HOUSE HEALTH, EDUCATION AND SOCIAL SERVICES STANDING COMMITTEE April 22, 1997 3:03 p.m. MEMBERS PRESENT Representative Con Bunde, Chairman Representative Joe Green, Vice Chairman Representative Al Vezey Representative Brian Porter Representative Fred Dyson Representative J. Allen Kemplen MEMBERS ABSENT Representative Tom Brice COMMITTEE CALENDAR CS FOR SENATE BILL NO. 13(RLS) "An Act relating to taxes on cigarettes and tobacco products and to the use of the proceeds of those taxes, and increasing by at least 35.5 mills the amount of excise tax levied on each cigarette imported or acquired in the state; and providing for an effective date." - MOVED HCS CSSB 13(HES) OUT OF COMMITTEE HOUSE BILL NO. 127 "An Act relating to the citizen review board and panels for permanency planning for certain children in state custody; renaming the Citizens' Review Panel For Permanency Planning as the Citizens' Foster Care Review Board; extending the termination date of the Citizens' Foster Care Review Board; and providing for an effective date." - MOVED CSHB 127(HES) OUT OF COMMITTEE HOUSE BILL NO. 195 "An Act relating to licensure of optometrists; and providing for an effective date." - HEARD AND HELD (* First public hearing) PREVIOUS ACTION BILL: SB 13 SHORT TITLE: INCREASE TOBACCO TAXES SPONSOR(S): SENATOR(S) SHARP, Ellis JRN-DATE JRN-DATE ACTION 01/03/97 17 (S) PREFILE RELEASED 1/3/97 01/13/97 17 (S) READ THE FIRST TIME - REFERRAL(S) 01/13/97 17 (S) HES, FIN 02/05/97 (S) HES AT 9:00 AM BUTROVICH ROOM 205 02/05/97 (S) MINUTE(HES) 02/10/97 (S) HES AT 9:00 AM BUTROVICH ROOM 205 02/10/97 (S) MINUTE(HES) 02/14/97 (S) HES AT 9:00 AM BUTROVICH ROOM 205 02/14/97 (S) MINUTE(HES) 02/14/97 355 (S) HES RPT CS 2DP 2NR NEW TITLE 02/14/97 355 (S) DP:WILKEN, ELLIS, NR: WARD, GREEN 02/14/97 355 (S) FISCAL NOTE TO SB (REV) 02/24/97 468 (S) FISCAL NOTE TO CS (REV) 02/24/97 468 (S) ZERO FISCAL NOTE TO CS (REV) 04/04/97 (S) FIN AT 10:00 AM SENATE FINANCE 532 04/04/97 (S) FIN AT 6:00 PM SENATE FINANCE 532 04/07/97 1024 (S) FIN RPT CS 4DP 2NR SAME TITLE 04/07/97 1024 (S) DP: PEARCE, SHARP, ADAMS, TORGERSON 04/07/97 1024 (S) NR: PHILLIPS, PARNELL 04/07/97 1024 (S) FN TO CS (REV) 04/10/97 1077 (S) RLS RPT CS CALENDAR AND 1DP NEW TITLE 04/10/97 1078 (S) PREVIOUS FN APPLIES (REV-#4) 04/10/97 1080 (S) READ THE SECOND TIME 04/10/97 1080 (S) RLS CS ADOPTED UNAN CONSENT 04/10/97 1081 (S) AM NO 1 OFFERED BY ELLIS 04/10/97 1081 (S) AM NO 1 FAILED Y7 N12 A1 04/10/97 1082 (S) AM NO 2 OFFERED AND WITHDRAWN 04/10/97 1085 (S) ADVANCED TO THIRD READING UNAN CONSENT 04/10/97 1085 (S) READ THE THIRD TIME CSSB 13(RLS) 04/10/97 1086 (S) PASSED Y16 N4 04/10/97 1086 (S) EFFECTIVE DATE(S) SAME AS PASSAGE 04/10/97 1086 (S) WARD NOTICE OF RECONSIDERATION 04/11/97 1106 (S) RECON TAKEN UP - IN THIRD READING 04/11/97 1106 (S) PASSED ON RECONSIDERATION Y15 N4 E1 04/11/97 1107 (S) EFFECTIVE DATE(S) SAME AS PASSAGE 04/11/97 1107 (S) TRANSMITTED TO (H) 04/14/97 1094 (H) READ THE FIRST TIME - REFERRAL(S) 04/14/97 1095 (H) HES, FINANCE 04/22/97 (H) HES AT 3:00 PM CAPITOL 106 BILL: HB 127 SHORT TITLE: FOSTER CARE REVIEW BOARD SPONSOR(S): HEALTH, EDUCATION & SOCIAL SERVICES JRN-DATE JRN-DATE ACTION 02/12/97 318 (H) READ THE FIRST TIME - REFERRAL(S) 02/12/97 318 (H) HES, FINANCE 03/27/97 (H) HES AT 3:00 PM CAPITOL 106 03/27/97 (H) MINUTE(HES) 04/10/97 (H) HES AT 3:00 PM CAPITOL 106 04/10/97 (H) MINUTE(HES) 04/22/97 (H) HES AT 3:00 PM CAPITOL 106 BILL: HB 195 SHORT TITLE: LICENSURE OF OPTOMETRISTS SPONSOR(S): HEALTH, EDUCATION & SOCIAL SERVICES BY REQUEST JRN-DATE JRN-DATE ACTION 03/14/97 667 (H) READ THE FIRST TIME - REFERRAL(S) 03/14/97 667 (H) HES 04/22/97 (H) HES AT 3:00 PM CAPITOL 106 WITNESS REGISTER SENATOR BERT SHARP Alaska State Legislature Capitol Building, Room 516 Juneau, Alaska 99801 Telephone: (907) 465-3004 POSITION STATEMENT: Sponsor of CSSB 13(RLS) GLENN PRAX 1015 Meadow Rue North Pole, Alaska 99705 Telephone: (907) 488-2400 POSITION STATEMENT: Testified against HCS CSSB 13(HES) WALTER GAUTHIER P.O. Box 2246 Homer, Alaska 99603 Telephone: (907) 235-2809 POSITION STATEMENT: Testified against HCS CSSB 13(HES) and in support of CSHB 127(HES) DIANE BUFFINGTON Kodiak, Alaska Telephone: (907) POSITION STATEMENT: Testified against HCS CSSB 13(HES) JOANNE LOVITZ-EDMISTON 347 Dailey Street Anchorage, Alaska 995151 Telephone: (907) 349-8358 POSITION STATEMENT: Testified against HCS CSSB 13(HES) TESHA SANCHEZ 5630 South Tahiti Anchorage, Alaska 99507 Telephone: (907) 561-6699 POSITION STATEMENT: Testified against HCS CSSB 13(HES) BOBBY SCOTT 521 Izembek Anchorage, Alaska 99508 Telephone: (907) 338-8257 POSITION STATEMENT: Testified against HCS CSSB 13(HES) NICHOLAS ZERBINOS P.O. Box 371 Glennallen, Alaska 99588 Telephone: (907) 822-3451 POSITION STATEMENT: Testified against HCS CSSB 13(HES) KEN JACOBUS 425 G Street, Number 920 Anchorage, Alaska 99501 Telephone: (907) 277-3333 POSITION STATEMENT: Testified against HCS CSSB 13(HES) SUZANNE FISHCHETTI 10336 Stewart Drive Eagle River, Alaska 99577 Telephone: (907) 694-7944 POSITION STATEMENT: Testified against HCS CSSB 13(HES) JODI OLMSTEAD, Founder Concerned Parents for Reform 1995 Athena Drive North Pole, Alaska 99705 Telephone: (907) 488-0334 POSITION STATEMENT: Testified against HCS CSSB 13(HES) and in support of CSHB 127(HES) JOHN CYR, President National Education Association-Alaska (NEA-Alaska) 114 Second Street Juneau, Alaska 99801 Telephone: (907) 586-3090 POSITION STATEMENT: Testified in support of HCS CSSB 13(HES) RUPERT E. ANDREWS, Representative American Association of Retired Persons (AARP) 9416 Long Run Drive Juneau, Alaska 99801 Telephone: (907) 789-7422 POSITION STATEMENT: Testified in support of HCS CSSB 13(HES) BLAIR McCUNE, Assistant Public Defender Central Office Public Defender Agency Department of Administration 900 West Fifth Avenue, Suite 200 Anchorage, Alaska 99501-2090 Telephone: (907) 264-4400 POSITION STATEMENT: Testified on CSHB 127(HES) PATTI SWENSON, Legislative Assistant for Representative Bunde Alaska State Legislature Capitol Building, Room 104 Juneau, Alaska 99801 Telephone: (907) 465-4843 POSITION STATEMENT: Testified on CSHB 127(HES) DR. JEFFREY A. GONNASON., O.D. 2211 East Northern Lights, Number 202 Anchorage, Alaska 99508 Telephone: (907) 276-2080 POSITION STATEMENT: Testified in support of HB 195 DR. SAM McCONKEY, M.D. 351 Gold Claim Avenue Fairbanks, Alaska 99701 Telephone: (907) 456-7760 POSITION STATEMENT: Testified against HB 195 DR. PETER E. CANNAVA, M.D. 161 North Binkley Street Soldotna, Alaska 99669 Telephone: (907) 262-4462 POSITION STATEMENT: Testified against HB 195 DR. RONALD ZAMBER, M.D. 3044 Riverview Fairbanks, Alaska 99709 Telephone: (907) 479-4317 POSITION STATEMENT: Testified against HB 195 DR. ROBERT FORD, M.D. 1600 A Street, Suite 200 Anchorage, Alaska 99501-5146 Telephone: (907) 272-2423 POSITION STATEMENT: Testified in support of HB 195 DR. HANS KELL, O.D. 1600 A Street, Suite 200 Anchorage, Alaska 99501-5146 Telephone: (907) 272-2423 POSITION STATEMENT: Testified in support of HB 195 DR. GORDON PREECS, M.D. 15795 Glacier Highway Juneau, Alaska 99801 Telephone: (907) 789-2290 POSITION STATEMENT: Testified on HB 195 TAPE 97-32, SIDE A Number 0000 CHAIRMAN CON BUNDE called the House Health, Education and Social Services Standing Committee meeting to order at 3:03 p.m. Members present at the call to order were Representatives Bunde, Green, Porter and Kemplen. Representative Vezey arrived at 3:12 p.m. and Representative Dyson arrived at 3:15 p.m. Representative Brice was absent. This meeting was teleconferenced to Anchorage, Fairbanks, Glennallen, Homer and Kodiak. SB 13 - INCREASE TOBACCO TAXES Number 0040 CHAIRMAN BUNDE announced the first item on the agenda, CSSB 13(RLS), "An Act relating to taxes on cigarettes and tobacco products and to the use of the proceeds of those taxes, and increasing by at least 35.5 mills the amount of excise tax levied on each cigarette imported or acquired in the state; and providing for an effective date." He referred to an amendment located in the committee file. Number 0092 SENATOR BERT SHARP, Sponsor of CSSB 13(RLS), stated that the amendment takes out the intent of using the tobacco tax for a dedicated purpose. Number 0186 CHAIRMAN BUNDE said the tobacco tax is separate from the cigarette tax. The cigarette tax existed before statehood and is already a dedicated tax. The tobacco tax refers to a tax on all tobacco, except cigarettes. This tax was instituted after statehood and therefore is not allowed to be a dedicated tax. Number 0226 SENATOR SHARP explained that Section 1 details the legislative intent. The dedicated school fund portion, otherwise known as the cigarette tax, will derive the largest portion of the proposed revenue. The school fund is one of three dedicated funds established prior to statehood and is legitimately constituted as a dedicated fund. This fund only allows for the rehabilitation, construction or repair of state schools or facilities. The other portion of the bill is the Senate version which is to use the tobacco tax, constituting $2.5 million to $3 million according to the Department of Revenue estimates, for anti-tobacco campaigns, enforcement of present tobacco laws and things of that sort. Grants would be given to municipalities to detect, apprehend and prosecute adults who make tobacco products available to children. The intent of these grants would be affected by the proposed Amendment 1. SENATOR SHARP stated that the tax in this bill is increased by 71 cents a pack to make the total tax equal $1. Number 0354 CHAIRMAN BUNDE referred to the chart located in the committee file regarding the existing tax, the tax if this bill passes with the dedication and the final scenario of the bill passing with the dedication found to be unconstitutional. He asked if this indicated the 71 cents or the $1. Number 0389 SENATOR SHARP indicated it was 71 cents, for a total tax of $1. The fiscal note addresses the reduction down to a 71 cent total, with a corresponding reduction in the tobacco product tax. The tobacco tax has the same percentage increase as the cigarette tax. SENATOR SHARP felt CSSB 13(RLS) was a bill addressing health care, education and revenue. Up to 80 percent of the funds could be dedicated to the schools. He said, "The other thing in the bill is a case of a constitutional challenge that would negate the dedication. There's a fail safe retroactive road block to make sure the tax stayed in effect and would not be lost or have to be refunded, that would only be subject to court decision, a negative decision as far as the ability to dedicate the funds to the dedicated account. That depending on who you talk to, there is nothing that prohibits an increased funding on cigarettes to go into that dedicated tax. We didn't want to entice a challenge to avoid the tax, if they should challenge the constitutionality of that. That was the purpose of the last few sections in the retroactive section in the bill. It has nothing to do with retroactive taxes." Number 0592 CHAIRMAN BUNDE said the bill would increase the existing tobacco taxes by 71 cents with those taxes on cigarettes dedicated to the school construction and maintenance fund. Those taxes on other forms of tobacco, if the committee adopts Amendment 1, would go to the general fund and could be appropriated, by the legislature, for the purposes discussed by Senator Sharp. SENATOR SHARP answered that this money could also be used to close the fiscal gap. Number 0607 CHAIRMAN BUNDE mentioned the briefing by Grant Woods, the attorney general from the state of Arizona, who began the lawsuit against Liggett. Some members of the general public feel that raising the fee would not serve as an economic barrier. Grant Woods referred to discussions held with the Chief Executive Officer (CEO) of Phillip Morris, who said that if the cost of cigarettes went up by $1 a pack, nationwide, use would go down by 45 percent. He commented that this information is vastly different from the lobbying effort which claims that raising the tax would not have an impact on use. Number 0660 SENATOR SHARP was a firm believer in the price signal concept. Most business people recognize that there is a definite price signal in regards to any product. Number 0670 CHAIRMAN BUNDE asked him if he had a problem with Amendment 1. Number 0682 SENATOR SHARP answered that he didn't have a problem and he didn't feel the Senate would object, as far as concurrence. The main concern, of the Senate, regarded the dedication. Number 0708 REPRESENTATIVE BRIAN PORTER made a motion to adopt Amendment 1, dated April 22, 1997\T.7. Hearing no objection, Amendment 1 was adopted. Number 0770 GLENN PRAX testified next via teleconference from Fairbanks. He was opposed to HCS CSSB 13(HES) and to the tax on cigarettes. He did not feel the state should assume more responsibility for taking care of citizens. Taking care of a person's health and well being sets a dangerous precedent for the state and is not an appropriate method for influencing public behavior. If the focus could be limited to taxing tobacco and nothing else, then maybe it would be okay. Often government gets some authority to do something and it soon gets out of hand. He cited the income tax and prohibition as examples where government tried to do something good, but it backfired. MR. PRAX did not feel the tax would have the desired effect, to reduce consumption. He indicated that there are studies which indicate both results. Tobacco was a product used to illustrate inelastic demand when he studied economics as it isn't that responsive to the influence of price. Once people get hooked, they will pay whatever the amount needed to get the product. He said some people might stop, but it won't be as significant as some advertise. MR. PRAX felt the tax would lead to smuggling. Kids would become involved in the black market in order to save money to buy cigarettes. He felt a sunset clause should be added to the bill. If the reaction isn't what the proponents of this bill say it is, then it should be repealed. Number 0915 CHAIRMAN BUNDE stated that nothing this legislature does would bind a future legislature. A future legislative body could chose to amend, change or repeal this bill if they felt it was not working. He appreciated the acknowledgement that there were different points of view and different studies, but asked why he felt it wouldn't be an economic deterrent for young people beginning to smoke. He referred to his testimony that once people are addicted, it is harder to change their behavior. He said the legislature hoped the economic deterrent would affect people before they're addicted. CHAIRMAN BUNDE explained that people who are addicted to tobacco products cost the state a considerable sum of money every year in health related expenses. He asked if he had a view on user fees. Number 0968 MR. PRAX advocated getting out of the business of taking care of people who are silly enough to smoke. It is obvious that the health effects of cigarettes are detrimental. People chose to smoke knowing the risks. The government cannot be so paternalistic as to think that society must take care of them when they choose to take foolish risks. He did not think this tax was an appropriate solution to this problem. Number 1011 CHAIRMAN BUNDE agreed, he would rather have people be responsible for themselves. He used the example of people who get into car accidents and are still taken to the hospital. He felt that on a humanitarian level, it would be difficult to change this type of assistance. Number 1022 WALTER GAUTHIER testified next via teleconference from Homer. He opposed any tobacco tax, no matter what shape or form in which it was done. He contended that it is a shell game, that any money dedicated to the Department of Education (DOE) will mean that less money will be included in the DOE budget. This money will be available to continue to fund a whole lot of state employees to push paper from one desk to another. The Republicans were elected to cut the budget. Any kind of tax is a revenue issue. He believed that when you talk about it being a health issue, the smokers costing the state of Alaska a certain amount of money then you have to realize that fat people, people who drink too much coffee, people who eat too many candy bars and get diabetes and people who drink alcohol cost the state a certain amount of money. People who are working for the DOE, the Department of Health and Social Services (DHSS) and non-profit agencies see their budgets shrinking. Those departments and agencies believe that by targeting the evil smokers they can get enough money until a Democratic legislature comes into power. He stated that this is a revenue issue, not a health issue. Number 1121 DIANE BUFFINGTON testified next via teleconference from Kodiak. She stated that HCS CSSB 13(HES) was not a education, health nor a revenue bill. This piece of legislation is a tax bill. This bill purports to dedicate some of the funds to educate children on the hazards of smoking. Over the past five years, the public service announcements have not decreased any type of drug use in our youth. Drug use is up 150 percent for cocaine and marijuana. An education campaign is not going to work. Education needs to begin at the family level. Taxing families is not going to decrease smoking. Fourteen states, in the past two years, have increased their cigarette tax. Most of those states have seen a rise in cigarette usage by teenagers. The state of Washington, who currently has the highest tax on cigarettes, is now attempting to lower their tax. MS. BUFFINGTON referred to enforcement costs. She referred to literature stating that it would cost more for enforcement, that several more employees would need to be added to the budget. She said 70 percent of the DHSS budget is slated for employees. The tax revenue would not filter down to the local municipalities and communities. This bill would violate the constitution. Taxes, according to Mr. Chenoweth, would remain at the same "2.5 which it is currently getting." The state should not enact any laws which would automatically trigger a judicial challenge. The fiscal gap needs to be closed through budget cuts. Number 1282 JOANNE LOVITZ-EDMISTON testified next via teleconference from Anchorage. She said it was an extraordinary abuse of governmental power to propose stealing money from a small group of people via taxation to provide for the education and the anti-smoking sentiments of others. She questioned how the legislature could justify having this small group of smokers pay for the education of other people's children above what is already paid for in property taxes dedicated to education. She did not have any children in the school system. If all people benefited, then all people should fund it. She questioned punishing smokers. She did not think that Alaskans would pay more money to fund increased governmental spending. As a member of Alaskans for Tax Reform she did not approve of increased taxation. MS. LOVITZ-EDMISTON described her upbringing where she learned that it was wrong for a conscience to escape the parameters of personal behavior and conduct. She said that Representatives Bunde and Green have repeatedly expressed that routine smoking and tobacco taxation are a matter of conscious. While she respected their sense of conscious in this matter, she believed that it was her responsibility to state that it is most inappropriate to use one's power to subjugate other free thinking adults who do not share in the same beliefs and values on taxes. Number 1458 CHAIRMAN BUNDE respectfully disagreed with her testimony. He stated that 71 percent of people support this issue according to the Dittman Poll. Number 1508 TESHA SANCHEZ testified next via teleconference from Anchorage. She is in opposition to HCS CSSB 13(HES). She has heard both sides of the tobacco issue. She felt putting a tax on people who smoke because it will stop kids from smoking was wrong. Kids can afford alcohol, drugs, Air Jordan tennis shoes. A dollar a pack won't mean a thing to them. She felt it was her responsibility to teach her children morals at home. Number 1554 BOBBY SCOTT testified next via teleconference from Anchorage. He did not condone the use of tobacco by minors. He stated that it was illegal right now for minors to have tobacco products in their possession. He has heard school principals, coaches and teachers say that they have watched students walk out of school to take a smoke break during school. He asked why these people weren't stopping these students if they were truly concerned. He said when you are a student you will get whatever you need to be popular no matter what it costs. Students don't care about price. It was his job to teach his kids respect, honesty and responsibility. MR. SCOTT works for (Indisc.) Distributing. He feared for the local retailer who would soon be out of business because of these laws. He felt HB 159 should be promoted, rather than the tax bill. The tax bill will not stop the kids, enforcement will. Number 1686 CHAIRMAN BUNDE asked him if he would be willing to pay a cop to watch every kid to ensure that children wouldn't smoke. MR. SCOTT asked if the chair would be willing to pay a cop for every kid to ensure that children didn't use drugs. CHAIRMAN BUNDE answered that he was not willing. MR. SCOTT said he would not be willing to do so either. CHAIRMAN BUNDE then questioned him why he felt enforcement would work. MR. SCOTT referred to a police report located in the committee file. He felt that HCS CSSB 13(HES) would cause people to break into trucks. CHAIRMAN BUNDE asked if young people, under the age of 19, should smoke. MR. SCOTT answered that he did not children should smoke. CHAIRMAN BUNDE commented that the average Alaskan begins smoking at age 14 and becomes addicted at that age. Number 1746 NICHOLAS ZERBINOS testified next via teleconference from Glennallen. He said this tax bill is the silliest thing he has every heard. He talked with legislators who said that they knew this bill was not going to stop kids from smoking, but money can be made on the taxes which can be used for something else. Legislators are not interested in the kids, they are interested in the money. He said the name of the legislators were confidential. He said tax money is not going to stop kids from smoking. Smoking is something that if you take too much of it, it will hurt you. He cited foods on the market that people can't eat including soft drinks, tomatoes and oranges. He suggested taxing these products. Taxes will not help anything, they will only allow the legislature to spend money on things they want. Number 1867 KEN JACOBUS testified next via teleconference from Anchorage. He did not think you needed to increase the tax on tobacco to keep children from smoking. He felt the tobacco companies were going to have to increase their prices because of the settlements from the nationwide lawsuits. He felt it would be possible to test the legislative theory when this occurred. Alaska's lower income group, including many Alaska Natives smoke in disproportionate numbers. He did not think we should force the increased cost of government onto Native Alaskans because they got hooked onto a bad product when they were younger. Number 1932 SUZANNE FISHCHETTI testified next via teleconference from Anchorage. She opposed HCS CSSB 13(HES). "Last Tuesday over 61 percent of the Anchorage voters passed a ballot proposition that required 60 percent majority vote to have a sales tax in Anchorage and I think that's the poll that the legislators should be listening to, not the Dittman Poll." She suggested that the state should try to recover the $100 million in defaulted student loans before they started raising tax revenue. Schools should be able to teach our students about smoking. The Centers for Disease Control have conducted studies, in Illinois, Nebraska and Hawaii where taxes were raised, which showed kids smoking increased. Number 1977 JODI OLMSTEAD testified next via teleconference from Fairbanks. She was opposed to the tobacco tax. She stated that this tax is against Alaskan Natives because a disproportionate high number of them smoke. It has always been illegal for kids to smoke, drink and do drugs. She questioned why the state's permanent fund monies were invested in Phillip Morris. She has talked to many people and has found no one who agrees with this bill. Kids say that the price increase will not change whether or not they smoke. She thought there were other things behind this tax, it did not have anything to do with children. She asked why we are going to have another law which will say that it is still against the law for kids to smoke. She did not feel that money should be invested to save people from themselves. Number 2102 JOHN CYR, President, National Education Association-Alaska (NEA- Alaska), said his organization supports the passage of HCS CSSB 13(HES). The increased cost of tobacco products will serve as a deterrent to use by Alaskan students. He said the age when most kids start to smoke is age 13 and 14 and this is the most price sensitive age. Tobacco use is the leading cause of death in Alaska. One out of five deaths are tobacco related. The United States Centers for Disease Control estimates that 18,000 Alaskans, currently under the age of 18, will die from tobacco related diseases. He said this is absolutely a health bill and something that is long overdue in this state. MR. CYR stated that schools in Alaska have suffered under deferred maintenance for years. There are schools with trash cans collecting the spring runoff. The schools in this state need the money that will be generated from this bill. His organization felt that this bill will be one of the best pieces of legislation that will be passed this year. It will positively affect the lives of children into the foreseeable future and it will make schools better places to be. Number 2202 RUPERT E. ANDREWS, Representative, American Association of Retired Persons (AARP), stated that the state legislative committee of AARP was in favor of any increased taxes on tobacco products. Last fall a survey was done in the membership. Currently there are 40,000 plus AARP members in Alaska, fifty years and older. A sample of 4,000 was chosen for the survey, 2,200 forms were returned. Some of the questions had to do with the tobacco tax. About 79 percent responded that they were in support of a tobacco tax as a health issue. Alaska has an informed electorate that sees this tax as an effective means to discourage children from starting to smoke. He felt this 79 percent fit in well with the Dittman Poll. Number 2268 REPRESENTATIVE JOE GREEN commented that none of the testimony given against the bill cited where that money would go; children and aggressive prosecution of those who sell tobacco products to children. He said this bill prevents children from becoming addicted to tobacco products. TAPE 97-32, SIDE B Number 0000 REPRESENTATIVE PORTER made a motion to move HCS CSSB 13(HES) out of committee. Number 0007 REPRESENTATIVE AL VEZEY objected to the motion. He then withdrew his objection. CHAIRMAN BUNDE stated that hearing no further objection, HCS CSSB 13(HES) was moved out of the House Health, Education and Social Services Standing Committee. HB 127 - FOSTER CARE REVIEW BOARD Number 0130 CHAIRMAN BUNDE announced the next item on the agenda as HB 127, "An Act relating to the citizen review board and panels for permanency planning for certain children in state custody; renaming the Citizens' Review Panel For Permanency Planning as the Citizens' Foster Care Review Board; extending the termination date of the Citizens' Foster Care Review Board; and providing for an effective date." He referred to an amendment before the committee. Number 0215 REPRESENTATIVE PORTER made a motion to adopt Amendment 1 to HB 127. This amendment would remove two of the three attorney positions on the board, limiting it to one position. Hearing no objection, Amendment 1 was adopted. BLAIR McCUNE, Assistant Public Defender, Central Office, Public Defender Agency, Department of Administration, testified next via teleconference from Anchorage. Number 0362 CHAIRMAN BUNDE asked if a representative from the Public Defender Agency attended the Title IV-E review with the Division of Family and Youth Services (DFYS). Number 0366 MR. McCUNE answered that this occurs sometimes. The agency does not have the staffing to cover all Title IV-E reviews so their attendance is rare. Number 0391 CHAIRMAN BUNDE asked if the fiscal note included the cost of this rare attendance. Number 0400 MR. McCUNE stated that currently the Title IV-E review doesn't generate a report used or submitted for a court disposition. The court has to make a finding about reasonable efforts to provide services. Under this bill, in Section 23, "the local panel shall submit a final report to Anchorage Court and temporary custody orders and dispositional hearings and reviews". He said this language has changed from the current language. If the foster care review panels are going to be set up as entities whose views are considered in court hearings, then his agency ought to be there to provide representation and input. If the review panels are not used for that purpose and are done on a more internal procedures basis, like the current Title IV-E procedures, then his agency would not have to attend. This bill expands the scope of the review. Number 0529 REPRESENTATIVE PORTER asked if he was referring to the review panel's consideration of their report in terms of the agency having to be present or being present when this report is presented in court. Number 0546 MR. McCUNE answered that he was referring to attending the local review panel hearings. Currently the review panels only review a third of the cases in Anchorage. If this system was implemented statewide for all out-of-home placement greater than 90 days, then he thought the agency should be a participant. Number 0608 REPRESENTATIVE PORTER observed that it was interesting that prior to the adoption of Amendment 1, an agency staff would have been on the Citizens' Foster Care Review Board, setting policy for the review committee. He suggested that his agency would want to be a advocate for their client, not as someone who sets policy for the review committee and acts in the best interest of the child. The attorney general's position and the public defender's position were eliminated from the Citizens' Foster Care Review Board, leaving the director or his designee from the Office of Public Advocacy. Number 0675 JODI OLMSTEAD, Founder, Concerned Parents for Reform, testified next via teleconference from Fairbanks. She referred to public law 96-272, the Child Welfare Assistance Act. This law says this review system works as a tool to cut back on the abuses. Nationally 28 percent of abuses happen within the foster care system. Our nation has the highest number of allegations and abuses of our children. These numbers play a role in overzealous social workers. The review panels serve as a check and balance for the foster care system. She referred to a case of her nephew who suffered abuse while in foster care. Fairbanks has a big foster care drift. MS. OLMSTEAD stated that citizen oversight will decrease the amount of cases which go through the foster care system. We need people to be there through every single case plan of each child and the programs they go through. No one has time to listen to the whole thing in the judicial system. Citizens on these review panels need to follow everything that goes on with the child, need to follow them from the beginning to the end and they need to report what they find. The Nebraska review panel tells what is done wrong and how it could be made right. MS. OLMSTEAD clarified that CSHB 127(HES) was extended to June 30, 2000. She asked to hear discussion on this point. There are a lot of children in foster care in Fairbanks and something needs to be done about it. Litigation does not have to be the answer. The interior delegation have been inundated with complaints about this situation. Number 0917 WALTER GAUTHIER testified next via teleconference from Homer. He was in support of CSHB 127(HES), but had some concerns. He referred to page 3, "The board consists of five public members appointed by the Governor". He suggested that part of the problem with the whole social services system is that it is all under the Department of Health and Social Services (DHSS) which is all under the Governor. He cited an example of a program that was cut from the budget last year which DHSS then funded out of another fund. The legislature has no power over DHSS. MR. GAUTHIER stated that for every Child in Need of Aid (CINA) case there are probably nine agencies, public and private, whom are concerned about the child. No one seems to be concerned about the parents or the family as a whole. The last review panel on foster care report stated that efforts were made to get the children into foster care. Once the children were in foster care, they were practically forgotten about and were in the system for an average of 18 months to two years. He thought the problems stemmed from the DHSS autonomy. MR. GAUTHIER referred to page 10, "at the child's request, a child who is ten years of age or older shall be allowed to be present at interviews of the review panel, that concerns that child's case unless the panel determines that for a good cause the child's presence would be contrary to the best interests of the child or there is other good cause for denying the child's request". He felt confidentiality has been used to shield mistakes and creates an overzealous approach. Any time these decisions are going to be made, the child should be allowed to be there. A large percentage of children recant previous testimony, a child will renounce things that a social worker states. On a whole, he is in favor of CSHB 127(HES). Number 1103 CHAIRMAN BUNDE assured him that the Citizens' Foster Care Review Board will be created and administered by the Department of Administration. The board will then recruit the volunteers, so this process will be removed from the Governor and his influence. Number 1149 CHAIRMAN BUNDE explained that current laws are inadequate, they don't give enough power to local panels. The panels are a weak duplication of DFYS. In many cases it is important that there be an outside citizen review of government functions. He was not saying that DFYS intentionally does things wrong, but it is important to have an additional review. He said CSHB 127(HES) amends the existing foster care review statutes and gives needed power to local panels, stressing local oversight and local panels. These local panels do not have the power to advocate for children in a court of law. This legislation allows local review panels to place their recommendations into the court record, this might reduce the number of cases where children get lost in the system. This provision gives the panels the power to be heard at the same level as the case worker, public defender, guardian ad litem and other parties who speak in court on the behalf of families. He felt that you couldn't discuss the welfare of a child without also acknowledging the importance of the family. CHAIRMAN BUNDE commented that another problem with the existing statutes is the duplication of services between DFYS and the local review panels. The DFYS completes federally mandated Title IV-E reviews for eligible children in out-of-home care every 180 days. The review process allows DFYS to collect federal funds for eligible children. The local review panels review the same children with a more thorough process every 180 days. The two separate reviews are seen as a duplication of effort, the legislation will not fund a board that duplicates functions of an existing department. This legislation gives the authority to the local review panels to do the Title IV-E and take some of the burden off DFYS. Number 1270 REPRESENTATIVE FRED DYSON mentioned his concern over the fiscal note. He though Alaska's social problems, including dysfunctional families and dislocated children, would be assisted by the citizens' review panels. The DFYS is in stress. Their credibility and the credibility of all state government is in question. The panels provide an objective outside review and oversight. It builds confidence in what government is or should be doing. He stated that his wife, who served on the Anchorage panel, found it valuable. Number 1379 REPRESENTATIVE GREEN asked someone to explain why the panel might determine that the child's future shouldn't be witnessed by the child. Number 1409 PATTI SWENSON, Legislative Assistant for Representative Bunde, stated that the panel doesn't really decide whether the child is present or not. This decision is made in conjunction with advice given by the Court Appointed Special Advocate (CASA) and the Guardian ad litem. Some children don't want to come to these reviews. Number 1455 REPRESENTATIVE GREEN commented that the way in which CSHB 127(HES) is written states that the child may be there unless the panel determines that they should not be there. He clarified that she was saying that the panel does not make this determination. Number 1463 MS. SWENSON stated that the board works closely with all of the people who are in contact with the children. A child would not be invited if it would harm them in any way. Number 1480 REPRESENTATIVE GREEN felt this language would create a restriction if the child wanted to attend the review. Number 1495 MS. SWENSON explained that some children feel they need to support their parents no matter how abusive their parents have been. The child might say that they want to go back to their parents, when in actuality that isn't what they want. Children that age don't necessarily tell the truth, no matter what their current situation is. The board makes the determination of a child's attendance based on those people who know the child best. A child might say something that could be misconstrued. Number 1524 REPRESENTATIVE GREEN verified that the court determined age 14 to be the age of reason. He clarified that the reason why a child wouldn't be invited to this review process is because their psychological make-up wouldn't stand a review process. Number 1553 CHAIRMAN BUNDE stated that first the Guardian ad litem, then the social worker and finally the review panel would help the child make the decision whether or not to attend the review. He shared his concern that if a child wants to attend, there might be three different entities describing why they shouldn't attend. Number 1571 REPRESENTATIVE GREEN felt that the board had the ultimate decision making power as contained in the language of CSHB 127(HES). Number 1581 MS. SWENSON said she has not seen this happen. Number 1583 CHAIRMAN BUNDE explained that the panel works on the advice of professionals. Number 1597 REPRESENTATIVE PORTER made a motion to move CSHB 127(HES) as amended with individual recommendations and attached fiscal notes. There being no objection, CSHB 127(HES) was moved from the House Health, Education and Social Services Standing Committee. HB 195 - LICENSURE OF OPTOMETRISTS Number 1629 CHAIRMAN BUNDE announced the next item on the agenda was HB 195, "An Act relating to licensure of optometrists; and providing for an effective date." Number 1634 JEFFREY A. GONNASON, O.D., stated that he has been licensed as a optometrist since 1976. He has been in an Anchorage practice for over 20 years. On behalf of Alaska Optometric Association he wanted to thank the committee for hearing HB 195. The association represents approximately 80 Alaskan doctors of optometry. He said 150 years ago dentistry progressed out of the barber shop and optometry progressed out of the jewelry store. Both professions have expanded their scope of practice over the years in accordance with technological advances. Today optometry is a primary health care profession that examines, diagnoses and treats disorders of the human eye. It utilizes medications and procedures in accordance with professional training and competency. DR. GONNASON explained that, historically, medical doctors have enjoyed unlimited legislative trust in their scope of practice. Alaska's optometrists have had their scope of practice unduly restricted by old state statutes which do not account for modern advancements in education and training. This bill, HB 195, was carefully drafted to give the board the authority to authorize the use of advanced methods and procedures for those optometrists who meet additional board qualifications. Currently optometry school graduates, trained in modern technology, cannot fully utilize their training in Alaska. DR. GONNASON said the bill will allow the board to determine the scope of practice through regulation within limited guidelines. This is currently done for dentistry and nurse practitioners. The limited use of lasers and other modern technology and limited non- evasive surgical procedures may be allowed through the board under this bill. Dentists and podiatrists perform surgery and do not attend medical school. He questioned why optometry should be subject to discrimination. DR. GONNASON stated a laser is a tool used in many different facets in health care as well as industry. This legislature trusted optometry in 1988 and in 1992, passing diagnostic and therapeutic medication legislation. Optometrists have shown themselves to be reasonable, competent and trustworthy under the expanded privileges. Previous testimony on the 1988 and 1992 legislation described the great harm that would occur to patients, including death and blindness, if optometrists were allowed to expand their scope. As of now, there have been no complaints of harm to the Division of Occupational Licensing in regard to the expansion of optometrists' privileges. Malpractice insurance rates have remained the same in states where the scope of optometric practice has been expanded. DR. GONNASON referred to the state audit report of the Board of Examiners in Optometry which concluded that, "the 1992 Optometry legislation benefited the public and furthered the public interest health and welfare and that the board does provide assurance that licensees are qualified and act in a competent manner." Optometrists are held to the same standards of care as medical doctors and other health care professionals. DR. GONNASON stated that HB 195 would provide better access to quality, affordable and cost effective health care. This is especially true for many of the smaller towns and villages which are only served by an optometrist. Optometrists are reasonable, educated and caring professionals. They are licensed by the state with strict standards. They are regulated by the state board, by legal liability concerns, community opinion, by medicine and by the legislature looking carefully over their shoulders. The state Board of Optometry should be allowed to determine the scope of practice through regulations, as is done by other health professions in Alaska, to keep current with advances in health care. No optometrist would attempt to perform a procedure or treatment that he or she was not trained or comfortable with doing. Optometrists should be treated as the trusted, learned professionals that they are. Number 1859 REPRESENTATIVE DYSON received letters from people in the medical community which informed him that no other state currently allows the expansion of responsibilities as would occur with the passage of HB 195. He stated that 47 states currently prohibit optometric surgery, 30 of these states have passed this legislation since 1991. Number 1886 DR. GONNASON said 37 states say that optometrists cannot use lasers. The reason why the Alaskan law says that optometrists cannot use lasers is because, in order to get the 1988 legislation passed, optometrists had to accept language prohibiting this procedure. Lasers are used by optometrists in four or five states. Optometrists do not use lasers because there is specific language stating that they can use them, but because they are not prohibited in their state. The use of lasers is currently taught in optometry school. Dr. Maynard Falconer, a recent retiree, has a daughter who just graduated from college and is trained in lasers. He emphasized that there are types of laser procedures that optometrists are not trained in such as retina treatment. There are also laser procedures which are straightforward and simple to use. Lasers are tools. DR. GONNASON referred to a study done by John Hopkins University which shows an Alaskan Native woman in the "slit lamp" laser. The article states that paraprofessionals and technicians, can learn to perform this sight saving procedure in a matter of minutes with no complications. This bill would specifically say that optometrists could use lasers as determined by the board based on the proper credentials and qualifications. Some older optometrists are not trained in the more modern procedures and would not be allowed to perform these additional procedures. Number 1985 REPRESENTATIVE DYSON stated that this bill allowed optometrists to prescribe more prescription drugs and asked if this was done in other states. DR. GONNASON answered that there are 33 or 34 states which allow optometrists to go beyond topical medications and prescribe systemic medications. The department was concerned whether or not the board would need to ask for more credentials. Currently those optometrists who use medications need to have an endorsement on their license. The board designed this endorsement to include the ability to prescribe systemic medications. In 1992, the oral portion of the bill was compromised in order to pass the bill. This left the ability to administer topical medications in the endorsement. The bill, HB 195, specifically excludes controlled substances, schedules I and II. Those drugs are considered dangerous. TAPE 97-33, SIDE A Number 0000 DR. SAM McCONKEY, M.D., testified next via teleconference from Fairbanks. He said he has been a board certified ophthalmologist with the eye clinic in Fairbanks since 1975. As a physician he is morally and ethically obligated to advocate for the patient. There are two important issues to identify in this discussion. The first issue is patient care and who is qualified to deliver it. He said a physician has a college degree followed by four years of medical school and three or more years of specialty training in medical and surgical diseases of the eye. This adds up to at least 12 years of school after high school. An optometrist has, in most cases, a college degree and four years of optometric school. Clinical training and experience is the path to competency, not legislation. It is difficult for the lay public to understand that even the drops used to treat eye problems can cause strokes, cardiac arrest, high blood pressure, depression, suicide and shock. DR. McCONKEY stated that the committee was being deceived by organized optometry. This bill by request is all about money. It has nothing to do with patient care. It has to do with the medical care dollar and how it is divided. For the last 25 to 30 years, organized optometry has realized that there are too many optometrists in the United States and cannot make a decent living fitting glasses and contact lenses. Optometric school administrators do not want their students to realize that there are too many optometrists because their schools would not remain full. DR. McCONKEY explained that practicing optometrists are not to be blamed for this, they are only the pawns in the larger scenario. This is an ingenious, well thought out, well financed, political strategy. It has been successful. Unsuspecting state assemblies have legislated optometrists into positions of medical care givers. Passage of these bills convinces state and federal agencies that optometrists should be included in the split of the health care dollar. He referred to the 1988 and 1992 bills, the legislature asked the two separate components to resolve this issue outside of the legislative process. Optometrists were given a few low risk drops to treat minor eye problems. The quid pro quo for this agreement was that optometrists would not initiate legislative initiatives until they received proper education, training and medical testing by someone other than their board. DR. McCONKEY said HB 195 would allow (indisc.) medical prescription drugs except narcotics, cataract surgery, eye muscle surgery on children, surgery for injuries and laser procedures. He said these items have to do with training and experience. The citizens of the state of Alaska do not deserve to be confused further about who is qualified and who has the responsibility for the medical and surgical care of their eyes. Number 0386 DR. PETER CANNAVA testified next via teleconference from Kenai. He presented a scenario where he was a flight attendant who has decided that he wanted to fly the airplane because he was no longer content with being a flight attendant. If someone asked him why he wanted to be a flight attendant pilot, he could answer that his flight attendant school gave a course in piloting and that they will tell him when he is qualified to pilot and will regulate him. He would redefine what a pilot is. His definition says that a pilot is going to be someone who only flies above 20,000 feet so it will be non-dangerous or non-invasive flying. There is a precedent for this shown by helicopters, jet pilots and test pilots who are only regulated by their boards. The legislature might retort that all the people mentioned are pilots by training, from the beginning of their school, whereas a flight attendant has no historical basis or schooling. The legislature might say that it is not the function of the legislature to give sanctions to born again professions and that to be a real pilot, he should go to the proper schools, pass the proper tests and be regulated by the proper authorities and stop trying to short circuit the system. DR. CANNAVA mentioned that the committee would hear some testimony by a physician who claims that optometrists are well trained. He encouraged them to ask this physician how much of his income is generated by optometric referrals and how much he has just invested in a clinic solely dedicated to take care of optometric referrals. DR. CANNAVA stated that if HB 195 was as innocuous as Dr. Gonnason explained, they would not have redefined non-invasive surgery as surgery done without a general anesthetic. Physicians and surgeons are currently doing everything under local anesthetic including neural surgery, knees, hips, hysterectomies, gall bladders and appendectomies. For optometry to be so naive as to classify all of these things as non-invasive, simply because they are done under local anesthetic, indicates the paucity of their training. DR. CANNAVA commented that the other part of HB 195 that should be questioned is where optometrists claim they need to use systemic or oral antibiotics and pain killers. Part of his responsibilities include plastic surgery, repairing broken sinuses and treating infections of the face and paranasal sinuses. It is only in treating sinuses, skin infections and things like that where he uses systemic antibiotics. The eye rarely needs antibiotics, other than by drop form. When antibiotics are needed it involves an injection into the eye. DR CANNAVA said optometrists claim they need oral pain killers. He probably writes three prescriptions for pain killers by mouth a year. There are topical medications which adequately take care of pain. Number 0739 DR. RONALD ZAMBER, M.D., testified next via teleconference from Fairbanks. He described his education and background. He spent no less than 20,000 hours of intense medical and surgical training to develop the competency to administer and prescribe appropriate medical therapeutics and surgical remedies. Despite this training, he could assure the committee that he was not overtrained. There are no groups in this nation qualified to provide complete medical and surgical management of eye diseases other than ophthalmologists. Neurosurgeons are not qualified to provide complete medical and surgical management of eye diseases. DR. ZAMBER said this bill addresses more than vision, it addresses general medical well being. During those 20,000 hours of training as an intern and surgical resident, he saw dozens and dozens of patients who had been prescribed medication which appeared benign but ultimately wound up causing multi-system failures. The issue is one of competency and qualifications. This bill talks about lasers, about instruments that can in a microsecond blind a patient. Number 0959 DR. ROBERT FORD, M.D., said he is an ophthalmologist and the founder of Pacific Cataract and Laser Institute which has 11 sites in the Northwest including one in Anchorage. He is licensed in Alaska. When he finished his ophthalmology training he came out with the same bias that other witnesses have presented. Shortly after he went into private practice, he started to indirectly work with optometrists. He began to work more closely with a particular optometrist who won his respect. He began to make the gradual transition to respecting optometrists. Ophthalmologists do have more training and are going to need to do the more complicated procedures, but optometrists are legitimately going to be the ones in the future of health care who will do the primary eye care. He has chosen to work cooperatively with optometry. Optometrists do the primary care and they refer patients to him to do surgery and then patients are referred back to do post operative care. DR. FORD mentioned the two previous pieces of legislation. He said these bills involved risk, but the risk was balanced by the reward. Time has proven that the risk was worth the reward. Now is the next phase of expansion of the optometric practice. The decision to expand optometric practice has not been an easy one for him. This bill would allow optometrists to use a YAG laser which accounts for a significant portion of the revenue that the company gets. It is harder and harder to make the books balance in medicine. A cataract surgeon's fee is about half what it used to be. He questioned whether or not the company could float financially if the YAG laser procedure was used by optometrists. He decided to maintain his commitment to principle that by giving to another profession, he would feel good about himself. DR. FORD stated that an honest reading of the Idaho law suggested that optometrists could do these laser treatments, so optometrists did these laser procedures. Over a hundred of these procedures were done, without any problems. A number of years ago it was felt this procedure could legally be done by a physician's assistant. In summary, he felt it was the American way to allow professions to grow. Optometry has grown a lot in the last ten years, it is a different profession than it used to be and he would like to see them continue to grow. We should allow them to further expand their practice. Number 1213 HANS KELL, O.D., cited his education and clinical background. Optometry is a profession which has grown progressively more sophisticated and capable. Currently, doctors of optometry complete eight to nine years of professional training; four years of undergraduate and four years of graduate training in optometry and a residency program. The training in optometry includes basic sciences, preclinical education and clinical experience. Admission requirements and tests are similar to those for dental and medical schools. Biomedical science taught in the first two years of optometry and medical schools are comparable and often share the same textbooks and instructors. In some universities the optometry, dental and medical students attend these classes together. Optometry schools are accredited by the same national agencies that accredit medical schools. Clinical training for optometry occurs in various clinics, Health Maintenance Organizations, Public Health, and Veterans' Administration hospitals. DR. KELL said this training prepares doctors of optometry to provide primary eye care similar to the family dentist providing general dental care or the family medical doctor providing primary health care. To establish perspective, there is value in comparing the education of optometry with that of medicine. In 1980, Dr. Rushmer conducted a review which observed that the professions of optometry, dentistry, podiatry and medicine all have similar state and national board requirements. These professionals attend accredited educational institutions. He further stated that, "the basic educational experience of these professions is remarkably similar and cannot account for consistent underutilization of non- medical health professionals." Number 1347 DR. KELL stated that optometry training in pharmacology, the use of lasers and other methods for the diagnosis and treatment of the eye are of the same quality as those methods taught to ophthalmologists. While the clinical application of these tools is relatively straightforward, their justification for use and providing follow up care is the most difficult component of treatment. Optometrists have safely and effectively used their clinical judgement to evaluate, recommend treatment and perform follow up care for many years. Number 1396 REPRESENTATIVE DYSON asked if this was a turf war. He referred to the similar chiropractic issue. Number 1432 DR. GONNASON agreed, on the national level, optometrists are paid to do Medicare procedures and there is competition for those patients. In managed care plans there is competition as to who gets to be the gate keeper. If the optometrist is the gate keeper, then there are a lot less surgeries done. Number 1456 REPRESENTATIVE DYSON did not want to imply that the medical doctors were only looking after their vested interest. Number 1472 DR. KELL agreed that we are all honorable people. Ophthalmologists as well as optometrists are patient advocates. He thanked the legislature for the bill that passed in 1992 which has given optometrists the privilege of following patients after surgery. Currently, optometrists examine the patient and, if necessary, the patient is referred for surgery. After surgery, those patients are followed up with medications. He stated that there are many types of lasers and their applications. Some procedures are much more straightforward than others. He felt the most important thing was the justification for the procedure and the correct follow-up of potential complications which could occur and what to do. The money really lies in the procedure itself. Number 1532 REPRESENTATIVE GREEN asked for a definition of non-invasive. Number 1547 DR. GONNASON answered that a non-invasive procedure is one which does not open the globe. A pimple on the eyelid might be drained under surgical conditions. He said clipping your fingernails is surgery. There are procedures currently being done that were authorized in the 1992 legislation, one of which is the removal of foreign bodies. In this procedure the eye is numbed with a medication, the metal is picked out and then a battery powered drill is used to grind out the rust. If that metal had penetrated the eye ball, then it would be under the realm of the specialty ophthalmologist. Number 1620 REPRESENTATIVE GREEN asked how the laser would be used. Number 1626 DR. GONNASON explained that the best example is one is called a Peripheral Iridotomy. Alaska Eskimos have the highest percentage of Acute Angle Closure Glaucoma. As compared with other forms of glaucoma where pressure slowly goes up, this glaucoma is an attack. The pressure of your eye builds as if the eyeball is going to burst. The eye will go blind if it is not treated within 24 or 48 hours. This is a definite medical emergency. The treatment is to poke a hole in the iris so that fluid can go from the front to the back. A laser focused inside the cornea burns a tiny hole which relieves that pressure and the patient is cured. He cited an example of the time and inconvenience caused when an optometrist could not do this procedure in Anchorage. He questioned what would have happened if this situation had occurred in Kotzebue or Barrow. Number 1711 REPRESENTATIVE PORTER asked if a neutral party could testify on this bill; someone outside of optometry and ophthalmology. He assumed giving optometrists the ability to perform these things would lower health care costs. Number 1759 REPRESENTATIVE GREEN asked what sort of things an optometrist might want to treat rather than submitting it to an ophthalmologist. Number 1786 DR. KELL answered that the most common procedure is a laser procedure called a YAG Capsulotomy. After cataract surgery a thin membrane of the patient's lens is removed. He clarified that the lens is removed during cataract surgery with the skin or the back of that lens left behind with an implant inserted in front of that. In approximately 33 percent of the eyes that membrane becomes opacified or cloudy. Years ago this was treated by having an ophthalmologist go inside the eye to make a hole in the eye. A laser is able to make a hole in the center which opens it up and allows the patient to see. Currently, optometrists evaluate these patients often and refer these patients for this procedure. The procedure itself takes a minute, then patients are referred back to the optometrists for potential complications like retina detachment. He said this is one procedure that optometrists feel that they could treat. Number 1851 REPRESENTATIVE GREEN asked about the other types of illnesses. Number 1859 DR. KELL mentioned Acne Rosacea which affects the lipid or fat producing glands around the eyelid. The glands and the vessels surrounding them become infected affecting either the make-up or atrophy of these glands so they don't produce the oil layer which helps keep tears from evaporating. This produces dry, scratchy eyes. One of the best treatments for this condition, besides the use of artificial tear lubrication, is to take tetracycline. Tetracycline is a simple, oral medication with minimal complications. Number 1900 REPRESENTATIVE GREEN mentioned the amount of study for both professions and asked what the differences were once you got past the basic courses. Number 1928 DR. KELL answered that ophthalmologists, after four years of medical school, have a year of internship which usually occurs in a hospital setting. Currently ophthalmology residency programs are three years, followed by a voluntary sub-specialty training. At the Bascom Palmer Eye Institute, the first year ophthalmology residents are not trained in surgery except for some of these limited, minor surgical procedures discussed. The ophthalmologists see the indigent patients. During the second year, an observational clinic occurs where the residents observe different sub-specialists. Ophthalmologists that have gone into sub- specialty training might focus only on the retina, pediatrics or neuro-ophthalmology. Those residents observe as well as begin to learn the procedures of their sub-specialties. The third year is when the residents hone their surgical skills. Ophthalmologists have a wonderful training, it is more extensive and more specialized. DR. KELL said that HB 195 proposes that optometrists not perform these specialized procedures, but to perform the more non-invasive, simple procedures. Number 2008 DR. ZAMBER said ophthalmology training varies a little from Dr. Kell's description in that the internship is a surgical, medical or rotating internship. Residents are often involved in emergency care settings, intensive care unit settings and clinical oncology cancer treatment settings. These settings expose the residents to the management of patients with various medical conditions. The purpose of that training is to develop a respect and competency for this process. He was appalled at the lack of respect for this issue. There are no shortcuts, those 20,000 hours were hours well served. Those are 20,000 hours beyond what an optometrist gets in training, treating the patients as a whole. DR. ZAMBER explained that the oral medications which would be allowed to be administered by HB 195 can kill patients. He has seen dozens of patients who have experienced Steven's Johnson Syndrome, a severe allergic reaction which is often life threatening and results in a scalded skin type syndrome and creates a ventilatory dependent state. This syndrome is the result of medications which would be allowed under this bill. Sulfa is the primary offending agent in these types of reactions. Many of the oral therapeutics used to treat glaucoma have a sulfa moiety. DR. ZAMBER explained that he is a published expert on complications related to topical and systemic beta blockers including the promotion and induction of beta blocker induced lupus, a life threatening condition. He emphasized that he is not overtrained. This is not a turf war, it is about patient care. He suggested having an O.D.M.D. testify. Those are optometrists who then went on to receive full medical and surgical training, with most training to be ophthalmologists. TAPE 97-33, SIDE B Number 0000 GORDON PREECS, M.D., said he trained eight years ago with three other people in his residency level. One of whom was a doctor of osteopathy, another form of allopathic medicine. This type of doctor has full licensure and authority to practice medicine in Alaska and most of the states. This person was the son of an optometrist and was an optometrist himself. He went back to medical school and received ophthalmologic training. DR. PREECS stated that during the first year of residency they did the dirty work; the injuries, the irritations and red eyes. Their main task, in part, was to screen the people who came through to determine what was serious and what wasn't. The osteopathy resident used to say that he saw more in one day working in the walk-in clinic, than he saw in his whole senior year of optometric school. His goal in optometric school was to learn how to fit contacts and work in a complimentary role to the process of vision care and refractive services. Eye disease was directed to medical care. He felt that if there had been a revolution in what is going on in the course and the exposure of realistic activities in optometric school, it simply escaped him. Number 0191 DR. PREECS addressed Section 7 (6), invasive surgery, which showed a remarkable lack of understanding of the process. He felt invasive surgery was anything that removed, damaged or intruded the tissue. Non-invasive procedures are those which allow you to visualize, allow you to inspect but do not allow you to change the tissue. Invasive surgery is changing tissue, cutting holes, drilling passage ways, making new affects. The fact that a knife is not use does not mean that it is non-evasive. YAG Capsulotomy is a rather simple procedure, but he did not think that allowing optometrists to do this procedure would reduce the cost. The goal would be to acquire access to that well-paid process. He felt that American medicine was over-equipped. There are competing hospitals duplicating services and trying to impress the provider and client communities that they have the best facilities. A ton of money is spent duplicating these processes. DR. PREECS felt discouraged by this subject. He commented that it seemed the medical community would be pecked to death as the state de-professionalizes the process of rendering care at every level, from every source. Every managed health care plan which wants to reduce the access to care by pushing decision-making power farther down stream in a gate keeper mode. Telephone nurses rather than on-site physicians, screening telephone technicians who will understand whether their care will be authorized. He felt this was a part of the process which says we will save money by trying to eliminate the expensive provider, ensure that we have enough cheap providers to go around and hope we don't make many mistakes. He shared in his colleague's concern that ophthalmologists were going to be slowly but surely, biannually by biannually, nickeled with these opportunities to expand and exchange the nature of medical practice. Number 0389 REPRESENTATIVE GREEN explained that he only has one eye and as a result he is nervous about allowing anyone, without the best possible training working, to treat his other eye. He agreed that there were procedures which both professions could learn to do. He refer to his wife's experience, who is a dental hygienist, and their expansion of care. She stated that she preferred to have a doctor available in case of a medical emergency. REPRESENTATIVE GREEN stated that there were some procedures which could be done by both professions; dentists and dental hygienists, chiropractors and medical doctors, and optometrists and ophthalmologists. He felt there had to be a limit put on those procedures because of the possible side effects. He asked if there was a concern among professions that a condition, which isn't obvious, might be overlooked. Number 0559 DR. PREECS referred to some of his first year textbooks which contained something of a warning poised in the image of a cartoon. It was titled, "A patient seen by the ophthalmologist". It depicted a person in a nice two piece suit with a fedora and an eyeball over his shoulders. The warning to the ophthalmologists, as physicians, was not to hone in on the eyeball and forget that they were operating on an entire human process. Optometrists learn about the human system components. How hormones result in life stage changes in the eyes in which neurologic and physiologic changes involve the eye, but are not limited to the eye. Medical practice in the United States is based on the principle that we will start with a profound base of training, a large body of experience and that we all have to do it no matter what we want to do when we finish. DR. PREECS referred to a personal experience when his father-in-law finally addressed his cataract which covered up a devastating retinal detachment. This condition was not able to be treated. He felt that he understood how critical this situation is for his patients and said it is imperative that we understand that we need to have concern the entire patient in the training. Number 0750 CHAIRMAN BUNDE stated that, as is usual, this is the first time the bill is heard and so the committee will not take action on it today. ADJOURNMENT There being no further business to conduct, CHAIRMAN BUNDE adjourned the meeting of the House Health, Education and Social Services Standing Committee at 5:30 p.m.