Legislature(2019 - 2020)CAPITOL 106

04/04/2019 03:00 PM HEALTH & SOCIAL SERVICES

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* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
*+ HB 84 WORKERS' COMP: POLICE, FIRE, EMT, PARAMED TELECONFERENCED
Heard & Held
-- Testimony <Invited/Public> --
*+ HB 89 OPIOID PRESCRIPTION INFORMATION TELECONFERENCED
Heard & Held
-- Testimony <Invited/Public> --
*+ HB 92 DIRECT HEALTH: NOT INSUR; ADD TO MEDICAID TELECONFERENCED
Heard & Held
-- Testimony <Invited/Public> --
*+ HB 114 MEDICAL PROVIDER INCENTIVES/LOAN REPAYM'T TELECONFERENCED
Heard & Held
-- Testimony <Invited/Public> --
+ Bills Previously Heard/Scheduled TELECONFERENCED
                    ALASKA STATE LEGISLATURE                                                                                  
      HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE                                                                     
                         April 4, 2019                                                                                          
                           3:09 p.m.                                                                                            
                                                                                                                                
                             DRAFT                                                                                            
                                                                                                                                
MEMBERS PRESENT                                                                                                               
                                                                                                                                
Representative Ivy Spohnholz, Co-Chair                                                                                          
Representative Tiffany Zulkosky, Co-Chair                                                                                       
Representative Matt Claman                                                                                                      
Representative Harriet Drummond                                                                                                 
Representative Geran Tarr                                                                                                       
Representative Sharon Jackson                                                                                                   
                                                                                                                                
MEMBERS ABSENT                                                                                                                
                                                                                                                                
Representative Lance Pruitt                                                                                                     
                                                                                                                                
COMMITTEE CALENDAR                                                                                                            
                                                                                                                                
HOUSE BILL NO. 84                                                                                                               
"An  Act relating  to  the presumption  of  compensability for  a                                                               
disability  resulting  from  certain diseases  for  firefighters,                                                               
emergency medical technicians, paramedics, and peace officers."                                                                 
                                                                                                                                
     - HEARD & HELD                                                                                                             
                                                                                                                                
HOUSE BILL NO. 89                                                                                                               
"An Act relating to the  prescription of opioids; relating to the                                                               
practice  of dentistry;  relating  to the  practice of  medicine;                                                               
relating to  the practice of  podiatry; relating to  the practice                                                               
of osteopathy; relating  to the practice of  nursing; relating to                                                               
the  practice  of optometry;  and  relating  to the  practice  of                                                               
pharmacy."                                                                                                                      
                                                                                                                                
     - HEARD & HELD                                                                                                             
                                                                                                                                
HOUSE BILL NO. 92                                                                                                               
"An Act  exempting direct health care  agreements from regulation                                                               
as  insurance; establishing  a direct  care  payment program  for                                                               
medical  assistance recipients;  and providing  for an  effective                                                               
date."                                                                                                                          
                                                                                                                                
     - HEARD & HELD                                                                                                             
                                                                                                                                
HOUSE BILL NO. 114                                                                                                              
"An Act relating to a workforce enhancement program for health                                                                  
care professionals employed in the state; and providing for an                                                                  
effective date."                                                                                                                
                                                                                                                                
     - HEARD & HELD                                                                                                             
                                                                                                                                
                                                                                                                                
PREVIOUS COMMITTEE ACTION                                                                                                     
                                                                                                                                
BILL: HB 84                                                                                                                   
SHORT TITLE: WORKERS' COMP: POLICE, FIRE, EMT, PARAMED                                                                          
SPONSOR(s): REPRESENTATIVE(s) JOSEPHSON                                                                                         
                                                                                                                                
03/06/19       (H)       READ THE FIRST TIME - REFERRALS                                                                        
03/06/19       (H)       HSS, L&C                                                                                               
04/04/19       (H)       HSS AT 3:00 PM CAPITOL 106                                                                             
                                                                                                                                
BILL: HB 89                                                                                                                   
SHORT TITLE: OPIOID PRESCRIPTION INFORMATION                                                                                    
SPONSOR(s): REPRESENTATIVE(s) SPOHNHOLZ                                                                                         
                                                                                                                                
03/11/19       (H)       READ THE FIRST TIME - REFERRALS                                                                        
03/11/19       (H)       HSS, FIN                                                                                               
04/04/19       (H)       HSS AT 3:00 PM CAPITOL 106                                                                             
                                                                                                                                
BILL: HB 92                                                                                                                   
SHORT TITLE: DIRECT HEALTH: NOT INSUR; ADD TO MEDICAID                                                                          
SPONSOR(s): REPRESENTATIVE(s) JOHNSTON                                                                                          
                                                                                                                                
03/13/19       (H)       READ THE FIRST TIME - REFERRALS                                                                        
03/13/19       (H)       HSS, FIN                                                                                               
04/04/19       (H)       HSS AT 3:00 PM CAPITOL 106                                                                             
                                                                                                                                
BILL: HB 114                                                                                                                  
SHORT TITLE: MEDICAL PROVIDER INCENTIVES/LOAN REPAYM'T                                                                          
SPONSOR(s): REPRESENTATIVE(s) SPOHNHOLZ                                                                                         
                                                                                                                                
03/27/19       (H)       READ THE FIRST TIME - REFERRALS                                                                        
03/27/19       (H)       HSS, FIN                                                                                               
04/04/19       (H)       HSS AT 3:00 PM CAPITOL 106                                                                             
                                                                                                                                
WITNESS REGISTER                                                                                                              
                                                                                                                                
ELISE SORUM-BIRK, Staff                                                                                                         
Representative Andy Josephson                                                                                                   
Alaska State Legislature                                                                                                        
Juneau, Alaska                                                                                                                  
POSITION STATEMENT:  Presented HB 84 on behalf of the bill                                                                    
sponsor, Representative Josephson.                                                                                              
                                                                                                                                
PAMELA MILLER, Executive Director                                                                                               
Alaska Community Action on Toxics                                                                                               
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  Testified in support of HB 84.                                                                           
                                                                                                                                
DARCEY PERRY, Vice President                                                                                                    
Public Safety Employees Association                                                                                             
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  Testified in support of HB 84.                                                                           
                                                                                                                                
MIRANDA DORDAN, Intern                                                                                                          
Representative Ivy Spohnholz                                                                                                    
Alaska State Legislature                                                                                                        
Juneau, Alaska                                                                                                                  
POSITION STATEMENT:  Presented the Sectional Analysis for HB 89                                                               
on behalf of the bill sponsor, Representative Spohnholz.                                                                        
                                                                                                                                
ERIN SHINE, Staff                                                                                                               
Representative Jennifer Johnston                                                                                                
Alaska State Legislature                                                                                                        
Juneau, Alaska                                                                                                                  
POSITION STATEMENT:  Presented HB 92 on behalf of the bill                                                                    
sponsor, Representative Johnston.                                                                                               
                                                                                                                                
LEE GROSS, MD                                                                                                                   
Epiphany Health                                                                                                                 
North Port, Florida                                                                                                             
POSITION STATEMENT:  Testified and answered questions in support                                                              
of HB 92.                                                                                                                       
                                                                                                                                
ANNA LATHAM, Deputy Director                                                                                                    
Juneau Office                                                                                                                   
Division of Insurance                                                                                                           
Department of Commerce, Community & Economic Development                                                                        
Juneau, Alaska                                                                                                                  
POSITION STATEMENT:  Answered questions during discussion of HB                                                               
92.                                                                                                                             
                                                                                                                                
BERNICE NISBETT, Staff                                                                                                          
Representative Ivy Spohnholz                                                                                                    
Alaska State Legislature                                                                                                        
Juneau, Alaska                                                                                                                  
POSITION STATEMENT:  Presented HB 114 on behalf of the bill                                                                   
sponsor, Representative Spohnholz.                                                                                              
                                                                                                                                
JILL LEWIS, Deputy Director - Juneau                                                                                            
Central Office                                                                                                                  
Division of Public Health                                                                                                       
Department of Health and Social Services                                                                                        
Juneau, Alaska                                                                                                                  
POSITION STATEMENT:  Presented a PowerPoint titled "HB 114                                                                    
Medical Provider Incentives/Loan Repayment."                                                                                    
                                                                                                                                
RACHEL GEARHART, Co-Chair                                                                                                       
SHARP Council                                                                                                                   
Juneau, Alaska                                                                                                                  
POSITION STATEMENT:  Testified during discussion of HB 114.                                                                   
                                                                                                                                
NANCY MERRIMAN, Executive Director                                                                                              
Alaska Primary Care Association                                                                                                 
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  Testified in support of HB 114.                                                                          
                                                                                                                                
JANE ERICKSON, President                                                                                                        
Alaska Nurses Association                                                                                                       
Palmer, Alaska                                                                                                                  
POSITION STATEMENT:  Testified in support of HB 114.                                                                          
                                                                                                                                
CONNIE BEEMER, Vice President                                                                                                   
Alaska State Hospital and Nursing Home Association (ASHNHA)                                                                     
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  Testified in support of HB 114.                                                                          
                                                                                                                                
                                                                                                                                
ACTION NARRATIVE                                                                                                              
                                                                                                                                
                                                                                                                                
3:09:53 PM                                                                                                                    
                                                                                                                                
CO-CHAIR  TIFFANY ZULKOSKY  called  the House  Health and  Social                                                             
Services  Standing  Committee  meeting  to  order  at  3:09  p.m.                                                               
Representatives Zulkosky, Spohnholz,  Claman, Tarr, Drummond, and                                                               
Jackson were present at the call to order.                                                                                      
                                                                                                                                
        HB 84-WORKERS' COMP: POLICE, FIRE, EMT, PARAMED                                                                     
                                                                                                                                
3:10:36 PM                                                                                                                    
                                                                                                                                
CO-CHAIR  ZULKOSKY announced  that  the first  order of  business                                                               
would be HOUSE  BILL NO. 84, "An Act relating  to the presumption                                                               
of  compensability  for  a   disability  resulting  from  certain                                                               
diseases   for  firefighters,   emergency  medical   technicians,                                                               
paramedics, and peace officers."                                                                                                
                                                                                                                                
3:11:02 PM                                                                                                                    
                                                                                                                                
ELISE  SORUM-BIRK, Staff,  Representative Andy  Josephson, Alaska                                                               
State Legislature, presented  a PowerPoint titled "HB  84, An Act                                                               
relating to  the presumption of  compensability for  a disability                                                               
resulting  from  certain  diseases  for  firefighters,  emergency                                                               
medical  technicians,   and  peace   officers."     She  directed                                                               
attention to slide 1, "Purpose  of the bill," and paraphrased the                                                               
slide, which read:                                                                                                              
                                                                                                                                
     Firefighters are already covered in current law                                                                            
                                                                                                                                
     To extend "presumption of compensability" for certain                                                                      
     diseases to three more professions:                                                                                        
      Emergency Medical Technicians                                                                                             
      Peace Officers                                                                                                            
      Paramedic                                                                                                                 
                                                                                                                                
     These first responder professions often are exposed to                                                                     
         the same dangerous situations and toxins that                                                                          
     firefighters are                                                                                                           
                                                                                                                                
MS.  SORUM-BIRK  pointed  out that,  although  firefighters  were                                                               
already covered under  a statute passed in the  25th Alaska State                                                               
Legislature  with bi-partisan  support and  an effective  date of                                                               
August  19, 2008,  this proposed  bill  would expand  presumptive                                                               
coverage for three professions left out of that legislation.                                                                    
                                                                                                                                
3:12:56 PM                                                                                                                    
                                                                                                                                
MS.  SORUM-BIRK  paraphrased  slide  2,  "What  is  "presumptive"                                                               
legislation?" which read:                                                                                                       
                                                                                                                                
     With work-related illness or injury-                                                                                       
     Typically worker must prove their ailment is a result                                                                      
     of occupational exposures                                                                                                  
                                                                                                                                
     With presumptive legislation-                                                                                              
      Line-of-duty claim, and subsequent benefits, can be                                                                       
         automatically approved as long as the specific                                                                         
     criteria are met under the state's regulations                                                                             
      Some states  choose broad language and  some choose to                                                                    
     be much more specific                                                                                                      
                                                                                                                                
MS. SORUM-BIRK explained that Alaska had used very specific                                                                     
language in the 2008 legislation, although many states used much                                                                
broader language.                                                                                                               
                                                                                                                                
3:13:26 PM                                                                                                                    
                                                                                                                                
MS. SORUM-BIRK paraphrased slide 3, "Alaska's Criteria," which                                                                  
read:                                                                                                                           
                                                                                                                                
     Narrowly defined and limited in AS 23.30.121                                                                               
      Presumption  of  coverage  may be  rebutted  based  on                                                                    
     tobacco  use,  physical   fitness,  weight,  lifestyle,                                                                    
     hereditary factors,  exposure from other  employment or                                                                    
     non-employment activities                                                                                                  
      May not  extend for more  than 3 months for  each year                                                                    
     of  service  or  60  months   following  last  date  of                                                                    
     employment                                                                                                                 
      Only to those  who have served for a  minimum of seven                                                                    
     years                                                                                                                      
      Only  to  individuals  who have  undergone  qualifying                                                                    
     medical  exam  and  requisite   annual  exams  with  no                                                                    
     evidence of disease                                                                                                        
      Only  if the  individual  with cancer  was exposed  to                                                                    
     known carcinogens in the course of employment                                                                              
                                                                                                                                
3:14:22 PM                                                                                                                    
                                                                                                                                
MS. SORUM-BIRK shared slide 4, "Sectional Analysis," which read:                                                                
                                                                                                                                
     Section 1:                                                                                                               
        Amends AS  23.30.121(b) throughout to  add emergency                                                                    
     medical  technician,  paramedic  and peace  officer  to                                                                    
     professions   presumed   covered  for   disability   or                                                                    
     disease.                                                                                                                   
        Creates  a  new  section to  include  breast  cancer                                                                    
     under  diseases for  which a  covered professional  can                                                                    
     claim compensation.                                                                                                        
        Extends  coverage   to  certain   professionals  who                                                                    
     entered active service prior to August 19, 2008.                                                                           
                                                                                                                                
     Section 2, Section 3, Section 4:                                                                                         
        Includes  emergency  medical  technician,  paramedic                                                                    
     and   peace   officer   among   presumptively   covered                                                                    
     professions                                                                                                                
                                                                                                                                
     Section 5:                                                                                                               
        Provides    definitions   of    "emergency   medical                                                                    
     technician,"   "firefighter,""paramedic,"  and   "peace                                                                    
     officer."                                                                                                                  
                                                                                                                                
     Section 6:                                                                                                               
        Clarifies that  AS 23.30.121  as amended  applies to                                                                    
     claims  made on  or after  the effective  date of  this                                                                    
     Act.                                                                                                                       
                                                                                                                                
     Section 7:                                                                                                               
        Encourages  revisors  to  update catch  line  of  AS                                                                    
     23.30.121 to reflect changes made by this Act.                                                                             
                                                                                                                                
3:15:39 PM                                                                                                                    
                                                                                                                                
MS. SORUM-BIRK moved on to paraphrase slide 5, "Diseases covered                                                                
in Alaska," [original punctuation provided] which read:                                                                         
                                                                                                                                
     Currently   covered:   respiratory   disease,   certain                                                                  
     cardiovascular  events   related  to   toxin  exposure,                                                                    
     primary  brain  cancer, malignant  melanoma,  leukemia,                                                                    
     non-Hodgkin's lymphoma, bladder  cancer, ureter cancer,                                                                    
     kidney cancer, prostrate cancer                                                                                            
                                                                                                                                
     Added by HB 84: breast cancer                                                                                            
       Emerging literature suggests a  higher rate of breast                                                                    
     cancer among women firefighters                                                                                            
                                                                                                                                
MS. SORUM-BIRK directed attention to an article [Included in                                                                    
members' packets] regarding research regarding higher rates of                                                                  
breast cancer with earlier onset for women firefighters.                                                                        
                                                                                                                                
3:16:35 PM                                                                                                                    
                                                                                                                                
MS. SORUM-BIRK explained slide 6, "First responders who entered                                                                 
service prior to August 19, 2008," which read:                                                                                  
                                                                                                                                
     AS  23.30.121(b)(4)-Allows  these   individuals  to  be                                                                    
     covered   if    a   firefighter,    emergency   medical                                                                    
     technician, paramedic, or peace officer                                                                                    
       received  "all medical  examination  provided by  the                                                                    
     department"                                                                                                                
       no  evidence of  the disease  during the  first seven                                                                    
     years of employment                                                                                                        
                                                                                                                                
        August 19, 2008 is date of original enactment of                                                                        
     "presumptive" legislation in Alaska                                                                                        
                                                                                                                                
MS.  SORUM-BIRK stated  that  this would  set  up parameters  for                                                               
individuals who entered  service prior to this August  date.  She                                                               
reported  that the  one case  dealing with  this issue  which had                                                               
gone to the Supreme Court had referred to this presumptive date.                                                                
                                                                                                                                
3:18:29 PM                                                                                                                    
                                                                                                                                
MS.  SORUM-BIRK  referred  to slide  7,  "Expands  definition  of                                                               
firefighters," which read:                                                                                                      
                                                                                                                                
        Adds firefighters who are state employees to the                                                                        
     definition of firefighter                                                                                                  
                                                                                                                                
MS. SORUM-BIRK paraphrased slide 8, "Conclusions," which read:                                                                  
                                                                                                                                
         A question of providing similar protections to                                                                         
     professional and volunteers who take comparable risk                                                                       
                                                                                                                                
     Protecting those who protect our state and communities                                                                     
                                                                                                                                
3:19:30 PM                                                                                                                    
                                                                                                                                
CO-CHAIR SPOHNHOLZ asked how the  rate of breast cancer in female                                                               
firefighters and  other first responders compared  to those rates                                                               
in the general population.                                                                                                      
                                                                                                                                
MS. SORUM-BIRK replied that, although research was still on-                                                                    
going,  it was  suggesting that  these  rates were  "quite a  bit                                                               
higher."                                                                                                                        
                                                                                                                                
CO-CHAIR SPOHNHOLZ  shared that a  concern for the  proposed bill                                                               
was for the costs related to  the inclusion of breast cancer, and                                                               
that  these facts  would be  important in  consideration for  the                                                               
proposed bill.                                                                                                                  
                                                                                                                                
3:21:24 PM                                                                                                                    
                                                                                                                                
PAMELA  MILLER, Executive  Director, Alaska  Community Action  on                                                               
Toxics  (ACAT), stated  that ACAT  was  an environmental  health,                                                               
research,   and  advocacy   organization  that   assisted  worker                                                               
concerns with chemical  exposure.  She paraphrased  from a letter                                                               
of support  for the  proposed bill dated  March 21,  [Included in                                                               
members' packets] [original punctuation provided] which read:                                                                   
                                                                                                                                
     Thank  you  for  your  leadership  in  introducing  and                                                                    
     serving  as  prime  sponsor  for HB  No.  84,  "An  Act                                                                    
     relating  to the  presumption of  compensability for  a                                                                    
     disability   resulting   from  certain   diseases   for                                                                    
     firefighters,     emergency    medical     technicians,                                                                    
     paramedics,   and  police   officers.  We   also  thank                                                                    
     Representatives  Tuck  and  Hopkins  for  co-sponsoring                                                                    
     this bill.                                                                                                                 
                                                                                                                                
     We strongly support  HB No. 84 because  it is inclusive                                                                    
     of  emergency  medical   technicians,  paramedics,  and                                                                    
     peace  officers in  addition  to  firefighters who  are                                                                    
     employed by  a state  or municipal fire  department and                                                                    
     volunteer  firefighters  who  are registered  with  the                                                                    
     state  fire marshall.  It is  critical  to include  all                                                                    
     first responders  under the provisions of  this bill so                                                                    
     that  they   and  their   families  are   eligible  for                                                                    
     compensation   in  the   tragic  event   of  disability                                                                    
     resulting from the performance of their duties.                                                                            
                                                                                                                                
     First responders risk their lives  every day to protect                                                                    
     the  communities they  live in.  However,  the risk  of                                                                    
     injury responding to fires is  not the only aspect that                                                                    
     makes  their  service  a  dangerous  occupation.  First                                                                    
     responders face  significant chemical exposures  on the                                                                    
     job  due to  the vast  quantity of  chemicals added  to                                                                    
     building   materials,   consumer   products   and   the                                                                    
     equipment they  use every day. Many  of these chemicals                                                                    
     have been  linked to cancer  and other  negative health                                                                    
     concerns. Firefighters  dying from occupational-related                                                                    
     cancers now account for 65  percent of the line-of-duty                                                                    
     deaths  each  year  as reported  to  the  International                                                                    
     Association  of  Firefighters.   This  is  the  largest                                                                    
     health-related issue facing the profession. Other first                                                                    
     responders are similarly at risk.                                                                                          
                                                                                                                                
     In 2010,  a NIOSH (National Institute  for Occupational                                                                    
     Safety and Health) study  examined cancer incidence and                                                                    
     cancer  deaths  in  approximately  30,000  firefighters                                                                    
     from  San  Francisco,  Chicago, and  Philadelphia  fire                                                                    
     departments between  1950 and 2009. The  results showed                                                                    
     that firefighters  have higher rates of  the digestive,                                                                    
     oral,  respiratory, and  urinary  systems cancers  than                                                                    
     the  general U.S.  population.  A  meta-analysis of  32                                                                    
     studies found  an association between  firefighting and                                                                    
     increased  incidence  of  cancers such  as  2  multiple                                                                    
     myeloma, non-Hodgkin's  lymphoma, prostate  cancer, and                                                                    
     testicular cancer, compared to the general population.                                                                     
                                                                                                                                
     We  support the  inclusion of  breast cancer  among the                                                                    
     diseases  for  presumptive  compensability  because  of                                                                    
     increasing  evidence  of  the association  with  higher                                                                    
     rates among  women firefighters.  A study  conducted in                                                                    
     the  San Francisco  Fire Department  found the  rate of                                                                    
     breast cancer  among female firefighters aged  40-50 is                                                                    
     six times the national  average. Studies also show that                                                                    
     firefighters  are at  greater risk  of contracting  the                                                                    
     following  cancers:  testicular  cancer  (102%  greater                                                                    
     risk);  multiple  myeloma   (53%  greater  risk);  non-                                                                    
     Hodgkin lymphoma  (51% greater risk); skin  cancer (39%                                                                    
     greater  risk);  prostate  cancer (28%  greater  risk);                                                                    
     malignant  melanoma (32%  greater  risk); brain  cancer                                                                    
     (32% greater  risk); rectum (29% greater  risk; stomach                                                                    
     (22% greater  risk); colon  cancer (21%  greater risk).                                                                    
     Testicular cancer should be  included in the provisions                                                                    
     of this bill for  presumptive compensability because of                                                                    
     the  high  occupational risk  and  the  fact that  PFAS                                                                    
     exposure (used  in industrial firefighting  foams), for                                                                    
     example, is closely associated with testicular cancer.                                                                     
                                                                                                                                
     We urge  support and  passage of  HB 84  and additional                                                                    
     measures to protect the health  and safety of our first                                                                    
     responders.                                                                                                                
                                                                                                                                
3:25:10 PM                                                                                                                    
                                                                                                                                
CO-CHAIR   SPOHNHOLZ  asked   how   the  rates   of  cancer   for                                                               
firefighters compared to the population at large.                                                                               
                                                                                                                                
MS. MILLER offered to provide the information.                                                                                  
                                                                                                                                
3:26:20 PM                                                                                                                    
                                                                                                                                
DARCEY   PERRY,   Vice   President,   Public   Safety   Employees                                                               
Association, said  that she had  been a firefighter  at Anchorage                                                               
International Airport since  2005 and was shocked to  find out in                                                               
2008 that she was not covered  by the legislation.  She explained                                                               
the oversights  in that legislation  and offered her  belief that                                                               
it had not been intended "to leave  our own off."  She stated her                                                               
support of the proposed legislation,  pointing out that all first                                                               
responders should be covered as  they were often entering unknown                                                               
situations.                                                                                                                     
                                                                                                                                
3:29:11 PM                                                                                                                    
                                                                                                                                
CO-CHAIR ZULKOSKY opened public testimony.                                                                                      
                                                                                                                                
3:29:49 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE JACKSON asked if  the firefighters were covered by                                                               
an insurance policy.                                                                                                            
                                                                                                                                
MS.  SORUM-BIRK  replied  that   there  was  some  insurance  for                                                               
firefighters, dependent  on their employers.   She clarified that                                                               
the proposed bill was directed toward workers compensation.                                                                     
                                                                                                                                
3:30:57 PM                                                                                                                    
                                                                                                                                
CO-CHAIR ZULKOSKY closed public testimony.                                                                                      
                                                                                                                                
[HB 84 was held over]                                                                                                           
                                                                                                                                
             HB 89-OPIOID PRESCRIPTION INFORMATION                                                                          
                                                                                                                                
3:31:03 PM                                                                                                                    
                                                                                                                                
CO-CHAIR  ZULKOSKY  announced that  the  next  order of  business                                                               
would be HOUSE BILL NO. 89,  "An Act relating to the prescription                                                               
of opioids;  relating to the  practice of dentistry;  relating to                                                               
the practice of  medicine; relating to the  practice of podiatry;                                                               
relating to the practice of  osteopathy; relating to the practice                                                               
of nursing; relating  to the practice of  optometry; and relating                                                               
to the practice of pharmacy."                                                                                                   
                                                                                                                                
3:31:35 PM                                                                                                                    
                                                                                                                                
The committee took a brief at-ease.                                                                                             
                                                                                                                                
3:32:09 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  TARR  moved  to   adopt  the  proposed  committee                                                               
substitute (CS)  for HB  89, labeled  31-LS0421\U, Fisher,4/3/19,                                                               
as the working draft.                                                                                                           
                                                                                                                                
CO-CHAIR ZULKOSKY objected for discussion.                                                                                      
                                                                                                                                
3:32:25 PM                                                                                                                    
                                                                                                                                
CO-CHAIR  SPOHNHOLZ introduced  HB 89,  explaining that  this was                                                               
re-visiting  a  bill  that  had  previously  been  introduced  by                                                               
Representation Gara in 2018.  She  stated that the purpose of the                                                               
proposed bill was  to ensure that Alaska  did everything possible                                                               
to  reduce  access  to opioids  and  the  associated  unnecessary                                                               
risks.    She introduced  a  PowerPoint  titled "House  Bill  89:                                                               
Opioid Addiction Risk  Disclosure."  She reported  that there had                                                               
been 100 overdoses  from opioids in 2017, and  although there had                                                               
been  progress through  a prescription  drug monitoring  program,                                                               
easier disposal of opioids, and a  reduction of use, it was still                                                               
a  problem as  80 percent  of  addiction to  street level  heroin                                                               
began  with legally  prescribed opioids,  whether or  not it  was                                                               
their  legal prescription.   She  suggested that  it was  best to                                                               
flip  the conversation  and  begin with  an  introduction to  the                                                               
risks  associated  with opioids  before  they  were taken.    She                                                               
stated that the proposed bill  offered "a couple of opportunities                                                               
for a  patient to be  educated about  the risks of  addiction and                                                               
dependence on opioids  before they can consume it."   She allowed                                                               
that there  would be exclusions  for emergencies and  other times                                                               
when it  was not possible for  an informed consent.   She offered                                                               
her belief  that education should  take place at  multiple points                                                               
as research  had indicated  that it takes  multiple times  for an                                                               
individual  to   hear  a  message   before  the   information  is                                                               
internalized.     She   paraphrased   slide   3,  "Research   and                                                               
Statistics," which read:                                                                                                        
                                                                                                                                
     A recent  meta-analysis of research (Schmidt  & Eisend,                                                                    
     2015)  published in  the Journal  of Advertising  found                                                                    
     that  it  takes an  average  of  8-10 exposures  for  a                                                                    
     person to remember a concept.                                                                                              
          The  more often  a patient  hears a  message about                                                                    
     the  inherent risks  of opioids,  the more  likely they                                                                    
     are  to have  an increased  awareness of  the potential                                                                    
     dangers of physical dependence and addiction.                                                                              
                                                                                                                                
     Statistics on Opioid Misuse and Opioid Related Deaths:                                                                     
          Drug  overdose  was   Alaska's  leading  cause  of                                                                    
     accidental death  in 2016 (Alaska Department  of Health                                                                    
     and Social Services).                                                                                                      
          More than  3 out  of 5  drug overdoses  involve an                                                                    
     opioid (Centers for Disease  Control and Prevention, AK                                                                    
     DHSS).                                                                                                                     
          4  out  of 5  heroin  users  started out  misusing                                                                    
     prescription  opioids  (American Society  of  Addiction                                                                    
     Medicine).                                                                                                                 
                                                                                                                                
     New research  (Weinheimer, Michelotti,  Silver, Taylor,                                                                    
     & Payatakes, 2018) on effective pain management:                                                                           
          A   combination   of    Ibuprofen   200   mg   and                                                                    
     Acetaminophen  500 mg  is  approximately  3 times  more                                                                    
     effective  than 15  mg of  Oxycodone. (Dr.  Don Teater,                                                                    
     Teater Health Solutions).                                                                                                  
                                                                                                                                
CO-CHAIR SPOHNHOLZ moved on and paraphrased slide 4, "Goals of                                                                  
House Bill 89, which read:                                                                                                      
                                                                                                                                
     Reduce  the  use of  opioids  for  pain management  and                                                                    
     increase use  of non-opiate  pain management  tools and                                                                    
     medications.                                                                                                               
     Increase communication  about the dangers and  risks of                                                                    
     opioids.                                                                                                                   
     Decrease  opioid misuse  and  opioid-related deaths  in                                                                    
     Alaska.                                                                                                                    
     Mitigate  the  opioid   related  public  health  crisis                                                                    
     Alaska is currently facing.                                                                                                
     Provide a  positive example to  other states in  the US                                                                    
     that are facing similar public health crises.                                                                              
                                                                                                                                
3:36:45 PM                                                                                                                    
                                                                                                                                
MIRANDA DORDAN, Intern, Representative Ivy Spohnholz, Alaska                                                                    
State Legislature, paraphrased slide 5, "Section 1: Legislative                                                                 
Findings" which read:                                                                                                           
                                                                                                                                
     Legislative findings  hold that the state  has a moral,                                                                    
     financial,  and  public  health  interest  in  reducing                                                                    
     opioid and heroin addiction in Alaska.                                                                                     
                                                                                                                                
     Medically   documented  evidence   finds  that   opioid                                                                    
     prescription drugs can lead  to physical dependence and                                                                    
     potential addiction.                                                                                                       
                                                                                                                                
     Studies have shown that a  significant amount of heroin                                                                    
     users started as opioid drug users.                                                                                        
                                                                                                                                
     The Opioid  Epidemic increases crime in  the state, and                                                                    
     the presence  of heroin  dealers in  the state  poses a                                                                    
     public safety threat.                                                                                                      
                                                                                                                                
     Opioid  addictions  tear   families  apart,  destroy  a                                                                    
     person's ability to hold a job, and decimate lives.                                                                        
                                                                                                                                
     Addiction  treatment is  costly and  hard on  families,                                                                    
     affecting quality of life.                                                                                                 
                                                                                                                                
     Addiction treatment and  additional public safety costs                                                                    
     are also expensive for consumers and the state.                                                                            
                                                                                                                                
3:38:08 PM                                                                                                                    
                                                                                                                                
MS.  DORDAN paraphrased  slide 6,  "Section  2: Dentists,"  which                                                               
read:                                                                                                                           
                                                                                                                                
     Requires dentists  to inform patients of  the potential                                                                    
     addictive  dangers   of  opioids  and   any  reasonable                                                                    
     treatment   alternatives   using   oral   and   written                                                                    
     information before prescribing an opioid.                                                                                  
                                                                                                                                
     The  State Board  of Dental  Examiners  will craft  and                                                                    
     enforce  regulations that  satisfy  requirements of  HB                                                                    
     89.                                                                                                                        
                                                                                                                                
MS. DORDAN directed  attention to a handout on  the Department of                                                               
Health and  Social Services website  as a visual aide  with great                                                               
information for opioid statistics specific to Alaska.                                                                           
                                                                                                                                
3:40:02 PM                                                                                                                    
                                                                                                                                
CO-CHAIR SPOHNHOLZ  pointed out  that the  bill sponsors  did not                                                               
want to over prescribe the way  this should be implemented at the                                                               
Board  level,  but  to  instead,  allow each  of  the  Boards  to                                                               
identify for themselves  the best way to regulate  and manage the                                                               
information.   She emphasized  that the  sponsors only  wanted to                                                               
ensure  that  providers  in  Alaska   offered  oral  and  written                                                               
communication about the risks and alternatives.                                                                                 
                                                                                                                                
3:40:40 PM                                                                                                                    
                                                                                                                                
MS. DORDAN moved  on to paraphrase slide 7,  "Section 3: Medical,                                                               
Osteopathy, and Podiatry Providers," which read:                                                                                
                                                                                                                                
     Requires  Medical, Osteopathy,  and Podiatry  Providers                                                                    
     to inform  patients of the potential  addictive dangers                                                                    
     of  opioids and  any reasonable  treatment alternatives                                                                    
     using oral  and written information  before prescribing                                                                    
     an opioid.                                                                                                                 
                                                                                                                                
     The  State   Medical  Board  will  craft   and  enforce                                                                    
     regulations that satisfy requirements of HB 89.                                                                            
                                                                                                                                
3:41:51 PM                                                                                                                    
                                                                                                                                
MS. DORDAN directed attention to slide 8, "Section 4: Registered                                                                
Nurses," which read:                                                                                                            
                                                                                                                                
     Requires registered  nurses to  inform patients  of the                                                                    
     potential   addictive  dangers   of  opioids   and  any                                                                    
     reasonable  treatment   alternatives  using   oral  and                                                                    
     written information before prescribing an opioid.                                                                          
                                                                                                                                
     The  Alaska Board  of Nursing  will  craft and  enforce                                                                    
     regulations that satisfy requirements of HB 89.                                                                            
                                                                                                                                
3:42:24 PM                                                                                                                    
                                                                                                                                
MS. DORDAN shared slide 9 "Section 5: Optometrists," which read:                                                                
                                                                                                                                
     Requires  optometrists   to  inform  patients   of  the                                                                    
     potential   addictive  dangers   of  opioids   and  any                                                                    
     reasonable  treatment   alternatives  using   oral  and                                                                    
     written information before prescribing an opioid.                                                                          
                                                                                                                                
     The State  Board of Examiners  in Optometry  will craft                                                                    
     and  enforce regulations  that satisfy  requirements of                                                                    
     HB 89.                                                                                                                     
                                                                                                                                
3:42:56 PM                                                                                                                    
                                                                                                                                
MS. DORDAN indicated slide 10 "Section 6: Pharmacists," which                                                                   
included the changes in the proposed committee substitute,                                                                      
Version U, which read:                                                                                                          
                                                                                                                                
     Requires   pharmacists  to   inform  patients   of  the                                                                    
     potential addictive  dangers of opioids using  oral and                                                                    
     written information before dispensing an opioid.                                                                           
                                                                                                                                
     The  Alaska Board  of Pharmacy  will craft  and enforce                                                                    
     regulations that satisfy requirements of HB 89.                                                                            
                                                                                                                                
3:44:57 PM                                                                                                                    
                                                                                                                                
MS. DORDAN directed attention to slide 11 "Section: Visual Aid,"                                                                
which read in part:                                                                                                             
                                                                                                                                
     DHSS must create a visual aid that providers can hand                                                                      
         out to patients when they are being prescribed                                                                         
     opioids.                                                                                                                   
                                                                                                                                
MS. DORDAN reiterated  that the handout had  already been created                                                               
and was on the Department of Health and Social Services website.                                                                
                                                                                                                                
3:46:16 PM                                                                                                                    
                                                                                                                                
MS. DORDAN shared the references  and letters of support on slide                                                               
12,  "Letters  of  Support:" which  included  the  Alaska  Dental                                                               
Society and Fallen Up Ministries.                                                                                               
                                                                                                                                
3:46:37 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE JACKSON offered her  belief that doctors had taken                                                               
an  oath  to do  everything  within  their  power to  keep  their                                                               
patients healthy  and that  there was  a federal  requirement for                                                               
doctors to explain each drug and  its side effects.  She asked if                                                               
the proposed bill  was requiring the state to  manage doctors for                                                               
how they inform and educate their patients.                                                                                     
                                                                                                                                
3:47:37 PM                                                                                                                    
                                                                                                                                
CO-CHAIR SPOHNHOLZ explained that  the proposed bill was designed                                                               
to add  another layer of  education for  patients.  She  shared a                                                               
personal  experience  with  opioids   and  noted  that  the  bill                                                               
proposed to begin the conversation  in the health care provider's                                                               
office.   She  offered her  belief that  more conversation  would                                                               
reduce   the  number   of  opioids   prescribed,  consumed,   and                                                               
distributed into our communities.                                                                                               
                                                                                                                                
3:49:34 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  JACKSON  acknowledged  awareness for  the  opioid                                                               
crisis, with  a variety of  organizations enforcing  education on                                                               
opioids.   She  asked for  clarification that  Co-Chair Spohnholz                                                               
had been offered medications without any education.                                                                             
                                                                                                                                
CO-CHAIR SPOHNHOLZ replied  that she had been  offered opioids by                                                               
a full range of medical professionals.                                                                                          
                                                                                                                                
REPRESENTATIVE JACKSON  asked if  the proposed bill  would ensure                                                               
monitoring through the various Boards  that doctors were offering                                                               
this education.                                                                                                                 
                                                                                                                                
CO-CHAIR SPOHNHOLZ replied  that the intent of  the proposed bill                                                               
was to  require medical personnel  to educate patients  about the                                                               
risks associated  and give them  printed materials to  take home.                                                               
The  proposed  bill  would  give  the power  to  the  Boards  for                                                               
enforcement.  She  emphasized that it was not  intended to define                                                               
in law  specific steps  that should  be taken.   She  offered her                                                               
belief  that  a   way  to  build  consensus  was   to  allow  the                                                               
professionals to determine the best way to regulate and enforce.                                                                
                                                                                                                                
3:51:51 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  JACKSON  acknowledged  that  "the  idea  and  the                                                               
intention is  fabulous" but asked  if there had  been discussions                                                               
with  the various  boards for  a timeframe.   She  suggested that                                                               
enforcement legislation  may be necessary  if the boards  did not                                                               
comply.                                                                                                                         
                                                                                                                                
CO-CHAIR SPOHNHOLZ  shared the history  of a prior  compromise to                                                               
allow  Department of  Health and  Social Services  to create  and                                                               
distribute information.   However,  it had  been decided  that it                                                               
was time  to introduce legislation,  as the boards had  a limited                                                               
scope of responsibility and needed a  law in order to take on new                                                               
regulations.    She  stated  that   she  had  been  talking  with                                                               
providers to craft a bill  that was practical while achieving the                                                               
public health goal for reduction of opioid dependence.                                                                          
                                                                                                                                
3:53:49 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  DRUMMOND  directed  attention   to  slide  2  and                                                               
expressed  her surprise  regarding the  combination of  ibuprofen                                                               
and acetaminophen  as three  times more effective  than 15  mg of                                                               
oxycodone.  She  asked if this was a  prescription combination or                                                               
was it available over the counter.                                                                                              
                                                                                                                                
CO-CHAIR  SPOHNHOLZ explained  that the  combination was  a legal                                                               
over  the counter  level  for  each of  those  medications.   She                                                               
acknowledged  that this  combination was  so much  more effective                                                               
than opioids.                                                                                                                   
                                                                                                                                
3:55:44 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  DRUMMOND  directed  attention   to  slide  3  and                                                               
expressed that she was impressed  with the 36 percent decrease in                                                               
opioid  overdoses   and  a  67   percent  decrease   in  fentanyl                                                               
overdoses.  She asked if each overdose resulted in death.                                                                       
                                                                                                                                
CO-CHAIR  SPOHNHOLZ clarified  that these  were overdose  related                                                               
deaths and not just overdoses.   She reported that overdose death                                                               
had  decreased with  the  broad distribution  of  naloxone as  it                                                               
allowed emergency responders to reverse an overdose.                                                                            
                                                                                                                                
3:57:28 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  DRUMMOND  referred to  slide  7  and asked  about                                                               
exemptions for palliative and hospice care.                                                                                     
                                                                                                                                
MS.  DORDAN  explained that  these  exemptions  could be  offered                                                               
although ultimately the Board would decide who was exempt.                                                                      
                                                                                                                                
CO-CHAIR SPOHNHOLZ  added that,  as the  delivery of  health care                                                               
was  very complex,  it was  the intention  not to  define in  law                                                               
exactly where the education should  take place and that, instead,                                                               
the medical  professionals make  that decision.   She  noted that                                                               
the  implementation  could  be  addressed  later  if  there  were                                                               
concerns.                                                                                                                       
                                                                                                                                
3:59:12 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  DRUMMOND  pointed  to  slide 9  and  asked  about                                                               
treatments performed by optometrists which required an opioid.                                                                  
                                                                                                                                
CO-CHAIR SPOHNHOLZ  explained that,  although it was  not routine                                                               
care,  optometrists could  perform  some  minor procedures  which                                                               
could create some  pain and necessitate the  prescription of pain                                                               
medication.                                                                                                                     
                                                                                                                                
4:00:34 PM                                                                                                                    
                                                                                                                                
CO-CHAIR ZULKOSKY removed her objection.   There being no further                                                               
objection,  the proposed  committee  substitute (CS)  for HB  89,                                                               
labeled 31-LS0421\U,  Fisher,4/3/19, was  adopted as  the working                                                               
draft.                                                                                                                          
                                                                                                                                
4:01:05 PM                                                                                                                    
                                                                                                                                
CO-CHAIR ZULKOSKY opened public testimony.                                                                                      
                                                                                                                                
4:01:22 PM                                                                                                                    
                                                                                                                                
CO-CHAIR ZULKOSKY said she would keep public testimony open.                                                                    
                                                                                                                                
[HB 89 was held over]                                                                                                           
                                                                                                                                
        HB 92-DIRECT HEALTH: NOT INSUR; ADD TO MEDICAID                                                                     
                                                                                                                                
4:01:30 PM                                                                                                                    
                                                                                                                                
CO-CHAIR  ZULKOSKY  announced that  the  next  order of  business                                                               
would be HOUSE BILL NO. 92,  "An Act exempting direct health care                                                               
agreements from  regulation as  insurance; establishing  a direct                                                               
care  payment  program  for medical  assistance  recipients;  and                                                               
providing for an effective date."                                                                                               
                                                                                                                                
4:01:44 PM                                                                                                                    
                                                                                                                                
ERIN SHINE, Staff, Representative Jennifer Johnston, Alaska                                                                     
State Legislature, paraphrased the Sponsor Statement [Included                                                                  
in members' packets], which read:                                                                                               
                                                                                                                                
     HB  92 amends  the  state insurance  code by  exempting                                                                    
     direct   care  agreements   from   the  definition   of                                                                    
     insurance. It  also, includes conditional  language for                                                                    
     the Department  of Health and Social  Services to apply                                                                    
     for  a  State  Plan  Amendment  with  the  Centers  for                                                                    
     Medicare &  Medicaid Services to allow  for direct care                                                                    
     agreements   for  and,   if  approved,   requires  that                                                                    
     providers accept  Medicare and Medicaid patients  up to                                                                    
     20 percent of their  patient population. This bill does                                                                    
     not mandate  that direct care  practices be  formed; it                                                                    
     only exempts  them from regulation  by the  division of                                                                    
     insurance.                                                                                                                 
                                                                                                                                
     Direct  care agreements  consist of  a practitioner  or                                                                    
     group  of  physicians   who  contract  with  individual                                                                    
     patients to provide  care outlined in a  contract for a                                                                    
     monthly, quarterly or  semiannual fee. The relationship                                                                    
     between physician  and patient  is contractual  and the                                                                    
     contractual relationship  can be altered or  amended by                                                                    
     the   same   means   that   already   govern   existing                                                                    
     contractual  relationships.  Through  this  arrangement                                                                    
     patients gain access to as much care as they need.                                                                         
                                                                                                                                
     Under  existing care  models, a  patient sees  a doctor                                                                    
     and then  the doctor bills the  patient's insurance. In                                                                    
     a  direct care  practice,  no bill  is  submitted to  a                                                                    
     third-party  payer. The  only  money  exchanged is  the                                                                    
     patient's monthly, quarterly  or semi-annual membership                                                                    
     payments.  This  arrangement  liberates  the  physician                                                                    
     from all  involvement with  insurance and  are relieved                                                                    
     from  paperwork  required  by payers.  Physicians  have                                                                    
     more time to spend on direct patient care.                                                                                 
                                                                                                                                
     The American  Academy of Family  Physicians "Principles                                                                    
     for Reform of the U.S.  Health Care System" holds that:                                                                    
     "Less complicated administrative  systems are essential                                                                    
     to reduce  costs, create a  more efficient  health care                                                                    
     system,   and   maximize   funding  for   health   care                                                                    
     services."                                                                                                                 
                                                                                                                                
     HB 92  creates an  environment where  a new  market for                                                                    
     the  delivery of  health  care can  exist  and grow  by                                                                    
     allowing  direct  care  agreements  to  create  a  less                                                                    
     complicated administrative system.                                                                                         
                                                                                                                                
4:04:20 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  DRUMMOND asked  if the  requirement that  doctors                                                               
accept Medicare  and Medicaid  patients for up  to 20  percent of                                                               
their  patient  population  would increase  the  availability  of                                                               
primary care providers to those patients.                                                                                       
                                                                                                                                
MS. SHINE offered her belief that  this would create an avenue to                                                               
access  care and  that a  provider with  a direct  care agreement                                                               
practice  would  be  one more  provider  accepting  Medicare  and                                                               
Medicaid patients.                                                                                                              
                                                                                                                                
4:05:14 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE JACKSON  asked if  this offered  practitioners and                                                               
physicians the opportunity to set  up a co-op for affordable care                                                               
between the physician and the patient.                                                                                          
                                                                                                                                
MS. SHINE  replied that  it allowed patients  to pay  a revolving                                                               
fee to a provider  or a group of providers for  access to care as                                                               
outlined  in a  contract.   She  pointed out  that  this was  not                                                               
insurance  and that  the  proposed bill  exempted  them from  the                                                               
definition of insurance.                                                                                                        
                                                                                                                                
REPRESENTATIVE JACKSON  stated her  support for  legislation that                                                               
would allow  physicians to have  direct payment from  patients as                                                               
an  alternative for  those without  insurance.   She asked  about                                                               
making  this  mandatory for  physicians  to  accept Medicaid  and                                                               
Medicare patients.                                                                                                              
                                                                                                                                
MS. SHINE said that providers  who accepted Medicare and Medicaid                                                               
patients could continue as status  quo, whereas the proposed bill                                                               
would allow a provider to set  up a different form of health care                                                               
delivery.  This would allow  a contract directly with the patient                                                               
and not  with a  third party.   The proposed  bill stated  that a                                                               
physician who chose  to set up this type of  practice must accept                                                               
Medicare and Medicaid patients.                                                                                                 
                                                                                                                                
4:08:01 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE CLAMAN  expressed concern  that the  proposed bill                                                               
would provide  access to  middle class  whereas those  with "much                                                               
tighter financial situations  really would never be  able to take                                                               
advantage of  this kind of situation."   He asked how  this would                                                               
work with medical savings accounts.                                                                                             
                                                                                                                                
MS. SHINE offered her belief that  this was an affordable way for                                                               
the patients  in 25 states  to access  primary care.   She opined                                                               
that Alaska would  be the first state to open-up  for other forms                                                               
of care,  and not  direct that  this be primary  care.   She said                                                               
that the  use of  medical savings  accounts was  a grey  area and                                                               
that there were  testifiers who could more  adequately answer the                                                               
question.                                                                                                                       
                                                                                                                                
REPRESENTATIVE  CLAMAN   asked  what  areas   beyond  traditional                                                               
primary care did the bill propose to offer.                                                                                     
                                                                                                                                
MS. SHINE  explained that this  had been left broad  to determine                                                               
whether  this was  a good  model  for access  to care  in a  more                                                               
efficient  manner.     She  offered  her   assumption  that  most                                                               
providers would set up an  agreement practice for primary care as                                                               
most general surgery could not charge enough on a monthly basis.                                                                
                                                                                                                                
REPRESENTATIVE  CLAMAN  asked  if  there  were  specialties  more                                                               
likely to be interested in this beyond primary care.                                                                            
                                                                                                                                
MS.  SHINE offered  her belief  that some  states were  currently                                                               
trying to expand the scope beyond primary care.                                                                                 
                                                                                                                                
4:12:18 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE DRUMMOND  asked about  statistics, history  in the                                                               
states where  the program is  allowed, and the cost  to consumers                                                               
for the direct care agreements.   She asked if those other states                                                               
with direct  care agreements contained the  Medicare and Medicaid                                                               
percentage requirement.                                                                                                         
                                                                                                                                
MS.  SHINE offered  her belief  that about  25 states  had direct                                                               
primary  care  agreements, although  she  did  not know  anything                                                               
about the cost  of care.  In response, she  opined that, although                                                               
no  other  states included  the  proposed  Medicare and  Medicaid                                                               
percentage requirement,  that was  not to  say that  Medicare and                                                               
Medicaid patients did not access this form of care.                                                                             
                                                                                                                                
REPRESENTATIVE DRUMMOND offered her  belief that it was difficult                                                               
to  find  primary  care  physicians  that  accepted  Medicare  in                                                               
Alaska,  even as  Medicare accepting  physicians  were much  more                                                               
available  in other  states while  being reimbursed  at a  better                                                               
rate.  She opined that this could also be true for Medicaid.                                                                    
                                                                                                                                
4:14:35 PM                                                                                                                    
                                                                                                                                
LEE GROSS, MD, Epiphany Health,  reported that he was a full-time                                                               
practicing  family  doctor.   He  stated  that this  model  could                                                               
simplify health  care delivery,  reduce the  cost of  care, lower                                                               
barriers to  access, reduce physician  burn-out, and  restore the                                                               
central  focus of  the health  care system  to the  patient.   He                                                               
shared  the  history  of  his practice,  noting  that  the  name,                                                               
Epiphany  Health, evolved  from the  question for  why to  insure                                                               
primary care  as this created  far too many barriers  between the                                                               
doctor  and the  patient.   He stated  that health  insurance was                                                               
being used  incorrectly.   He declared  that routine  health care                                                               
should be  made affordable for everyone,  with predictable, price                                                               
transparency,   that  insurance   should  be   a  hedge   against                                                               
catastrophic loss, and not to pay  for basic, essential care.  He                                                               
reported that,  in 2010,  his practice  had created  a membership                                                               
based  primary care  program  for patients  aged  five years  and                                                               
older with  a flat  monthly fee  of $60 per  month for  an adult,                                                               
which covered all  the services his practice provided.   He added                                                               
that a  child was $25  per month,  with each additional  child in                                                               
the family  for $10 per  month.  He  pointed out that  there were                                                               
not  any co-pays  for any  services which  could be  done in  the                                                               
office.   He  explained  that,  in order  to  practice outside  a                                                               
traditional  third-party payment  system, he  had reached  out to                                                               
independent labs, image services,  and others to secure wholesale                                                               
prices.   He  compared  the  prices of  these  services to  those                                                               
through  a   traditional  office   visit.    He   reported  that,                                                               
currently,  there were  about  1,000 of  these  practices with  a                                                               
direct  primary  care  model.    He  added  that  some  of  these                                                               
practices  also offered  wholesale dispensing  of medications  to                                                               
allow  affordable  access.   He  reiterated  that there  were  25                                                               
states with legislation to protect  this practice model, pointing                                                               
out that no states had  regulated against the provision of direct                                                               
primary care  services.  He  noted that he did  oppose provisions                                                               
in the proposed  bill that set quotas for  Medicare and Medicaid,                                                               
pointing  out that  no other  states set  these quotas,  and that                                                               
portion of the proposed bill would  be the first in the nation to                                                               
mandate participation  in Medicare and  Medicaid.  He  stated his                                                               
enthusiastic support for the rest of the proposed bill.                                                                         
                                                                                                                                
4:20:04 PM                                                                                                                    
                                                                                                                                
CO-CHAIR SPOHNHOLZ asked how the rates were developed.                                                                          
                                                                                                                                
DR. GROSS replied that, as the  cost for routine care was cheaper                                                               
than  a cell  phone plan,  they had  determined that  this was  a                                                               
reasonable price.   He  added that this  had also  stabilized the                                                               
finances for his  practice.  He noted that prior  to shifting his                                                               
practice model, his office was  not a Medicaid provider, but with                                                               
his  new primary  care model,  he did  have Medicaid  patients as                                                               
they could afford the services provided.                                                                                        
                                                                                                                                
CO-CHAIR SPOHNHOLZ asked  about the risks to the  consumers, if a                                                               
patient became too expensive to care for.                                                                                       
                                                                                                                                
DR. GROSS replied  that, under existing law, a  doctor could drop                                                               
a  patient for  any  reason,  adding that  the  provision in  the                                                               
proposed  bill which  allowed for  cancellation  by either  party                                                               
with two months' notice was  longer than the notice which existed                                                               
in current  law.  He pointed  out that the model  was designed to                                                               
attract   people  with   chronic  diseases,   heavier  utilizers,                                                               
although it  was not  always the  same utilizer  each month.   He                                                               
stated that these were the people a practice should keep.                                                                       
                                                                                                                                
CO-CHAIR SPOHNHOLZ asked  how many patients he had let  go in the                                                               
last year.                                                                                                                      
                                                                                                                                
DR. GROSS replied that he had  not terminated anyone, and that he                                                               
had a three month wait list for new patients to his practice.                                                                   
                                                                                                                                
CO-CHAIR  SPOHNHOLZ  asked how  this  practice  model made  money                                                               
without culling the expensive patients.                                                                                         
                                                                                                                                
DR.  GROSS  explained  that this  practice  was  not  financially                                                               
viable as a  fee for service insurance-based  practice because of                                                               
all the  expenses necessary to  provide medical care  through the                                                               
insurance   companies,  which   included  proprietary   software,                                                               
staffing, and the other 60  percent of overhead necessary to bill                                                               
the  insurance companies.   He  noted that  his overhead  was now                                                               
some of the lowest  in the country, between 20 -  30 percent.  He                                                               
shared some of the costs,  noting that there was little incentive                                                               
to cull the high utilizers.                                                                                                     
                                                                                                                                
4:25:20 PM                                                                                                                    
                                                                                                                                
DR. GROSS,  in response to  Representative Claman, said  that the                                                               
main office for his practice was  in North Fork, Florida, with an                                                               
expansion office  in rural Florida  where there was a  50 percent                                                               
uninsured rate  with a  median income  of $25,000  per year.   He                                                               
added that  they had  integrated with  the critical  access rural                                                               
hospital an employee benefit into  their health plan as an option                                                               
to a  traditional health plan.   He  reported that 80  percent of                                                               
the  hospital  employees  signed   up  for  membership  with  his                                                               
practice,  a projected  savings of  more than  $1 million  in the                                                               
first  year  for  the  hospital   while  also  reducing  employee                                                               
premiums 20  percent and eliminating their  network restrictions,                                                               
co-pays, and deductibles for routine care.                                                                                      
                                                                                                                                
REPRESENTATIVE CLAMAN asked how many  physicians were in his main                                                               
clinic.                                                                                                                         
                                                                                                                                
DR.  GROSS  replied that  there  were  two  doctors and  a  nurse                                                               
practitioner.     In  response   to  Representative   Claman,  he                                                               
acknowledged that he was one of the doctors.                                                                                    
                                                                                                                                
REPRESENTATIVE CLAMAN asked about Medicaid payments.                                                                            
                                                                                                                                
DR.  GROSS explained  that his  practice did  not take  any money                                                               
directly  from  Medicaid  as  the   Medicaid  patients  paid  his                                                               
practice  directly.   He  reported  that,  because the  State  of                                                               
Florida  had  a  Medicaid  share  of cost  with  a  high  patient                                                               
deductible  which  reset  every  month, the  patients  could  not                                                               
afford access to chronic care management.                                                                                       
                                                                                                                                
REPRESENTATIVE CLAMAN asked  if the State of  Florida offered any                                                               
reimbursement  to   Medicaid  recipients   for  payment   to  his                                                               
practice.                                                                                                                       
                                                                                                                                
DR. GROSS  replied that  it was most  likely easier  for Medicaid                                                               
recipients  to pay  his  monthly  fee out  of  pocket instead  of                                                               
trying to  work through the  Medicaid system for  routine primary                                                               
medical services.   He declared that  it was difficult to  find a                                                               
doctor in Florida who took Medicaid.                                                                                            
                                                                                                                                
REPRESENTATIVE  CLAMAN   asked  if   the  monthly   fee  included                                                               
prescription medications.                                                                                                       
                                                                                                                                
DR.  GROSS said  that his  practice encouraged  patients to  have                                                               
insurance  for   non-routine  and  catastrophic  expenses.     He                                                               
reiterated that  the monthly fee only  included services provided                                                               
in  his  office.   He  reported  that  some practices  did  offer                                                               
medications as a  path through cost directly to  the patient, and                                                               
he  shared  the prices  of  some  generic  drugs used  to  manage                                                               
chronic conditions.   He noted  that often it was  more expensive                                                               
for a patient  to use their insurance to pay  for the medications                                                               
instead of paying cash.                                                                                                         
                                                                                                                                
REPRESENTATIVE  CLAMAN asked  if medication  services as  a pass-                                                               
through cost  did not add  to the base  monthly fee and  was only                                                               
reimbursed to his office.                                                                                                       
                                                                                                                                
DR. GROSS agreed that there would  be a pass-through cost for the                                                               
wholesale cost for the medication.                                                                                              
                                                                                                                                
REPRESENTATIVE  CLAMAN asked  how many  providers similar  to his                                                               
clinic were in Florida.                                                                                                         
                                                                                                                                
DR. GROSS  offered that there  were about 60 providers,  and that                                                               
the legislation  had only just passed  about one year prior.   He                                                               
added that the Florida legislature  was already looking to expand                                                               
this.                                                                                                                           
                                                                                                                                
4:31:21 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE JACKSON stated  that she thought this  was a great                                                               
idea and asked  if the current laws under  the Patient Protection                                                               
and Affordable Care Act (PPACA) recognized this process.                                                                        
                                                                                                                                
DR.  GROSS said  that Section  1301 of  the PPACA  did contain  a                                                               
provision that  specifically allowed  direct primary care  with a                                                               
wrap around catastrophic  plan to qualify as  minimal coverage in                                                               
order to avoid the tax penalty.                                                                                                 
                                                                                                                                
4:32:58 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE DRUMMOND asked if the  prescriptions for a Type II                                                               
diabetic counted as a heavy utilizer in his practice.                                                                           
                                                                                                                                
DR. GROSS  said that the  Type I and  Type II diabetics  were the                                                               
ideal patients  in his practice  because they came in  for visits                                                               
"five, six, seven times a year."   He noted that, as the A1C test                                                               
for  the   three-month  average   blood  sugar   monitoring,  was                                                               
administered in his  office there was no charge for  the point of                                                               
care testing.  He explained  that these patients could be managed                                                               
over the  phone, by  text, or  by e-mail.   He reported  that one                                                               
diabetic   patient   could   no   longer  afford   to   see   the                                                               
endocrinologist because of the $600 per visit.                                                                                  
                                                                                                                                
REPRESENTATIVE DRUMMOND asked  about the cost of  the insulin, as                                                               
it  had  skyrocketed  in  the  last few  years  even  though  the                                                               
medication had not changed.                                                                                                     
                                                                                                                                
DR.  GROSS  expressed his  agreement  that  the new  pricing  for                                                               
insulin was a  national problem.  He said they  did the best they                                                               
could  given  the  available  resources   and  would  often  work                                                               
directly with the manufacturers.   He noted that sometimes, given                                                               
the  income level  of  his patients,  they did  not  have to  pay                                                               
anything for medications.                                                                                                       
                                                                                                                                
REPRESENTATIVE DRUMMOND asked how  diabetic patients could afford                                                               
the  best  insulins.    She asked  if  these  prescriptions  were                                                               
covered by insurance.                                                                                                           
                                                                                                                                
DR. GROSS said that patients who  did have insurance would use it                                                               
to pay  for the prescriptions,  although his practice  would work                                                               
with  the  manufacturers  for patients  without  insurance.    He                                                               
reported that Type II diabetics  required more time to teach them                                                               
lifestyle changes  and wean them  away from the medications.   He                                                               
declared that it took 3 minutes  to prescribe a medication but 30                                                               
minutes to not prescribe a medication.                                                                                          
                                                                                                                                
REPRESENTATIVE DRUMMOND asked if  the manufacturers supplied free                                                               
insulin forever to  a Type I diabetic who could  not live without                                                               
insulin.                                                                                                                        
                                                                                                                                
DR. GROSS  replied, "at the  moment, they  do.  Forever,  I can't                                                               
certainly tell  you that."  He  explained that, if a  patient was                                                               
not  eligible   for  a  government  program   such  as  Medicare,                                                               
Medicaid,  or  benefits,  and they  were  not  presently  getting                                                               
health  insurance, then,  in most  cases they  would qualify  for                                                               
free insulin  based on income.   He  expressed his desire  to see                                                               
federal changes to  the pharmacy benefits management  as it could                                                               
not be fixed at the direct primary care level.                                                                                  
                                                                                                                                
4:40:34 PM                                                                                                                    
                                                                                                                                
CO-CHAIR  ZULKOSKY shared  concern that  an exemption  for direct                                                               
care agreements from insurance  regulations would remove consumer                                                               
protections, and  ultimately limit patients to  contractual items                                                               
contained  in  the   care  agreements.    She   asked  about  the                                                               
regulation of  rates and the guaranteed  coverage allowed through                                                               
the various  care agreements  ensuring that  clients who  may get                                                               
sick outside the contracts were able to receive coverage.                                                                       
                                                                                                                                
DR. GROSS explained  that they were not asking  for physicians to                                                               
not be regulated, but that  physicians should not be regulated as                                                               
insurance  companies.   He  declared  that  physicians were  very                                                               
heavily regulated  and that would  not change for  direct primary                                                               
care.                                                                                                                           
                                                                                                                                
CO-CHAIR  ZULKOSKY  asked if  regulations  of  these direct  care                                                               
agreements were managed  through contractual law in  the State of                                                               
Florida.                                                                                                                        
                                                                                                                                
DR. GROSS  replied that  this law  managed the  actual agreement;                                                               
whereas, the conduct  of the practice, the  practitioner, and the                                                               
delivery of care was monitored through the State Medical Board.                                                                 
                                                                                                                                
CO-CHAIR  ZULKOSKY  asked  if  the   Division  of  Insurance  had                                                               
conducted an analysis  for the impact on  consumer protections in                                                               
Alaska  with  the  exemption  of   direct  care  agreements  from                                                               
insurance regulations.                                                                                                          
                                                                                                                                
4:43:06 PM                                                                                                                    
                                                                                                                                
ANNA  LATHAM,   Deputy  Director,  Juneau  Office,   Division  of                                                               
Insurance,   Department  of   Commerce,   Community  &   Economic                                                               
Development, said that  the division had not  analyzed any impact                                                               
to  consumers  should  these  agreements  occur.    She  directed                                                               
attention  to   a  report   by  the   Office  of   the  Insurance                                                               
Commissioner  in  the  State  of   Washington.    She  said  that                                                               
Washington  had been  groundbreaking  in  direct care  practices,                                                               
with  41  direct  care  practices  currently  exempted  from  the                                                               
insurance  code.    She  noted that  direct  care  and  concierge                                                               
medicine had been  prevalent in Washington since  the early 2000s                                                               
and  were exempted  in  2007.   She  reported  that  part of  the                                                               
regulation  required an  extensive report  to the  Office of  the                                                               
Insurance  Commissioner.   She suggested  that this  report could                                                               
have  some analysis  for the  consumer impact.   She  pointed out                                                               
that  these agreements  were very  transparent for  what services                                                               
were provided.                                                                                                                  
                                                                                                                                
CO-CHAIR ZULKOSKY  asked for  the history  to the  management and                                                               
regulation  of  rates  and  coverages   within  the  direct  care                                                               
agreements.  She suggested that  they were managed largely by the                                                               
provider groups  and not  through regulation  by the  Division of                                                               
Insurance.                                                                                                                      
                                                                                                                                
MS. LATHAM  explained that the  rates were set by  the practices.                                                               
She offered some information to the  variance of the rates in the                                                               
past two years.   From 2016 - 2018, 11  practices increased fees,                                                               
6 decreased  fees, and 5 offered  no changes in fees.   According                                                               
to the  Direct Primary Care  coalition, the median fee  was about                                                               
$70  per person  per month,  or $165  per month  for a  family of                                                               
four.                                                                                                                           
                                                                                                                                
CO-CHAIR  ZULKOSKY   asked  about   the  percentage   of  average                                                               
increase.                                                                                                                       
                                                                                                                                
MS.  LATHAM  said  that  she  could provide  the  Office  of  the                                                               
Insurance Commissioner report.                                                                                                  
                                                                                                                                
REPRESENTATIVE CLAMAN  asked if Health Savings  Accounts could be                                                               
used to pay the fees.                                                                                                           
                                                                                                                                
MS.  LATHAM offered  her belief  that the  use of  Health Savings                                                               
Accounts was not  allowed for these plans.  She  noted that there                                                               
had been  some federal effort in  2017 to allow for  this but the                                                               
bill did not pass.                                                                                                              
                                                                                                                                
DR. GROSS  expressed his agreement  that Health  Savings Accounts                                                               
could not be used to pay  for direct care contracts, as they were                                                               
not eligible under federal code.                                                                                                
                                                                                                                                
DR. GROSS, in  response to Representative Jackson,  said that the                                                               
Health Savings  Accounts had  to be used  with a  qualifying high                                                               
deductible  health  plan.    He   pointed  out  that  these  high                                                               
deductible health  plans could not  cover direct primary  care as                                                               
it was  first dollar coverage.   He offered his belief  that most                                                               
people  believed  that  direct  primary  care  membership  should                                                               
qualify under the Internal Revenue code.                                                                                        
                                                                                                                                
4:49:34 PM                                                                                                                    
                                                                                                                                
CO-CHAIR ZULKOSKY opened public testimony.                                                                                      
                                                                                                                                
4:49:58 PM                                                                                                                    
                                                                                                                                
CO-CHAIR ZULKOSKY closed public testimony.                                                                                      
                                                                                                                                
[HB 92 was held over.]                                                                                                          
                                                                                                                                
        HB 114-MEDICAL PROVIDER INCENTIVES/LOAN REPAYM'T                                                                    
                                                                                                                                
4:50:11 PM                                                                                                                    
                                                                                                                                
CO-CHAIR  ZULKOSKY announced  that  the final  order of  business                                                               
would be  HOUSE BILL  NO. 114,  "An Act  relating to  a workforce                                                               
enhancement  program for  health care  professionals employed  in                                                               
the state; and providing for an effective date."                                                                                
                                                                                                                                
4:50:55 PM                                                                                                                    
                                                                                                                                
CO-CHAIR SPOHNHOLZ paraphrased from the Sponsor Statement for HB                                                                
114 [Included in members' packets], which read:                                                                                 
                                                                                                                                
     Health  care is  one of  the largest  and most  dynamic                                                                    
     industries in Alaska, yet  many citizens, especially in                                                                    
     rural  areas, continue  to  experience challenges  with                                                                    
     accessing  care.   The  availability  of   health  care                                                                    
     services   is   important   for   maintaining   health,                                                                    
     preventing  and managing  disease,  and reducing  costs                                                                    
     from  unnecessary emergency  room visits,  and hospital                                                                    
     readmissions and temporary  staffing. One reason access                                                                    
     to care  is limited,  particularly in rural  Alaska, is                                                                    
     due  to shortages  of healthcare  professionals. Health                                                                    
     care  sites  struggle  with  recruiting  and  retaining                                                                    
     health   care  professionals.   Further,  health   care                                                                    
     professionals have  challenges with large  student loan                                                                    
     debt  and  high cost  of  living  in rural  and  remote                                                                    
     locations.                                                                                                                 
                                                                                                                                
     To  meet the  ongoing demand,  Alaska must  continue to                                                                    
     address the  shortage of health care  professionals. HB                                                                    
     114  (SHARP-3) does  this  by  establishing the  Health                                                                    
     Care  Professionals  Workforce Enhancement  Program,  a                                                                    
     public-private  partnership  that   will  increase  the                                                                    
     number of  providers while minimizing the  use of state                                                                    
     funds.  Health care  professionals  agree  to work  for                                                                    
     minimum of  three years in Alaska  in underserved areas                                                                    
     in exchange  for repayment of  student loans  or direct                                                                    
     incentives.  Employers  will  fully fund  the  program,                                                                    
     taking advantage  of a federal tax  exemption available                                                                    
     only to a state-run program.                                                                                               
                                                                                                                                
     The success of healthcare  loan repayment and incentive                                                                    
     programs  in  increasing  the healthcare  workforce  in                                                                    
     Alaska was  demonstrated in  SHARP-2. Between  2013 and                                                                    
     2015,  SHARP-2  was  successful  in  recruiting  and/or                                                                    
     retaining   83   clinicians    statewide,   with   most                                                                    
     clinicians placed in locations  off the road system and                                                                    
     emphasizing    care   for    rural   and    underserved                                                                    
     populations.  With the  sunset of  SHARP-2 on  June 30,                                                                    
     2019, other healthcare  practitioner incentive programs                                                                    
     are  needed to  reduce  healthcare workforce  shortages                                                                    
     throughout Alaska.                                                                                                         
                                                                                                                                
     SHARP-3  builds  on the  success  of  SHARP-2 with  new                                                                    
     practice settings, new  occupations, new employers, new                                                                    
     locations,  and new  roles.  Employers  can hire  much-                                                                    
     needed staff, providers get  assistance with their loan                                                                    
     payments which  makes it more  affordable to work  in a                                                                    
     rural   community,  and   Alaskans   living  in   rural                                                                    
     communities  have improved  access to  health care--all                                                                    
     without the use of state general funds.                                                                                    
                                                                                                                                
4:54:22 PM                                                                                                                    
                                                                                                                                
JILL LEWIS,  Deputy Director -  Juneau, Central  Office, Division                                                               
of  Public  Health, Department  of  Health  and Social  Services,                                                               
presented   a  PowerPoint   titled  "HB   114  Medical   Provider                                                               
Incentives/Loan Repayment."   She directed attention  to slide 2,                                                               
"HB 114," which read:                                                                                                           
                                                                                                                                
     Establishes  a  Health   Care  Professionals  Workforce                                                                    
     Enhancement Program to address  shortage of health care                                                                    
     workforce.                                                                                                                 
                                                                                                                                
     Health  care  professionals  agree to  work  for  three                                                                    
     years in  underserved areas  in exchange  for repayment                                                                    
     of student loans or direct incentives.                                                                                     
                                                                                                                                
     Employers  fully  fund  the  program.  No  unrestricted                                                                    
     general funds are involved.                                                                                                
                                                                                                                                
     Replaces  the existing  program in  AS 18.29  scheduled                                                                    
     for sunset June 30, 2019.                                                                                                  
                                                                                                                                
4:55:38 PM                                                                                                                    
                                                                                                                                
MS.  LEWIS  noted  that   Representative  Spohnholz  had  already                                                               
reviewed the challenges listed on  slide 3, "Challenges in health                                                               
care access,"  and she  directed attention to  slide 4,  "SHARP -                                                               
2," which read:                                                                                                                 
                                                                                                                                
     Operated 2013  2018                                                                                                        
     No  new   contracts  after  2015   due  to   GF  budget                                                                    
     reductions                                                                                                                 
     83 contracts: 39 Tier 1 and 44 Tier 2                                                                                      
     47-53% positions very hard-to-fill                                                                                         
     $25,560 average payment per contract per year                                                                              
     10-30% employer match                                                                                                      
     31 employers distributed across 25 communities                                                                             
     Primarily non-profit and hospital associated                                                                               
     Similar  numbers of  tribal  and  non-tribal affiliated                                                                    
     organizations                                                                                                              
                                                                                                                                
MS. LEWIS moved on to paraphrase slide 5, "An innovative                                                                        
solution," which read:                                                                                                          
                                                                                                                                
     A  public-private partnership  that  ensures access  to                                                                    
     health  care by  expanding the  distribution of  health                                                                    
     care  professionals  all Alaskans  at  no  cost to  the                                                                    
     state.                                                                                                                     
                                                                                                                                
     SHARP-3 builds  on the  success of  SHARP-1 and SHARP-2                                                                    
     with  new  practice   settings,  new  occupations,  new                                                                    
     employers, new locations, and new roles.                                                                                   
                                                                                                                                
     Benefit will not  be limited to rural  areas or primary                                                                    
     care;  there is  also  room for  specialists and  urban                                                                    
     health care professionals.                                                                                                 
                                                                                                                                
     Takes  advantage of  a federal  law  that exempts  loan                                                                    
     repayment from federal income tax  if awarded through a                                                                    
     state-run program.                                                                                                         
                                                                                                                                
     Public-private partnerships  increases  the  number  of                                                                    
     providers while minimizing the use of state funds.                                                                         
                                                                                                                                
4:56:56 PM                                                                                                                    
                                                                                                                                
MS. LEWIS shared slide 6, "Benefits," which read:                                                                               
                                                                                                                                
     Health care sites can hire much needed staff                                                                               
     Health  care professionals  get  assistance with  their                                                                    
     student loans                                                                                                              
     Alaskans have improved access to health care                                                                               
     Access to health care is  important for maintain health                                                                    
     and reducing costs                                                                                                         
     All without the use of undesignated general funds                                                                          
                                                                                                                                
4:57:21 PM                                                                                                                    
                                                                                                                                
MS. LEWIS explained slide 7, "SHARP - 3," which read:                                                                           
                                                                                                                                
     Health   care   professionals  receive   student   loan                                                                    
     repayment  and/or  direct  incentives  for  working  in                                                                    
     underserved areas.                                                                                                         
     Employer   sites  provide   health  care   services  in                                                                    
     underserved  or   health  care   professional  shortage                                                                    
     areas.                                                                                                                     
     3 year contract with renewals; 12 year lifetime limit.                                                                     
     Employer   payments    fully   cover   cost    of   the                                                                    
     professional's  program payment  and an  administrative                                                                    
     fee.                                                                                                                       
     An  advisory council  recommends eligibility  criteria,                                                                    
     prioritization   of   sites   and   professionals   for                                                                    
     participation, and contract awards.                                                                                        
                                                                                                                                
4:58:36 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE CLAMAN asked whether  the 3-year contract with the                                                               
12-year  lifetime limit  was intended  to pay  the entirety  of a                                                               
loan or only the amount due each  year of that contract time.  He                                                               
offered  an  example  of  a  20-year loan,  asking  if  a  3-year                                                               
contract would allow payment for 3 years of the 20-year loan.                                                                   
                                                                                                                                
MS. LEWIS replied  that a provision only allowed  up to one-third                                                               
repayment of  a loan  in each  of the  3 years,  if a  person was                                                               
using the loan repayment option and not a direct incentive.                                                                     
                                                                                                                                
4:59:31 PM                                                                                                                    
                                                                                                                                
MS.  LEWIS directed  attention to  slide 8,  "SHARP -  3," adding                                                               
that   this  could   further  address   the  question   posed  by                                                               
Representative Claman, which read:                                                                                              
                                                                                                                                
     Tier 1: dentist, pharmacist, physician                                                                                   
     $35,000/year regular or $47,250 very hard-to-fill                                                                          
     Tier  2: dental  hygienist, registered  nurse, advanced                                                                  
     practice   registered   nurse,   physician   assistant,                                                                    
     physical  therapist, clinical  psychologist, counseling                                                                    
     psychologist,  professional counselor,  board certified                                                                    
     behavior  analyst,  marital  and family  therapist,  or                                                                    
     clinical social worker                                                                                                     
     $20,000/year regular or $27,000 very hard-to-fill                                                                          
     Tier 3: not otherwise eligible under Tier 1 or Tier 2                                                                    
     $15,000/year regular or $20,250 very hard-to-fill                                                                          
                                                                                                                                
MS. LEWIS  stated that, although  these were the  current amounts                                                               
currently set  in statute for  SHARP 1  and SHARP 2,  the amounts                                                               
could be  set by the commissioner.   She pointed out  that Tier 3                                                               
was new with the proposed  bill, stating that each tier addressed                                                               
different levels of educational attainment and practice.                                                                        
                                                                                                                                
5:01:49 PM                                                                                                                    
                                                                                                                                
MS. LEWIS  moved on to  the diagram  on slide 9,  which described                                                               
the  process for  the program.   She  explained that  health care                                                               
professionals who  have applied and  were accepted would  work at                                                               
an eligible  site for  a calendar  quarter.  At  the end  of that                                                               
quarter, the site would report back  to the SHARP program on that                                                               
professional's hours  worked and the  amount of care given.   She                                                               
noted that SHARP  could adjust the maximum payments  based on the                                                               
actual hours worked, and that  individuals had an option for full                                                               
or half  time.  She  noted that  the service was  provided before                                                               
the employer  made any payments.   SHARP would invoice  the sites                                                               
for the professional's  payment and the administrative  fee.  The                                                               
sites  would send  payment back  to the  SHARP program  with that                                                               
money being used to make loan  payment to the lender, or a direct                                                               
incentive payment to  the professional.  She  reported that SHARP                                                               
routinely  provided   data  back  to  the   Advisory  Council  to                                                               
prioritize and establish criteria.                                                                                              
                                                                                                                                
5:04:07 PM                                                                                                                    
                                                                                                                                
MS. LEWIS presented slide 10, "In closing..." which read:                                                                       
                                                                                                                                
     HB 114                                                                                                                   
       Keeps   health   care   professionals   in   rural                                                                       
     communities                                                                                                                
          Promotes health and economic community stability                                                                      
          Ensuring a healthier future for all Alaskans                                                                          
          At the lowest possible cost.                                                                                          
                                                                                                                                
5:04:35 PM                                                                                                                    
                                                                                                                                
CO-CHAIR ZULKOSKY  referenced slide  4 and  noted that  the SHARP                                                               
program  offered  opportunities  to  all  communities  throughout                                                               
Alaska.                                                                                                                         
                                                                                                                                
5:05:01 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE DRUMMOND,  directing attention  to slide  4, asked                                                               
if SHARP  - 2 was  paying an average of  $25,500 per year  for 83                                                               
different  contracts.    She  stated that  this  was  about  $2.1                                                               
million per  year from  the general  fund and  asked if  this was                                                               
before or after the employer match.                                                                                             
                                                                                                                                
MS. LEWIS  reported that the  program had  ramped up in  2013 and                                                               
2014 and was fully operating in  2015 with more than 40 contracts                                                               
added  each  year.   After  that,  as  there were  no  additional                                                               
general funds,  no new contracts  were extended.  She  added that                                                               
there  had  been  significant state  match,  with  the  employers                                                               
paying between 10 and 30 percent for each of the contracts.                                                                     
                                                                                                                                
REPRESENTATIVE DRUMMOND asked  if the $2.1 million  was before or                                                               
after the employer match.                                                                                                       
                                                                                                                                
MS. LEWIS  stated that this was  the total cost and  included the                                                               
employer's share.                                                                                                               
                                                                                                                                
5:06:53 PM                                                                                                                    
                                                                                                                                
CO-CHAIR SPOHNHOLZ pointed out that  there was a "Final Report to                                                               
the  Legislature," dated  December  2018,  [Included in  members'                                                               
packets] and she  directed attention to page 9,  which listed the                                                               
range  of  health care  providers  and  contract expenses  listed                                                               
under  SHARP  2.    She  emphasized  that  the  proposed  current                                                               
legislation for SHARP  3 was all privately funded.   She reported                                                               
that under SHARP  2 the general fund expense  had been $4,909,038                                                               
and the employer match was $1,455,438.                                                                                          
                                                                                                                                
REPRESENTATIVE DRUMMOND asked where the  money was coming from to                                                               
pay for proposed HB 114.                                                                                                        
                                                                                                                                
CO-CHAIR SPOHNHOLZ  explained that the  SHARP 3 program  would be                                                               
entirely  funded  by the  employer  community,  as there  was  an                                                               
interest  in  recruiting  health  care  providers  and  providing                                                               
incentives.  She  noted that there was a tax  benefit to both the                                                               
employer and  the employee.   She offered  her belief  that there                                                               
was  still  a state  interest  to  ensure  that health  care  was                                                               
provided,  both in  Rural Alaska  and underserved  populations in                                                               
urban Alaska.   She noted  that it was  necessary to use  "all of                                                               
the tools  in our  tool kit  to recruit  and retain  providers in                                                               
those underserved areas of health care."                                                                                        
                                                                                                                                
REPRESENTATIVE  DRUMMOND asked  what would  happen to  the health                                                               
care providers  currently covered  by the loan  repayment program                                                               
if proposed HB 114 did not pass.                                                                                                
                                                                                                                                
5:09:50 PM                                                                                                                    
                                                                                                                                
MS. LEWIS explained that there would  be no new contracts for the                                                               
SHARP 2  program, and that  all the existing contracts  have been                                                               
paid.  She reported that SHARP  1, the federal option, was an on-                                                               
going grant that  was not affected by either SHARP  2 or proposed                                                               
HB 114.                                                                                                                         
                                                                                                                                
5:10:44 PM                                                                                                                    
                                                                                                                                
RACHEL GEARHART, Co-Chair, SHARP  Council, reported on the status                                                               
of health care professionals in  each committee member's district                                                               
and noted that the proposed bill  provided a benefit to all their                                                               
constituents.   She acknowledged  how valuable the  proposed bill                                                               
would  be  for  recruiting  and  retaining  quality  health  care                                                               
professionals with no  additional expenditure to the  state.  She                                                               
noted that  she had been a  SHARP 2 recipient, which  had allowed                                                               
her to  be free of student  loan, and that she  was still working                                                               
for the  same agency as when  she had received her  benefit.  She                                                               
pointed to  the letters  of support from  SHARP recipients.   She                                                               
shared  that  the SHARP  data  from  the quarterly  work  reports                                                               
offered   tracking   for   important  demographics   to   further                                                               
recruitment  and  retention  efforts,  noting  the  retention  of                                                               
permanent  workers in  substance use  capacity.   She noted  that                                                               
proposed HB 114  would allow the biggest  community mental health                                                               
centers  to  be  eligible  sites  without also  having  to  be  a                                                               
federally  qualified  health  center.     SHARP  3  would  expand                                                               
eligible  sites and  eligible professions,  including respiratory                                                               
therapists,  occupational  therapists,  case  managers,  chemical                                                               
dependency  councilors, and  training  coordinators.   She  noted                                                               
that,  in mental  health work,  the therapeutic  alliance with  a                                                               
client  was considered  one  of the  most  important factors  for                                                               
working together.  She explained  that, when those with high ACEs                                                               
scores  started to  connect with  a  mental health  professional,                                                               
progress  was  made.    She  pointed  to  disruption  to  service                                                               
delivery  due  to  staff  turnover,  which  SHARP  3  could  help                                                               
alleviate.                                                                                                                      
                                                                                                                                
5:16:00 PM                                                                                                                    
                                                                                                                                
NANCY   MERRIMAN,  Executive   Director,   Alaska  Primary   Care                                                               
Association, stated support for proposed  HB 114 to establish the                                                               
SHARP 3  program and help  Health Centers better  serve Alaskans.                                                               
She  declared   that  there  was   a  shortage  of   health  care                                                               
professionals  of all  types in  Alaska, and  that Health  Center                                                               
leaders  constantly grappled  with vacant  health care  clinician                                                               
positions.    Although  health care  jobs  remained  the  fastest                                                               
growing sector  in the Alaska  labor force, the  demands outpaced                                                               
the  availability  and, as  Alaskans  grew  older, there  was  an                                                               
increased need  for health  care with  an increased  incidence of                                                               
chronic disease  requiring more constant  care.  She  pointed out                                                               
that  health  care  professionals  were  not  distributed  evenly                                                               
across the state.                                                                                                               
                                                                                                                                
MS. MERRIMAN declared  that the SHARP programs  were critical for                                                               
community health centers, reporting that  the SHARP 1 program had                                                               
issued 172  contracts to  health centers  since its  inception in                                                               
2010; the  SHARP 2  program had issued  47 contracts  with health                                                               
care providers.   She shared that APCA surveys  revealed that the                                                               
most  important  work  force  issues  were  for  recruitment  and                                                               
retention, with noted  appreciation for SHARP.   She relayed that                                                               
SHARP  had  also   addressed  some  of  the   disparity  for  the                                                               
distribution  of  providers.   She  added  that Alaska  community                                                               
health  centers had  benefited from  the  SHARP program,  sharing                                                               
that 80  of the 105 candidates  awarded into the SHARP  1 program                                                               
were practicing in community health centers.                                                                                    
                                                                                                                                
MS.  MERRIMAN stated  that SHARP  3  was innovative  and did  not                                                               
require  any  state  general  fund   dollars,  while  offering  a                                                               
valuable state infrastructure.   It would provide  the ability to                                                               
expand  the  benefits  of  SHARP  to  many  areas  not  currently                                                               
designated as  health professional shortage areas.   The proposed                                                               
bill  would also  expand  the provider  types  eligible for  loan                                                               
repayment.                                                                                                                      
                                                                                                                                
REPRESENTATIVE  CLAMAN  asked  if  the  increase  of  funding  by                                                               
employers to 100  percent for the proposed SHARP  3 program would                                                               
be an issue.                                                                                                                    
                                                                                                                                
MS. MERRIMAN explained that the  program funding would not be 100                                                               
percent by  the employers, as there  would be a request  to other                                                               
bodies for a cost share  to help support the additional necessary                                                               
funding.                                                                                                                        
                                                                                                                                
REPRESENTATIVE  CLAMAN  asked for  information  as  to the  other                                                               
bodies.                                                                                                                         
                                                                                                                                
MS.  MERRIMAN   suggested  that  these  could   be  philanthropic                                                               
organizations, labor unions, or associations.                                                                                   
                                                                                                                                
5:21:56 PM                                                                                                                    
                                                                                                                                
JANE  ERICKSON,  President,  Alaska  Nurses  Association,  stated                                                               
support of  proposed HB 114.   She stated that the  Alaska Nurses                                                               
Association  strongly  believed  in   the  value  of  the  SHARPS                                                               
program, which  improved access  to high  quality health  care by                                                               
providing  incentives to  health care  professionals to  create a                                                               
more  equitable distribution  of health  professionals throughout                                                               
Alaska.   She reported that  Alaska faced  continual difficulties                                                               
in  recruitment  and  retention  for  a  health  care  workforce,                                                               
especially in  rural and remote  communities.  She  declared that                                                               
SHARP 3  was a critical  need for this recruitment  and retention                                                               
of  health  care professionals.    She  declared that  the  SHARP                                                               
program had  made a  tremendous positive  difference and  was the                                                               
main state program to support  placement of a range of providers.                                                               
She added  that the program  was a  smart financial move  for the                                                               
state.  She pointed out that  private funds would be used instead                                                               
of  state dollars  and would  expand the  eligibility beyond  the                                                               
strictures of  the previous SHARP  programs.  This  would greatly                                                               
impact the health and welfare of communities statewide.                                                                         
                                                                                                                                
5:24:57 PM                                                                                                                    
                                                                                                                                
CONNIE BEEMER, Vice President, Alaska  State Hospital and Nursing                                                               
Home Association  (ASHNHA), stated  support for proposed  HB 114.                                                               
She paraphrased  from a prepared statement  [Included in members'                                                               
packets] which read:                                                                                                            
                                                                                                                                
     The Alaska State Hospital  and Nursing Home Association                                                                    
     (ASHNHA) is  offering this letter of  support for SHARP                                                                    
     - 3.   As a  member of the  SHARP Council we  have been                                                                    
     involved  with  the  program since  its  inception  and                                                                    
     believe in  the value  of the  program to  support high                                                                    
     quality  care  through  an  equitable  distribution  of                                                                    
     health professionals throughout Alaska.                                                                                    
                                                                                                                                
     The SHARP program has  helped Alaska's hospitals ensure                                                                    
     an adequate  supply of healthcare  providers and  is an                                                                    
     important tool to help  with recruitment and retention.                                                                    
     We support  the addition  of a third  component through                                                                    
     SHARP - 3 legislation.                                                                                                     
                                                                                                                                
     SHARP - 3 will support  a variety of practice settings,                                                                    
     locations (especially  those not eligible as  a HPSA or                                                                    
     other  federal programs  for SHARP  -  1) and  provider                                                                    
     types.  We need to  use whatever tools are available to                                                                    
     support healthcare organizations  to recruit and retain                                                                    
     employees.  SHARP  - 3 would expand the  use of federal                                                                    
     tax exemption for education  loan repayment and enhance                                                                    
     the  number  and  variety  of  financial  contributors.                                                                    
     There  is  a  need  to  give  local  control  to  allow                                                                    
     communities to  designate funds to  support recruitment                                                                    
     of providers.   SHARP -  3 utilizes the  existing SHARP                                                                    
     infrastructure  while   maximizing  contributions  from                                                                    
     local  communities  or  foundations.   Money  could  be                                                                    
     contributed  from different  local  sources  such as  a                                                                    
     business,   private   foundation,  trade   association,                                                                    
     government entity, foundations or employers.                                                                               
                                                                                                                                
     SHARP   3  provides   valuable  state   infrastructure,                                                                    
     without  additional  state   general  funds,  and  will                                                                    
     provide us the ability to  expand the benefits of SHARP                                                                    
     to  areas that  are  not  Health Professional  Shortage                                                                    
     Areas (HPSAs), a require for SHARP 1.                                                                                      
                                                                                                                                
     ASHNHA is  prepared to support  our members  in efforts                                                                    
     to utilize SHARP  3 as soon as it is  available.  We're                                                                    
     eager to continue the momentum  of SHARP and to support                                                                    
     workforce development efforts in Alaska in this way.                                                                       
                                                                                                                                
5:27:56 PM                                                                                                                    
                                                                                                                                
CO-CHAIR ZULKOSKY opened public testimony.                                                                                      
                                                                                                                                
5:28:15 PM                                                                                                                    
                                                                                                                                
CO-CHAIR ZULKOSKY closed public testimony.                                                                                      
                                                                                                                                
[HB 114 was held over.]                                                                                                         
                                                                                                                                
5:29:16 PM                                                                                                                    
                                                                                                                                
ADJOURNMENT                                                                                                                   
                                                                                                                                
There being no further business before the committee, the House                                                                 
Health and Social Services Standing Committee meeting was                                                                       
adjourned at 5:29 p.m.                                                                                                          

Document Name Date/Time Subjects
HB084 Sectional Analysis 4.3.19.pdf HHSS 4/4/2019 3:00:00 PM
HHSS 4/25/2019 3:00:00 PM
HB 84
HB084 Sponsor Statement 3.28.19.pdf HHSS 4/4/2019 3:00:00 PM
HHSS 4/25/2019 3:00:00 PM
HB 84
HB084 Supporting Document- Breast Cancer in Women Firefighters.pdf HHSS 4/4/2019 3:00:00 PM
HHSS 4/25/2019 3:00:00 PM
HB 84
HB084 Supporting Document- Letter of Support ACAT 4.3.19.pdf HHSS 4/4/2019 3:00:00 PM
HHSS 4/25/2019 3:00:00 PM
HB 84
HB084 Supporting Document- Asbestos 03.28.19.pdf HHSS 4/4/2019 3:00:00 PM
HHSS 4/25/2019 3:00:00 PM
HB 84
HB084 Supporting Document- RADS in Police from Chemical Spill 3.28.19.pdf HHSS 4/4/2019 3:00:00 PM
HHSS 4/25/2019 3:00:00 PM
HB 84
HB084 Fiscal Note DLWD WC 04.03.19.pdf HHSS 4/4/2019 3:00:00 PM
HHSS 4/25/2019 3:00:00 PM
HB 84
HB084 Letter of Support- APOA 3.28.19.pdf HHSS 4/4/2019 3:00:00 PM
HHSS 4/25/2019 3:00:00 PM
HB 84
HB084 Opposition Document- AML Joint Insurance Association 3.29.2019.pdf HHSS 4/4/2019 3:00:00 PM
HHSS 4/25/2019 3:00:00 PM
HB 84
HB084 Presentation 4.3.19.pdf HHSS 4/4/2019 3:00:00 PM
HHSS 4/25/2019 3:00:00 PM
HB 84
HB0089 Supporting Document-DHSS Handout 03.27.2019.pdf HHSS 4/4/2019 3:00:00 PM
HHSS 4/9/2019 3:00:00 PM
HB 89
HB0089 Supporting Document-Support Letter 04.03.2019.pdf HHSS 4/4/2019 3:00:00 PM
HHSS 4/9/2019 3:00:00 PM
HB 89
HB0089 Supporting Document-Support Letters 1.27.2019.pdf HHSS 4/4/2019 3:00:00 PM
HHSS 4/9/2019 3:00:00 PM
HB 89
HB0089-Opposing Document-Opposition Letter 04.03.2019.pdf HHSS 4/4/2019 3:00:00 PM
HHSS 4/9/2019 3:00:00 PM
HB 89
HB0089 Draft Proposed Blank CS ver U 04.03.2019.pdf HHSS 4/4/2019 3:00:00 PM
HHSS 4/9/2019 3:00:00 PM
HB 89
HB0089 Explanation of Changes ver U 04.03.2019.pdf HHSS 4/4/2019 3:00:00 PM
HHSS 4/9/2019 3:00:00 PM
HB 89
HB0089 Sectional Analysis ver A 03.27.2019.pdf HHSS 4/4/2019 3:00:00 PM
HHSS 4/9/2019 3:00:00 PM
HB 89
HB0089 Sponsor Statement 03.27.2019.pdf HHSS 4/4/2019 3:00:00 PM
HHSS 4/9/2019 3:00:00 PM
HB 89
HB092 ver U 3.27.19.PDF HHSS 4/4/2019 3:00:00 PM
HB 92
HB92 Fiscal Note DCCED-IO 3.31.2019.pdf HHSS 4/4/2019 3:00:00 PM
HB 92
HB92 Fiscal Note DHSS-MS 3.31.2019.pdf HHSS 4/4/2019 3:00:00 PM
HB 92
HB92 Sponsor Statement 3.31.19.pdf HHSS 4/4/2019 3:00:00 PM
HB 92
HB092 Sectional Analysis ver U 3.27.19.pdf HHSS 4/4/2019 3:00:00 PM
HB 92
HB114 Letters of Support 04.03.19.pdf HHSS 4/4/2019 3:00:00 PM
HHSS 4/9/2019 3:00:00 PM
HB 114
HB114 Sectional Analysis 04.03.19.pdf HHSS 4/4/2019 3:00:00 PM
HHSS 4/9/2019 3:00:00 PM
HB 114
HB114 SHARP-2 Final Report to Legislature 04.01.19.pdf HHSS 4/4/2019 3:00:00 PM
HHSS 4/9/2019 3:00:00 PM
HB 114
HB114 Sponsor Statement 04.03.19.pdf HHSS 4/4/2019 3:00:00 PM
HHSS 4/9/2019 3:00:00 PM
HB 114
HB114 DHSS Presentation 04.01.19.pdf HHSS 4/4/2019 3:00:00 PM
HHSS 4/9/2019 3:00:00 PM
HB 114
HB114 Fiscal Note DCCED CBPL 04.01.19.pdf HHSS 4/4/2019 3:00:00 PM
HHSS 4/9/2019 3:00:00 PM
HB 114
HB089 ver U Presentation.pdf HHSS 4/4/2019 3:00:00 PM
HHSS 4/9/2019 3:00:00 PM
HB 89