the reappropriation in
the scenario would be a different action from the bill. She
wondered whether the legislature could only reappropriate
the funds to one thing or if it had carte blanche through
its appropriation power to put the funds towards any
disability services.
Mr. Mayes responded that ATLA was the implementing agency
that DLWD worked with. The department's Division of
Vocational Rehabilitation had a set of rehabilitation
counselors who may use ATLA to assess technology needs.
There was no other entity in the state that he was aware
of. He explained that ATLA was federally recognized under
the 21st Century Assistive Technology Act.
Representative Saddler added that it was his understanding
that with funds established through law, often the lender
specified the fund balance included original appropriation
plus earnings. He would look into HB 65, the 1995 vehicle
that established the fund.
Co-Chair Foster thought it was a good question asked by
Representative Hannan about whether $100,000 could be
reappropriated to another program. He would be happy with a
simple yes or no answer.
Representative Galvin thanked Representative Saddler for
finding money that was not being spent and was meant to be
spent on behalf of individuals who need the funds. She
referenced support letters included in members' packets
(copy on file). She looked at language specifying that ATLA
remained one of the only nonprofits to provide services to
all Alaskans regardless of age, location, income, or
diagnosis. She stated that the language "one of the only"
made her wonder if there were others. She asked if there
had been a process in which the department had chosen to
focus on ATLA.
Representative Saddler asked which letter and location she
was referencing.
Representative Galvin referred to paragraph three of a
letter from the Association of Assistive Technology Act
(copy on file). She noted that the sentence was in a couple
of the letters. She referenced a letter from Articulate
Speech and Language Therapy (copy on file) as another
example.
Representative Saddler responded that ATLA and DVR had made
him aware of the issue and had suggested the bill. He
believed ATLA was one of a few nonprofits providing the
services, but ATLA was the primary entity with the most
experience and efficacy. He thought ATLA was the only
agency that had every facilitated the grants. He concluded
that ATLA was in the best position and best nonprofit
available to deliver the money to people who need it. He
deferred to the executive director of ATLA to answer if
there were other agencies that may qualify.
1:54:42 PM
MYSTIE RAIL, EXECUTIVE DIRECTOR, ASSISTIVE TECHNOLOGY OF
ALASKA, ANCHORAGE (via teleconference), answered that ATLA
was the only agency in the state dealing with assistive
technology and it was the implementing agency of the
federal AT Act.
Representative Galvin stated that all of her questions were
answered if the grant was single sourced toward only one
purpose.
Co-Chair Foster noted that Mr. Mayes was listed as invited
testimony. He asked if Mr. Mayes had additional comments.
Mr. Mayes shared that he had worked in the state system for
35 years. He started out in 1989 as the rehabilitation
counselor for the deaf and hard of hearing and had worked
in the position for nine years. He relayed that ATLA was
with him at the time, and he often used the agency to
identify technology needs for deaf, blind, or hard of
hearing. He relayed that with the exception of senior and
disability services and the Governor's Council on
Disabilities and Special Education, ATLA was the sole
agency the rehabilitation counselors worked for. He relayed
that the skill set counselors needed to have was
complicated and it was rare to find someone with that level
of skill. He stated that ATLA had been around for a long
time and was the lifeline for DVR.
1:57:17 PM
Representative Hannan remarked that DVR had previously had
an assistive program to help deaf individuals, but it no
longer existed. She wondered if some of the funding could
be used to reinstate such a program. Alternatively, she
wondered if the funding was constrained and could not be
used for that purpose.
Mr. Mayes deferred the question to Ms. Rail.
Ms. Rail responded that she was not aware of the specific
program that had previously existed under DVR. She relayed
that ATLA was a community rehabilitation provider for the
division. She explained that the division counselors
referred individuals to ATLA for a full assessment and to
provide recommendations on the right assistive technology.
Representative Hannan shared that she had some active deaf
constituents who had repeatedly told her they used to have
supports at DVR, but the programs had been cut. She
elaborated that they found it very hard to find access to
services and supports within state agencies to interact
with state agencies. She explained that the individuals
continually asked when the positions could be reinstated.
She was trying to determine whether the funding could only
be directed to individuals or if it could be used to
provide a deaf assistance person at the division that deaf
Alaskans could contact for a variety of supports.
Co-Chair Foster thought it sounded like some research and
follow up was needed.
Representative Saddler stated that he had some difficulty
understanding Ms. Rail possibly due to speakerphone. He
believed Ms. Rail had said that if someone was referred to
ATLA, the agency would conduct an assessment of the
person's disabilities and would be able to help provide
assistive technology if a person was deaf or hard of
hearing.
2:01:07 PM
Ms. Rail agreed. She detailed that ATLA provided AT and the
associated services. The agency had additional programs it
was able to administer to provide specific types of devices
for deaf or hard of hearing individuals and individuals
experiencing speech impairment. She speculated that the
constituents that Representative Hannan was speaking of
were likely looking for services beyond assistive
technology and the services provided by ATLA. She explained
that ATLA was very focused on providing AT and the
surrounding services.
Co-Chair Foster asked Ms. Rail to provide any comments as
an invited testifier.
Ms. Rail shared that ATLA had become a 501(c)(3) in 1994
and the implementing agency of the federal Assistive
Technology Act under the direction of DVR. She noted that
the federal funds went directly to DVR and were passed on
to ATLA. The agency's mission was to enhance the quality of
life for Alaskans through assistive technology. She relayed
that ATLA was the state's only comprehensive assistive
technology resource center that provided services statewide
to Alaskans at any age with any disability, injury, or
illness. She noted that most other nonprofits were specific
to certain ages, disabilities, or areas within the state.
She explained that ATLA partnered with all of those
agencies.
Ms. Rail supported the activities outline in the Assistive
Technology Act. She detailed that assistive technology was
defined as any item, piece of equipment, software program,
or product system used to increase, maintain, or improve
the functional capabilities of people with disabilities.
She explained that AT could be as simple and low tech as
putting rubberized grips on a pen for a person experiencing
arthritis or as high tech as a device called Eyegaze that
enabled a person to control a computer or iPad using only
their eyes. She elaborated that AT could range from
solutions made ourselves to specialized equipment from AT
manufacturers to everyday off-the-shelf devices like an
iPad or Amazon's Alexa. She stressed that AT was not a one
size fits all solution. She relayed that devices and
services were unique to each person ATLA worked with. She
provided examples of individuals receiving assistance
through ATLA. She highlighted an elder in rural Alaska who
was losing his vision and was now able to read his own mail
with the assistance of a digital magnifier. Another example
was a non-verbal six-year-old with autism in Ketchikan who
had recently told her mom "thank you" for the first time
using a symbol-based communication device.
Ms. Rail stated that AT devices and services were critical
to ensure Alaskans with disabilities were able to live,
work, and participate in their communities independently.
2:06:27 PM
Ms. Rail continued to provide details about ATLA. She
relayed that as the implementing agency of the Assistive
Technology Act, ATLA provided demonstrations of the devices
to offer opportunities for Alaskans to become familiar with
the different types of technology that could help them. She
explained that it offered Alaskans a chance to compare and
contrast the functions and features of each device through
hands-on exploration by an AT professional. The agency also
allowed individuals to borrow equipment for two to four
weeks to determine whether the item would meet their needs
prior to purchase. The agency also supported the reuse of
AT in order for multiple people to benefit from a device.
The AT Act did not allow ATLA to purchase technology
directly for a person, but it allowed ATLA to do state
financing activities to administer other initiatives for
funding resources that did support the acquisition of the
AT for consumers at no cost using dollars from non-AT Act
sources. The agency also used AT Act dollars to provide
outreach and awareness and to collaborate with partner
agencies across the state. The intent of HB 219 would be to
support the activities already provided by ATLA through the
AT Act.
Ms. Rail stressed that technology was rapidly changing as
were the needs of Alaskans served by the agency. She stated
that the funds received by the agency through the AT Act
did not begin to cover the need to purchase more AT for
demonstration centers or to be able to provide short-term
loans. She stated that the funds [that would result from HB
219] would ensure ATLA could meet the increased urgency for
AT and to help improve and continue to improve the quality
of life for Alaskans with disabilities. The additional
funds would also strengthen and sustain the gaps in
services or in devices that were needed to support
Alaskans. She thanked the committee for the opportunity to
speak.
Co-Chair Foster thanked Ms. Rail for her testimony. He
asked Representative Saddler for any closing comments.
2:09:30 PM
Representative Saddler thanked the committee and was
available for questions.
Representative Tomaszewski asked if the fund had collected
any interest over its 30-year lifespan.
Representative Saddler deferred the question to Mr. Mayes.
Mr. Mayes confirmed that there was some interest made on
the funding, but he did not have the specific numbers on
hand. He would follow up with the information.
Co-Chair Foster set the amendment deadline for Friday,
March 29 at 5:00 p.m.
HB 219 was HEARD and HELD for further consideration.
HOUSE BILL NO. 115
"An Act relating to the practice of naturopathy;
establishing the Naturopathy Advisory Board; relating
to the licensure of naturopaths; relating to
disciplinary sanctions for naturopaths; relating to
the Department of Commerce, Community, and Economic
Development; and providing for an effective date."
2:11:21 PM
Co-Chair Foster asked for a brief recap of the bill. He
relayed that the committee would also hear invited
testimony followed by public testimony.
REPRESENTATIVE MIKE PRAX, SPONSOR, relayed that HB 115 was
designed to allow naturopaths to practice to the full
extent of their training including prescription authority
and minor in-office surgical procedures. The intent was to
reduce the cost of care for those choosing to use a
naturopath for medical care. He stated that the bill would
benefit Alaska by getting more premier care physicians
available to serve.
Co-Chair Foster moved to invited testimony. He relayed that
of the eight invited testifiers there were four in support
and four opposed to the bill.
2:14:38 PM
DR. CARRIE BALDWIN-SAYRE, ASSOCIATE VICE PRESIDENT,
ADVANCEMENT AND COMMUNITY ENGAGEMENT, NATIONAL UNIVERSITY
OF NATURAL MEDICINE, PORTLAND, OREGON (via teleconference),
stated that her testimony was intended to highlight the
education and training of naturopathic physicians and how
the training was overseen by national accreditation
organizations. She relayed that naturopathic medical
programs were four-year graduate programs. The National
University of Natural Medicine (NUNM) programs included
5,047 hours of total education, including 1,254 training
hours of direct student involvement in clinical care. The
training hours were comparable to the education
requirements for other healthcare professions and far
exceeded the 1,000 hours required in the two-year family
nurse practitioner program at Oregon Health Sciences
University (OHSU).
Dr. Baldwin-Sayre noted that with less clinical training
than naturopathic physicians, nurse practitioners had fully
autonomous prescriptive authority including controlled
substances and had no post-graduate residency requirements
while playing a vital role in the Alaska healthcare system.
The first two years of instruction [for naturopathic
physicians] consisted of biomedical sciences and diagnostic
training, followed by an extensive study in diagnostic
methods and procedures. The second two years focused on
translating the basic science knowledge into clinical
application. The courses developed graduates into primary
care physicians and included cardiology, gastroenterology,
gynecology, endocrinology, and many other subjects.
Students took courses on disease management and prevention
using therapeutic modalities such as nutrition, lifestyle
medicine, mechanical medicine, pharmaceutical prescribing,
and minor surgical in-office procedures.
Dr. Baldwin-Sayre emphasized that students received
specific instruction in pharmaceutical prescribing
throughout 15 different courses in their second two-year
block of time in addition to the prescribing done in
primary care settings during students' internships.
Students received extensive hands-on clinical training in
dermatology with minor surgical procedures including
surgical techniques and laceration repair. Students' hands-
on clinical training included progressively increasing
levels of responsibility for patient care. She relayed that
students were required to pass three hands-on clinical
examinations with the final exam occurring after one year
with their own supervised patient load in a state
credentialed primary care medical home. After graduation,
all naturopathic doctors were required to pass two national
board examinations.
Dr. Baldwin-Sayre elaborated that licensed naturopaths all
attended accredited naturopathic medical schools. She
stated that NUNM had a programmatic accreditor and a
regional institutional accreditor, both overseen by the
U.S. Department of Education. The programmatic accreditor
was the Council on Naturopathic Medical Education, and the
regional accreditor was the Northwest Commission on
Colleges and Universities, which was the same accreditor to
oversee OHSU and the University of Alaska. She relayed that
naturopathic medical colleges prepared graduates to be
competent, safe, effective healthcare providers. She stated
that the practice authority requested in HB 115 was a very
low-risk addition to their existing scope of practice and
was well within the confines of their training. She thanked
the committee.
2:18:24 PM
Representative Josephson stated that the committee had been
told that naturopaths wanted to practice medicine that
overlapped in its primary care purpose with physicians and
osteopaths. He asked if naturopaths should be held to the
same standard of care as traditional primary care
physicians.
Dr. Baldwin-Sayre responded that naturopaths were held to
the standard of care for naturopathic physicians. For
instance, in states where naturopaths were licensed as
primary care physicians (e.g., Oregon), naturopaths were
held to the standard of naturopathic medicine. She stated
it was based on "our" board of naturopathic medicine, which
included a variety of naturopathic physicians and public
members and determined how the standard of care was upheld
in the state. She believed the bill included a naturopathic
advisory board, which would determine the same.
Representative Josephson stated there was an emphasis in
the presentation that the pharmacological training and
training in laceration repair and minor surgery was of the
same quality as allopathic medical care. However, Dr.
Baldwin-Sayre's suggested that naturopaths would establish
their own standard of care. He thought in some ways it
seemed that naturopaths were saying they wanted to be on
the same playing field as allopathic medicine, yet they
were going to operate under a different standard of care.
He asked how to reconcile those two things.
Dr. Baldwin-Sayre responded that in areas where there were
overlaps in scope such as pharmacology, if naturopaths were
to prescribe a medication, they would be expected to
prescribe the medication exactly as it was intended to be
prescribed. She stated it was the same with laceration
repair or suturing. Naturopaths would not have a different
way of suturing up a wound than a nurse practitioner or a
medical doctor. She explained that when it came to
discipline within the State of Oregon, the Board of
Naturopathic Medicine determined how a naturopathic doctor
was disciplined versus the Board of Medicine, which
determined how medical doctors and osteopathic doctors were
disciplined.
2:22:05 PM
DR. SEAN HIGGINS, EMERGENCY ROOM DOCTOR, ANCHORAGE (via
teleconference), shared that prior to becoming an Alaskan
he had worked in several medical communities in Washington
State where licensed naturopaths were permitted to work
with a broad scope of practice. He relayed that as an
emergency room doctor, he was seeing an increasing number
of things that should be managed by primary care providers
including medication refills, antibiotics for urinary tract
infections, contraception, management of chronic conditions
such as diabetes and high blood pressure, and procedures
such as laceration repair. He estimated that during a
typical shift around 30 percent of the patients who visited
the emergency room were there for primary care related
medical concerns. He stated it equated to expensive bills
for patients and was a significant strain on emergency room
staff. Wait times and patient volume had increased
substantially with patients coming in for primary care,
which put a strain on people showing up with true
emergencies.
Dr. Higgins continued that shortage of primary care
providers forced emergency room doctors to practice on the
fringes and even outside of their expertise. Patients
receiving primary care in the emergency room by providers
who were not trained in primary care received a disservice
due to a lack of consistency and follow-up care. He
believed allowing naturopathic doctors to practice to the
extent of their training would increase the number of
primary care providers in Alaska and would give more
patients access to primary care, which would keep emergency
rooms free for emergencies. He had many working
relationships with naturopathic providers from Alaska and
Washington and the curriculum and training for naturopathic
medical school was comparable to the courses he took at
allopathic medical school. He stated that the providers had
used the same textbooks and study programs he had used for
the licensing exams. He previously witnessed naturopathic
colleagues manage prescriptive medications and perform
minor in office procedures safely and effectively in
Washington State. He was somewhat baffled that naturopathic
doctors in Alaska needed to refer their patients to
physician's assistant or nurse practitioner colleagues for
medication management and minor office procedures when he
knew that naturopathic doctors had more rigorous and
lengthy training. In his experience, naturopathic doctors
were more deliberate and forward thinking. He stated that
allowing naturopathic doctors to practice to the full
extent of their training would help Alaskans receive the
primary care needed to keep them healthier and out of the
emergency room.
Co-Chair Foster recognized Representative Justin Ruffridge
in the audience.
Representative Josephson stated he had read the Food and
Drug Administration (FDA) had proposed a ban on curcumin
being compounded with naturopathic drugs. He asked if it
was a source of concern if naturopaths chose to compound
the drugs notwithstanding the prohibition or if the
prohibition existed and they should not do it.
Dr. Higgins replied that he could not speak directly to the
subject. He was unaware of a ban on curcumin, which was an
over the counter supplement. He did not know of many
dangers with curcumin, but he would defer to a naturopathic
colleague as he did not have experience with curcumin.
Representative Josephson asked if he had heard of a
colleague who was not a naturopath using ozone therapy.
Dr. Higgins responded that he had heard of medical doctors
using ozone therapy, but it he had not used it in his
practice.
Representative Josephson asked if Dr. Higgins had any
concerns with the treatment.
Dr. Higgins responded that he was not up to date with the
literature on ozone therapy, but he was aware of medical
practitioners, physician's assistants, and medical doctors
utilizing that treatment modality. As an emergency room
physician, it was not something he was familiar with.
2:26:55 PM
Representative Galvin shared that she had various concerned
constituents. She highlighted a constituent was a paramedic
and now a physician with 9,000 hours of direct clinical
care. The individual relayed that he was still unable to
practice independently because his knowledge base was not
sufficient. She added that the individual was just about to
complete a three-year residency. She asked whether Dr.
Higgins thought an individual with the education similar to
his should have the ability to prescribe medications
sooner.
Dr. Higgins responded that once a person finished four
years of medical school there were not restrictions for
prescribing and practicing primary care. He was not sure
what sort of residency program Representative Galvin's
constituent was in. He believed the individual could
practice independently. He stated that an individual could
moonlight while in residency and practice independently. He
challenged the individual's initial concern about the
issue. He believed the individual could practice
independently at present in a primary care center.
Representative Galvin understood that the bill would give
naturopathic doctors the authority to prescribe medications
immediately after completion of a program whose focus was
avoiding the very medications that could be prescribed. She
stated her constituent had concern that part of the program
may be in conflict with the treatment they may have to use.
Additionally, her constituent thought there would be very
limited training for naturopathic doctors related to minor
surgical procedures. She stated that the individual was
suggesting that he spent years learning to be comfortable
with minor procedures that were less invasive than what was
proposed in the bill. She asked if Dr. Higgins had any
concerns about the procedures.
Dr. Higgins responded that it depended on the specifics of
the procedure. He relayed that naturopaths were trained on
simple laceration repair. He stated that in terms of
motivations for prescribing medicines, he believed
naturopaths' ethos was to avoid pharmacology until
absolutely necessary, but that for conditions such as
diabetes, patients needed insulin. He elaborated that
lifestyle and naturopathic interventions could be used up
to a certain point, but at some point, when things like
antibiotics, traditional blood pressure medication, and
insulin needed to be prescribed, it was well within a
naturopathic doctor's training.
Representative Galvin had heard concern around the removal
of a mole for example and whether a naturopath had enough
of a background to catch something. She stated that
according to a letter she had received, primary care
doctors conferred with dermatologists routinely because
there were many complicated procedures.
Dr. Higgins responded that just as he had been trained in
medical school, part of a naturopath's training was to
recognize when they were in over their head. For example,
if a naturopathic doctor saw a mole, skin lesion, or wart
that needed to be frozen, removed, or biopsied, they would
apply the same judgement he would use. He relayed that if
something looked cancerous, those patients were typically
referred to specialists such as dermatologists. He stated
that as far as he knew, ensuring an individual was
practicing within the standard of care was emphasized in a
naturopathic doctor's training. Theoretically everyone was
trained to make decisions and to not perform procedures
outside of their scope that would be against the standard
of care.
2:33:23 PM
DR. CLYDE JENSEN, PROFESSOR OF PHARMACOLOGY, COLLEGE OF
OSTEOPATHIC MEDICINE, ROCKY VISTA UNIVERSITY, ST. GEORGE,
UTAH (via teleconference), shared that he had a Ph.D. in
pharmacology and had taught in MD, DO, naturopathic, PA,
nursing, and other colleges. He relayed that the
pharmacology training given to naturopathic students was
not only similar, but probably identical to the training
given to MD and DO students in their first two years of
medical school. The training was provided in naturopathic
medical schools for several reasons, wherein educators
wanted naturopathic graduates to be able to prescribe
medications in the jurisdictions that fell within their
scope of practice. Another reason pharmacology was taught
to naturopathic medical students was in order for them to
understand the potential interactions between drugs, herbs,
and nutrients. He elaborated that most patients who were
prescribed nutrients or herbs by naturopaths were also
taking drugs that in many cases had been prescribed by MDs
or DOs. Naturopathic physicians were especially well
trained in drug and herb interactions. The third reason
naturopathic physicians were trained in pharmacology was
because patients were generally using drugs and
naturopathic physicians needed to be able to counsel their
patients. He opined that as a professor of pharmacology and
as the former president of MD, DO, and ND colleges, that
naturopathic physicians were capable of confidently and
conservatively prescribing medications commonly used in
primary care practices.
Representative Josephson stated that the bill would delete
a prohibition on the use of poison. He asked if Dr. Jensen
knew the reason.
Dr. Jensen responded that all drugs were poisons, it was
simply a matter of what dose was given that enabled their
side effects to rise to the level that would be considered
poison. He suspected the language may have been entered
into the bill to caution the prescribers to use drugs
appropriately and to avoid the use of substances that had
levels of toxicity that the risk of using the drug exceeded
the benefit.
Representative Josephson believed he had not received a
good answer about why it was okay that naturopathy largely
dispensed with a residency program requirement. He noted
that a retired emergency room doctor and friend from Juneau
was specifically accredited as a family practice physician.
He stated that every five years the doctor had to renew his
accreditation. He stressed there had been tough
requirements even though the individual had been a senior
emergency room doctor. He wondered why naturopathy did not
require residency programs of any serious level.
Dr. Jensen stated it was an excellent question. He believed
the reason naturopathic physicians were not required to do
residencies was because unlike MD and DO graduates, funded
residencies were not available to naturopaths through
Medicare. He stated it meant that when naturopaths took
residencies, they were taking residencies that were
privately funded usually by hospitals or clinics. He stated
there were simply not enough residencies to satisfy the
aspirations of all naturopathic physicians who may like to
take them. He added that it would be desirable for
naturopathic physicians to all have access to residencies
just like MDs and DOs, but those residencies were funded by
the federal government and were not available to
naturopathic physicians. He shared that he had testified
before Congressional committees about the funding of MD and
DO residencies. He highlighted there had been concern about
the expenditure of public funds just to provide funding for
those residencies.
Representative Josephson thought that because [residencies]
were not available [to naturopathic physicians] he thought
it would support a collaborative agreement law so that
something akin to residency could be accomplished.
Dr. Jensen thought that a collaborative relationship
between a newly prescribing naturopathic physician and a
veteran prescribing MD and DO was not a bad idea. He shared
that earlier in the day he received a call from the
president of an osteopathic medical school who had
testified on a naturopathic licensing/prescription bill in
another state. The individual had asked him the same
question Representative Josephson had just asked. The
individual communicated he was going to propose or favor
the inclusion of pharmaceuticals in the scope of practice
of naturopathic physicians, but he would also feel more
comfortable speaking on behalf of that bill if it contained
a collaborative requirement. He and the other individual
had agreed that if a collaborative relationship were to be
established, it should have a finite time period of perhaps
one year and the collaborative professional would be a
licensed MD or DO (not a PA or NP) with residency training.
2:43:11 PM
Representative Coulombe referenced Dr. Jensen's statement
that the training [for naturopathic students] was identical
to the first two years of MDs. She asked if she had heard
him accurately. She asked if residency started two years
after an MD started training.
Dr. Jensen confirmed that she had heard him correctly. He
shared that when he and colleagues had taught pharmacology
in naturopathic medical schools, they had given the same
number of contact hours and lecture using the same drugs
and same content as were used in MD and DO schools. He
relayed that most professors used the same textbooks in
each of those types of schools. He relayed that
pharmacology training was given during the first two years
of school. Subsequent to the first two years, naturopathic
physicians, MDs, and DOs had another two years of clinical
training. He noted that Dr. Baldwin-Sayre had described the
number of hours spent in clinical training. He stated that
the number of hours for naturopathic physicians was
comparable to the number of hours for MDs and DOs. He noted
that the difference between the training of naturopaths and
MDs and DOs resided in the residency program. He stated
that many naturopathic physicians did not have access to
residency programs because the funding for naturopathic
residencies through the federal government did not exist.
Representative Galvin asked if there was any difference in
pharmacology versus finding the correct diagnosis and
matching it up with the correct selection of medicine. She
thought it was an ever evolving science. She remarked that
the options for medicines on various diagnoses changed
constantly. She wondered if there was continuing
prescription education for naturopathic doctors.
Dr. Jensen responded that they were approaching the edge of
his pharmacology expertise. He turned to some of his
expertise as a leader of medical schools to answer the
question. He relayed that naturopathic physicians had
continuing medical education requirements that were similar
to MD and DO continuing education requirements. He stated
the requirements were similar in number of hours and to a
large extent in content. When there were new developments
pertaining to existing drugs or new drugs that had come on
the market since a naturopathic physician had graduated,
the new discoveries would be taught to naturopathic
physicians in the same way they were taught to MD and DO
physicians. He noted that Representative Galvin's question
touched on standard of care. He relayed that his
observation, as a leader of medical schools who attended
conferences for all types of medical schools, was that the
standard of care for the use of pharmaceuticals was uniform
among MDs, DOs, and naturopathic physicians. He stated that
it was taught in continuing medical education in all of
those professions.
2:48:41 PM
Representative Hannan asked about the pharmacological exam.
She explained that HB 115 required an individual to pass a
pharmacological exam. She asked whether there was one
pharmacological exam taken by DOs, MDs, PAs, and
naturopathic doctors.
Dr. Jensen replied that the MD, DO, and naturopath
professions each had their own board examinations. He
explained that the pharmacology tested in the examinations
was embedded within the exams. He noted that recently
graduate medical education requirements and the governance
of graduate medical education for MDs and DOs had been
combined. The change meant that DOs had a choice to take a
standardized DO exam or an exam that MDs also took. He
relayed that naturopaths took an exam that was prepared
specifically for naturopathic physicians, which included
pharmacology. He personally had the opportunity to write
questions for the DO and naturopathic board exams in
pharmacology. His questions for DOs and naturopathic
physicians were the same level of difficulty.
Representative Hannan asked Dr. Jensen if it was his
conclusion that anyone currently taking a naturopathic
doctor exam to practice in a state that allowed them to
have a scope of practice including pharmacology was taking
an exam that was equivalent to other practitioners with
pharmacological authorities.
Dr. Jensen agreed.
Representative Ortiz referenced a letter of concern from
someone in the American Medical Association (AMA). The
letter stated that the AMA did not have access to the
testing material for naturopathic doctors and did not know
whether it was equivalent testing material when it came to
pharmaceuticals. He thought it sounded like Dr. Jensen had
access to the material and he wondered why the AMA did not.
Dr. Jensen replied that he never had access to any of the
examinations. He clarified that he had written questions in
pharmacology for the examinations. He did not know what
would happen if the AMA were to have a bona fide
representative ask the testing body for naturopaths if they
could have access to some of the questions. He had never
requested the information. He shared that when he had
written questions for DO and ND exams, the questions he had
written in pharmacology were comparable. He believed all
writers of examinations were writing questions that test
contemporary knowledge that was necessary to prescribe
drugs whether a person was an MD, DO, or ND.
2:54:42 PM
DR. ROBERT DOWNEY, FAMILY PRACTICE PHYSICIAN, SOUTH
PENINSULA HOSPITAL, HOMER (via teleconference), clarified
that he was speaking on behalf of himself and not on behalf
of the hospital. He shared that he was dual certified in
family medicine and functional medicine through the
Institute for Functional Medicine. He relayed that in 2006,
he met a naturopathic doctor, Hillary Daily, who encouraged
him to attend the Institute for Functional Medicine. He
relayed that he had worked with Dr. Daily for many years,
including in Alaska from 2012 to 2014. He stated that the
naturopathic doctors he worked with were well trained. He
referenced the prior testimony from Dr. Jensen that his
curriculum and instructional content for MDs and DOs was
the same for naturopaths. After working in the same room
with naturopaths for 17 years and making decisions with
them, he had no reservations regarding their training. He
referenced data from the Federation of Naturopathic
Medicine's regulatory authority showing naturopathic care
to be safe, even with the scope of practice as requested in
HB 115.
Dr. Downey found it puzzling that nurse practitioners in
Alaska had less formal education and broader scope of
practice then what naturopaths were seeking. He explained
that naturopaths could refer patients to a nurse
practitioner to receive a prescription and have a
laceration sutured even though they both received medical
degrees with no post-graduation residency. He stated that
some of his colleagues argue that lack of residency
training made naturopaths unsafe. He underscored that nurse
practitioners had no post-graduation residency, yet they
had exercised broad prescriptive rights safely in Alaska
for decades. He underscored that the importance of the
particular point could not be overstated given how strongly
it paralleled the safety the state would see from
naturopaths when they should and would receive the
prescriptive authority in HB 115.
Dr. Downey relayed that naturopathic doctors knew when a
patient's blood pressure required immediate care, yet under
current restrictions, a patient had to go to a second
medical appointment or go to the emergency room to get
required medication. He stressed that even one hour between
diagnosis and treatment may have dire consequences. He
relayed that naturopathic doctors were trained to determine
whether lifestyle changes could mitigate underlying health
problems. He highlighted the shortage of primary care
providers in Alaska, which was placing a burden on
emergency room care. He stated there was no factual
evidence that a naturopathic doctor who had graduated from
a certified four-year medical program and passed required
post-graduation exams measuring their pharmaceutical
knowledge should not be able to prescribe medications as
the bill would allow. He remarked that if the state wanted
to get serious about the primary care shortage,
[naturopathic] doctors needed to be granted the prescribing
authority they had earned.
Dr. Downey explained that naturopathic doctors would
prescribe the same way he did. He stated they would become
familiar with a small group of medications and would know
them well and use them safely. He elaborated that
individuals who were currently opposed, would subsequently
feel the same way they feel about the great care nurse
practitioners were currently providing in a safe manner. He
stated that curcumin was invoked around FDA prohibitions
regarding compounding [earlier in the meeting], which he
believed conflated two issues. He relayed that curcumin was
an important botanical with the same benefits as prednisone
without the downsides or safety concerns. He noted that
curcumin was rarely compounded in his 17 years of
functional medicine practice and familiarity with NDs. He
remarked that it was an excellent example of a professional
grade supplement that worked well and safely. He
highlighted that he had addressed the safety of supplements
in prior testimony.
Dr. Downey shared that ozone therapy tended to create free
radicals, which disrupted tissue and the therapeutic
advantages created by the tissue response. He expounded
that it was an aggressive therapy, not favored by many in
natural and integrated medicine. He addressed concerns by a
constituent [highlighted earlier in the meeting by
Representative Galvin] about being able to prescribe
sooner. He thought it missed the point that the amount of
training naturopaths received regarding procedures and
prescribing was very adequate. Additionally, he clarified
that naturopaths were not taught to avoid medication, they
were taught to choose the right thing, in the right place,
at the right time. He highlighted that residency was not
necessary to do the work safely. Lastly, he pointed out
that part of the issue was a cultural divide. He compared
it to a divide between skiers and snowboarders in the past,
who were now happily sharing the slopes. He stated that
once the legislation passed, over the next five to ten
years more Alaskans would be served, and people would not
be hearing the same concerns invoked as they were
presently.
3:00:40 PM
Representative Galvin appreciated the ski analogy and
valued working together. Referred to concerns around
continuing education. She had asked earlier about
continuing education and had been reassured it was taking
place, but she was considering the difference between the
number of hours required. She understood that MDs spent 50
hours every two years. She looked at line 9 on page 5 of
the bill and highlighted a requirement for 15 hours of
continuing education over a five-year period. She noted a
couple of other references in the bill related to
continuing education that amounted to about 10 hours. She
observed that the difference was substantial. She wanted to
ensure there was an equal playing field in terms of medical
providers understanding what to prescribe when.
Dr. Downey responded that he felt very comfortable
commenting based on his 17 years of working daily with NDs.
Additionally, the ND community of professionals were all
extremely rigorous and concerned about this. He shared that
the naturopathic community took the power of the
prescriber's pen just as seriously as the conventional
allopathic community. He stated that any "of us" who value
the power also had an immense respect for what could go
wrong if the prescriber's pen was wielded improperly. There
was no difference between the two camps. Second, there was
already prescribing happening safely in the U.S. akin to
nurse practitioner's prescribing in Alaska. Lastly, many
providers of conventional medicine, particularly in primary
care, had a small handful of medicines they used safely
over and over again. Some of his favorite and most
effective medications were medications he became familiar
with in medical school and residency. He was certainly
excited when new medications came out. For example, when
biologics came out to treat autoimmune conditions like
rheumatoid arthritis, which had revolutionized the ability
to serve people, he was still conservative and looked at
when and how to refer for those medications. He noted he
currently did not prescribe those medications and had a
specialist prescribe them. He explained that newer was not
always better. He stated there were separate issues around
the pharmaceutical industry wanting providers to feel that
way, but most medical providers with prescription authority
had a sturdy toolkit of excellent pharmacological education
that they were exceedingly familiar with in order to be
safe.
Co-Chair Foster noted that the meeting would likely go
longer than anticipated. He continued with the remaining
four invited testifiers.
3:06:26 PM
DR. ROXANNE JONES, ALASKA ACADEMY OF FAMILY PHYSICIANS,
ANCHORAGE (via teleconference), testified in opposition to
the bill as written. She shared that she had previously
lived and practiced in the Norton Sound region of Alaska
for five years and had served as the lead physician for
four villages including Elim, White Mountain, Golovin, and
Little Diomede. She currently worked in Anchorage as an
assistant program director for a family medicine residency
program and as a medical director of one of Anchorage's two
safety net clinics. She detailed that she had worked in a
primary care clinic that accepted Medicare, Medicaid, and
self-pay. She had intimate knowledge of the complexity of
primary care needs in Alaska and of the training physicians
undertook to become independent practitioners. The
organization opposed the bill because it provided full
prescriptive authority and in-office surgical procedures;
however, the organization was very supportive of the
creation of a regulatory board for naturopaths in order
formalize their pathway to licensure in the state.
Dr. Jones relayed that she would address the risks
associated with prescriptive authority and the claim that
the bill would expand the primary care provider pool in the
state. She stated that while accreditation was a great tool
to create a minimal acceptable standard and more uniformity
across schools, it was accreditation for naturopathic
standards. She argued that naturopathic standards were not
equivalent to the standards for physicians. She understood
that other testifiers had used NPs and PAs as examples, but
she would specifically compare the standard of care and
training for naturopaths to those of family physicians
because the Council on Naturopathic Medical Education
Standards specifically noted that the goal of the
accredited institutions was to train "primary care/general
practice physicians/doctors." She pointed out that having
the same accreditor as another institution had no bearing
on the scope of practice of those trained under accredited
programs. She highlighted that her family medicine
residency was accredited by the same accrediting agency as
neurosurgeon residency. She noted they were certainly not
training neurosurgeons in her form of medicine.
Dr. Jones stated that the Council on Naturopathic Medical
Education (CNME) standards included pharmacology as one of
the required academic components. She elaborated that
sometimes the exact same lecture was delivered to
naturopath students and first or second year medical
students. However, first or second year medical students
should not be given licenses for full prescriptive
authority because they sat through a lecture. She stated it
was combination of the lectures and thousands of hours of
supervised clinical practice that made a physician
competent to safely prescribe pharmaceuticals. As a faculty
member at a residency, she saw residents training and
growing daily. She relayed that it was not until they were
close to their third year of clinical supervised practice
in a residency that they were ready to competently and
safely prescribe pharmaceuticals.
Dr. Jones shared that naturopath students had 850 hours
involved in patient care. She knew that another testifier
had spoken to 1,254 hours at their school. She pointed out
that the minimum requirement according to accreditation was
850 hours. She stated it was a minimum of 225 patients for
whom a naturopath acted as the primary student clinician
prior to graduation. She noted there was no residency
requirement. She relayed that medical students completed
3,000 to 5,000 hours of supervised clinical practice by the
time they graduated medical school. She stated that the
additional supervised practice was needed to fully learn
and appreciate the complexity of medicine and how to safely
diagnose and treat patients. She highlighted that family
physicians had an additional three years or approximately
10,000 to 12,000 hours of supervised practice prior to
becoming an independent practitioner. She detailed that the
10,000 hours included minimum standards of over 2,000
patient encounters for which they were the primary care
provider. She stressed that the residents were not ready
right out of the gate and were not ready until they had
thousands of hours under their belts. She corrected earlier
testimony and relayed that in Alaska if a person graduated
medical school after 1995, they were required to have a
minimum of two years of post-graduate residency training
before they could be independently licensed to practice
medicine.
Dr. Jones hoped the committee could see that the comparison
being made was between apples and oranges. The organization
believed it was too risky to give prescription authority to
naturopaths. She addressed earlier comments about
increasing the pool of primary care providers in Alaska.
She did not feel that naturopaths were the equivalent to be
primary care physicians. She argued that naturopaths would
not meet the need within the community because the biggest
need was for Medicare patients. She emphasized that Alaska
was desperate for more Medicare primary care providers. She
relayed that Medicare, Tricare, and the Veterans
Administration did not recognize naturopaths as medical
providers. She thanked the committee for its time.
3:14:08 PM
DR. HILLARY JOHNSON-JAHNGIR, AMERICAN SOCIETY FOR
DERMATOLOGIC SURGERY, IOWA (via teleconference), shared
that she was board certified in dermatology, micrographic
surgery, and other. She frequently worked with medical
professional organizations on issues important for patient
safety and weighed in on policy impacting dermatology. She
was passionate about protecting patients especially in
rural areas. She stated that like Iowa, Alaska's incidence
of melanoma of the skin was rising more than in the rest of
the country, especially in the Native Alaskan population.
Her practice covered a broad rural area, and she used
physician led team-based care. She elaborated that teamwork
focused on patient safety and saving healthcare dollars by
avoiding unnecessary testing. For example, when a patient
had a skin lesion, they used advanced clinical tools like
dermatoscopy, to help determine whether the lesion was
benign or needed a costlier skin biopsy to check for
cancer.
Dr. Johnson-Jahngir relayed that her exposure to
naturopathy was through family. She detailed that her
parents moved to Iowa from Arizona for better healthcare.
She elaborated that her stepmother's Arizona primary care
was delivered by a naturopath and unfortunately, she was
prescribed thyroid hormone replacement therapy even though
her thyroid test results were normal. She expounded that
her pre-diabetes had gone unnoticed. She stated there was
not a shortcut to being able to safely prescribe
prescription drugs. Prior to prescribing, she reviewed a
patient's entire medical history including other drugs they
were taking, in order to avoid risky interactions or other
adverse events. She stated that an advanced clinical
training well beyond basic pharmacology was required.
Dr. Johnson-Jahngir shared that her older sister currently
lived in Arizona and saw a naturopath for primary care. Her
sister had a skin lesion that was not diagnosed as skin
cancer until she visited a dermatologist. She worried that
HB 115 would permit naturopaths to care for skin lesions
and perform minor office procedures. She explained it was
concerning in terms of getting the most accurate diagnosis
and the appropriate management. She noted it was not easy
and required extensive education and training. She
underscored that there were over 3,000 skin diseases and
many mimickers of skin cancer.
Dr. Johnson-Jahngir stated that if a potentially cancerous
skin lesion was surgically removed before a full medical
exam and testing it could render the skin cancer
undetectable or lead to a cancer spread or altered
pathology so that the diagnosis was delayed or even result
in death. She stated that the bill included a broad
expansion of office procedures that could be interpreted as
practice of medicine that could involve lasers, injection
or insertion of foreign or natural substances in or under
the skin, liposuction, coagulation and bleeding, grafting
skin, or even rotating skin through skin flaps to repair
wounds. She relayed that naturopaths did not have the
proper qualifications to perform the procedures. Nor would
they be able to respond to possible complications that
could arise. She summarized that allowing naturopaths to
perform tasks beyond their training could have severe
consequences for Alaskan patients.
3:18:10 PM
DR. KRISTIN MITCHELL, PRESIDENT ELECT, ALASKA STATE MEDICAL
ASSOCIATION, SOLDOTNA (via teleconference), was speaking to
the committee in her capacity as the president elect of the
Alaska State Medical Association. She shared that she was
also board certified in internal medicine by the American
Board of Internal Medicine. She practiced in Soldotna and
had cared for adults with highly complex medical conditions
for 25 years. Additionally, she was faculty at Washington,
Wyoming, Alaska, Montana, and Idaho (WWAMI) and clinical
faculty for the University of Washington School of
Medicine. She relayed that her concern was for patient
safety, and she believed that Alaskans deserved reliable,
safe, excellent medical care. She stated that the care was
best provided by teams led by a physician. She quoted from
the American College of Physicians, "physicians have
extensive education, skills, and training that make them
most qualified to exercise advanced clinical
responsibilities within teams." She referenced testimony
from Dr. Jones about the extent of residency training and
how the additional three-year period of supervised practice
with an experienced clinician leader helping people make
the best possible decisions, double checking their decision
making, and providing input was an essential part of what
made a medically trained physician qualified and competent
to care for patients.
Dr. Mitchell highlighted two items she thought would be of
particular importance to the finance committee: malpractice
implications and insurance coverage. She referenced
testimony the committee had received from naturopaths that
they had low rates of disciplinary action. She recommended
the committee keep in mind that any disciplinary action was
reviewed by the board comprised of naturopaths and there
was no established standard of care for naturopathic
practice with which to compare a complaint. She stated that
if naturopaths were to be granted prescription authority
that was parallel to those granted by the state for
licensed medical physicians, she would expect as a resident
of Alaska that naturopaths should be held to the same
standard of malpractice liability as medical physicians.
Dr. Mitchell referenced testimony heard by the committee
that expanding the scope of practice for naturopaths would
help address the primary care shortage in the state. She
was acutely aware of the primary care shortage challenges.
She shared that her clinic in Soldotna had just started an
internal medicine residency program where they would train
additional physicians. She had great respect for Dr. Jones
and her family medicine training program. She elaborated
that there were a lot of physicians who were working hard
to try to choose the right physicians for Alaska and train
physicians who were qualified to take care of Alaskans. She
agreed with Dr. Jones that expanding naturopathic practice
would not solve the primary care access problems faced by
Alaskans because the Centers for Medicare and Medicaid
Services (CMS) did not recognize naturopathic practices.
She stated it would still leave a tremendous gap in
patients who were most vulnerable.
Dr. Mitchell addressed the pharmacology aspect of the bill.
She shared that she had reviewed the naturopathic study
guide. She referred to testimony during the meeting that
common drugs and primary care were covered by naturopathic
practice and training. She found the study guide
surprising. She elaborated that there were a number of
oncology drugs that were only given intravenously and would
never be given in a primary care office and would only be
part of a practice in consultation with an oncology
specialist. Additionally, there were extended spectrum
antibiotics for treating resistant [indecipherable]
infections that were only given intravenously and did not
have a role in primary practice due to the crisis with drug
resistant bacteria. She was concerned that some of the
emphasis on the study guide was not appropriate to primary
care practice. She was concerned about ongoing medical
education. She highlighted that the newest drugs showing
tremendous promise in diabetes were not part of the study
guide. She stressed there was so much change in medicine
and the expansion of pharmaceuticals required internal
medicine providers to stay on top of it annually. She would
be very concerned about granting unlimited practice to
someone who did not have a clear responsibility to maintain
their ongoing education.
Dr. Mitchell addressed an earlier question about curcumin.
She relayed that curcumin was a supplement and supplements
were not regulated by the FDA. She stated that the concern
about the drug was due to the death of a patient of a
licensed naturopath in California who had been given an IV
infusion. She stated that because curcumin was a
supplement, the bill would not change the current ability
of a naturopath to infuse curcumin or other supplements for
patients in Alaska. She stated that the practice of
medicine was highly complex. She believed it was difficult
for the legislature to understand all of the issues in
depth even with the testimony by her colleagues and over
the years that the bill had been introduced. She encouraged
legislators to look outside of Alaska for examples and
guidance. She stated that it was unlawful to practice
naturopathy in three states. She elaborated that 28 states
did not license naturopaths and only 11 states allowed for
any prescriptive authority for pharmaceutical medication.
She stated that naturopaths were not equivalent to primary
care physicians and should not be granted equivalent
prescribing and surgical privileges. She communicated that
it was the standard of practice in the U.S. and elsewhere.
For example, in the United Kingdom, the National Health
Service stopped funding homeopathic remedies in 2017 and
Australia's main medical body concluded that homeopathy
should not be used to treat chronic, serious, or
potentially serious health conditions.
Dr. Mitchell provided concluding remarks. She stated that
Alaska's current statute regarding restrictions on the
practice of naturopathy specified that a practitioner may
not give, prescribe, or recommend a prescription drug, a
controlled substance, a poison, engage in surgery, or use
the word physician in their title. She believed it would be
confusing, misleading, and dangerous to pass the bill
certifying to Alaskan patients and consumers that
naturopath training was sufficient to allow for broad
prescription of pharmaceutical medication and the practice
of minor surgery. She encouraged members to reject HB 115.
3:26:21 PM
DR. SCOTT FERGUSON, PHYSICIAN AND BOARD OF TRUSTEES,
AMERICAN MEDICAL ASSOCIATION (AMA), WEST MEMPHIS, ARKANSAS
(via teleconference), shared that he was a previous
legislator, and his wife was currently a legislator in
Arkansas. He encouraged committee members to oppose HB 115.
He stated that prescribing medication was the practice of
medicine. He elaborated that to prescribe safely, a
practitioner needed robust clinical training and
comprehensive education in pharmacology. He stressed that
individuals learned to prescribe in clinical medicine
standing side by side when evaluating a patient and talking
about the necessary treatment. He urged the committee to
recognize that a naturopath's education was distinct from a
medical education. The AMA did not believe naturopaths were
adequately trained to prescribe. He stated that individuals
learned to prescribe during residency. He emphasized that
the education students received in pharmacology during
their first two years occurred in a lecture hall. He
stressed that it did not involve taking care of patients.
Dr. Ferguson stated there were crucial gaps in naturopaths'
clinical training. He highlighted that naturopaths were
required to complete a minimum of 850 patient care hours
during their 1,200 hour clinical training. He stressed that
physicians were required to have a minimum of 12,000 hours
in training. He stated that accreditation standards for
naturopathic programs imposed no requirement for students
to see patients of any particular age or any illness or
condition as part of their training. He relayed that there
was no guarantee a naturopathic student would ever see
patients who were sick or hospitalized. He elaborated that
they may never take care of vulnerable patients like
children or the elderly during their training.
Dr. Ferguson remarked that if the legislation opened the
door for naturopaths to prescribe powerful medications to
any patient with any illness, the legislature should not
assume a graduate of an accredited naturopathic program
received a comprehensive pharmacological education. He
elaborated that receiving education on basic sciences in a
lecture hall was not where the art of medicine, caring for
patients, and prescribing occurred. He stated that the
naturopathic curriculum focused largely on non-medical
content. He remarked that scientific content was riddled
with principles and therapeutics that lacked a foundation
in medical evidence. He stressed that it called into
question the integrity of the pharmacological content. He
relayed that the curriculum in medical schools was
rigorous, highly standardized, and had its foundation in
evidence based medicine. He elaborated that consequences of
prescribing incorrectly could be dire. He asked the
committee to take the risk to patients seriously.
Dr. Ferguson indicated that workforce maps showed that
naturopaths and physicians practice in the same areas of
the state and that the number of physicians practicing in
Alaska far exceeded the number of practicing naturopaths in
the state. He reported that AMA data suggested there were
fewer than 50 practicing naturopaths in Alaska. He
emphasized that granting naturopaths prescriptive authority
would not increase access to care. He urged the committee
to oppose the bill.
Co-Chair Foster OPENED public testimony. He asked
individuals to keep their testimony to two minutes.
3:33:05 PM
DR. NATALIE WIGGINS, ALASKA ASSOCIATION OF NATUROPATHIC
DOCTORS, JUNEAU, shared that she is a naturopathic doctor
in Anchorage. She detailed that she had previously
practiced medicine in Arizona as a naturopathic doctor
where she had a scope of practice that reflected her level
of training, knowledge, and competency. She relayed that
the federal government recognized the competency acquired
through completion of her program and entrusted her with a
DEA number allowing her to prescribe scheduled medications
and noncontrolled medications. She had decided she wanted
to raise her children in Alaska. Her training, knowledge,
and ability to safely practice medicine had not changed
when she crossed the state line. Only her residency had
changed.
Dr. Wiggins addressed comments and areas of concern
highlighted during the meeting. When she had practiced in
Arizona her continuing education requirement was to
complete 30 hours of CMEs [continuing medical education]
including 10 hours of pharmaceutical education. She relayed
it was the standard of practice of states that had scope of
practice including prescriptive authority. She pointed out
that the bill was not requesting broad prescriptive
authority as the committee had been led to believe. She
elaborated that broad prescriptive authority was occurring
in Arizona, which was the reason she had a DEA number. She
clarified that naturopaths in Alaska were not requesting to
prescribe controlled medications. The request was for
things like antibiotics and for GLP-1 medications. She
agreed that medicine was constantly changing, and it was
necessary to stay up to date on changes occurring, which
was reflected in CME hours.
Dr. Wiggins addressed safety concerns. She pointed out that
some of the concerns could be directed to states with scope
of practice that reflected naturopath training and the
associated safety evidence. She agreed that the committee
may hear about particular cases where things had popped up.
She noted that likewise there were situations that occurred
for medical doctors as well. She highlighted information in
members' bill packets that pointed to the safety of
naturopaths in states that were licensed, including Oregon.
Members' packets also included information about the safety
of the practice currently in Alaska. She noted that even in
states that were already utilizing broader scope of
practice, the safety was well illustrated.
Co-Chair Foster asked Dr. Wiggins what position she held
with the Alaska Association of Naturopathic Doctors.
Dr. Wiggins replied that she is the secretary.
Co-Chair Foster asked if Dr. Wiggins lived in Juneau.
Dr. Wiggins answered that she lived in Anchorage.
Co-Chair Foster noted that Dr. Wiggins had flown all the
way to Juneau, and he wanted to take advantage of the
opportunity to ask questions.
3:37:28 PM
Representative Galvin thanked Dr. Wiggins for being in
Juneau and taking the time to come from Anchorage. She
referenced a chart provided by Dr. Wiggins related to the
number of disciplinary actions related to concerns where
patients had somehow been impacted negatively. She remarked
that the disciplinary actions pertained to DOs, MDs, and
NDs. She asked for more detail. She heard a lot that there
was no comparison because people were not unhappy with
naturopaths.
Dr. Wiggins believed Representative Galvin was asking about
the difference in disciplinary action. For example, in
Alaska, disciplinary action occurred through licensing.
There were other sanctions happening in states with broader
scope of practice. She noted that MDs, DOs, and NDs all had
their own separate boards.
Representative Galvin stated her understanding that in
Oregon there were far fewer disciplinary actions
(percentage wise) against naturopaths as opposed to DOs and
MDs.
Dr. Wiggins agreed. She noted that the document illustrated
there were far fewer disciplinary actions for NDs than
there were for the other provider types. She confirmed that
the document pertained to Oregon, where the practice of
naturopathic medicine had been broad for many years.
3:40:23 PM
Representative Ortiz stated that one of the compelling
arguments in support of the legislation was that it would
help alleviate the shortage in access to primary care
physicians; however, the committee had also heard that
Medicaid and Medicare did not cover naturopathic care and
it would not help much with the shortage of primary care.
He asked for comment.
Dr. Wiggins confirmed that naturopaths were not billing
services to Medicare and whatnot. She thought it was great
that organizations were training primary care doctors to
cover that need. She stated that the need was very
extensive. For example, she started keeping track of the
number of times she was needing to prescribe to her
patients and over the past three days there was a need for
19 different prescriptions for 12 patients. She explained
that although she was trained and skilled to write the
prescriptions, the patients had to go get a separate
medical care visit to fulfill the need. She agreed there
was a huge need for Medicare and Medicaid access; however,
there was still a large need for primary care in all
aspects of medicine.
Representative Tomaszewski noted that there had been prior
testimony that stated that naturopaths were disciplined by
naturopaths. He remarked that the inference was that
naturopaths were protecting their own. He thought MDs were
disciplined by a medical doctor board. He asked for
verification that it was a similar comparison.
Dr. Wiggins responded in the affirmative. She relayed that
each individual board disciplined its own participants.
Representative Tomaszewski asked for verification that if
Dr. Wiggins was able to fill the prescriptions for her
patients, they would not have to go to an MD to further
clog up the system and create more need.
Dr. Wiggins replied that Representative Tomaszewski was
accurate. She shared that two of the patients she saw the
previous week had to go to urgent care to get
prescriptions. She stressed that the other patients were
waiting to get the prescriptions. She explained it was a
huge problem because a wait may be difficult for the
treatment patients needed, which meant individuals
sometimes had to go to the emergency room, further clogging
the system.
3:44:06 PM
Representative Galvin there had been significant
correspondence around the amount of continuing education
not having parity. She asked Dr. Wiggins to comment on the
issue. She had heard from one physician in particular who
stated they were required to have 50 hours every two years
and there was nothing that compared. She asked if it was
different in different states.
Dr. Wiggins responded it was part of the statute in the
state of Arizona. Currently, naturopathic doctors did not
have any requirements in the state for CMEs. She stated it
[taking CME courses] was standard, so she and her
colleagues continued to do it. She stated that in other
states naturopaths were exceeding the 50 hours every two
years.
3:45:36 PM
BRUCE CAMPBELL, SELF, FAIRBANKS (via teleconference),
testified in support of HB 115. He shared that his family
had received primary healthcare from licensed naturopaths
for many years and he believed the bill was necessary to
update the policy for naturopathic care. He noted that he
was on Medicare and his naturopathic provider worked
directly with AlaskaCare. He stated that the slate of
experts that had spoken to the bill had been impressive. He
thought Dr. Jensen's discussion of pharmacology as being
much the same was very important. He believed Dr. Baldwin-
Sayre's testimony on the comparison of hours with nurse
practitioners was also important. He noted that Section 4
of the bill would establish an equivalent pharmacology
test, which he believed the state would do well. He had
received excellent care from nurse practitioners, but he
believed it was illogical for a patient to have to set up a
separate appointment. For example, when his daughter's
primary care pediatrician retired, his family had been told
by a local clinic they would have to sign up for a new
doctor because they would face a five to six-week wait to
see a pediatrician every time they called. To get
prescriptions refilled he and his wife had to go to urgent
care where they had to wait for hours and explain the
issues. He believed it was an added cost and impediment to
care, especially if his naturopathic doctor had already
completed labs, explained the current literature, and
detailed the evidence based care she was recommending. He
stressed that the bottom line was, he determined who he
saw, what he did, and what he consumed. He stated it was
his responsibility for his medical care. He reiterated his
support for the bill.
3:48:28 PM
BART GRABMAN, SELF, ANCHORAGE (via teleconference), opposed
HB 115. He was currently a resident physician who received
his MD degree through the WWAMI program in Alaska and he
was in the process of completing his three-year emergency
medicine residency. He believed highlighting some of the
differences between naturopathic and MD education may be
helpful in understanding his opposition to the bill. He
stated that according to written testimony provided to the
committee by the American Association of Naturopathic
Physicians, naturopathic school included about 4,000 hours
of training and 1,200 hours of hands on clinical education.
He elaborated that according to one of the leading
naturopathic schools, National University of Health
Sciences, most education on pharmacology was focused on
herbal and natural remedies with only three credit hours
throughout the entire education specifically focused on
medications used in allopathic care. He highlighted that
the minor surgery class was 1.5 credit hours total. He
noted that naturopaths were not required to do additional
advanced residency training.
Dr. Grabman shared that during his time at the University
of Washington through the WWAMI MD program he had weekly
lectures and regular exams on pharmacology. After the first
two years he spent the next two years in clinical rotations
that included pediatrics, surgery, psychiatry, anesthesia,
neurosurgery, and more. He completed more than 5,000 hours
of clinical time in addition to classroom time. By the time
he completed residency he would complete 8,000 additional
hours of direct clinical care. He relayed that even though
he had completed more than 10,000 hours to date, he was
still not allowed to practice or prescribe independently.
He relayed that a primary care resident worked more hours
than he did and had the same restrictions. He still
consulted dermatologists on questions regarding diagnosis.
He stated that conditions were frequently too complex for
non-dermatologists to manage. He stated that the bill would
give naturopaths prescriptive authority and the ability to
perform minor surgical procedures. He stated their training
was focused almost entirely on nonpharmacologic and
nonallopathic care. He stated that the focus and training
between naturopaths and physicians was very different. He
urged the committee to not pass the bill. He referenced a
review on disciplinary actions taken against naturopaths in
Oregon included at least 42 actions since 2018.
3:51:45 PM
KAREN GONNE-HARRELL, SELF, ANCHORAGE (via teleconference),
shared that she had used a naturopath for 35 years, partly
because her son had allergies and his medical doctor would
not consider the possibility. She had seen the same
naturopathic doctor for 35 years. Her doctor did all of her
bloodwork, but she had to make a separate appointment with
a nurse practitioner to fill prescriptions who may have
less training than a naturopath. She no longer had
insurance, but when she did, she received half as many
doctor visits because she had to double up on doctors. She
thought there was an acceptable solution moving forward
that included ways to increase a naturopath's scope of
practice, and to allow them to prescribe simple medications
like antibiotics and thyroid medications. She stated there
were cases where people had abused their licenses on both
sides of the fence. She urged support of the bill in a safe
manner.
3:54:39 PM
DR. TIM BIRDSALL, ALASKA ASSOCIATION OF NATUROPATHIC
DOCTORS, ANCHORAGE (via teleconference), shared that he was
a practicing naturopath in Anchorage and also held licenses
in Arizonia, California, and Washington state. He urged the
committee to look at the data and ensure it was comparing
apples to apples. He relayed that naturopaths were not
asking to be considered the same as MDs and it did not make
sense to him to compare their level of training to that of
an MD; however, naturopathic doctors were well trained to
function in a primary care role to prescribe medications
they were comfortable with and to do procedures within
their education and training. He stated that the bill
increased the scope of practice and the responsibility for
naturopaths. He highlighted that the bill clarified the
amount of continuing education. He believed it should be
equivalent to other licensed states, which would be roughly
30 hours per year including a 10-hour minimum of
pharmacology training. The bill also required naturopaths
to report communicable diseases, which was not currently a
statutory requirement. He noted there were a variety of
other things that needed to be added to the naturopathic
statute, which was over 35 years old.
Dr. Birdsall believed there were many reasons the bill made
sense. He underscored that naturopaths were not asking for
unlimited prescriptive authority or for the ability to do
all types of surgery. He clarified that naturopaths were
asking for the ability to do the things that according to
statute were within the scope of education, training, and
experience of naturopathic doctors. He highlighted that the
committee had heard from multiple physicians during the
meeting whose MD license would allow them to do brain
surgery for example. He knew Dr. Downey and guaranteed that
the doctor would never consider doing brain surgery on a
patient because he was not trained to do so. He elaborated
that those professions were allowed to determine what was
appropriate based on the individual's education, training,
and experience. He referenced a case study from nurse
practitioners in Alaska. He relayed that Alaska was one of
the leaders in the nation in granting nurse practitioners
independent practice authority 40 years ago and the safety
record of nurse practitioners was admirable, and nurse
practitioners had a broader scope of practice than what was
requested in HB 115. He encouraged committee members to
look at the safety record. He stated it was true that no
profession was perfect and the purpose of the robust
disciplinary section in the bill was to ensure anyone who
stepped outside of the limits of a provider's education,
their license could be restricted, suspended, or revoked as
necessary. He thanked the committee.
3:59:51 PM
PAM VENTGEN, EXECUTIVE DIRECTOR, ALASKA STATE MEDICAL
ASSOCIATION, ANCHORAGE (via teleconference), relayed that
the Alaska State Medical Association supported many
sections in HB 115. The association urged an increase in
the number of CMEs required. She stated that most of the
sections of the naturopath statutes needed to be updated.
She noted that the big things were the minor surgery and
prescribing authority. There were approximately 1,300
primary care physicians currently practicing in Alaska. The
vast majority were in urban areas, with the remainder in
rural areas. She stated there were fewer than 50 practicing
naturopaths, all essentially in urban areas. She stated
that the reported shortage of primary providers was
primarily a shortage of providers who accept Medicare
patients. She stated that CMS did not recognize naturopathy
as a viable medical practice; therefore, they did not cover
naturopathic services. She added that there were no
federally endorsed residency training programs for
naturopaths. She remarked that there was probably a reason
for that.
Ms. Ventgen stated that the claim that giving surgical
privileges and prescribing authority to naturopaths would
change primary care availability was a faulty argument. She
relayed that most insurance plans only covered what was
allowed in state statute. One of drivers of increased
healthcare cost was increased availability. She stated it
had been seen during the COVID-19 pandemic when mental
health services became available via telehealth. She stated
that the cost to Medicaid went up dramatically. She
remarked that she was not arguing the pros or cons but
expanding the scope of practice to include minor surgical
procedures and prescribing, would influence insurance plans
to cover naturopathic services, which would increase the
overall cost of healthcare. She noted that in some cases
patients had to go to another provider to get their
prescriptions. She had heard testimony that a lot of
practices included a naturopath and nurse practitioner. She
stated in that case they were in the same office, which
seemed to be a minor inconvenience. She urged the committee
not to pass 115 as written. She thanked the committee.
4:04:00 PM
Co-Chair Foster CLOSED public testimony. He provided the
email address for written testimony.
Representative Ortiz asked the bill sponsor whether there
had been two previous committees of referral prior to the
bill's arrival in the House Finance Committee.
Representative Prax answered that the bill had also gone
through the House Health and Social Services Committee and
the House Labor and Commerce Committee.
Representative Ortiz asked if there were a number of
amendments proposed and adopted by the House Health and
Social Services Committee that were not a part of the
current version of the bill.
Representative Prax responded that there were initially
[amendments made to the legislation], but the bill had
returned to its original intent.
Representative Ortiz asked if amendments had been adopted.
He asked for more detail.
Representative Prax responded there were a number of
amendments proposed in the House Health and Social Services
Committee and the first amendment covered a "whole list of
things" that took the bill away from its original intent.
The committee had rescinded the amendments and sent the
bill to the House Labor and Commerce Committee. The only
amendment he recalled being adopted that was in the current
version of the bill had removed the word "advisory" related
to the board. The bill was "pretty much in its original
form."
Representative Ortiz asked if the amendments that were
initially adopted dealt with some of the concerns that had
been raised during the current meeting.
Representative Prax responded affirmatively. He stated
there had been discussion about including a list of drugs
that could be administered [by naturopaths]. Another
amendment pertained to collegial practice where a
naturopath would work under the authority of a doctor.
4:07:38 PM
Co-Chair Foster asked Representative Prax for any closing
comments.
Representative Prax remarked that the discussion during the
meeting had been very interesting. He stated that it was
difficult to write a statute that covered every situation.
He clarified that the bill did not intend to claim that
naturopaths were the same as medical doctors. The bill was
about a scope of practice and a scope of training. He noted
that within the medical doctor community individual
physicians focused on their specialty. He elaborated that
they may be licensed to do many other things, but they
focused on a few of them. Likewise, they may be licensed to
prescribe anything, but focused on a handful of drugs. He
stated his expectation that the same thing would happen
with naturopaths where they would focus on what they knew.
He reasoned that it would be impossible to write a statute
to cover all situations. He remarked that if a doctor or
naturopath were doing something outside of their scope of
training they could be exposed to malpractice. He did not
see how that could be avoided. He stated that if someone
prescribed something beyond their scope of training it
would be covered. He provided an example pertaining to
certified car mechanics who focused on a select number of
car brands, while others focused on other brands. He stated
that just because a person knew how to fix cars in general
did not mean they would work on just any car; they focused
and became proficient at working on specific cars. He
stated the market worked itself out and people focused on
what they were trained to do.
Co-Chair Foster thanked the sponsor. He reviewed the agenda
for the following meeting.
HB 115 was HEARD and HELD in committee for further
consideration.
ADJOURNMENT
4:12:00 PM
The meeting was adjourned at 4:11 p.m.
| Document Name | Date/Time | Subjects |
|---|---|---|
| HB 219 Sponsor Statement 2.6.24.pdf |
HFIN 3/22/2024 1:30:00 PM SFIN 5/1/2024 9:00:00 AM |
HB 219 |
| HB 219 Sectional Analysis ver B 2.6.24.pdf |
HFIN 3/22/2024 1:30:00 PM SFIN 5/1/2024 9:00:00 AM |
HB 219 |
| HB219 NEW FN DOLWD-SP-03-15-24.pdf |
HFIN 3/22/2024 1:30:00 PM |
HB 219 |
| HB 219 Public Testimony Rec’d by 3.18.24.pdf |
HFIN 3/22/2024 1:30:00 PM |
HB 219 |
| HB 219 Responses to HFIN Questions 3.22.24.pdf |
HFIN 3/22/2024 1:30:00 PM |
HB 219 |
| HB 115 Additional Authorities and Responsibilities 4.3.24.pdf |
HFIN 3/22/2024 1:30:00 PM |
HB 115 |
| HB 115 Follow Up Answers from 3.22.24 (FIN) Mtg..pdf |
HFIN 3/22/2024 1:30:00 PM |
HB 115 |
| HB 115 Public Testimony Rec'd by 040424.pdf |
HFIN 3/22/2024 1:30:00 PM |
HB 115 |
| HB 115 Public Testimony Rec'd by 041724.pdf |
HFIN 3/22/2024 1:30:00 PM |
HB 115 |