Legislature(2015 - 2016)CAPITOL 106
03/24/2016 03:00 PM House HEALTH & SOCIAL SERVICES
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| Audio | Topic |
|---|---|
| Start | |
| Presentation on Telehealth | |
| HB344 | |
| HB315 | |
| HB328 | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| + | TELECONFERENCED | ||
| += | HB 315 | TELECONFERENCED | |
| += | HB 334 | TELECONFERENCED | |
| += | HB 328 | TELECONFERENCED | |
| + | TELECONFERENCED | ||
| += | HB 344 | TELECONFERENCED | |
ALASKA STATE LEGISLATURE
HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE
March 24, 2016
3:03 p.m.
MEMBERS PRESENT
Representative Paul Seaton, Chair
Representative Liz Vazquez, Vice Chair
Representative Neal Foster
Representative Louise Stutes
Representative David Talerico
Representative Geran Tarr
Representative Adam Wool
MEMBERS ABSENT
All members present
COMMITTEE CALENDAR
PRESENTATION ON TELEHEALTH
- HEARD
HOUSE BILL NO. 344
"An Act relating to the controlled substance prescription
database; and providing for an effective date."
- MOVED CSHB 344(HSS) OUT OF COMMITTEE
HOUSE BILL NO. 315
"An Act relating to an electronic visit verification system for
providers of certain medical assistance services."
- HEARD & HELD
HOUSE BILL NO. 328
"An Act prohibiting smoking in certain places; relating to
education on the smoking prohibition; and providing for an
effective date."
- HEARD & HELD
HOUSE BILL NO. 334
"An Act relating to visitation and child custody."
- SCHEDULED BUT NOT HEARD
PREVIOUS COMMITTEE ACTION
BILL: HB 344
SHORT TITLE: DRUG PRESCRIPTION DATABASE
SPONSOR(s): REPRESENTATIVE(s) SEATON
02/24/16 (H) READ THE FIRST TIME - REFERRALS
02/24/16 (H) HSS
03/01/16 (H) HSS AT 3:15 PM CAPITOL 106
03/01/16 (H) Heard & Held
03/01/16 (H) MINUTE (HSS)
03/08/16 (H) HSS AT 3:00 PM CAPITOL 106
03/08/16 (H) Heard & Held
03/08/16 (H) MINUTE (HSS)
03/10/16 (H) HSS AT 3:00 PM CAPITOL 106
03/10/16 (H) -- Rescheduled to 3/11/16 at 8:00 a.m.
--
03/11/16 (H) HSS AT 8:00 AM CAPITOL 106
03/11/16 (H) -- MEETING CANCELED --
03/15/16 (H) HSS AT 3:00 PM CAPITOL 106
03/15/16 (H) Heard & Held
03/15/16 (H) MINUTE (HSS)
03/17/16 (H) HSS AT 3:00 PM CAPITOL 106
03/17/16 (H) Scheduled but Not Heard
03/24/16 (H) HSS AT 3:00 PM CAPITOL 106
BILL: HB 315
SHORT TITLE: ELECTRONIC VISIT VERIFICATION: MEDICAID
SPONSOR(s): REPRESENTATIVE(s) VAZQUEZ
02/17/16 (H) READ THE FIRST TIME - REFERRALS
02/17/16 (H) HSS
03/22/16 (H) HSS AT 3:00 PM CAPITOL 106
03/22/16 (H) Heard & Held
03/22/16 (H) MINUTE (HSS)
03/24/16 (H) HSS AT 3:00 PM CAPITOL 106
BILL: HB 328
SHORT TITLE: REGULATION OF SMOKING
SPONSOR(s): REPRESENTATIVE(s) TALERICO
02/22/16 (H) READ THE FIRST TIME - REFERRALS
02/22/16 (H) HSS, JUD, FIN
03/22/16 (H) HSS AT 3:00 PM CAPITOL 106
03/22/16 (H) Heard & Held
03/22/16 (H) MINUTE (HSS)
03/24/16 (H) HSS AT 3:00 PM CAPITOL 106
WITNESS REGISTER
KATE BLACKMAN
National Conference of State Legislatures
Denver, Colorado
POSITION STATEMENT: Introduced the PowerPoint presentation on
Telehealth.
MARIO GUTIERREZ
Center for Connected Health Policy
Sacramento, California
POSITION STATEMENT: Presented a PowerPoint titled "Transforming
Health Care With Connected Health."
JANEY HOVENDEN, Director
Division of Corporations, Business, and Professional Licensing
Department of Commerce, Community & Economic Development
Juneau, Alaska
POSITION STATEMENT: Testified and answered questions during
discussion of proposed HB 344.
ANITA HALTERMAN, Staff
Representative Liz Vazquez
Alaska State Legislature
Juneau, Alaska
POSITION STATEMENT: Testified and answered questions during
discussion of HB 315, on behalf of the prime sponsor,
Representative Vazquez.
DEB ETHERIDGE, Deputy Director
Division of Senior and Disabilities Services
Department of Health and Social Services
Juneau, Alaska
POSITION STATEMENT: Testified and answered questions during
discussion of HB 315.
JOSHUA BANKS, Staff
Representative Dave Talerico
Alaska State Legislature
Juneau, Alaska
POSITION STATEMENT: Answered questions on HB 328 on behalf of
Representative Talerico, prime sponsor.
CHUCK KOPP, Staff
Senator Peter Micciche
Alaska State Legislature
Juneau, Alaska
POSITION STATEMENT: During the hearing of HB 328, offered
testimony and answered questions on behalf of Senator Micciche.
HILARY MARTIN, Attorney
Legislative Legal and Research Services
Legislative Affairs Agency
Alaska State Legislature
Juneau, Alaska
POSITION STATEMENT: During the hearing of HB 328, answered
questions.
Gary Superman, Owner
Hunger Hut Bar, Motel and Liquor
Nikiski, Alaska
POSITION STATEMENT: During the hearing of HB 328, offered
opposition to the legislation.
CHRYSTAL SCHOENROCK, Owner
Hunger Hut Bar, Motel and Liquor
Nikiski, Alaska
POSITION STATEMENT: During the hearing of HB 328, offered
opposition to the legislation.
DANIEL LYNCH
Soldatna, Alaska
POSITION STATEMENT: During the hearing of HB 328, offered
opposition to the legislation.
SHEB GARFIELD
Anchorage, Alaska
POSITION STATEMENT: During the hearing of HB 325, offered
opposition to the inclusion of vaping in the legislation.
GREGORY CONLEY, Attorney
President, American Vaping Association
Medford, New Jersey
POSITION STATEMENT: During the hearing of HB 328, offered
opposition to the inclusion of vaping in the legislation.
MICHAEL CERVANTES, Owner
Banks Ale House
Fairbanks, Alaska
POSITION STATEMENT: During the hearing of HB 328, offered
opposition to the legislation.
ANGELA CERNICH, Owner
Artic Industries
Anchorage, Alaska
POSITION STATEMENT: During the hearing of HB 328, offered
support for the legislation.
CARMEN LUNDE, Director
Kodiak CHARR
Kodiak, Alaska
POSITION STATEMENT: During the hearing of HB 328, offered
opposition to the legislation.
ISAAC HEWELL, Owner
Cold Vapes 907
Anchorage, Alaska
POSITION STATEMENT: During the hearing of HB 328, offered
opposition to the inclusion of vaping in the legislation.
ALISON HALPIN
Anchorage, Alaska
POSITION STATEMENT: During the hearing of HB 328, offered
opposition to the inclusion of vaping in the legislation.
BRIAN PREBLE
Anchorage, Alaska
POSITION STATEMENT: During the hearing of 328, offered
opposition to the inclusion of vaping in the legislation.
LARRY HACKENMILLER
Fairbanks, Alaska
POSITION STATEMENT: During the hearing of HB 328, offered
opposition to the legislation.
JENNIFER VARGASON
Fairbanks Alaska
POSITION STATEMENT: During the hearing of HB 328, offered
opposition to the inclusion of vaping in the legislation.
JESSE WALTON
Fairbanks, Alaska
POSITION STATEMENT: During the hearing of HB 328, offered
opposition to the inclusion of vaping in the legislation.
TERRY CROWSON
Delta Junction, Alaska
POSITION STATEMENT: During the hearing of HB 328, offered
support for the legislation.
CHERYL SCHOOLEY
Delta Junction, Alaska
POSITION STATEMENT: During the hearing of HB 328, offered
support for the legislation.
WAYNE CROWSON
Delta Junction, Alaska
POSITION STATEMENT: During the hearing of HB 328, offered
support for the legislation.
ROBIN MINARD, Director
Public Affairs
Mat-Su Health Foundation
Wasilla, Alaska
POSITION STATEMENT: During the hearing of HB 328, offered
support for the legislation.
PETE BURNS
Anchorage, Alaska
POSITION STATEMENT: During the hearing of HB 328, offered
support for the legislation.
JOHN YORDY, M.D.
Anchorage and Valley Radiation Therapy Centers
Wasilla, Alaska
POSITION STATEMENT: During the hearing of HB 328, offered
support for the legislation.
OWEN HANLEY, M.D.
Fairbanks Memorial Hospital
Fairbanks, Alaska
POSITION STATEMENT: During the hearing of HB 328, offered
support for the legislation.
ERIC VARGASON
Fairbanks, Alaska
POSITION STATEMENT: During the hearing of HB 328, offered
opposition to the inclusion of vaping in the legislation.
STEVEN MAPES
Kenai, Alaska
POSITION STATEMENT: During the hearing of HB 328, offered
opposition to the inclusion of vaping in the legislation.
BOB URATA, M.D.
Valley Medical Care
Juneau, Alaska
POSITION STATEMENT: During the hearing of HB 328, offered
support for the legislation.
ANGELA CARROLL
Smoke-Free Alternative Trade Association
Wasilla, Alaska
POSITION STATEMENT: During the hearing of HB 328, offered
opposition to the inclusion of vaping in the legislation.
JUNE ROGERS
Fairbanks, Alaska
POSITION STATEMENT: During the hearing of HB 328, offered
support for the legislation.
DANNY RUEREP
Fairbanks, Alaska
POSITION STATEMENT: During the hearing of HB 238, offered
opposition to the inclusion of vaping in the legislation.
QUOC DONG
Akiak, Alaska
POSITION STATEMENT: During the hearing of HB 328, offered
opposition to the inclusion of vaping in the legislation.
OCTAVIA HARRIS
American Lung Association in Alaska
Fairbanks Alaska
POSITION STATEMENT: During the hearing of HB 328, offered
support for the legislation.
EMILY NENON, Director
Alaska Government Relations
American Cancer Society Cancer Action Network
Anchorage, Alaska
POSITION STATEMENT: During the hearing of HB 328, offered
support for the legislation.
ACTION NARRATIVE
3:03:36 PM
CHAIR PAUL SEATON called the House Health and Social Services
Standing Committee meeting to order at 3:03 p.m.
Representatives Seaton, Vazquez, Talerico, and Stutes were
present at the call to order. Representatives Tarr, Foster, and
Wool arrived as the meeting was in progress.
^Presentation on Telehealth
Presentation on Telehealth
3:05:35 PM
CHAIR SEATON announced that the first order of business would be
a PowerPoint titled "Transforming Health Care With Connected
Health" by the National Conference of State Legislators and the
Center for Connected Health Policy.
3:07:31 PM
KATE BLACKMAN, National Conference of State Legislatures,
advised she is a policy specialist with the bipartisan
membership organization of all state legislatures, the National
Conference of State Legislatures (NCSL). She explained that
NCSL advocates for the interests of states and territories, and
provides policy makers with the opportunity to exchange ideas.
She explained that the presentation stems from an interest of a
team of key Alaska legislators, their staff, and executive
branch representatives who convened a National Conference of
State Legislatures (NCSL) meeting in August to discuss how
health care payment and delivery systems reform. Telehealth has
seen increasing adoption and expansion across the nation and the
NCSL has been working on these issues in providing information
and technical assistance to states. The NCSL also recently
prepared a white paper on Telehealth which is meant to serve as
a resource to state legislatures.
MS. BLACKMAN related that the NCSL partnered with Mario
Gutierrez, Executive Director, Center for Connected Health
Policy located in Sacramento, California. She offered that Mr.
Gutierrez has had over 30 years of experience in California's
non-profit health and health philanthropy sectors, and she then
listed his vast experience.
3:09:47 PM
MARIO GUTIERREZ, Center for Connected Health Policy, directed
attention to the PowerPoint presentation, "Transforming Health
Care with Connected Health. State and National Telehealth
Trends and Issues," slide 2, and offered a disclaimer that he is
not a lawyer, the information is purely for informational
purposes, and the Center for Connected Health Policy is not
funded or supported by any vendor or commercial products or
services as it is an independent non-profit organization. He
explained that the Center is part of a larger public health
institute and its ultimate goal is to achieve equity in health
care, and quality and affordable care for all, and further
explained that technology is a means toward reaching that goal.
He turned to slides 3-4, "Center for Connected Health Policy,"
and said the Telehealth Resource Center is part of a family of
organizations funded through the Office of the Advancement of
Telehealth under the Office of Rural Health Policy (ORHP). He
turned to slide 5, "TTAC," and explained that TTAC is their
sister organization based in Anchorage, and it provides
objective information and support related to telehealth and IT
technology.
3:12:47 PM
MR. GUTIERREZ, in response to Representative Tarr, explained
that the TTAC located in Anchorage is affiliated with the Alaska
Native Tribal Health Consortium.
REPRESENTATIVE STUTES asked the difference between telehealth
and telemedicine.
MR. GUTIERREZ answered that "telehealth" is the common
terminology currently used because it encompasses the entire
medical field, and a sub-set of that could be considered
"telemedicine."
MR. GUTIERREZ turned to slide 6, "HRSA/OAT Grant 2012 - 2016,"
and said the detailed information, including this discussion, is
on their web site together with legal and research policies,
research papers, and basic information. He turned to slide 7,
"Telehealth Pioneer?" and explained that the idea of
communicating electronically to provide health care services has
been envisioned since 1925, and operational for 40-50 years.
Although, the advances in the technology and how it is being
used is new.
3:15:00 PM
MR. GUTIERREZ turned to slide 8, "The Value Proposition for
Telehealth," and said that telehealth is an important aspect of
health care reform and improvements in quality of care because
the advances in telecommunication technologies can help
redistribute health care expertise when there are shortages and
limitations, to create the greatest value for consumers, payers,
and health systems. Slides 9-18, "Value of Telehealth." He
explained there are three key values of telehealth, "1. Timely
Access to Diagnosis & Treatment" with primary and specialty care
services, direct to consumer, and emergency care. He explained
that cost avoidance is a benefit particularly from the patient
side wherein the average cost to an outpatient, waiting two
hours, is $43 per visit, although in Alaska it is a much higher
number. "2. Enhanced Consultation/Communication," the second
key value having to do with enhanced consultation and
communication allowing consumers to report to their physician
through portals, specialists and primary care providers to
communicate, or for multiple communications within a team.
Examples of communications are e-Consult and the Project Echo
Model. The third value of telehealth is "3. Remote Patient
Monitoring" is related to health care when chronic conditions
become acute and there is the ability to monitor chronic
conditions, allow people to be served in their home particularly
home-aging in place, and acute emergency situations.
He explained that Medicare approved Omada as a reimbursable form
of Digital Therapeutics that allows the intersections of
science, technology, and design wherein consumers could monitor
and learn about their own health care. According to a number of
studies, he advised, remote monitoring saves money, time, and
improves quality. Illnesses that can benefit from remote
monitoring include, congestive heart failure, obstructive
pulmonary disease, and stroke, and a Canadian study showed they
could reduce hospital stays by 50 percent. He opined there will
be more use of decentralization of care through remote
monitoring to the home, and institutionally based outside of the
hospital with less dependence on acute care hospitals which is
the most expensive.
3:21:51 PM
MR. GUTIERREZ turned to slide 17, and advised there are
limitations and the joke on the slide demonstrates that
telehealth is not for every form of care. Slide 18, "Power of
Connected-Health Technology." He related that in terms of the
value, it is always important to think about telehealth in the
context of the three-legged stool as follows: the electronic
health records and health information exchanges to ensure there
is intra-operability; connection so that the HER's repository of
the electronic diagnostic information ultimately leads to
improvements in health outcomes; and health plans through the
health information exchange. When considering policies, he
opined, it is important to consider it in this larger context.
3:22:50 PM
MR. GUTIERREZ directed the committee's attention to the "State
Policy Analysis & Trends" section, slides 20-27, and turned to
state policy. He reminded the committee that the Medicaid
program is different in every state and the Centers for Medicare
& Medicaid Services (CMS) give the states the ability to define
for themselves how it will deliver and pay for health care
services using Medicaid resources with matching dollars. The
result, he noted, has been a patchwork of laws, regulations and
policies where no two states are alike. Subsequent to receiving
a federal grant, the Center now has a continuous update on the
laws and regulations in every state, which is located on its
website. He explained that he defines telehealth policy
according to the key areas listed on slide 24. More commonly 43
states still use a form of telemedicine, 28 states have moved to
using telehealth as the umbrella terminology, and 2 states do
not have any definition. The most common form of reimbursement,
because it has been around the longest, has been live video but
in some ways live video could be the most inefficient form of
care.
3:25:11 PM
MR. GUTIERREZ noted that on slide 25, despite all the evidence
in the field and studies performed, only 9 states currently will
reimburse for "store and forward", and 16 states for remote
patient monitoring. Parity in payment is something that Alaska
is currently considering, and there are 27 states that have some
form of language related to parity, but parity is difficult to
determine. It must be clear whether it is just parity in
services that are covered, or whether it also includes parity in
payment. He explained that a majority of states have a clause
that says "subject to the terms and conditions of a contract."
Which means that depending upon the payer, they can determine
whether or not they will pay for telehealth, whether they don't
pay for a particular service, or whether it is not included in
their policy. It is important when considering legislation and
policies that it be clear that if there will be parity it has to
be without any kind of conditional clauses attached to it. He
related a large upsurge this past year in bills introduced
across the country reforming telehealth laws, and that 2016 has
shown an even greater amount. The majority focus on telehealth
standards, across state licensing, prescribing, and just changes
to telehealth laws.
3:27:22 PM
MR. GUTIERREZ turned to the "Highlights of Individual States"
section, slides 28-37, and offered that the State of Nevada has
a clear and clean definition of telehealth, it removed any prior
authorization from the provision of telehealth services which
says that telehealth should not be treated as something
different. In 2011, California passed a comprehensive bill that
covers much of what he would like to see in legislation around
the country, although there are areas that need improvement.
Key here, he pointed out is that the State of California now has
language that will reimburse for all forms of telehealth and it
removes the restriction on the geographic and institutional
location of where telehealth services can take place. Another
large change was the requirement that it is only limited to
certain professions, mostly the medical profession, and it was
changed to allow that any licensed professional can now use
telehealth for health care. The parity legislation still has
the clause "subject to the conditions of the policy." The State
of Mississippi has one of the more advanced policies in the
country and it recently passed a law that requires all employee
benefit plans to cover all forms of telehealth, and requires
reimbursement for store and forward. The State of Minnesota
recently changed its laws and it now has a clean definition of
telehealth that covers live video, store and forward, and remote
monitoring through its Elderly Waiver (EV) program. The State
of Indiana passed a law this past week which still defines it as
telemedicine but has clearly defined video conferencing, store
it forward, and remote patient monitoring. The most important
piece of this legislation is that it now allows not just
physicians but physician assistants and advanced-nurse
practitioners to treat patients via telemedicine without a prior
in-person visit, and to prescribe without the requirement that
the person be seen in-person, with some conditions.
3:30:53 PM
MR. GUTIERREZ asked the committee to keep in mind that beyond
this legislation, the administrations in each state - the
departments of health care and health care services also have a
say in how they interpret those legislations, so he warned that
the committee be sure that that is consistent. Also, licensing
boards are now becoming more important as each professional
licensing board can now put its own limits on what could be used
for telehealth and under what conditions, and the courts are now
playing a big role. He noted that Alaska is considering cross-
state licensing with the Federation of State Medical Boards
(FSMB). He pointed out that this does not create a telehealth
national license as it simply facilitates the process through
the compact that is created for any physician in any state in
good standing to apply for a license in another state to take
place much earlier. Two major cases in the courts include:
Planned Parenthood of the Heartland, Inc., and Jill Meadows v.
Iowa Board of Medicine, in which the Board of Medicine has a
rule requiring an in-person examination for the administration
of an abortion inducing drug and an in-person follow-up visit.
He explained that that became a model other states were going to
follow; however, it was ruled unconstitutional by the Iowa
Supreme Court and so those laws have now been rolled back.
Another lawsuit closely watched is Teledoc, Inc. v. Texas
Medical Board, where the medical board is requiring a medical
doctor face-to-face visit before a physician can prescribe
medication and this case is currently moving through appeals.
3:32:52 PM
MR. GUTIERREZ turned to the "Federal Telehealth Policies"
section, slides 38-46, and said that this is a field that is
moving at the speed of light, but on the federal telehealth
policy side it is moving at the speed of Old Man River. He
remarked that the Social Security Act defines how Medicare is
administered, what is payable and reimbursed, and under what
conditions, and was passed when the first smart phone was
invented by Maxwell Smart. Although, he commented there have
been a few incremental changes, but by and large Medicare is
stuck in an old way of thinking in terms of health care
delivery. Universally, across the county among telehealth
providers and policy makers, it is believed that Medicare
policies are sorely outdated. (Indisc.) must be in a medical
home in a strictly defined rule area. Alaska and Hawaii are
part of a demonstration project for "Store and Forward" and
Alaska is using store and forward in remote villages for care.
It is the policy of this federal administration, moving forward,
that all of Medicare will be in some form of managed care plan
by 2018. This provides a lot of opportunity for telehealth, but
thus far only 1 percent of Medicare beneficiaries are able to
take advantage. Currently, there are only two plans that
provide for telehealth through their plans at the University of
Pittsburg. House Resolution 2 in Congress, the Medicare Access
and Chip Program had some good language related to advancing
telehealth practices; however, a couple of studies are being
called for before anything can be done.
3:35:15 PM
MR. GUTIERREZ referred to Next Generation ACO and said it is a
breakthrough in telehealth and the CMS is now funding 20 pilot
programs across the country for a two year demonstration in
which it has lifted all of the requirements related to
geographic limitations, and is encouraging the use of
telehealth. He described Congressional Bill S. 2484 as an
exciting bill in that the sponsors have been careful to craft it
so it meets the neutrality requirements of the Office of
Management & Budget and Congressional Budget Office on their
scoring to ensure that all bills are budget neutral, and opined
it may have a chance of passing during the lame duck session.
Important factors to keep in mind around telehealth is that this
is a mode of delivery and it is not a different form of health
care so all laws apply, he said. This is important,
particularly around liability and confidentiality and privacy
through HIPAA. Alaska still remains one of the 10 worst states
in access to broadband internet, clearly as Mr. Michael Rilly
reported from the FCC, Alaska is different in size,
transportation, and weather creates huge blocks for access to
care. Even though, he noted, Alaska has a model program, there
is still a long way to go in terms of no matter what laws are in
place, if it doesn't have the super highway to deliver, Alaska
will be inhibited in its ability to take full advantage of
telehealth.
3:37:5 PM
MR. GUTIERREZ turned to the "Technology-Enables Health Care
Trends in the 21st Century section, slides 47-62, and said that
Joseph Kvedar, M.D., wrote The Internet of Healthy Things and
that he would highlight a number of points from the book to keep
in mind in where the nation will be in health care. The
movement from volume to value where the results will be paid for
rather than paying for the inefficient pay for service model
will be the standard. Including, he added, the idea that the
21st century is moving from illness care to keeping people
healthy, moving away from in-patient focus and hospital and
physician focus to more of a continuum of care and a model where
there are shared risk between payers, providers, and consumers.
The pathway to greatness in health care delivery and making
health care accessible to all with quality and efficiency is to
think about where the nation will be in the future. Making
incremental changes in moving forward is helpful, but the nation
wants the kind of policies it can grow into and allow for these
technologies to flourish with the proper safeguards. Slide 50,
he advised, depicts the traditional model of the physician being
at the center of health care, mostly in-person, facility
centric, of which is becoming outdated. The health care model
of the future is depicted on slide 51, wherein the consumer will
be and should be at the center of all approaches to health care
delivery in which all forms of care, whether specialty care,
primary care, or community resources providing holistic care,
can be interconnected between virtual means of communication and
support. He described this as one of the most untapped,
underutilized forms in telehealth, but being able to build a
system allowing this type of approach will be critically
important, particularly given the types of challenges being
faced in Alaska.
3:40:38 PM
MR. GUTIERREZ turned to "2. Commercialization of Health Care: A
Fact of Life," is Dr. Kvedar's second point about the future in
that commercialization of health care is everywhere, including
consumer driven direct where the consumer can be at home with a
sick child, call a doctor on demand or American Well, and pay
with their credit card for a consultation and a non-narcotic
prescription. He described it as a multi-billion dollar
industry that continues to grow, and it is tied to the retail
market place so places such as Walmart Care Clinic, CVS Caremark
have invested significantly. He pointed out that Walgreens is a
leader and it partnered with Providence Health Care Services and
now has 25 retail clinics in Oregon and Washington and expects
to expand nationally. Interestingly, he noted, Walgreens is
tying the whole notion of retail health care to its retail
business so that within the records of its members, it will
provide loyalty points for improvements in wellness care that
can be used for retail purchases.
3:42:15 PM
MR. GUTIERREZ turned to "Technology is Growing and Here to
Stay," and related that this is not the future as this is now
the ability for the consumer to use their iPhone to
instantaneously through Bluetooth and in real time, review their
EKG or send it to the consumer's cardiac physician, or an
organization that can provide an instant reading. The
flexibility and ability to use technologies now, as long as
there is access to high speed broadband, is at the consumer's
fingertips. He remarked that the world of clunky cameras and
monitors is a thing of the past except in the carts used in
hospitals. Currently, there are peripherals that can generate
information from long distances using telehealth with high
quality and definition when using wireless devices. For
example, the Berkeley "Tricorder" is the smallest remote
monitoring on the market today and it is smaller than the size
of a quarter. By using Bluetooth connectivity it can send
information on a real time basis, in any number of biometric
measures, to the consumer's health care provider. Although, he
opined, this will be outdated in the next year as new forms come
into play. Incredibly, there is now the ability to monitor
patients taking their medications with a microchip that has been
approved by the FDA, which dissolves in a patient's system and
sends a signal to the physician or health care team through
Bluetooth internet. He related that this appears to be similar
to "Nanny Government" but consider the hundreds of millions of
dollars lost in poor medication adherence either by not taking
the medications or taking the wrong medications and this is a
way of not only improving the quality of care but also improving
the cost efficiency.
MR. GUTIERREZ advised that Dr. Kvedar's last point is "4.
Virtual Care Anywhere" and perspective is that the nation is
moving to the point where care could be provided in many
locations and, in fact health care delivery is moving in that
direction with over 75 million virtual visits predicted by 2020.
Kaiser Permanente has been a pioneer in this regard and is the
largest national non-profit health plan. In 2013, and in
Northern California alone, Kaiser Permanente documented 10.5
million virtual visits, and by the end of 2016 it is expected
the number of virtual visits will exceed the number of in-person
visits. Over time Kaiser Permanente expects that 75 percent of
all visits will be performed virtually. He explained that it is
not reducing the number of in-person visits rather that the
patients seen by their physicians and specialists are patients
that really need to be seen. Routine follow up visits, checking
in, communication visits, and labs can be performed virtually.
He stated that his favorite organization is Mercy Virtual based
just outside of St. Louis, and the slide depicts an actual
picture of a hospital without beds in which it acts as the
command center for four states in which they are interconnected
with clinics, hospitals, and physicians in other facilities to
provide everything from routine monitoring to emergency care
from this facility. It expects that within the next five years
it will have performed 3 million virtual visits, he said.
CHAIR SEATON commented that this presentation brought the
committee along from the traditional model of medicine. He then
listed the individuals available for testimony or questions.
3:47:50 PM
REPRESENTATIVE WOOL referred to his statement that telehealth
virtual visits will not reduce the number of inpatient visits a
health care providers sees in one day, together with the portion
of the physician's day spent with telehealth visits and asked
whether their days would be spent in telehealth and face-to-face
patients.
MR. GUTIERREZ explained the idea is that a physician can now
increase their reach to the number of patients in a panel by
working through their health care team, using physician
extenders, to provide care using telehealth and the ability to
do their routine visits using the health care delivery team. He
said it is not always the physician communicating directly with
the patient, and what Kaiser Permanente has been promoting, and
what it is proving in its work, is that it increases the
efficiency, and allows its physicians and specialists to work at
the top of their license. The patients actually being seen are
patients who really need to be seen, so it is an enrichment and
not a replacement to care.
3:49:30 PM
REPRESENTATIVE WOOL surmised that the sickest patients most in
need of the highest level of the licensing would see that
person. Obviously, he noted, the geographical barriers are
being knocked down so it does not matter whether the patient
lives next door to the clinic, the patient may still be treated
by telehealth. He offered his hope that the pricing is more on
a global scale which would be helpful, and asked whether there
are instances where a patient who wants to see their physician
would still have access, or would that access be more towards a
Cadillac or higher end level coverage.
MR. GUTIERREZ explained that the ability to see a physician, or
a specialist in particular when there is a shortage of the
distribution of specialists, is one that is causing rationing of
health care by the de facto and long delays in getting access to
that care. To the extent that this accelerates the process for
a physician to either have an e-consult with a specialist about
a particular patient to avoid having a long wait, or to actually
have a consultation either in-person or through the store and
forward, telehealth allows it to be performed in a more
efficient manner. Yes, he said, if a patient really wants to
see their physician to the extent there is an appointment time
involved, certainly. He opined there truly are times a patient
needs to be seen by a physician encompassing the touch factor
that is always important in the ideal world, but this is an
opportunity to expand care.
3:51:48 PM
CHAIR SEATON asked for clarification of the term "physician
extenders," and asked whether that includes other people within
their practice with a lower level of licensing who can take care
of the routine issues.
MR. GUTIERREZ said that was correct, advanced practice nurseries
would include nurse practitioners who are trained to take care
of most routine forms of medical care and are supervised by a
physician. In some states nurse practitioners are allowed to
practice independently, but in most cases they are being
supervised by a physician so in the event there is a
complication or an issue they can reach out to that physician.
A physician assistant is a national licensing with specific
training, similar to a nurse practitioner and operates in the
same manner.
3:52:56 PM
REPRESENTATIVE TARR referred to slide regarding over 200 bills
in 42 states, with a bullet point of "Telehealth Professional
Standards," and another slide that discussed the interstate
compact, and not changing what it means to be licensed as a
doctor in a state or an ANP and surmised that those licensed
people are being defined a scope of practice for telehealth.
MR. GUTIERREZ responded not in a scope of practice, but within
the context of how telehealth is used. For example, some states
require a physical examination before a telehealth visit can be
provided, and some states are repealing those types of issues to
make it more accessible. Another example would be where the
physician can be licensed in another state and separate from the
compact, can provide care under certain conditions in that
state.
REPRESENTATIVE TARR described this as more about delivery of
health and not so much about any new type of ethical standards
or expectations on the provider end of things as those
opportunities are expanded.
MR. GUTIERREZ said no, that it is important to keep in mind that
telehealth is a modality; therefore, to the extent that whatever
licensing requirements there may be for whatever profession
beyond just physicians, that all standards apply. It is not a
separate or above that license or requirement, and he hasn't
seen anything in other states.
REPRESENTATIVE TARR asked about store and forward.
MR. GUTIERREZ replied that this is a form of care that has been
used successfully with dermatology and ophthalmology with high
definition digital images. Currently, with smart phones it is
even possible to get the type of high definition that meets the
standards. For example, in ophthalmology, the retina of a
diabetic patient could be sent to a specialist a long distance
away and the specialist could review that during their down time
and make a determination as to whether or not that patient has a
likelihood of damage to the retina that could lead to blindness.
He related that it has been very successful, particularly with
Native populations. Another example is dermatology wherein an
image can be sent through secure email to a specialist for
review and they can make a diagnosis and determination as to
whether or not it is a suspicious lesion and advise back to the
primary care physician.
3:56:57 PM
CHAIR SEATON asked about the State of Nevada slide which read,
"Prior authorization provision is specific ... is expressly
prohibited," and asked whether that provision was part of an
overall bill, or a standalone provision, or is it in Medicaid or
private practice, or both.
MR. GUTIERREZ opined that this was in Medicaid and it was part
of the Medicaid regulations that initially required that before
a service could be provided there had to be prior authorization.
The requirement was in the State of California and it was a
deterrent for physicians to utilize the technologies because
getting prior authorization from a state office of Medicaid in
many cases causes more problems than it is worth. By lifting
that requirement it facilitated the process ...
CHAIR SEATON asked whether that was a requirement in the
Medicaid plan.
MR. GUTIERREZ answered in the affirmative.
CHAIR SEATON referred to Omada, the digital therapeutics, and
asked him to explain the slide that reads, "A new category of
medicine, and then offers each employer and a health plans a
full service ... full service team at no cost."
MR. GUTIERREZ answered that the CMS has now approved Omada for
reimbursement under Medicare, and he felt it was important to
include in this presentation. He opined that he does not know
much about it other than the fact that it is a sophisticated
technology that allows a consumer to monitor their own chronic
condition and be coached through a virtual means to the Omada
system and control their diabetes, obesity, hypertension and all
of the major chronic diseases that can become killers as they
become acute. Omada has been one of the more successful
companies and their website is the best place to go for
information. Contrary to a lot of the obesity prevention
programs that have low compliance after six months, this form
has proven to be successful with high compliance for up to one
year. Omada is seeing extensive cost savings and, he opined,
that is what Medicare was most impressed with in terms of
preventable conditions.
4:00:12 PM
CHAIR SEATON asked whether this was a CMS determination or
something that must be in the state plan as well.
MR. GUTIERREZ opined that it was a CMS determination for
Medicare, and for Medicaid it would have to be part of the state
plan.
CHAIR SEATON said the committee would note that as it goes
through Medicaid reform legislation.
4:00:39 PM
REPRESENTATIVE TARR opined that the application of telehealth in
Alaska has been entirely providing services in more remote areas
where there wouldn't be specialists and where services were more
limited. She said she saw a paradigm shift with his
presentation to something that is more expansive in the
application and referred to his testimony of enhancing the
system and quality. She pointed out that she is not yet seeing
it as useful in every circumstance and she is hung up on the
need for an in-person visit and the Nevada bill explicitly
prohibits that. It is hard for her, she offered, to see how to
obtain the strength in the doctor/patient relationship that is
needed for a long term positive interaction if they never
actually meet face to face. She asked for his comments as to
whether that is a patchwork of how people feel.
MR. GUTIERREZ related that it is important to highlight that
telehealth does not replace the necessity for an in-person visit
and opined that the State of Nevada law specifically lifted the
requirement for a prior visit. Certainly, telehealth has been a
valuable resource for isolated rural communities and it is a
great opportunity to enhance care and access. Although, virtual
care and technology is a powerful tool for achieving the triple
aim of health care, when pondering the value of all health care
in any geographical area consider the proposition of giving the
most value and the greatest efficiency of health care resources
available. Telehealth does not replace the in-person care,
telehealth is an enhancement to the delivery of high quality
care and it is a value tool in that sense, but not one that
should ever be seen as replacing the necessity of an in-person
visit, he remarked.
CHAIR SEATON thanked Mr. Gutierrez, and noted that the
presentation expanded the committee's knowledge and raised
issues it will want to take up in moving forward.
HB 344-DRUG PRESCRIPTION DATABASE
4:04:12 PM
CHAIR SEATON announced that the next order of business would be
HOUSE BILL NO. 344, "An Act relating to the controlled substance
prescription database; and providing for an effective date."
[Before the committee was the proposed committee substitute (CS)
for HB 344, Version 29-LS1378\N, Bruce, 3/14/16, as a working
document.]
4:04:30 PM
The committee took an at-ease from 4:04 p.m. to 4:07 p.m.
4:07:40 PM
CHAIR SEATON moved to adopt Amendment 2, labeled 29-LS1378\N.3,
which read:
Page 16, line 16, following "patient":
Insert "more than a three-day supply of"
REPRESENTATIVE TARR objected for discussion.
CHAIR SEATON explained that this amendment would add an
exemption to the mandatory review of the database required in
Sec. 19, page 16, lines 14-20. The exemption would mean that a
practitioner or pharmacist would not be required to check the
database if they are dispensing a controlled substance with a
supply of three days or less. Although, they could still check
but there would not be a requirement to check.
4:08:59 PM
REPRESENTATIVE TARR noted that it reads more than a three day
and surmised that it includes the third day.
CHAIR SEATON agreed, and said three days or less.
4:09:28 PM
REPRESENTATIVE TARR removed her objection. There being no
objection, Amendment 2 was adopted.
4:10:00 PM
CHAIR SEATON moved to adopt Amendment 3, Version 29-LS1378\N.5,
which read:
Page 17, line 17, following "state":
Insert "for an occupation or activity listed
under AS 08.01.010"
REPRESENTATIVE STUTES objected for discussion.
CHAIR SEATON referred to Sec. 20, subsection (q), page 17, lines
15-17, which read:
(q) A pharmacist or practitioner may only
delegate access to the database under (b) or (d) of
this section to an employee or agent who is licensed
or registered in the state.
CHAIR SEATON explained that the amendment would clarify that the
person must be licensed or registered for an occupation or
activity listed in AS 08.01.010. The reason being to make clear
that they must be licensed or registered with the Division of
Corporations, Business, and Professional Licensing and not some
unintended registration, such as the sex offender registry,
thereby, designating which licenses or registration would be
covered, he advised.
4:11:18 PM
REPRESENTATIVE STUTES removed her objection. There being no
objection, Amendment 3 was adopted.
4:11:47 PM
CHAIR SEATON moved to adopt Amendment 4, Version 29-LS1378\N.6,
which read:
Page 18, line 15, following "TRANSITION.":
Insert "(a)"
Page 18, following line 18:
Insert a new subsection to read:
"(b) On or before October 1, 2019, the
Department of Commerce, Community, and Economic
Development shall solicit comments on the level of
burden on providers created by the review requirement
in AS 17.30.200(k)(4), enacted by sec. 19 of this Act.
The department shall summarize, in a report to the
legislature, the comments received by the department
and its findings based on the comments. The department
shall deliver the report to the senate secretary and
the chief clerk of the house of representatives not
later than October 1, 2019, and notify the legislature
that the report is available. The legislature may
assess whether the review requirement under AS
17.30.200(k)(4), enacted by sec. 19 of this Act,
remains necessary or if alternative language should be
considered based on the report."
REPRESENTATIVE TARR objected for discussion.
CHAIR SEATON explained that the amendment would add to the
uncodified law, under Sec. 22 of the HB 334. He paraphrased
that the amendment directs the Department of Commerce, Community
& Economic Development to solicit comments from providers
regarding the level of burden on providers created by the review
requirement of AS 17.30.200(k)(4) and to deliver to the
legislature a report summarizing the comments and the Department
of Commerce, Community & Economic Development's findings based
on the comments. The report would be due October 1, 2019, and
the legislature may assess whether the review requirement is
still necessary or whether alternative language would be
preferable. Basically, he pointed out, this directs the
Department of Commerce, Community & Economic Development to
collect comments on the burden on providers created by the
requirement to review the database prior to prescribing,
dispensing, or administering, and the department would then
present comments to the legislature with the findings. The
legislature would then have the option to re-examine and review
the requirement. It is not a sunset but it is a review and
report. The date of October 1, 2019 would give the department
two years and three months from the effective date to collect
these comments and generate a report.
4:13:45 PM
REPRESENTATIVE TARR asked who would prepare the report because
the Department of Commerce, Community & Economic Development
(DCCED) is the stop gap to move the database over to the
department as it does the professional licensing, but is the
department well equipped to receive comments. For example, the
Department of Health and Social Services (DHSS) is regularly
communicating with its Medicaid providers, and suggested that
possibly it should be DCCED and DHSS.
CHAIR SEATON said he presumed that each one of the professional
boards would be handling those, and called on Ms. Janey Hovenden
to respond.
4:14:54 PM
JANEY HOVENDEN, Director, Division of Corporations, Business,
and Professional Licensing, Department of Commerce, Community &
Economic Development, explained that as she reads the amendment,
the program coordinator would coordinate all information with
all of the different boards and members in licensing, which is
how a survey would be generated. The survey would go out to all
registered people with a database and solicit their input,
collect the information and prepare the required report to the
legislature, she said.
4:15:42 PM
REPRESENTATIVE TARR asked whether she felt equipped to handle
this task and the volume of respondents which could be in the
hundreds or thousands. She further asked that whether with
existing resources the department would be able to pull together
a report, or whether the report would be a self-generated report
with something such as "Survey Monkey and that would be
sufficient.
MS. HOVENDEN replied that even though the department is slowly
gathering email addresses it isn't quite equipped for that and
would notify as it does all regulation projects or anything like
that, send snail mail to everyone. The program coordinator
being requested in this bill would spearhead that entire project
as one of the duties of the position.
REPRESENTATIVE TARR related that sounds more realistic in terms
of a hefty project and she did not know what to expect and
sometimes given the opportunity people have a lot to say.
CHAIR SEATON commented that he agrees that without a program
coordinator if the legislature was just dumping this on the
department, which would not be something that would be easily
handled.
4:17:15 PM
REPRESENTATIVE STUTES asked whether this project could be
performed in a timely fashion. She described concern that
people cannot receive a response from the Division of
Corporations, Business, and Professional Licensing, currently.
CHAIR SEATON reiterated that there is a program coordinator
hired for this specific coordination of the database and it is
not giving the department another job. The description of a
program coordinator is located within the fiscal note and the
report period is for two years and three months only. There
will be a summary of the problems received prepared for the
legislature.
REPRESENTATIVE STUTES asked whether the coordinator would work
under the Division of Corporations, Business, and Professional
Licensing.
MS. HOVENDEN replied yes.
REPRESENTATIVE STUTES said that was her concern.
4:19:22 PM
REPRESENTATIVE VAZQUEZ said she likes the intent of the
amendment in receiving feedback from providers regarding the
burden that will be placed upon them, but she is concerned there
will not be feedback until three and one-half years away because
that is too long of a period of time. At most it should be one
year from now, or something in January, 2017. Although, she
commented, not all of the information will have been received to
assess the type of burden but there would be an initial
indication and annual reports thereafter. She referred to line
11 of Amendment 4, and pointed out that the amendment states a
report shall be submitted on "not later than October 1, 2019,"
and it is now March 24, 2016.
4:20:32 PM
CHAIR SEATON explained that the effective date is July 2017.
REPRESENTATIVE VAZQUEZ asked to shorten the time frame in order
to know the type of burden it will impose on the providers.
4:21:08 PM
CHAIR SEATON responded that he was trying to give at least one
year of the program being in effect to coordinate that
information in an effective manner, and this is not an annual
report. He remarked he has tried to eliminate some of the
burden by allowing the chief pharmacist to also authorize
someone who is licensed or registered in the health field, and
there is accountability against their license. The testimony
the committee received was that the department is the busiest at
the end of the legislature or the fiscal year and the best time
to prepare the report is October or November so it would be
ready for the legislature in the following year. He commented
that preparing a report in June or July for the legislature may
not be reviewed until the next session, and receiving a shorter
term report wouldn't cover an entire year's worth of the program
and the intention is to calculate feedback. In the event the
committee does not wish to have a report, he said he could
remove the report.
4:23:40 PM
REPRESENTATIVE TARR noted that the effective date is July 1,
2017, and a full year would be 2018, and suggested using January
1, 2019.
CHAIR SEATON asked whether the department could change the
report date.
MS. HOVENDEN responded that the report will be presented
whenever it is requested.
4:24:50 PM
REPRESENTATIVE TARR moved to adopt Conceptual Amendment 1 to
Amendment 4, to change the date on line 6 to January 1, 2019;
and on line 11 to change the date to January 1, 2019.
CHAIR SEATON objected. He surmised that it would be Conceptual
Amendment 1 to Amendment 4 to change October 1, 2019, to January
1, 2019, on line 6 and line 11.
REPRESENTATIVE TARR agreed.
4:25:41 PM
REPRESENTATIVE WOOL said that based on the pharmacist's comments
that expressed possibly foreseeable problems, he opined that it
gives them a year to evaluate, and after that year the
department has five months to complete a report. He related
that it is a good timeline.
CHAIR SEATON removed his objection. There being no objection,
Conceptual Amendment 1 to Amendment 4 was adopted.
4:26:34 PM
REPRESENTATIVE TARR removed her objection to Amendment 4 as
amended. There being no objection, Amendment 4, as amended, was
adopted.
4:27:36 PM
REPRESENTATIVE VAZQUEZ moved to report CSHB 344, Version 29-
LS1378\N, as amended, out of committee with individual
recommendations and the accompanying fiscal notes. There being
no objection, CSHB 344(HSS) was reported from the House Health,
Education and Social Services Standing Committee
4:28:20 PM
The committee took an at-ease from 4:28 p.m. to 4:31 p.m.
HB 315-ELECTRONIC VISIT VERIFICATION: MEDICAID
4:31:24 PM
CHAIR SEATON announced that the next order of business would be
HOUSE BILL NO. 315, "An Act relating to an electronic visit
verification system for providers of certain medical assistance
services."
4:31:43 PM
REPRESENTATIVE VAZQUEZ moved to adopt CSHB 315, Version 29-
LS1287\E, Glover, 3/21/16, as the working document.
REPRESENTATIVE STUTES objected
4:32:18 PM
ANITA HALTERMAN, Staff, Representative Liz Vazquez, Alaska State
Legislature, read from prepared testimony as follows:
The most salient points of this bill is that the bill
protects the most vulnerable of our population. It
does so by allowing an alert to be triggered for the
home and community based provider agency who then can
remediate this matter with a beneficiary. The goal of
HB 315 is to ensure that the state only pays providers
for the approved services that are rendered by the
appropriate home health agency personnel while within
that recipient's home or other authorized setting.
Alaska's population is aging and the demand for PCA
and home care services will increase. Accordingly it
will continue to become increasingly more important to
ensure that the home care is delivered properly and
that publically funded resources are being managed and
spent appropriately. It is anticipated that Alaska
has the potential to realize savings of between $15
million and $35 million with this bill.
CHAIR SEATON asked how the anticipated savings are to be
realized.
4:34:01 PM
MS. HALTERMAN answered that she would like to get a little bit
more background on the bill, there's been a lot of questions
about the bill that have been raised by the public and the
Department of Health and Social Services. She asked that she be
allowed to read notes written for the record, as follows:
House Bill 315 is the electronic visit verification
Medicaid bill. A 2012, the Government Accountability
Office (GAO) report has indicated that 40 percent of
all national fraud convictions initiated by the
Medicaid Fraud Control Units (MFCUs) are related to
services that are rendered in the home and community
based settings. According to the institutes of
Medicaid ... medicine fraud ... medical fraud and
abuse in health care costs $75 billion annually, and
the cost to unattended patients can be immeasurable.
It has been reported that the adoption of use of
technology is not only about compliance, it is about
survival. Even FedEx deliveries of a $4 item requires
an electronic signature proving the delivery. Why
shouldn't something as valuable as patient care be
electronically documented and verified? Perspective
approaches to combatting fraud, waste, and abuse, are
far more effective than reactive or retrospective
approaches such as audits and imposing new mandates.
To give a little bit of history, the State of Alaska
has previously considered using electronic visit
electronic verification systems. On July 28, 2014, it
was reported by the Anchorage or the ... the ADN that
the state was considering a pilot for EVV. The
Assistant Attorney General at that time reported that
Medicaid fraud was costing Alaska Medicaid a
conservative estimate of $45 million per year. EVV
systems are easy to use, they don't require any
installation of software or hardware. They ensure
that beneficiaries receive the services that are
authorized for the support that has been approved and
for which the state is being billed. A person who can
use EVV, typically can use the telephone. EVV is used
for compliance and for quality assurance purposes
throughout the nation. Beneficiaries are identified
by either a landline or a GPS location and caregivers
are identified by a unique identifier, and a biometric
match that allows the system to verify that the calls
were made from the proper caregiver for the
beneficiary. EVV systems authenticate the presence of
service providers, they may rely on telephony, which
is the most commonly used form of EVV, GPS tracking,
biometrics, computers for the provider agencies,
mobile tablets, tokens, or other applications - those
names of devices vary by vendor, and then smart
phones. An individual without landline or systems
used to authenticate services can be provided a device
by a vendor, kind of like a pager. This generates a
client ID with a ... that provides a digital readout
that can be given to the caregiver who can call in and
then enter that code into a system about that client.
Our research indicates that it appears the average
cost of ... of that verification is approximately
$0.15 per visit. Biometrics are critical component
for successful EVV implementation. They ensure
further reduction of fraud, waste, and abuse by
identifying that caregiver's identify. Statewide
independent approaches involve vendor solutions and
are considered funded mandates. These are cloud-based
platforms that allow for remote patient monitoring.
The states that have chosen the statewide approaches
have done so because they want to maintain oversight
over their EVV systems. Statewide vendor solutions do
the following: it allows the state to access federal
assistance matching percentages of up to 90 percent
for frontend system development; they gain 75 percent
for recurring costs when the systems are plugged into
the claims system; it removes fraud liability from the
consumer directed home care provider agency and it
places it directly on the consumer directed PCA or
caregiver under her consumer directed clients. This
morning I confirmed with the department that only
approximately 1.5 percent of the clients are served
under an agency based model, so this would limit
liability from any of our consumer directed
beneficiaries and their agencies.
4:39:13 PM
CHAIR SEATON asked for more explanation.
MS. HALTERMAN explained there are two different models, such as
an agency based model that typically requires that the agency
staff the beneficiary's care in that home, and sends someone,
typically a CNA, to the home to provide that care. The agency
has some direct responsibility over directing the care when it
is an agency based caregiver. When it is a consumer directed
PCA model, the consumer directly hires, supervises, and fires
their caregivers, they provide the training, and they are
responsible for the oversight of their care. These systems
place that responsibility more directly on the consumer and its
caregivers, rather than the agency, she said.
4:40:16 PM
MS. HALTERMAN continued reading her written testimony as
follows:
Statewide vendor solutions can also be set to trigger
an alert so that they can be sent to the provider
agency in order for that agency to investigate a gap
in care. These can be set to set an alert to an
administrator within the state agency, but only if the
state chooses that option. EVV systems can monitor to
ensure visits are happening as expected and/or alert
that provider agency when a gap in care is occurring.
The reports and these alerts are optional for the
Department of Health and Social Services. Provider
agencies maintain all control over scheduling and
resolving any gaps in care with that direct caregiver.
Generally, vendors provide training and the use of the
EVV systems to administrative staff within those
agencies, who then provide training to the direct
caregiver. EVV systems statewide allow for con ...
configuration of new software so EVV systems can
incorporate programs specific business rules for each
of our agencies. They ensure for comprehensive
training to be consistently provided, which may
include providing a training kit, visual aids, videos,
or documentation on best practices. EVV systems can
generate reports that alert agencies when the
caregiver fails to show up. EVV systems can be
integrated, again with the existing provider systems,
to minimize the impact on those provider agencies.
A standards based approach, which we've heard some
folks testify and some ... we've seen some written
testimony in support of. Um, I want to kind of define
the standards based approach. It is an approach where
the department sets the minimum set of requirements
that the provider must meet with the use of an EVV
system. The provider then needs to ensure that those
requirements ... um, occur with the solution that they
provide ... or they procure on their own. Standards
based approaches are unfunded mandates. States have
chosen those options but those that have done so have
experienced that they have little control and
oversight over their data. The standards approach may
lead to increased reimbursement due to the cost and
complications of implementing new systems for each
provider. For instance, the State of Washington we
have learned has increased reimbursement to providers
due to the implementation of a standards based
recordkeeping system or timekeeping system. It's not
technically a fully ... fully functioning EVV system.
It has no oversight or management of claims
integration.
4:43:15 PM
MS. HALTERMAN continued reading her written testimony as
follows:
Standards based EVV systems do not necessarily lead to
the savings that are found in the vendor based
solutions because the provider still maintains control
and check the validity of all of the data that is sent
to the state. There is no data sent to the state
independently and; therefore, no independence of any
EVV data. Standards based solutions may become too
costly for some of our smaller providers. They may
become far too complicated for smaller providers to
implement. Even our PCA Association has pointed this
fact out. Our fear is that if we implement a
standards based solution this could cause some of our
small providers in Alaska to close their doors and
impede competition due to an unfunded mandate of the
development of new systems. Standards based EVV
systems can significantly slow implementation because
if the state allows for integration of standards based
EVV solutions into existing business practices it may
take a lot longer to finish full implementation.
Standards based EVV approaches can be challenging for
some of our providers, it can be complicated for those
providers. They may delay the full implementation or
cause non-compliance for provider agencies that can't
fully implement. They may reduce the savings
generated, again due to the lack of oversight and
control. This is still essentially a (indisc.) model
with no upfront fraud prevention. Standards based
solutions place the burden of verifying or certifying
systems within the State of Alaska on the department
in order to assure that strong technical controls are
placed and maintained. Requiring the state to make
exceptions to address the needs of remote or small
providers as has been suggested by some, may force a
vendor solution in part to be considered along with a
standards based solution because otherwise small
providers may be forced to close their doors.
4:45:34 PM
MS. HALTERMAN continued reading her written testimony as
follows:
So, I want to talk a little bit about what EVV systems
do. EVV systems can do the following: they can reduce
inappropriate billing for home health and personal
care attendant services; they can improve
efficiencies; reduce paid work for both the agencies
and the State of Alaska's Medicaid Agency. They can
improve quality by ensuring services are provided for
the most vulnerable of our populations. They may
assist agencies and providers in helping to identify
unmet needs or missed or late appointments when
caregivers don't show. They may improve the ability
to make adjustments to care quickly by triggering an
alert to an agency who then knows the caregiver didn't
show up, they can initiate a backup plan. They can
improve policy decisions and improve strategies due to
the ... having access to the encounter data that the
state has never had before. It can improve data
collection, evaluation, and also provide a unified
view of each home and community based and PCA service
that will allow care to be examined across multiple
agencies and possibly multiple provider types. This
will improve the quality of services for those
beneficiaries. EVV systems can afford a more
effective invoice, billing, scheduling, and
documentation of the service delivery process and they
can lead to enhanced administrative processes for
those agencies. EVV systems capture and
electronically submit claims data with accurate dates
from visits that are verified which allows the state
to validate that the data is coming from an
independent source. EVV systems can ease reporting by
providing a central location that identifies the
support and services that those providers are
rendering. EVV systems can generate exception reports
that can be run ad hoc ... um, and they can reduce
adult protective service issues and the need for
investigations. These reports may help DHSS identify
concerns earlier than they have been able to do so in
the past. So, the benefits of EVV include the
potential to eliminate the padding of timesheets by
caregivers, it allows for a flag to the supervisors,
the agencies ... um, to alert to suspected abuse or
neglect. It can reduce errors, it can save money for
agencies and for the State of Alaska. If plugged into
the claims system it can speed up payments if
implemented with that claims system. It can ensure
compliance with state and federal regulations. It can
improve quality assurance and streamline processes
including payroll for many of our agencies. They can
improve efficiencies and effectiveness. And, lastly
save money on audits because the proof of care will be
automated.
I have in our research, Rep. Vazquez and I have
discovered...
4:49:10 PM
REPRESENTATIVE VAZQUEZ interjected that she wanted to place
certain relative experiences on the record and offered her
extensive Medicaid fraud background. She related that many
states have been using electronic visit verification (EVV)
systems for years, if not decades. As a prosecutor she attended
numerous national conferences on Medicaid fraud and has seen
demonstrations on how these systems work. Currently, there is
evidence that these systems can save states money by reducing
fraud, waste, and abuse, and add to the quality of care that the
most vulnerable of Alaska's population needs. Recent research
indicates that Congress has gotten onto this idea, and in 2015,
Representative Steven Guthrie introduced HR 2446, which would
require these types of systems for every state offering
Medicaid, which is now all 50 states, and stipulates that states
that do not implement the system will be subject a decrease of
Federal Medical Assistance Percentage (FMAP), the federal share.
The most recent action on this bill was November 4, 2015, when
the bill was forwarded to the subcommittee on Health to the full
Energy and Commerce Committee. In 2015, on the House of
Representatives side of Congress, Senator Charles "Chuck"
Grassley introduced SB 2416, which also would require EVV
systems in Medicaid and in addition Medicare. The bill
stipulates that states that do not implement will be subject to
a decreased federal share in Medicaid, or FMAP. She explained
that it's always difficult, as a prosecutor who also dealt with
civil cases, to chase after Medicaid providers after the fact
because it very difficult once the horse has left the barn to
recover money. In 2015, there was a PCA agency owner and it was
alleged that $1.2 million were billed inappropriately to the
Medicaid program. Restitution was ordered by the judge at
judgement but recovering $1.2 million posed a difficult
challenge for the state. This bill in essence would try to
catch the fraud, waste, and abuse, upfront before the horse
leaves the barn and it also adds to the quality of care for
individuals, she explained.
4:53:32 PM
MS. HALTERMAN added that their research identified a number of
vendors that provide this service. Sandata is the vendor the
sponsor's office has been working with to crunch numbers that
used some data from Kaiser Family Foundation from 2012. She
pointed out that Sandata would like to analyze more current data
and the department has been speaking with this vendor and they
had a meeting to share insights about these systems, and answer
questions. There are a number of vendors such as, First Data,
Vilify Health, Access, Technology Solutions, and Care Watch are
all EVV vendors. She explained that it has been made clear to
Sandata that no guarantee were offered to Sandata in the RFP
process. She said that unfortunately, of the 130 fraud cases
that have been investigated by Alaska's Medicaid Fraud Control
Unit, 120 of them are directly related to the populations that
would be targeted with this bill.
MS. HALTERMAN referred to Sandata's Brian Lawson's previous
testimony and said he is willing to make himself available for
anyone with further questions to explain the benefits of
analyzing real data and the return on investment found from an
effective implementation of an EVV system. Although, Sandata
was not their only research tool, it helped develop the pricing
and return on investment forecast is collected from the Kaiser
Family Foundation, its 2012 data. It has been noted that the
enrollment in populations in the Medicaid expenditures are down,
but only PCA data was presented. Ms. Halterman continued
reading her written testimony as follows:
While the return on investment that was generated by
Sandata includes not just PCA, it identifies potential
savings for home and community based waiver. Now, in
the targets that they presented on that return and
investment because it was not using actual Medicaid
data. They would need to have access to true data,
real data, from the department, enrollments numbers
and spending outcomes in order to present a more valid
forecast of what these savings could be. So now the
current data does show that the beneficiaries and
spending are down slightly for these populations that
would be targeted with this bill. It is clear that
the proper implementation of an EVV system would
provide a significant return on investment regardless
of what the numbers are, regardless of how much is
spent. The 5 percent return on investment was based
on the PCA and home and community based population
savings that use an EVV system. And the total of
those expenditures was approximately $305 million, the
numbers again used for the analysis was sample data
and it used fail information that the vendor
identified from a source that was valid but wasn't a
reliable ... necessarily a 100 percent reliable
source. If the department is willing to provide more
reliable data, the vendor is willing to analyze
current real data to come up with a realistic return
on investment. It should be noted that while Sandata
did present a return on investment that used 5
percent, 8 percent, and 12 percent returns, Medicaid
Fraud Control unit has alerted us that those are
conservative estimates because they have presented
that fraud has conservatively reached approximately 20
percent with those populations. So sadly, in light of
the testimony last year in Senate Finance and House
Finance it is clear that Alaska has a fraud problem.
Several documents...
4:59:54 PM
REPRESENTATIVE SEATON interrupted and pointed out that the
committee actually wanted a summary of changes. Before each
member is HB 315, with a proposal to take up a committee
substitute which is different, he said. The committee wanted a
summary of those changes which he opined that one requires that
a standards based model be used, and Version E is that the
department shall contract with the vendor to implement an
electronic visit verification (EVV) system. Also, he said it
required real time reporting, to the extent feasible. He asked
whether the committee has questions on considering the vendor
model versus the standard based model in the original bill.
5:01:25 PM
REPRESENTATIVE TARR advised she does not have Version E.
The committee took an at-ease from 5:01 p.m. to 5:05 p.m.
5:05:23 PM
REPRESENTATIVE WOOL noted that the committee heard from the
vendors during the last committee meeting and asked whether the
committee has heard from the department.
5:06:29 PM
DEB ETHERIDGE, Deputy Director, Division of Senior and
Disabilities Services, Department of Health and Social Services,
said she is available.
REPRESENTATIVE SEATON asked Ms. Etheridge to discuss fiscal note
wherein it lists $224,000 each year for the next five years;
however, in the analysis, he paraphrased the following: "Three
states passed legislation to implement an EVV program and two
are fully implemented but that they reported there was high cost
of however reported initial cost for implementation of $13
million." He remarked that he is trying to relate that although
they have a larger population, but it reads that "a timeline for
implementation be 24 months." He pointed out that this fiscal
note relates to Version A.
5:07:47 PM
REPRESENTATIVE VAZQUEZ offered a correction that the fiscal note
before the committee, OMB Component Number 2663, states that the
total cost is $224,200, and it would be 50 percent federal match
so the general fund match would be $112,100.
REPRESENTATIVE SEATON offered that it is a recurring cost and he
is trying to determine how that corresponds to the narrative,
and he paraphrased the following, "that said in several places
that the impacts were substantial.
5:08:55 PM
MS. ETHERIDGE responded that the fiscal note before the
committee is a fiscal note to the administrative component, and
it captures the department's personnel costs for implementation
and ongoing compliance and oversight of the electronic visit
verification (EVV) system. The fiscal note was developed on the
original version and not on Version E. The other estimated cost
that the department struggled to develop would have impacted the
Senior and Disability Services Medicaid component and at this
time there is not an indeterminate Medicaid component note.
However, the division did note in the narrative on its
administrative fiscal note that there would be expenditures
impacting its Medicaid budget, and it gave some logic about what
the division anticipates or why it had difficulty anticipating
the cost associated with how it would impact Medicaid.
REPRESENTATIVE SEATON surmised that was looking at one GGU
Health Program Manager II positions in Anchorage, and it is the
main portion of the fiscal note.
MS. ETHERIDGE agreed that it is the main portion of the
administrative fiscal note.
REPRESENTATIVE SEATON asked whether Ms. Etheridge had had a
chance to look at the vendor portion and generate a fiscal note.
MS. ETHERIDGE stated that she had an opportunity today to learn
more about the intention of the implementation of the EVV system
and she has a better understanding of what the obligations may
be and she is preparing a fiscal note.
REPRESENTATIVE SEATON added that he just wanted to clarify that
because there is a single fiscal note there, but that's if the
department would do it and not through the vendor model which is
Version E.
5:11:38 PM
REPRESENTATIVE TARR offered that due to the recent changes to
the PCA program, and also the major Medicaid reform package that
is moving through the legislature, her concern is that this is
potentially too many things at once.
MS. ETHERIDGE related that the department does, and the Division
of Senior and Disability Services has a number of initiatives in
which it is working on currently through Medicaid reform,
through its CMS compliance necessary for the home community
based services. Which includes the initiatives the department
has taken to streamline and have more oversight over its
personal care program. She noted that is part of the reason the
department would require additional staff to implement this
program, and the department anticipates it will take 24 months,
at least.
REPRESENTATIVE TARR surmised that the changes that affected the
amount of time each recipient is receiving, in part to address
the issue of potential fraud or misuse of the time. She opined
that in this particular instance, some of the potential problems
may have been addressed through that process.
MS. ETHERIDGE answered that the division has made some changes
to account for time for task, and it allocates time and then the
recipient receives a time that is authorized weekly. The
division feels like it has oversight and a more clear
understanding of the services it has been authorizing; however,
it understands the benefits of an EVV system as it has explored
implementing that system. There are some examples of rounding
that may happen that it may capture if it was to be directly
tied into the division's enterprise system so that claims were
tied into the system so there could be some efficiencies in that
way. She advised that it is difficult for the division to say
what percent of fraud would be realized at this time, but she
has talked to other states and is trying to get a handle on it.
5:14:24 PM
REPRESENTATIVE SEATON reminded the committee that the motion to
adopt Version E, a vendor system, is still on the table.
5:14:33 PM
REPRESENTATIVE STUTES removed her objection to adopt CSHB 315,
Version 29-LS1287\E, Glover, 3/21/16, as the working document.
There being no objection, Version E was before the committee.
CHAIR SEATON asked Ms. Etheridge to round out some numbers for
Version E.
MS. ETHERIDGE agreed.
[HB 315 was held over.]
HB 328-REGULATION OF SMOKING
5:16:36 PM
REPRESENTATIVE SEATON announced that the final order of business
would be HOUSE BILL NO. 328, "An Act prohibiting smoking in
certain places; relating to education on the smoking
prohibition; and providing for an effective date."
5:17:26 PM
REPRESENTATIVE TALERICO moved to adopt the proposed committee
substitute (CS) for HB 328, Version 29-LS1502\W, Martin,
3/18/16, as the working document.
REPRESENTATIVE SEATON objected for discussion.
5:18:20 PM
REPRESENTATIVE TALERICO noted that current Alaska law prohibits
smoking in many areas of the state, including healthcare
facilities, schools, childcare facilities, and public meeting
rooms in government buildings. He offered that one of his
biggest concerns is the state level of Medicaid expenditures
attributed to smoking is about $67 Million per year. There is
no doubt, he said, that a fair portion of this is certainly
driven by Alaska's current fiscal situation, but this committee
has routinely discussed healthcare and preventative measure to
improve Alaska's situation statewide.
CHAIR SEATON asked for a quick explanation of the significant
changes between the original bill and the committee substitute
being considered.
5:19:59 PM
JOSHUA BANKS, Staff, Representative Dave Talerico, Alaska State
Legislature, advised that Version W was drafted to mirror the
changes made to SB 1. [He presented a slideshow titled "HB 328,
The 'Take it Outside' Act," slides 1-6.]
5:20:10 PM
REPRESENTATIVE SEATON removed his objection to adopt Version W
as the committee's working document. There being no further
objection, Version W was before the committee.
5:20:48 PM
MR. BANKS continued his presentation and advised that HB 328 is
all about saving lives and dollars, helping Alaskans to be
healthier, and to spend less on healthcare. The bill will
provide a smoke-free work environment for Alaska's workforce, it
will create a standard for smoking that is effective statewide,
and it will put all businesses and workplaces throughout Alaska
on a level playing field. Currently, approximately one-half of
Alaska's population is covered by smoke-free workplace laws, yet
a 2015 Dittman Research survey shows that 88 percent of Alaskans
support a statewide smoke-free law. The sponsor's office has
conclusive evidence regarding Anchorage's smoke-free ordinance
that smoke-free laws do not have adverse economic consequences
for restaurants and bars subject to the laws. The bill does not
ban smoking or the use of e-cigarettes and Section 1 of the bill
depicts the areas where smoking is prohibited under AS
13.85.301.
5:22:27 PM
MR. BANKS explained that Section 1, AS 18.35.301(a) and (b)
provides a statewide smoking prohibition in enclosed public
spaces, public transportation vehicles and facilities, places of
employment, government buildings, buildings or residences where
a business is located for paid childcare, paid adult care,
healthcare facilities, Pioneer Homes, Veteran's Homes, and
vehicles that are places of employment with certain exceptions.
Also included under AS 18.35.301(c) are school grounds, public
parks, outdoor arena seating, smoke-free campuses, and areas
within certain distances from entrances, windows, and air in-
take vents of buildings where smoking is prohibited.
MR. BANKS continued that under Sections 2-4, 6-7, the Department
of Environmental Conservation (DEC) commissioner adopt
regulations for filing, processing, and investigating violations
of this bill, including the filing of complaints and issuance of
citations. AS 18.35.321 requires the DEC to work with the
Department of Health and Social Services to implement this
smoking prohibition and provide educational programs to those
affected by this bill. The DEC can also delegate
responsibilities to another agency, such as the Department of
Health and Social Services under AS 18.35.316(b). The bill
requires that a person in charge of a place where smoking is
prohibited display signs under AS 18.35.306, and the signs can
be provided by the Department of Environmental Conservation.
The Division of Public Health's Tobacco and Prevention and
Control Program will be responsible for providing public
education materials, he said.
5:24:21 PM
CHUCK KOPP, Staff, Senator Peter Micciche, Alaska State
Legislature, [referred to slides 7-12], and advised that the
Surgeon General's report is the 31st report in 50 years issued
to document the dangers of involuntary exposure to second-hand
smoke. More recent data suggests that this public health
concern is described as a "quite urgent matter" that must be
addressed. Since the period of time the Surgeon General began
reporting on this issue, over the last 50 years, the nation's
premature deaths caused by smoke and exposure to secondhand
smoke is up to approximately 21 million Americans. With regard
to DUI fatalities where people die violently and quickly, there
are 10,000 in one year, yet the nation has over 41,000
secondhand smoke fatalities in one year. The national blood
alcohol content (BAC) was 0.15 percent, then it was changed to
0.10 percent, and currently the BAC is 0.08 percent or greater.
He noted that drinking and driving a vehicle and secondhand
smoke both involve the reckless use of a dangerous substance
that kills people. He advised that approximately 440,000
smokers die in the United States each year.
5:26:25 PM
MR. KOPP noted that stroke is the most recent causally linked
disease to secondhand smoke exposure by the Centers for Disease
Control and Prevention (CDC). It is known that exposure to
secondhand smoke within 30 minutes has a "nearly immediate"
impact on the cardiovascular system, damaging blood vessels,
making blood more likely to clot, and increasing the risk for
heart attack and stroke. The Surgeon General's Report is that
there is no safe level of secondhand smoke exposure and it is
casually linked to 20 percent to 30 percent increased risk for
stroke. The national cost is $5.6 billion per year in lost
productivity due to exposure to secondhand smoke, and in Alaska
60 deaths each year and more than $1 million each year directly
related to lost productivity. He related that $1 million is
probably a conservative number, which is not counting Medicaid
costs which Representative Talerico covered earlier. He stated
that evidence is sufficient to infer this causal relationship
and the implementation of a smoke-free policy leads directly to
reduction in coronary events among people age 65 years and
older. There are several large municipalities in the United
States that have gone smoke-free, such as Colorado and Arizona,
that had upwards of 40 percent and 45 percent decrease in
coronary and stroke incidents over one year after going smoke-
free. The only variable they could contribute to the decrease
was going smoke-free. Mr. Kopp pointed out that the bill
sponsor looks at this bill as a question of rights of people
that choose to smoke versus the need to breathe, and a clean
indoor policy does not prohibit smoking it only requires that
those who choose to smoke do so in manner that does not threaten
or harm others.
5:28:25 PM
MR. BANKS turned to slides 13-20 of the slideshow and pointed
out that a good portion of the opposition to this bill is that
e-cigarettes are included within the bill as smoking. The
sponsor believes there is good rationale for grouping e-
cigarettes with traditional cigarettes even though they are
different from traditional cigarettes. E-cigarettes are
generally battery operated and use an atomizer to heat liquid
from a cartridge until it becomes a chemical-filled aerosol, and
can contain nicotine, ultrafine metal particles, volatile
organic compounds, and other carcinogenic toxins. The use of e-
cigarettes by high school students has increased dramatically
from 1.5 percent in 2011, to 13.4 percent in 2014. He remarked
that slide 14 depicts the trend in contrast to the decrease in
use of the traditional cigarettes by high school students. This
trend, as well as advertising by e-cigarette companies have many
people worried, including the CDC which believes that the
increased marketing and use by youth of e-cigarettes could
reverse the progress in preventing tobacco use by youth. The
CDC noted that some of the same marketing strategies used by the
tobacco industry are being used to encourage the use of e-
cigarettes by today's youth. Under AS 11.76.109, it is illegal
to sell or give products containing nicotine to anyone under the
age of 19, and e-cigarette retailers do not need a sales license
endorsement, so there is no program of compliance checks for
these sales, he pointed out.
5:30:19 PM
MR. BANKS, turned to side 17, and advised that separating
smokers from non-smokers, air cleaning technology, and
ventilation systems cannot effectively and reliably protect
public health. Smoke-free workplace laws have been seen to help
reduce tobacco use among smokers, and former Surgeon General C.
Everett Koop, who served under President Ronald Reagan, stated
the following:
The right of smokers to smoke ends where their
behavior affects the health and well-being of others;
furthermore, it is the smoker's responsibility to
ensure that they do not expose non-smokers.
MR. BANKS continued that as previously mentioned, approximately
one-half of Alaska's population is protected by local ordinances
from secondhand smoke at work, including: Anchorage, Juneau,
Bethel, Dillingham, Unalaska, and Palmer. The remaining
boroughs with large populations do not have the legal health
powers to enact smoke-free laws, and this does not include the
unorganized boroughs of Alaska. Overall, Alaskans support laws
such as HB 328, and 88 percent of Alaskans overall agree that
all Alaskan workers should be protected from secondhand smoke in
the workplace. This includes the majority of smokers who
support smoke-free workplace laws, and by regions in Alaska the
support of this law ranges from 75 percent to 88 percent. He
related that the legislation is good for Alaskan's health,
businesses, and good for Alaska overall. He said that a number
of research sources used to create the slideshow are slides 20-
21.
5:32:14 PM
REPRESENTATIVE SEATON referred to Section 1, AS 18.35.301(b)(7),
page 2, lines 13-14, which read:
(7) in a building or residence that is the
site of a business at which the care of adults is
provided on a fee-for-fee basis;
CHAIR SEATON asked whether that includes PCAs that are receiving
personal care health services in their own home. He explained
that they've been trying through Medicaid to get out of
institutional care by providing services at home.
MR. KOPP responded that it does not, this was an amendment in
the Senate side to specifically make it so that a residence
being occupied by a homeowner who is provided personal
assistance care is not required to stop smoking. He explained
that it is only when a residence is used as a business, which is
why specific language was included, that it is site of a
business in which the care of adults is provided. Unless it is
an adult care business, a homeowner can smoke "if they are
receiving care from a personal care assistant," he explained.
5:33:58 PM
CHAIR SEATON referred to Section 1, AS 18.35.301(d)(1)(D), page
3, lines 13-14, which read:
(D) that is a freestanding building not
attached to another business or to a residence;
CHAIR SEATON asked the relationship to subparagraph (D) versus
"it doesn't share a ventilation system with another part of the
building." He asked whether that is the purpose of the
freestanding building, that it is not attached to any other
building or business.
5:34:39 PM
MR. KOPP replied that primarily its purpose is to prevent fumes
and particulates from being shared and a free standing building
accomplishes that. Representative Seaton is correct in that the
primary concern is that it is not impacting other businesses, he
replied.
REPRESENTATIVE WOOL referred to the free standing building, and
used the example of downtown Juneau where it is buildings,
buildings, buildings touching, although there are separate
walls, it depends upon the actual structures. He asked whether
those are free standing because there is not an air gap between
them or are they continuous buildings.
MR. KOPP opined that from an engineering standpoint most of
those building would probably be considered free standing
because they do not appear to be structurally dependent upon one
another.
5:35:50 PM
REPRESENTATIVE WOOL opined that if one of those buildings was
torn down the others would still be standing, hence free
standing.
MR. KOPP responded yes, that is a good way to define it.
REPRESENTATIVE WOOL said he was uncertain whether the buildings
touched walls at the Rockwell, in downtown Juneau.
REPRESENTATIVE SEATON noted that his normal definition of a free
standing building is buildings that are not in contact with each
other. He opined that the definition needs to be clarified.
MR. KOPP agreed.
REPRESENTATIVE STUTES noted that there is a zero fiscal note,
yet DEC is required to provide signs to hundreds of places, is
required to enforce the statute, and is required to educate the
public. She asked how that is possible with no money.
5:37:17 PM
MR. KOPP offered that under the law, DEC is already required to
do this and this bill is amending current law. The DEC already
has regulatory oversight of the prohibition of smoking and
already works with the Department of Health and Social Services
with signage. The sponsor drafted the bill so that the signs
required are part of its current inventory, and many of these
places are already posted "smoke-free" workplaces involving
state facilities and buildings. He advised that it is part of
the Department of Environmental Conservation's ongoing expense
that it is already engaged with. Current law was just amended
but it currently has this regulatory oversight, he related.
REPRESENTATIVE STUTES surmised that approximately 50 percent of
the municipalities, villages, and cities in Alaska are smoke-
free.
MR. KOPP agreed and related that most of the buildings that have
the infrastructure and population base are already covered.
REPRESENTATIVE STUTES said she does not believe there is no
fiscal note that should be attached to this because it doesn't
make sense.
CHAIR SEATON advised that the department will be asked to
justify its fiscal note.
5:39:20 PM
REPRESENTATIVE TARR referred to Section 1, AS 18.35.301(c), page
2, line 18, which read:
(c) Smoking is prohibited outdoors
REPRESENTATIVE TARR advised that these are in new sections of
the bill and referred to paragraph (c)(1), which read:
(1) at an area located at a public or
private school or a state or municipal park that is
primarily designated as a place for children to play;
REPRESENTATIVE TARR opined that she thinks of Alaska's public
lands as being available for anyone to enjoy whether an adult or
a child. For example, currently someone could be at a municipal
park and smoke a cigarette and this bill would prohibit that.
She asked who is going to say whether the park has to have a
certain number of picnic tables that a certain percentage of
adults would also frequent.
MR. KOPP responded that the key qualifier for that language is
that it is a park that is primarily designated as a place for
children to play. Municipal parks are not primarily playgrounds
as some are campgrounds, and the emphasis here is those that are
primarily designated as a place for children to play.
5:41:13 PM
REPRESENTATIVE TARR referred to page 2, line 21, (c)(2), which
read:
(2) in a seating area for an outdoor arena,
stadium, or amphitheater;
REPRESENTATIVE TARR noted there are places that have gone smoke-
free and have physically built something to be a smoking area.
Although, if this were an outdoor facility where there was a
designated smoking area it appears that the language is broad
enough that that would also be prohibited. She asked that the
restrictiveness of that language be explained.
5:42:06 PM
HILARY MARTIN, Attorney, Legislative Legal and Research
Services, Legislative Affairs Agency, Alaska State Legislature,
responded that the park issue on paragraph (1) reads that it is
primarily designated as a place for children to play, although
it is slightly unclear there would have to be a decision made
that it is primarily a place for children to play. She referred
to the park strip in downtown Anchorage where there are ball
fields and other things, and then there is a playground area
and, she opined, that is what the bill is getting at. Signs
would also have to be posted with the idea that a person
wouldn't be walking and suddenly walk into an area where smoking
is prohibited and didn't realize, she offered.
REPRESENTATIVE TARR pointed out that she has difficult with that
because in the neighborhoods she represents she frequently sees
people at the parks smoking, but they are doing it there rather
than being at home where the children are. She described it as
trying to make a good decision to not smoke around children by
going to a different nearby location that has a picnic table or
a swing. Although, she said, that would put them in a situation
of being in violation of the law. She expressed discomfort
because it appears that enforcement could be difficult and it
may be left to interpretation as to what is legal in that
particular area, and unfairly get someone in trouble.
MR. KOPP suggested deleting "primarily" and the provision would
read "designated as a place" so there is no question, and a no
smoking sign must be posted close to the playground.
5:44:45 PM
REPRESENTATIVE WOOL pointed out that there are many outdoor
recreational areas that have a smaller area within it where
children play, and within that same body of land people may be
walking their dogs, and adults hangout and play Frisbee with
other adults. He offered that he can see mission creep as far
the "Take it Outside" issue wherein a person can't just take it
outside in that they have to take it outside to a certain area
outside. He referred to Section 1, AS 18.35.301(c)(4)(A) and
(B), page 2 lines 25-29, which read:
(A) 10 feet of an entrance to a bar or
restaurant that serves alcoholic beverages;
(B) 20 feet of an entrance, open
window, or heating or ventilation system air intake
vent at an enclosed area at a place where smoking is
prohibited under this section; or
5:45:43 PM
REPRESENTATIVE WOOL remarked that a person walking down the
sidewalk in downtown Juneau smoking would have to walk in the
middle of the street to not violate (c)(4)(A) and (B).
MR. KOPP clarified that the intention with not being within 10
feet of a bar or restaurant is that those tend to be higher
volume businesses, people step outside and don't have to step
out as far. They do not have to walk in the middle of the
street and can walk up or down the sidewalk. He turned to
(c)(4)(B) and said 20 feet of an entrance would also cover
health care facilities and other places because it reads "at a
place where smoking is prohibited under this section." This
entire section covers a number of places that Mr. Banks
highlighted that fall under this provision. Rather than trying
to break down an individual distance it was standardized, he
explained.
REPRESENTATIVE WOOL surmised that prohibited other places may be
a hardware store, jeweler, or sandwich shop and would all be at
a 20 foot buffer so it may be difficult to walk down the
sidewalk, and he noted that may be the intent. He reiterated
that he is referring to a dense urban area such as downtown
Juneau or Anchorage.
MR. KOPP advised that the idea to keep the smoke outside is
primarily what the sponsors are getting at. Representative Wool
is correct, that the distance may be something to be discussed.
REPRESENTATIVE TARR referred to the questions regarding the
fiscal note and said that she noticed on page 4, beginning line
17 with the notice of prohibition and said smoking prohibited by
law and the burning cigarette but, she pointed out, if this will
be expanded to e-cigarettes and vaping she did not see a
definition in the bill for what would be considered those
products. She noted that these technologies are changing so she
was unsure whether that is a necessity. She referred back to
the "Notice of prohibition," and opined it would need to be more
explicit because there is a lot of confusion about the
international no smoking people are thinking like a traditional
tobacco cigarette. She said she was unsure whether she would
automatically think that e-cigarettes and vaping were
prohibited, and the language should be more explicit and in that
sense maybe the existing inventory of signage wouldn't actually
be as useable, or maybe could have a sticker put on it.
5:49:25 PM
MR. KOPP referred to the definition of smoking, Section 12, AS
18.35.399(11), page 9, lines 28-30, which read:
(11) "smoking" means using an e-cigarette or
other oral smoking device or inhaling, exhaling,
burning, or carrying a lighted or heated cigar,
cigarette, pipe, or tobacco or plant product intended
for inhalation.
MR. KOPP explained that the sponsors tried to cover as many
things as possible under that definition so the smoking signs
would work. Also, the public information campaign has rolled
out with the smoke-free law which is significant, and the
Department of Health and Social Services does that in
cooperation with the Department of Environmental Conservation,
which is identified in a later section and they work hand in
glove. Currently, that is one of the duties of the Department
of Health and Social Services under AS 44.29.020(a)(14), which
read:
(14) a comprehensive smoking education,
tobacco use prevention, and tobacco control program;
to the maximum extent possible, the department shall
administer the program required under this paragraph
by grant or contract with one or more organizations in
the state; the department's program must include
(A) a community-based tobacco use
prevention and cessation component addressing the
needs of youth and adults that includes use of
cessation aids such as a nicotine patch or a nicotine
gum tobacco substitute;
(B) youth-based efforts that involve
youth in the design and implementation of tobacco
control efforts;
(C) anti-tobacco counter-marketing
targeting both youth and adult populations designed to
communicate messages to help prevent youth initiation
of tobacco use, promote cessation among tobacco users,
and educate the public about the lethal effects of
exposure to secondhand smoke;
(D) tobacco use surveys of youth and
adult populations concerning knowledge, awareness,
attitude, and use of tobacco products; and
(E) an enforcement component;
5:50:36 PM
MR. KOPP agreed about the public education, and Alaska Airlines
as an example in that it advises no smoking and that includes e-
cigarettes.
REPRESENTATIVE SEATON referred to Section 1, AS 18.35.301(f)(2),
Page 4, lines 5-6, which read:
(2) on a marine vessel when the vessel is
engaged in commercial fishing or sport charter fishing
or is otherwise used as a place of employment.
CHAIR SEATON noted it is an exemption; however, he asked why the
language solely discusses ocean vessels because sport fishing
takes place in guiding on free water systems. He asked whether
the terminology "marine vessel" specifically is in there to mean
only at sea.
MR. KOPP referred to line 6, and noted that it includes sport
charter fishing. He said that charter means a vessel which is a
place of employment; therefore, sport fishing boats are also
exempted for the same purpose that a commercial fishing vessel
is. The state territorial waters only go out three miles so for
a near shore fisherman it means working on open decks where
there is outdoor, fresh air exposure. The skipper or captain
can regulate how far from the air intake or vent a fisherman
must stand when smoking. He described this as angels dancing on
the head of a pin - some of the judgment calls, but the people
in the work boat industry brought to the sponsors attention that
they are outdoors all of the time.
5:50:40 PM
REPRESENTATIVE SEATON remarked that the language will have to be
looked at because it starts on a marine vessel, and the others
are modifying what is being done but it is on a marine vessel.
It does not say that it is on a sport charter fishing vessels,
but rather a marine vessel when engaged either in commercial or
sport fishing. In the event a fisherman is halibut fishing this
would apply, but if the fisherman was on the Kenai River fishing
for King Salmon they are not on a marine vessel.
MR. KOPP noted that if the fisherman is out with friends sport
fishing, they can smoke. He referred to page 4, lines 1-6,
which read:
(f) Notwithstanding (b) of this section, unless
the owner or operator prohibits it, smoking is allowed
(2) on a marine vessel when the vessel is
engaged in commercial fishing or sport charter fishing
or is otherwise used as a place of employment.
MR. KOPP explained that it is being used as a place of
employment at that time, but if a fisherman is out having fun
fishing it wouldn't apply.
REPRESENTATIVE SEATON related that the language would be looked
at further.
5:54:10 PM
REPRESENTATIVE TARR referred to Section 1, AS 18.35.301(a)(3),
page 1, lines6-7, and lines 11-12, which read:
(a) Smoking is prohibited in an enclosed area in
a public place, including an enclosed area
(3) at a public transit depot, bus shelter,
airport terminal, or other public transportation
facility;
REPRESENTATIVE TARR opined that currently when going through an
airport terminal there is an enclosed designated smoking area
and asked whether the provision makes those areas illegal.
5:54:39 PM
MR. KOPP opined that currently there are not any airports, other
than international terminals which do because people are in
transit and are not under FTSA regulation. They may be allowed
to leave the airport while in transit and they do have a smoke-
free room. This legislation covers that as an exemption wherein
they can have the smoke rooms in those airports where people
cannot leave the airport to step outside.
5:55:11 PM
REPRESENTATIVE STUTES offered concern about the enforcement and
described it as passive enforcement such that "they are going to
give you a 1-800 number and if somebody's in violation you just
pick up the phone and call 1-800 and say, hey this place is in
violation," and that concerns her. To 86 someone, they will be
on the horn in a pair of seconds telling someone the
establishment is in violation. It further reads that "citations
could be made by the Department of Health and Social Services
designated staff or another agency," which is unclear. This can
be addressed at a later time but, she expressed, it is a concern
as it is the enforcement.
MR. KOPP advised that when Anchorage went smoke-free in 2007,
within five years of enforcement it only had three citations
because there was almost 100 percent voluntary compliance. This
is not a heavy handed thing and it is complaint driven and not
pro-active. In fact, for a peace officer to be involved these
offenses must occur in their presence and not called in.
Traditionally, he offered, it has been passively carried out
because people want this and they voluntarily comply. Joe
Darnel, with the Tobacco Prevention Program can speak to how the
program works as they have been doing this and it is low
maintenance on them to gain compliance. He explained that they
have a program of warnings, educating business owners, and that
Anchorage is over 300,000 people and have only had three
citations in five years.
REPRESENTATIVE STUTES commented that areas Mr. Kopp referred to
have voluntarily gone smoke-free, this is not a voluntary
program as the legislation is taking one-half of the state that
is non-smoking and, she said, it has been on the ballots and
they've voted it down.
5:57:40 PM
REPRESENTATIVE WOOL read, "in a seating area for an outdoor
arena, stadium, or amphitheater" means a seating area in the
prior three areas.
MR. KOPP responded where the public can come and be seated.
REPRESENTATIVE WOOL continued that an outdoor amphitheater
grassy hill is fine, although if it is a seating area ...
MR. KOPP advised it is a designated seating area for the public
to come in and sit for an event.
REPRESENTATIVE SEATON opened public testimony and advised all
testifiers to limit their testimonies to two minutes.
5:58:55 PM
GARY SUPERMAN, Owner, Hunger Hut Bar, Motel and Liquor advised
that he sits on the state board of CHARR, and said that all of
Mr. Kopps' citations and figures are alarming and provocative
for everyone to chew on. Unfortunately, he stated, they've been
promulgated out of a 1992 EPA study that was thrown out by the
United States District Court in 1995 as being pure junk science.
Advocacy groups assert that these bans help shape individual
preferences against smoking, and in fact these re-education
efforts have drastic reshaped attitudes of smokers and non-
smokers alike. He related that Alaska is acclimated to the fact
that public buildings and private building are now non-smoking,
what is unacceptable is the advocacy groups' absolute
unwillingness to allow a few remaining venues to accommodate
Alaskans own preferences. At this juncture in time, the rights
of non-smokers and non-patrons of bars supersede the rights of
his smoking patrons and himself as a business owner. He
expressed that there is no net benefit to anyone, this is simply
a taking, no one is compelled to enter his establishment, and he
respects adults choosing to make their own decisions. He
referred to postings and articles he has seen describing the
upcoming Senate vote on SB 1, and described it as little more
than a proclamation of disgust from his view point. It looks
like the former mayor of Soldatna and current mayor of Kenai
will soon be triumphant once and for all in their relentless
crusade to save society. Their zeal seeks to impose one of the
ultimate nanny state devices down the throat of those who only
wish to be left alone in the last refuges left in the state.
There is no smoking in public buildings and HB 328 and SB 1 are
de facto already as the only places left that allow a few bars
whose numbers dwindle annually, and he and his wife own one. He
related that the battle has smacked of elitism and basic
contempt for the unwashed working classes who still partake. He
advised that he will not comply and "you will have to bring the
strong arm of the state down on me. I will not be re-educated.
I loathe their politically correct agendas and dangerous
genuflections to special interests groups whose only interest is
control over those of us who still have a notion of what freedom
is."
6:01:58 PM
CHRYSTAL SCHOENROCK, Owner, Hunger Hut Bar, Motel and Liquor,
said she is the secretary for Kenai Peninsula CHARR and a member
of the Alaska State CHARR. She put forth that she would like to
know why smokers can't have the same rights as non-smokers as
there should be an area that does not prohibit smoking so
smokers do not have to go outside 20-30 feet from a building at
-10 to -30 below. Her patrons want smoking, all of her
employees smoke, and her patrons help her to pay the bills,
licenses, permits, stock, and taxes. She referred to the low
rate of oil prices and that people are being laid off, and said
she cannot wait five years to increase the amount of patrons in
her bar. When the small businesses are forced to close, Alaska
does not receive their taxes. She agreed to post signs
indicating that smoking is permitted, and if a patron doesn't
want to enter because they are a non-smoker, "then don't come
in. So be it." As it stands, the smokers have no rights and
this is not fair and just, and "as far as I'm concerned, my
patrons, and I have people coming in my bar that doesn't smoke,
nor do they drink. But, I feel that my patrons have a right to
have what they need and I feel that as a business owner paying
all my everything, that I should have the right to say what
going goes on in my establishment and not have to worry about
what's going on in my parking lot or in a little building."
6:04:20 PM
DANIEL LYNCH said he is representing himself and freedom in
Alaska. He related that it makes his heart sing to see so many
economic free market Republicans on the committee knowing that
they are not believers of the nanny state government and he has
confidence they will do the right thing and leave this
legislation in committee. America was built on tobacco and
freedom. There are two "watering holes" in Soldotna across the
street from one another, and one establishment has chosen not to
allow smoking, and the owner of the other establishment has
chosen to allow smoking. The BFW, Elks, and veterans currently
decide through their membership how to run their rules and their
buildings. He described that the numbers related to secondhand
smoke are speculative at best, and that he works on equipment
that causes his mustache to wring with oil yet he wouldn't be
allowed to smoke. In the event he succumbs to lung issues,
people would say that he was a smoker and it had nothing to do
with the diesel running out of his mustache. The fallacy of
being a workplace safety issue is a simple strawman, and driving
to the LIO office he passed six fast-food drive-through
restaurants and a dozen drive-through coffee shacks all with
employees hanging out the window sucking in carbon monoxide from
every vehicle, engine and tailpipe. It is known that smoking is
not a good habit and in his 45 years of doing so he has
contributed $10s of thousands of dollars to the federal, state,
borough, and city tax collectors, and he said he presumes the
legislature will increase alcohol and tobacco taxes again this
year. He asked that if the revenue from tobacco stopped, how it
would be replaced, by taking away the freedom of smokers.
6:07:22 PM
SHEB GARFIELD advised he is an ex-smoker and is now an avid
vaporer. He asked that the vaping provision in the legislation
be completely removed in that vaping is in this bill because it
looks like smoking. The bill includes vaporizers due to the
fear of secondhand vapor being as dangerous as secondhand smoke,
and it pre-emptively bans its use in public places and
businesses even though a short time on google will show the
opposite. He then read various studies and health expert's
reports that he would submit to the committee.
6:10:14 PM
CHAIR SEATON asked Mr. Garfield to send the studies
electronically to the committee.
6:10:29 PM
GREGORY CONLEY, Attorney, said he has been a leading advocate
for vapor products, e-cigarettes, and that he used them to quit
smoking approximately five years ago. He explained that vapor
products are not tobacco products, as it is anti-tobacco
technology products. Vapors are smoke-free, tobacco-free, and
often nicotine-free and are increasingly being recognized as a
smart way to get smokers to transition away from dangerous and
densely combustible cigarettes. Contrary to claims previous
made in this committee, there is no evidence that these products
pose risks to bystanders, but there is evidence of long harm
reversal or quality of life improvement in smokers who have made
the switch including smokers with COPD and asthma. He advised
that in previous testimony he discussed a review published last
year by Tuttle Publishing advising that one of its main
conclusions is that vaping should not be treated like smoking,
and it was endorsed by a dozen of the largest (indisc.) groups
in the United Kingdom, including Cancer Research United Kingdom,
the Royal College of Physicians, and the United Kingdom's
largest anti-smoking organizations. He surmised that these
groups support smoking bans but government mandated vaping
restrictions go too far. These restrictions could have grave
unintended consequences, such as sending a deadly message to
smokers that vaping is no less hazardous than inhaling burning
smoke. In 2014, among adult smokers that quit in the last year,
22 percent were using vapor products and these products are
helping smokers quit. These products also have the potential to
save Medicaid and Medicare costs because a study by State Budget
Solutions suggested a multi-billion savings if smokers need to
switch. He urged the committee to amend the bill's definition
of smoking to only include products that actually create smoke.
He added that this is also true for the vapor product retailers,
they need to be exempt from this bill even if they share a wall
to another business. Both Chicago and New York City, two anti-
tobacco cities that have banned smoking and retail tobacco
stores, created exemptions that allow vaporing in vape stores.
He asked that if the bill must move forward to consider
exempting bars, private workplaces and other places where the
public is invited and only adults congregate.
CHAIR SEATON advised that he was welcome to submit written
comments to the committee as well.
6:13:19 PM
MICHAEL CERVANTES, Owner, Banks Ale House, said he is a board
member for Alaska CHARR, and that as an owner of a local
business it is his choice to be smoke-free or not, and this bill
takes that privilege away from local entrepreneurs in the state.
He referred to testimonies regarding secondhand smoke and its
impact on individuals and he agrees that secondhand smoke is a
choice for an individual to make when entering a smoking
establishment. Most areas throughout the state, whether the
establishment is posted non-smoking or smoking allowed the signs
are posted at the entrance of most bars or restaurants. He
expressed that he disagrees with the testimony that when a
smoking establishment goes non-smoking they do not feel a
financial impact because friends and other owners who have gone
smoke-free and (indisc.) claim businesses grow because the
customers have left their establishment to go into a smoking
establishment. Not every owner has the opportunity to wait
multiple years to gain back or re-establish that customer base
that they lost to another restaurant or bar. He asked that the
committee oppose HB 328 as it does offend and restrict owners
and others from smoking being available to their community.
6:16:19 PM
ANGELA CERNICH, Owner, Artic Industries, said she is an Alaska
born Athabascan woman who along with her husband own and operate
Artic Industries. There is no irony in the fact that her
business focuses on (indisc.) in the workplace. Secondhand
smoke is a personal concern for her because as a child she was
raised in a smoke filled environment complements of her parents
who were proverbial chain smokers. This caused a profound
effect on her personal health in that she has many issues
related to her severe allergies with smoke. After moving out of
her home, many of the severe issues subsided; however, as a
young adult she always felt the asthmatic and lung issues
related to the damage done to her lungs. Last year at the
hospital with lungs that were collapsing, she was diagnosed with
Chronic Obstructive Pulmonary Disease (COPD) and she personally
never smoked a day in her life, but is now facing a lifelong
disease that will shorten her life, a disease she has to fight
with all of its symptoms. Even a common cold becomes a lengthy
disease that causes her to have coughing bouts that cause
migraine-like headaches and, yet she is not the one who caused
this. She expressed that when she hears 'no one should be
allowed to take away their right to smoke', she responds that
she does have a right to be in a smoke-free environment. She
related that some areas in Alaska are small with few jobs and
while taking care of her father who suffered from cancer, the
only job she could find was at the Inlet (indisc.), which is a
restaurant/bar that allowed smoking. Within one week she was so
sick she had to quit her job and because no other jobs were
available she was forced to leave and did not have the chance to
spend that time with her dying father. She related that if her
father were alive today, without a doubt he would look a person
in the eye and tell them to take smoking outside.
6:19:23 PM
CARMEN LUNDE, Director, Kodiak CHARR, said the Kodiak CHARR
opposes the bill because it believes strongly that business
owners have the right to make their own choices without
government on any federal, state, local level mandating laws for
a small business owner to go against their wishes. Punishing
smokers for their own good is repulsive to basic freedoms of
choice and she does not feel government has any role in making
these choices for its citizens. Kodiak has positively handled
the smoking the issue and has used the common sense approach
that works. There are 16 non-smoking establishments and 6
smoking establishments giving every adult a free choice to enjoy
their drinks in both type establishments, and this demonstrates
free choice at its best. Alaskans live in a country where
personal choice is one of its most cherished freedoms.
Personally, she said, every day one or more of our personal
choices are being taken away from us. She asked the committee
to not take another freedom away as people should not be forced
to stand outside to smoke a cigarette in cold and freezing
temperatures. She advised that two of Kodiak's busiest
establishments went non-smoking last year and within three
months had to re-instate smoking due to their heavy losses of
income, and she wonders how many businesses can weather that
loss in being forced to close their doors. Please leave the
choice of smoking or non-smoking to the men and women who own
these establishments as they have the right to do what is best
for their individual establishments, she said.
6:21:32 PM
ISAAC HEWELL, Owner, Cold Vapes 907, said he is vice-president
of Clear The Air Alaska which is the state's local trade
association and consumer advocacy for the vaping industry. He
advised is a former smoker who saved his life by switching to
electronic cigarettes and feels tremendously healthier as a
result. The use of e-cigarettes benefits the environment,
health, and costs to consumers, and it is premature to suggest
that vaping is unhealthy just by certain national health
advocacy's suggestions. He related that he is unaware of any
national double-blind multi-year academic studies but noted
various studies in the United Kingdom. Most recent studies
completed by the (indisc.) and funded by the FDA and NIH have
found that electronic cigarettes are not a gateway to tobacco
use, and that 75 percent of minors get cigarettes from social
sources. The exit for current tobacco users is to switch to
safe alternatives, and other states have recognized that vaping
is not smoking, such as Idaho, Nevada, and New York, he said.
6:24:31 PM
ALISON HALPIN offered that the bill violates individual human
rights and includes vaporizers as smoking. Vaping and smoking
are two entirely different things as stated in People v. Thomas,
in that an electronic cigarette does not contain or burn
tobacco. The court noted, instead the use of such a device
which is commonly referred to as vaping, involve the inhalation
of vaporized (indisc.) cigarette liquid consisting of water,
nicotine, (indisc.), and vegetable glycerin occasionally
(indisc.). She related that this state has a tobacco use
problem and as a former smoker who tried multiple DHSS approved
(indisc.) devices to try to quit tobacco and failed with each
product, she found vaping and has been tobacco free for three
years. Vaping has been proven by public health in England to be
95 percent safer than with combustible cigarettes. Alaska is
fighting against the tobacco problem, not the nicotine problem
in that is an organic chemical created by plants naturally.
Nicotine is found in many vegetables, such as eggplants,
potatoes, tomatoes, kale, and many other green leafy vegetables.
Nicotine is the only trait similar to tobacco products and she
urged the committee to remove vaping from this bill.
6:26:16 PM
BRIAN PREBLE said he agrees with everything the last two
witnesses testified to in that vaping is not smoking. He has
four children and does not allow them around his vaping, they do
not enter places that allows vaping which is his choice as an
adult and an American. He does choose to vape in his work
vehicle and outdoors and, he opined that responsible users of
vapor products often try to keep it out of the line of those it
could affect because they know what cigarettes have done to
people. He asked the committee to oppose this bill or at least
rewrite it to focus more on actual smoking and secondhand smoke,
and until more is known about vaping it should not be lumped in
with the issue of secondhand smoke.
6:27:52 PM
LARRY HACKENMILLER said that the mere presence of smoke inside a
building where the public is allowed does not legally constitute
a public health hazard, or where people are employed. In
federal law in the Clean Air Act, indoor air quality is
controlled by OSHA and under this act all air contaminants known
today are listed in the air contaminant standards of 29 CRF
1910.1000. It lists the concentration of the contaminant being
inhaled and the time of exposure to come up with a risk
assessment, and they all have "permissible exposure levels or
limits" to determine the public health risk associated with the
chemical. As for secondhand smoke in the air, OSHA the
authority of indoor air quality, has stated outright "field
studies on environmental tobacco smoking indicate that under
normal conditions the components in second ... in tobacco smoke
are diluted below existing permissible exposure levels (PELs) as
referenced in the Air Contaminant Standard. Further, it would
be very rare to find a workplace with so much smoking that any
PEL would be exceeded." He said it is difficult to justify the
need for HB 328, to protect the public health when no public
protections are needed under existing federal standards. The
data relating to death and major health issues attributed to the
presence of secondhand smoke in the workplace does not cite OSHA
as a reference in their quoted science references. He asked
whether the committee found that odd that the people with the
authority and control of indoor air quality has not been
referenced in all of these scientific studies about the woes of
secondhand smoke, 60 people dying a year of something that OSHA
indicates a person can't get enough of in a building. He
suggested asking the references of what OSHA has to say about
their research and to ask the experts to testify. This is
indoor air, what about outdoor air, what was the concentration
of the contaminants causing death and major health issues
outside the baseball stadium. Currently, AS 18.35 regulates
smoking in certain areas and states "the statute considers
smoking in any form a nuisance and a public health hazard and;
therefore, prohibits smoking in public places and indoor
places." This is in conflict with the Clean Air Act, he pointed
out, which identified public health hazard through the air
contaminant standards in practice today. The key word here is
hazard and the starting point for each of these issues is that
the indoor air quality does not legally recognize secondhand
smoke as a public hazard. He asked that someone show him the
science about outdoor air and testify about the patterns of
secondhand smoke and what the permissible exposure limit is for
outside air quality on secondhand smoke. He referred to the
fiscal note problem and said if the bill is passed that the
state will have to send a trooper out to the villages to give a
$50 citation so there will be a fiscal note.
6:31:33 PM
JENNIFER VARGASON said vaping saved her life from the ball and
chain of tobacco use, she and her family are healthier, and she
does not understand how smoking tobacco and vaping is the same.
Vapor products do not contain tobacco so there is no combustion
and research has shown that vaping does not have the harmful
effects of smoking, and there are no carcinogens for bystanders.
The ingredients in a liquid are in everyday food products
consumed, and it has been shown that nicotine is not harmful.
She referred to an article that stated that there have been
instances where nicotine has been known to help certain
conditions, such as Alzheimer's, depression, Parkinson's
disease, and more. She is an ex-smoker who, initially, rolled
her eyes at vaping but then gave it a try and since December
2013 has been completely without tobacco. She asked the
committee to please reconsider HB 328.
6:34:25 PM
JESSE WALTON asked that all references to vaping be removed from
the bill. She has been vaping since 2013 when she received a
Christmas gift from a nurse practitioner, which allowed her to
quit smoking. She feels healthier, has more energy, and is able
to get the snow machine unstuck. She listed the amount of
milligrams she started on and is now down to, and listed the
various remedies she previously tried, yet always found herself
with a cigarette in her hand. [Difficult to decipher Ms.
Walton's testimony due to audio.] There are many people in
Fairbanks trying to quit smoking for themselves and their
families, and there are reputable vape shops around Alaska where
people are welcome to learn about the industry, she said.
6:36:18 PM
TERRY CROWSON said that the committee is aware that secondhand
smoke is bad and how bad [background noises masked the audio].
She related that when a local vote to prohibit smoking is held,
those who vote against public smoking and lose the vote, lose a
lot more than face because the public loses the opportunity for
clean air. Although, the public has the choice to not go where
smoking is allowed, the public loses the opportunity to
socialize, do business, or whatever is offered. This bill would
protect not only folks who need a job bad enough to take a job
in a smoking situation, but also everyone who does business in
these places. The legislature has an opportunity to promote and
enable a healthier Alaskan environment. Please take action to
make this positive difference for healthy living for those
Alaskans who can't count on a clean deep breath, she asked. In
small communities there often is only one choice of a similar
place to do business and when that business allows smoke there
is no choice for those who want to avoid secondhand smoke.
After listening to prior testimony, she suggested removing the
vaping provisions and move on to protect Alaskans from
secondhand smoke.
6:38:41 PM
CHERYL SCHOOLEY said that people who have made the responsible
choice to not smoke are victims of secondhand smoke in
establishments where smoking is still legally allowed. This
backward mindset sends a message from the legislature that it is
okay to light up, and puff up, secondhand smoke. This bill
promotes a healthier Alaska which will lower health costs and
help budget challenges, without this bill it appears the state
is choosing to promote the negative effects. Alaska has a
pristine image to be proud of, and is a market for the tourism
industry, let's be a class act, she remarked.
6:39:38 PM
WAYNE CROWSON said he has listened to smokers testify today, and
listened to them having trouble breathing and coughing as they
spoke, which was him 20 years ago. His lungs are much clearer
now since he's quit smoking and he would like to keep them that
way, he commented. Please move this bill to the governor for
signing this session as the governor wrote "Alaskans Health
First," he said.
6:40:26 PM
ROBIN MINARD, Director, Public Affairs, Mat-Su Health
Foundation, said she strongly supports HB 328. While making
great headway in the Mat-Su and Alaska, she pointed out that
Alaska continued to have some of the highest tobacco use rates
in the nation. Tobacco use rates bump up its chronic
respiratory disease rates, such as bronchitis, asthma, and COPD.
Tobacco use costs Alaska $579 million annually in direct medical
costs and lost productivity due to tobacco related deaths. She
stressed that enacting this law in Alaska to require smoke-free
public places will help reduce these costs and will also help
reduce Medicaid costs, something that the legislators and the
Foundation care deeply about. Much has been said about the
effects of secondhand smoke and e-vaping, and she stated that
Alaska needs robust clean indoor air statutes that includes e-
cigarettes because adolescents perceive e-cigarettes as safer
than traditional cigarettes. In addressing the myths that these
products are safer or that they are a cessation tool, she
advised they are the opposite. These products are a grooming
tool, grooming kids to accept, like, and become dependent upon
smoking and nicotine. A 2015, National Institute of Health
report showed that ninth-graders using these e-cigarettes were
over three times more likely to begin using traditional tobacco
products than those who didn't. She asked the committee to keep
in mind that e-cigarettes have not been approved by the FDA as a
smoking cessation aide. As discussed earlier, only one-half of
Alaskans are protected by smoke-free workplace laws and many
jurisdictions, such as Mat-Su, do not have the health powers
necessary to pass an areawide smoke-free ban. This legislation
is the next step in further reducing smoking rates and
secondhand smoke exposure in Alaska, it is the next step in
raising the health status of all Alaskans, the Mat-Su Health
Foundation supports the bill, and she asked that the committee
expedite its passage.
6:42:40 PM
PETE BURNS said he is testifying for himself and Humpy's Great
Alaskan Ale House. He offered testimony as follows:
I know this sounds bad that sometimes go against the
grain and CHARR has always been a great advocate for
various industry stuff, but for this one I have to go
against them.
My story is, my father was born in 1936. He started
smoking in 1951, in 1994 he passed. He gave up
smoking. 1998 he had his first heart attack. He was
wheelchair bound from then for the next part of his
life. 2002 I had a pain in my hip, I went to the
doctors here in Anchorage, they sent me to the Seattle
Cancer Care Alliance in Seattle. One thing is that I
had never smoked, I had never been around it in my
life. I spent three and one-half months in the Cancer
Care Alliance, over a year am able to walk. And I
vividly remember my dad sitting in a wheelchair
sobbing thinking he had caused cancer in me. Whether
he did or didn't it did not matter when you are a
child your father is your idol. I went in remission
at that time, within one year and one-half. 2009 May
15th, my father got sick with what he thought was a
chest cold, he was admitted to a hospital in
Knoxville, Tennessee. July 29th, 45 days later he
passed away and in those 45 days he went from 185
pounds to 85 pounds. He developed emphysema and COPD.
He hid it from our family, he didn't want us to know.
Our family incurred over $300,000 in debt for his
hospital stays. It is a debt that we gladly would
have paid any day just to have one more day with our
father.
I am selfish. I miss my father. I wish someone back
in the 1950s and 1960s had done this to my father.
Taken that away from them. It's not about me, it's
not about you, it's about the families, their kids
that don't have a choice in this to grow up like me.
I'm a 44 year old man and mention my father puts me on
the ground. I cannot see him again, I cannot even
begin, I cannot learn from him again. All I can do is
know that he knows that I am fighting a good fight for
him. I beg you pass this, end it now. Thank you.
6:45:43 PM
JOHN YORDY, M.D., Anchorage and Valley Radiation Therapy
Centers, said he is testifying in support of this bill and on
behalf of the Anchorage and Valley Radiation Therapy Centers and
himself, he lives and works in Wasilla, and treats cancer
patients with radiation therapy. He related that his concern is
with the health risks of secondhand smoke and the disease
causing properties of being exposed to smoke. He referred to
the testimonies regarding businesses and individuals opposing
smoke-free work environments and explain that from the health
care perspective in treating cancer patients on a daily basis
and watching the effects of what cancer does, as well as knowing
the exposure to smoke has directly caused some of the cancers
that he is treating makes him compelled and passionate about
trying to eradicate smoking from the workplace. There are many
reasons why people may feel compelled to expose themselves to
secondhand smoke despite a desire to the contrary. It may be
the only job or the best job they can get and, he pointed out,
many people live in an area where it may be difficult to find a
good job so they feel compelled to put themselves into the
[smoked-filled] situation so they can put food on the table or
buy medicine for their children. There are other professions
dependent upon protecting themselves in a public situation such
as musicians, who may feel compelled to perform in an
environment that is smoke-filled. He related that his concern
is for these people who may not be smokers themselves, but are
being forced to partake in work situations that cause them to
breathe in smoke that can be harmful to their health. For these
reasons, he said he strongly supports this legislation and asked
that the committee consider passage so all Alaskans can work and
live in smoke-free workplace environments.
6:48:15 PM
OWEN HANLEY, M.D., Fairbanks Memorial Hospital, said he is a
pulmonary lung doctor and he strongly supports the legislation.
He pointed out that patients in Fairbanks want the same
protection that citizens in Juneau and Anchorage have, and
disagrees with the remark that one-half of the state wanted it
and the other half didn't want it and voted it out. He related
that Fairbanks hasn't had an opportunity because our borough has
no health powers. [Audio difficulties.] My patients would love
to have a smoke-free environment (indisc.) in Fairbanks. Some
patients are living in housing and on oxygen but the people in
the hallways and next door are smoking and have ventilation
systems (indisc.). Most Alaskans would like to enjoy the same
opportunities of smoke-free clean air that legislators have in
their buildings, he said. (Indisc.) testimony that since OSHA
doesn't find secondhand smoke exceeds a particular toxic
standard that it is therefore safe. The science of the evidence
is overwhelming that secondhand smoke is lethal, and the
evidence is overwhelming that limiting secondhand smoke has
dramatic reduction in heart attacks and strokes. E-cigarettes
must be banned, while it may be true that some e-cigarettes are
safe, there are enumerable things that can be put in the
containers such as, nicotine, marijuana, or an unlimited amount
of chemicals, an e-cigarette is just a delivery device and it
would be impossible to legislate or enforce what is in an
individual vaping device. He stated that there is no way to
ensure that an e-cigarette contains a safe substance, and
whether the person next to them is producing a harmful toxin.
The legislation is not asking people to quit using it, just to
take it outside, he pointed out.
6:51:00 PM
ERIC VARGASON referred to the prior testimonies and opined that
everyone wants the same thing, although, he does not believe
including vaping and e-cigarettes language is most prudent. He
said he opposes this bill due to the inclusion of the vaping
language because by not allowing sampling "e-juices" in vape
shops the bill is basically pushing more people to smoke, at the
end of the day. He advised the committee that everyone wants
clean air and to consider the relevant studies testified to
today, otherwise, it as not only jumping the gun but it is
irresponsible and overreaching. He said that when he is alone
in his house vaping and his children are with their mother, he
is still left to these standards. Not only is that not fair, he
advised but the government is telling him what he can and cannot
do in his own house provided he is not hurting anyone else. He
said he has chosen to not vape around anyone else, vaping has
made him healthy, and speaking as a former smoker he does not
need a study to tell him how he feels right now.
6:53:21 PM
STEVEN MAPES said he is speaking in opposition to HB 328 and is
speaking for all of the adults on the Kenai Peninsula who have
made the choice to vape rather than smoke. He referred to
various studies and noted that one study indicated the threshold
limit values of vapors produced by e-cigarettes were magnitudes
below OSHA limits. Adults choosing to vape rather than smoke
looked to unbiased independent studies to help them make
informed decisions. He stated that vaping has saved previous
smokers thousands of dollar because they "ain't paintin their
lungs with tar and fillin their blood stream with carbon
monoxide" and it has had a tremendous positive impact on their
lives, including his. This bill would effectively regulate this
healthier alternative out of existence, and it will harm the
health and wellbeing of the citizens of Alaska. The standalone
language for vape shops and secondhand vape goes against all of
the science and research available today. He related that both
of his parents died of lung cancer and it was ugly, and he made
the choice to quit smoking and finally found vaping. He has
been vaping for four years and can breathe and exercise and
feels about 1,000 times better. On a side note, he said he sees
adults writing testimonies for their children to read at these
teleconferences, and he watches this happening at the Kenai LIO
every time he goes down there, and these actions taint this
process.
6:55:41 PM
BOB URATA, MD, Valley Medical Care, said he was born and raised
in Wrangell, and has practiced medicine in Juneau since 1984.
He has been a volunteer for the American Heart Association for
16 years and is testifying today as a representative for the
American Heart Association and himself. He expressed his
support for this bill and the inclusion of e-cigarettes because
every 34 seconds an American dies of a heart attack, every 40
seconds an American dies of a stroke; and cancer and
cardiovascular disease are the number one and two causes of the
deaths of Alaskans. Secondhand smoke is one of the main causes,
he stressed and it kills over 50,000 Americans each year, it is
expensive as the CDC reports secondhand smoke exposure causes
the United States to spend $5.6 billion a year in lost
productivity, tobacco expenditures in the United States are $133
billion in direct medical care for adults, and this state may
save $5 million in Medicaid medical expenses if not more. An
example of a success of the Clean Air Act is Pueblo, Colorado -
1.5 years before and after passage of its smoke-free ordinance
it saw a 20 percent rise in bar and restaurant sales tax revenue
and a 27 percent decrease in heart attacks. He opined e-
cigarettes should be included due to the serious questions about
their safety because the FDA found toxins that are known to
cause problems to health, and also nicotine in the products. A
medical saying is "First do no harm" and he believes that vaping
must remain in the bill. Imagine the many lives saved if
cigarettes had been properly studied before being placed on the
market and Alaskans must make sure that e-cigarettes are safe
before exposing everyone to them. In closing, the positive
impacts will benefit many in the short and long term and on
behalf of the American Heart Association and many Alaskans, he
urged the committee to support this bill.
6:58:27 PM
ANGELA CARROLL, Smoke-Free Alternative Trade Association, said
she represents the Smoke-Free Alternative Trade Association and
noted that more states are looking at electronic delivery
systems to add a solution to the tobacco problem. These states
are reviewing the science behind this new technology that is
saving lives and could ultimately save billions in health care
costs including lost work time, per a scientific study released
by the State Budget Solutions in March 2015. She read various
studies and peer reviewed studies and advised that they have
been submitted as documents of opposition. She remarked that as
representatives of Alaska the committee has an opportunity to
show its constituents the members care about their health, and
are in favor of Alaskans utilizing a safer alternative to
combustible cigarettes by supporting vape shops. Alaskans make
the choice to enter a vape shop to test flavors and find the
device to help them to maintain that vapor alternative. This
bill would force current vape owners to relocate (indisc.) for
vape products and this one provision will force most vape shop
owners out of business in Alaska, eliminating the opportunity
for adult Alaskans who currently smoke from discovering this
alternative to combustible cigarettes. For these reasons the
members of the Smoke-Free Alternative Trade Association (SFATA)
are asking that the vape language be removed from this bill, and
in the alternative SFATA is asking for the standalone
requirement to be removed so they can continue to operate in
their current location. No shop currently meets these
requirements and it would be cost prohibitive for these "mom and
pop" establishments to (indisc.) standalone structures. If the
bill passes as written the SFATA members would close up existing
shops and this alternative combustible cigarette would be lost.
She asked that the legislation be re-written before passing it
out of committee.
7:01:47 PM
JUNE ROGERS said she is testifying as a concerned member of the
community and as a business owner. She said she has long been
in favor of a smoke-free environment because 15 years ago when
she and her husband began their business, a coffee house and
recording studio, they determined that the business would be
smoke-free. A significant factor in her strong support of this
bill is that her mother was diagnosed with emphysema and had
never smoked, although, she did work in smoke filled restaurants
for most of her life. Ms. Rogers advised she has never smoked,
but in earlier times of her performance work she spent too many
hours in smoke filled rooms, breathing more deeply than perhaps
anyone else in the room as she sang for their entertainment.
While she does not have the severe condition that her mother
has, she does have issues of allergic and problematic breathing
responses to smoke filled rooms. She referred to the comment
that people make the choice to work in such conditions, true
enough and; therefore, made the decision to create her own smoke
free workplace where her band performs every Friday and Saturday
evening. However, she pointed out this is not a realistic
option for most musicians, particularly young hopeful musicians,
and stressed that they should not have to put their health in
jeopardy in order to work. In speaking with club owners who
have converted to smoke free venues she is not surprised when
they advise that their revenue increased substantially. Only
recently did she investigate the properties of e-cigarettes but
based upon what she has learned, she firmly agrees that
including them as an item that does not deserve acceptance in a
smoke-free venue. As Alaskan leaders, legislators are called
upon to decide on a broad spectrum of issues that relate to the
wellbeing of Alaska's communities, she asked that the committee
give its upmost consideration to this bill as it will provide a
more productive and healthy workplace, and not surprisingly will
also benefit in less healthcare costs for Alaska.
7:04:00 PM
DANNY RUEREP said his opposition to HB 328 is based solely [on
vaping] because he does not want to see the vape shops in local
communities removed because it will destroy the vaping local
economies. He described this as a step in the wrong direction
because he had been a smoker for 20 years until he found a local
vape shop and sampled every liquid he desired, and advised he
has now been two years free of cigarettes. He related to the
committee that in taking the vaping provisions out of the bill
there will be less opposition.
7:055 PM
QUOC DONG said that he had smoked for 10 years, vaped for three
years, quit vaping, and has gone from 18 milligrams of nicotine
to zero. He opined that it is a good tool for people to
transition their lives from tobacco smoking. While in school he
was taught that if he made a mistake with something he had to do
it in the correct manner twice before he could learn it
correctly, and felt that is the same for any habit. In order to
quit smoking, he opined, a couple of years might be a more
reasonable expectation of people and that eventually most people
vaping will quit vaping in addition to not smoking. The
environment in which vaping has been created is not similar to
smoking as it is built on innovations. In an economy that has
led to many devices and different types of e-liquids in a short
period of time, if bills such as HB 328 continue to be passed in
the United States, different innovations will arise and the
legislature will be dealing with a whole other thing that could
be far worse than vaping. In order to pre-empt that, he opined
the committee should reconsider the language and reconsider how
vaping is used before actually passing laws. With the
introduction of marijuana to Alaska, he opined that the two
industries side-by-side and a negative view on vaping could
potentially create a hazardous environment for nicotine users.
He advised that some vape shops in Anchorage sell marijuana
tools which, unsurprisingly, are smokeless devices that don't
produce vapor. Speaking as a person who formerly vaped, he said
he has quite a bit of vaping paraphernalia which also includes
100 milligrams per milliliter nicotine. He related that if he
were to drink the entire bottle he would die so some people may
have the wrong impression about what vaping is.
7:08:56 PM
OCTAVIA HARRIS, American Lung Association in Alaska, said the
American Lung Association in Alaska supports HB 328 as there is
no safe level of secondhand smoke or aerosol exposure. She
pointed out that there is statewide support for this bill and
approximately 1,000 businesses and organizations from all
corners of the state have signed resolutions in support of this
measure, and an updated version will be submitted to the
committee. She asked that committee support the legislation and
pass it out of committee.
7:10:11 PM
EMILY NENON, Director, Alaska Government Relations, American
Cancer Society Cancer Action Network, noted that a number of
volunteers contacted her after Tuesday's hearing regarding not
getting a chance to testify and she suggested that the folks
send in their written comments. She pointed out that the
legislation is modeled after a number of the existing ordinances
in the state including Anchorage. The language around the
children's play area is discussing playground equipment, which
is identical to the language already in place in Anchorage and
existing ordinances around the state. No smoking on a toddler's
swing is how it has been interpreted over time, she remarked,
and the bill is focused on inside workplaces. Regarding the
questions around the education program, the Department of Health
and Social Services has an existing tobacco prevention program
with grantees around the state performing educational (programs)
regarding secondhand smoke and other tobacco issues. She
pointed out that those folks performing the education work now
will be transitioning some of their work to implementation, and
education around this bill is already in place and being
performed which is one of the reasons there is no additional
cost. Many discussions have come up around electronic
cigarettes as cessation products which, she related, is not the
argument at hand in this bill because it is simply discussing
exposure to secondhand aerosol.
REPRESENTATIVE SEATON, after ascertaining no one wished to
testify, closed public testimony.
7:13:06 PM
REPRESENTATIVE SEATON advised he will take the bill up at a
future hearing, questions were submitted to the sponsor who
indicated he will return the answers to the committee, and it
would be best that all amendments are prepared by Legislature
Legal and Research Services.
[HB 328 was held over.]
7:13:45 PM
ADJOURNMENT
There being no further business before the committee, the House
Health and Social Services Standing Committee meeting was
adjourned at 7:13 p.m.