HOUSE LABOR AND COMMERCE STANDING COMMITTEE February 8, 1999 3:15 p.m. MEMBERS PRESENT Representative Norman Rokeberg, Chairman Representative Andrew Halcro, Vice Chairman Representative Jerry Sanders Representative Lisa Murkowski Representative Tom Brice Representative Sharon Cissna MEMBERS ABSENT Representative John Harris COMMITTEE CALENDAR * HOUSE BILL NO. 10 "An Act extending the termination date of the Board of Certified Direct-Entry Midwives; and providing for an effective date." - MOVED HB 10 OUT OF COMMITTEE (* First public hearing) PREVIOUS ACTION BILL: HB 10 SHORT TITLE: EXTEND CERTIFIED DIRECT-ENTRY MIDWIVES BD SPONSOR(S): REPRESENTATIVES(S) HUDSON Jrn-Date Jrn-Page Action 1/19/99 20 (H) PREFILE RELEASED 1/8/99 1/19/99 20 (H) READ THE FIRST TIME - REFERRAL(S) 1/19/99 20 (H) HES 1/21/99 47 (H) REMOVE FROM HES 1/21/99 47 (H) L&C REFERRAL ADDED 1/21/99 47 (H) REFERRED TO L&C 2/08/99 (H) L&C AT 3:15 PM CAPITOL 17 WITNESS REGISTER REPRESENTATIVE BILL HUDSON Alaska State Legislature Capitol Building, Room 108 Juneau, Alaska 99801 Telephone: (907) 465-3744 POSITION STATEMENT: Presented HB 10 as the bill's sponsor. MARILYN HOLMES, Public Member and Secretary Board of Certified Direct-Entry Midwives; Member, Citizens for Midwifery 969 Goldbelt Avenue Juneau, Alaska 99801 Telephone: (907) 586-2316 POSITION STATEMENT: Testified in support of HB 10. CATHERINE REARDON, Director Division of Occupational Licensing Department of Commerce and Economic Development P.O. Box 110806 Juneau, Alaska 99811-0806 Telephone: (907) 465-2538 POSITION STATEMENT: Testified in support of HB 10, provided additional information. PAM WEAVER, Chair Board of Certified Direct-Entry Midwives; Board Member, North American Registry of Midwives P.O. Box 671427 Chugiak, Alaska 99567-1427 Telephone: (907) 688-2000 POSITION STATEMENT: Testified in support of HB 10. KAYE KANNE Midwives Association of Alaska; Member, Board of Certified Direct-Entry Midwives 3225 Hospital Drive, Number 106 Juneau, Alaska 99801 Telephone: (907) 586-1203 POSITION STATEMENT: Testified in support of HB 10. ACTION NARRATIVE TAPE 99-5, SIDE A Number 0001 CHAIRMAN NORMAN ROKEBERG called the House Labor and Commerce Standing Committee meeting to order at 3:15 p.m. Members present at the call to order were Representatives Rokeberg, Halcro, Sanders, Brice and Cissna. Representative Murkowski arrived at 3:21 p.m. HB 10 - EXTEND CERTIFIED DIRECT-ENTRY MIDWIVES BD Number 0049 CHAIRMAN ROKEBERG announced the committee had before it HB 10, "An Act extending the termination date of the Board of Certified Direct-Entry Midwives; and providing for an effective date." Number 0064 REPRESENTATIVE BILL HUDSON, Alaska State Legislature, came forward to present HB 10 as the legislation's sponsor. He thanked the chairman for his welcome, noting the references to his previous service on the House Labor and Commerce Standing Committee. Representative Hudson stated that HB 10 would extend the operation of the Board of Certified Direct-Entry Midwives (CDMs) for another four years to June 30, 2003. He indicated board members and midwives were present to answer questions. Representative Hudson commented that Alaska was among the forerunners in the worldwide movement to establish a midwifery model of care as an alternative choice to the medical model, as noted in the sponsor statement, and, since the board was in its final year, he indicated some legislation must pass this session if the board was to continue. He noted they appreciated the timely hearing of the legislation. Representative Hudson indicated he would be happy to try to answer any questions before stepping back to allow others to testify on the good works of the Board of Certified Direct-Entry Midwives and to answer questions. CHAIRMAN ROKEBERG asked Representative Hudson about the decision to use the year 2003, rather than 2004, as was recommended in the audit report done by the Division of Legislative Audit [audit control number: 08-1454-9; January 9, 1998]. Number 0267 REPRESENTATIVE HUDSON indicated the same bill had been introduced the previous session, originating on the Senate side and he thought the 2003 date had come from discussion that year with the prime sponsor of the previous Senate bill, and Kaye Kanne and some of the others, in order to avoid contention. In answer to Chairman Rokeberg's follow-up question, Representative Hudson confirmed that previous bill had not made it to "conference." CHAIRMAN ROKEBERG noted the committee would proceed to further testimony and indicated the 2003 issue might be addressed later. Number 0379 MARILYN HOLMES, Public Member and Secretary, Board of Certified Direct-Entry Midwives; Member, Citizens for Midwifery, came forward to testify in support of HB 10. Ms. Holmes stated Citizens for Midwifery was a national grassroots organization which promoted midwifery in general. She commented the organization promoted the midwifery model of care: medical midwives as well as direct-entry midwives. Ms. Holmes referred to the past legislative session's HB 459 which provided Medicaid funding to certified direct-entry midwives. Ms. Holmes indicated the reason the board had not been extended the previous year was because of some confusion around the comparatively high licensing fees for certified direct-entry midwives. She indicated the fees were high because there were currently very few certified direct-entry midwives in Alaska, but because they were becoming licensed their numbers would increase as time went on. She added that it was to the state's advantage to regulate and license midwives in order to have control over safety issues and the other items governed by licensure. Ms. Holmes said the previous year's sunset bill had gotten somewhat "hung-up" on that issue of Medicaid funding. She noted the Medicaid funding had gone through and was now available for direct-entry midwives; it should now just be a matter of course to extend the board because if there were midwives practicing and receiving third-party reimbursement, they should be regulated. REPRESENTATIVE CISSNA confirmed with Ms. Holmes that the receipt of Medicaid funding did not change the higher licensing fees. Number 0551 MS. HOLMES indicated the receipt of funding did not change the fees but it did mitigate them, noting that there was now another market for the services so there would be an expansion of the profession into that area. She indicated the licensing fees would decrease as the number of midwives increased. Ms. Holmes additionally indicated the board's costs would decrease because increased regulation of midwives would reduce the number of people operating outside of the system, lowering the board's costs associated with investigations. She said the more regulation and more state control over the body of midwives, the less cost to the state. Ms. Holmes added that the state actually made money on midwifery through Medicaid dollars, explaining that a midwifery birth cost approximately 57 percent of a medical birth. Therefore, the same mother on Medicaid receiving care would be paying less and the state would be paying less. Ms. Holmes added that the babies were healthy, with few problems, so follow-up costs were lower. Additionally, she said these babies were breast-fed most of the time, which made for healthier babies, so there were lower costs down the line. REPRESENTATIVE SANDERS asked if the Medicaid payment was a lump sum to the state or if it was per each birth. Number 0700 MS. HOLMES replied it was per each birth. She commented there were 4,500 pregnant women in the state. In response to Representative Sanders' further question about how the state would save money, Ms. Holmes indicated the state matched funds to the Medicaid dollars received from the federal government. CHAIRMAN ROKEBERG clarified that there were "two different baskets of money, so to speak," and there was no connection between licensing fees and state savings. He said he appreciated Ms. Holmes' point of view that Medicaid costs to the state were reduced by using direct-entry midwives' services, but he indicated there was no resulting monetary benefit to the board. Number 0763 REPRESENTATIVE HALCRO asked how many licensed certified direct-entry midwives there were as of January 1999. MS. HOLMES said she thought the number was 19. AN UNIDENTIFIED SPEAKER noted the number was 14. Number 0777 REPRESENTATIVE HALCRO referred to the auditor comments section of the audit report, noting the comments seemed a bit dated because they spoke of a July 1997 letter. He indicated the comments spoke of the high licensing fees as a barrier to entry into the profession and asked Ms. Holmes if she thought having Medicaid reimbursement would help draw more people into the program. Representative Halcro commented the audit report noted 15 licensed CDMs, so apparently one had been lost. MS. HOLMES said she was unsure about the count of 14. Number 0825 CATHERINE REARDON, Director, Division of Occupational Licensing, Department of Commerce and Economic Development, stated she would call to confirm that information, at the chairman's request. Number 0833 MS. HOLMES replied, in response to Representative Halcro's question, that the licensed midwives were happy to pay their fees and willing to carry that cost. She said she thought it had been conjecture on the part of the auditor that the high fees were a possible deterrent to the profession's growth. Ms. Holmes commented they had created a procedures guide in the last year which clearly spelled out the fee structure. She indicated she thought this had not deterred anyone; in many ways it had made it clearer. She said people were trying to apply all the time. Ms. Holmes said she thought it was difficult to become licensed in Alaska because of the many requirements, including tests and a large number of births. She indicated she thought the level of difficulty was appropriate. Ms. Holmes noted, however, the money was only part of it, and now that they had the Medicaid reimbursement there would be more money to go around. REPRESENTATIVE MURKOWSKI asked if Ms. Holmes could tell her how many pregnant women would use a midwife's services as opposed to the services of a regular physician. She commented on information in the bill packet stating that 95 percent would use a physician and four percent would use a midwife. Number 0932 MS. HOLMES replied that there were 4,500 pregnant women in Alaska eligible for Medicaid, noting those were just the Medicaid births. She indicated she thought midwifery births accounted for about five percent of all births, both in Alaska and nationally, and the numbers were increasing. Ms. Holmes referred to materials in the bill packet pointing out that the countries with the lowest incident of infant mortality used midwives for 70 percent of births, without a physician in attendance. She emphasized this was the model that was the safest and was having the best effect in the world, indicating the United States was twenty-second on the list in terms of birth outcomes. Ms. Holmes noted the United States might use a medical model for 95 percent of its births but it was twenty-second when it came to safety. Number 0997 REPRESENTATIVE CISSNA said she had some questions about the apparent high number of unlicensed individuals. She confirmed from Ms. Holmes that unlicensed midwives had to go through enough births in order to qualify for licensure and this was part of the reason for having apprentices. Number 1054 PAM WEAVER, Chair, Board of Certified Direct-Entry Midwives; Board Member, North American Registry of Midwives (NARM), testified next via teleconference from Anchorage in support of HB 10. She indicated she was a practicing licensed certified direct-entry midwife in Anchorage. She noted the North American Registry of Midwives was the national certification board; she said she also served as liaison to state legislators and policymakers. Ms. Weaver indicated she had spoken with the Division of Medical Assistance, Department of Health and Social Services, for some updated facts and figures that morning. She stated approximately 45 percent of Alaskan pregnant women were currently eligible for Medicaid, and her understanding was that another approximately 800 pregnant women were expected to become eligible as of April 1 because the federal poverty guidelines were changing. Ms. Weaver noted Ms. Holmes had mentioned 4,500, but she indicated she had heard the number 10,000 from Nancy Weller's office [Nancy Weller, Medical Assistance Administrator, Division Medical Assistance, Department of Health and Social Services] that morning. Ms. Weaver indicated this figure made approximately 50 percent of the market accessible to midwives, which she said was "going to change the face of direct-entry midwifery and out-of-hospital births here in Alaska." On that note Ms. Weaver said she highly recommended the extension of the board as a regulatory process: keeping the oversight, guiding the issues and public safety, the "minimal" competency of practitioners, et cetera. CHAIRMAN ROKEBERG asked if Ms. Weaver could clarify the difference between the legislation's 2003 extension date and the legislative audit's recommendation. Number 1211 MS. WEAVER stated she knew the auditors had recommended a six-year board extension because the auditors had given them "high marks (indisc.) as a board," and said she also understood, from conversations with legislators, that it was rare or nonexistent for board to be extended past the normal four years. Commenting that she hadn't been involved the discussions regarding the 2003 date, Ms. Weaver said she assumed it was a happy medium. CHAIRMAN ROKEBERG noted Ms. Reardon's return and requested her clarification on the previously-mentioned number of licensees. Number 1256 CATHERINE REARDON, Director, Division of Occupational Licensing, Department of Commerce and Economic Development, stated her division provided the staff assistance to the Board of Certified Direct-Entry Midwives. Ms. Reardon said there were currently 14 licensed midwives and 6 licensed apprentices. She said the expiration and renewal date had been December 31, 1998, and it was not unusual to see one or two people choose not to renew but, generally, that loss was regained as new people came in during the two-year period. Ms. Reardon commented that perhaps one or two of the apprentices would move up. She confirmed for the chairman that the biennial cycle ran January 1, 1999, to 2000. Number 1305 CHAIRMAN ROKEBERG asked if there were any further questions for Ms. Weaver. REPRESENTATIVE MURKOWSKI observed there was a discrepancy between the number of licensed midwives, 14, and the number of Medicaid-eligible women. She asked what efforts were being made to recruit and train more [midwives]. Number 1344 MS. WEAVER responded that all of those women were not necessarily going to choose, or be eligible for, direct-entry midwifery care, noting that CDMs could only attend low-risk women through their pregnancies and childbirth. Ms. Weaver indicated the majority of those women would choose or fall into the conventional medical model of care. Ms. Weaver stated the majority of that eligible 50 percent of pregnant women would choose physicians or in-hospital care with certified nurse midwives. She indicated, however, the small fraction certified direct-entry midwives would receive of those Alaskan Medicaid-eligible women was a great deal more than the current zero amount. REPRESENTATIVE MURKOWSKI asked again if there were efforts being made to recruit and train additional midwives, noting these efforts would probably not be through the licensing board. Number 1403 MS. WEAVER answered in the affirmative. She indicated there were education and advocacy efforts in place and advancing, commenting, "Getting the word out about midwifery model of care specifically, out-of-hospital births, safety issues, and all of those things that you can imagine would be of concern to policymakers and the public." CHAIRMAN ROKEBERG mentioned the July 7, 1997, letter from Ms. Reardon in the audit which contained eight suggestions for cost-containment on the board to lower the rather high biennial licensing fees caused by the relatively small number of licensees. He asked Ms. Weaver if the board had considered the suggestions and if anything had come of those recommendations. Number 1464 MS. WEAVER said, speaking as a member of the association, that they had definitely considered the suggestions. She said the board had also discussed the suggestions and she herself had spoken with Ms. Reardon at fair length about them. Ms. Weaver indicated none of the points satisfied the association enough for the association to advocate moving towards the suggestions. She noted Ms. Reardon's presence at the meeting and said their discussion was more regarding the fiscal matters if the board was or was not extended as a result of those eight points. Ms. Weaver added it was her recollection that there would not be an appreciable decrease in the licensure fees should the board not be extended. CHAIRMAN ROKEBERG said he had been struck by the recommendation to lower the board size from the current five members. He commented it seemed the board had a pretty good cross-section: a mandated nurse midwife, a physician in the area, two midwives [certified direct-entry midwives], and a public member. He asked if going to three members would hurt the board's ability "to have proper oversight and input into the activities of the board." Number 1569 MS. WEAVER replied she personally thought that was a possibility. She said she was not sure if that change could ever be successfully proposed, indicating legislators in 1992 when the statute was enacted were strongly in favor of the board's current composition. Ms. Weaver noted she personally wouldn't mind seeing it reduced, commenting on the situation of members from one profession governing members of another profession. CHAIRMAN ROKEBERG noted it was the committee's purview to make sure the regulatory structure was in place and working effectively. He asked to what degree they relied on the department for their licensing and examinations. Number 1628 MS. WEAVER indicated their licensing examiner accepted and screened applications initially before forwarding the applications to the board for review. She stated, "He also (indisc.) with the national testing agency for test dates for those applicants who are ready to test." Ms. Weaver indicated the licensing examiner additionally arranged for proctors and performed the staff duties of that nature. She confirmed for the chairman that they used the national standardized examination. She added that the national certification board she belonged to [NARM] had developed this examination. CHAIRMAN ROKEBERG confirmed there were no more questions for Ms. Weaver. Number 1698 KAYE KANNE, Midwives Association of Alaska; Member, Board of Certified Direct-Entry Midwives, came forward to testify in support of HB 10. Ms. Kanne stated she was a practicing certified direct-entry midwife in Juneau, noting she had been practicing here for 15 years and the previous April they had opened a freestanding, nonprofit birth center in Juneau. She invited the committee members to visit the birth center. Ms. Kanne addressed some of the questions which had arisen. She stated that they did 10 percent of the births in Juneau and sometimes more. At the birth center there was another certified direct-entry midwife and herself, and three students. Ms. Kanne indicated the 10 percent figure was based on 500 births a year in Juneau, although sometimes there were fewer than 500 births, of which the midwives were doing at least 50. She stated she was really proud of the certified direct-entry midwives in Alaska and their accomplishments, noting she had served on the board since its inception in 1992 and had worked very hard to get the board into place. She said she felt they really had accomplished a lot in that time: written the regulations, defined the scope of practice, and defined the required course of study for apprentices. She noted the statistics for midwives in Alaska had been very good. Ms. Kanne said she thought the midwives as a group were doing very well. They continued to provide quality care for low-risk women who chose that option. She noted that option was low-cost in addition to being safe, indicating it was available for people without insurance or for those who didn't qualify for Medicaid. She clarified for Representative Sanders that there were two midwives in Juneau and they did all the births together as a team. REPRESENTATIVE SANDERS asked what their capacity was, wondering whether they could do one birth a week and be adequate. Number 1807 MS. KANNE replied that sometimes they did three or four births a week, noting the births tended to come in bunches, with sometimes four in one week and none in the next. She said they could probably do twice that and still be functioning very well, mentioning they had three students who worked very hard also. Ms. Kanne noted she thought their maximum capacity, doing it well, would be ten births a month as a group, two midwives together. She said they were actually recruiting for a third midwife. Ms. Kanne referred to the figure of six that had been given for licensed apprentices. Ms. Kanne stated there were many more apprentices than that in the state of Alaska; she knew because she had three apprentices who were not licensed with the state at that point. Ms. Kanne said, "There is a loophole in the law that says that you don't have to be a licensed apprentice until ... maybe the last two years of their apprenticeship and they'll get ... their certification and then go into -- and I have a waiting list of four people who want to be midwives -- so there's definitely a lot of women out there that do want to be certified direct-entry midwives and are working towards that goal." She stated the cost of the license was not a deterrent to the midwives; they would like it to be lower but were willing to pay because they thought having the board was very important. Ms. Kanne noted the apprenticeship for certified direct-entry midwives was less expensive than going to medical school or becoming a certified nurse midwife, for example. She said the apprentices didn't have student loans that needed to be repaid once they began practicing, indicating the licensing fee could just be considered part of the education cost. REPRESENTATIVE MURKOWSKI noted Ms. Kanne mentioned she had both licensed and unlicensed apprentices. Representative Murkowski asked what the difference was for a licensed apprentice versus a non-licensed apprentice in their responsibilities and what they could do. Number 1893 MS. KANNE clarified that apprentices were not licensed: it was just a certificate which said the person could be an apprentice. She noted all apprentices had to have direct in-room supervision from a certified direct-entry midwife. CHAIRMAN ROKEBERG asked Ms. Kanne to explain how her care would compare to that of an "OB/GYN" [physician specializing in obstetrics and gynecology] in terms of post and prenatal care, and the entire services she brought to a birth. Number 1935 MS. KANNE indicated that was a very long explanation. She stated that, first of all, they spent a lot more time with women. For a normal prenatal visit, midwives would spend an hour with a woman instead of ten minutes or whatever. The midwives spent a lot more time on nutrition, on the woman's overall health. She indicated they checked on how the woman was feeling and on areas she might want to know more about. Regarding postpartum, the midwives spent the entire labor with the woman, rather than coming in just at the end and delivering the baby. They also stayed with the woman after the birth. After the birth the midwives visited the woman every day for three days; they saw the woman at one, two, three, four and six weeks after the birth. At each one of those visits they did well-baby checks, and checked the mother for everything: how she was doing physically and emotionally, how was breastfeeding going, how was her life in general. Ms. Kanne said they had new mother breastfeeding support groups and brought in speakers every week on subjects like infant massage, breastfeeding and bonding, and vaccinations. She noted most midwives did the same thing she did. She commented that there was more of a continuity of care with the women the midwives saw; there was a relationship that developed. CHAIRMAN ROKEBERG indicated he would like Ms. Kanne to give the committee an estimate of the cost for her services to one patient versus the cost for a typical medical birth. Number 1991 MS. KANNE replied that the charge for all of their care was $2,800 with an additional $800 if the patient had her baby at the birth center. She noted those figures did not include lab or ultrasound. Ms. Kanne said the physicians' fees in Juneau were comparable to the midwives' fees; the hospital itself made most births cost well over $5,000, and if the women had medications, epidurals, interventions, the cost could be close to $10,000. CHAIRMAN ROKEBERG commented, "So it's a facility that you provide as much as the services, and then there's a shift in the philosophy of services and time too, is that correct?" MS. KANNE agreed, noting they did home births as well as birth center births. CHAIRMAN ROKEBERG asked how it worked in terms of their training with that major issue: when they thought there was an anomaly and referred to a physician. He questioned how their training gave them the ability to alert themselves to the fact they needed additional medical expertise. Number 2038 MS. KANNE stated that when they needed to refer was spelled out very clearly in their regulations and scope of practice. She added, however, that there was also the intuition all midwives had that a particular birth just wasn't going very well. Ms. Kanne commented her transport rate was about 10 percent. She indicated this was mostly first-time mothers and the labor was taking too long - either the membranes had been ruptured too long or the contractions were just too painful, they were not progressing, and the woman might need an epidural. She said if there was an immediate complication which had to be dealt with at that moment, for example, a postpartum hemorrhage or a baby that needed to be resuscitated, the midwives were trained to deal with that and then transport. CHAIRMAN ROKEBERG noted there had been two pieces of legislation passed to assist midwives in terms of insurance coverage mandates and the previously-mentioned Medicaid coverage. He indicated that had gone into effect the previous year. Chairman Rokeberg asked how much increase they had seen in their business, particularly from the Medicaid eligibility aspects. Number 2081 MS. KANNE replied the Medicaid [reimbursement] would begin February 12; the regulations had taken that long to be completed and signed into law. Ms. Kanne said they had continued to take Medicaid clients in the meantime and written them off as part of the nonprofit birth center, noting they hadn't turned anyone away. CHAIRMAN ROKEBERG commented on the excellent lesson this provided for the newer committee members regarding the effective date of legislation and the time it took to implement regulations before there was actual practical effect of passing legislation. Number 2116 REPRESENTATIVE SANDERS commented on an article about midwives in that morning's Anchorage Daily News. He highly recommended it to everyone, indicating it was approximately 20 pieces of Eskimo advice from the times before Western physicians. Number 2147 REPRESENTATIVE MURKOWSKI asked Ms. Kanne to describe the professional relationship between the physicians in Juneau and the midwives. She asked if the physicians viewed the midwives as a professional threat because the midwives were taking some of their patients, or if the physicians had accepted the obvious benefits that came from midwifery. Number 2165 MS. KANNE responded she thought it depended on the individual doctor. She said she would say in Juneau she had always had a good relationship with the physicians. Ms. Kanne indicated she felt there was some healthy fiscal competition, but she thought the relationship was very healthy for the most part. Ms. Kanne stated the midwives were autonomous practitioners, they did not require physician backup. In other words, they did not have to have an official relationship with a physician. She said she thought that made the physicians feel more comfortable because the physicians did not have to say officially that they backed the midwives up, so they then did back them up in reality. Ms. Kanne said the physicians were there for the midwives, the midwives could call them at any time. CHAIRMAN ROKEBERG noted that the committee had received written testimony as well from Ms. Kanne. He invited Ms. Reardon forward again. Number 2208 CATHERINE REARDON, Director, Division of Occupational Licensing, Department of Commerce and Economic Development, came forward again to testify. She stated the department strongly supported the legislation and the continuation of the Board of Certified Direct-Entry Midwives. Ms. Reardon clarified that her previously- referred-to memorandum in the audit was her list of all of the possible steps she could think of for somewhat lower licensing fees; it was not a list of recommended actions. Ms. Reardon noted most of the items on the list would have some significant negative effects. She indicated one of those items had been eliminating the board and having the department regulate the profession directly, which meant she and her staff would be writing the regulations and, more importantly, without the necessary knowledge determining whether someone had practiced competently as a midwife. Ms. Reardon indicated her division would probably end up having to hire experts to review files and such, and that these costs might be more than the cost of the board. She said, therefore, they found having a board very useful, especially in a profession like this. Ms. Reardon mentioned one of the other items which related to the current five-member board size of one nurse midwife, one obstetrician, two certified direct-entry midwives, and one public member. She indicated one of the possible downsides from reducing the board to three members was the possibility that one of the members would have a conflict of interest related to a disciplinary procedure and would be unable to vote. MS. REARDON stated she knew it had been important to both the nursing and medical professions to be able to be involved in the discussions and decisions involving direct-entry midwifery. She said this was because midwifery was relatively new in terms of a state-licensed function. Ms. Reardon indicated she thought having some representation from those other professions was part of the compromises that permitted the creation of the board. She noted she thought there might be some concerns if they were to disrupt the consensus that had developed. Ms. Reardon stated she personally thought having the option of certified direct-entry midwifery was very valuable to Alaskan women and she would not want to see it disappear. She said she thought they did need both the medical model and the certified direct-entry midwife model, noting CDMs handled the low-risk cases. Ms. Reardon indicated she thought they might hear from the nurse midwives and the physicians noting some of the difference in cost was because the more expensive cases would go to the medical model. She commented she thought that was appropriate and only made sense. Ms. Reardon encouraged the committee to pass the legislation, stating she would be happy to answer any questions. Number 2366 REPRESENTATIVE BRICE confirmed from Ms. Reardon that the certified direct-entry midwives paid for the administration of their board 100 percent. REPRESENTATIVE CISSNA asked about the distribution of the midwives throughout the state. She asked how many of the licensed CDMs were located in the Bush, and if there were unlicensed apprentices in the Bush who did not have access to a licensed midwife. Representative Cissna mentioned the high cost of bringing people in from the Bush, and just the problems there were with childbirth and the possibilities in the Bush. Number 2406 MS. REARDON replied she did not believe very many, if any, of their licensed midwives were actually in a village, and she said that perhaps some of the midwives that had testified could give the most feedback about the reasons for that. Ms. Reardon noted part of it was that they were talking about a licensed profession which had only developed since 1993. She stated there was an exemption in the law for practice of midwifery that was part of a person's cultural inheritance and she indicated she thought that was likely intended initially to cover probably Native midwives in villages. Ms. Reardon further indicated the exemption's wording had created some problems because people from many backgrounds and distances from that cultural tradition could perhaps legally claim coverage under the exemption, although that may not have been the exemption's intent. However, she said she thought for that reason there very well might be Native midwives in villages who were legally exempt and who were practicing. Ms. Reardon stated she would be happy to provide the committee with a list of addresses for the 14 midwives the division had. She commented she suspected there were two midwives in Juneau because Ms. Kanne had been active in reaching out to the community and in the training of other midwives. Number 2474 CHAIRMAN ROKEBERG confirmed there was no one else who wished to testify on HB 10 and stated the public hearing was closed. Number 2485 REPRESENTATIVE BRICE made a motion to move HB 10 out of committee with individual recommendations and the accompanying zero fiscal note. There being no objections, HB 10 moved out of the House Labor and Commerce Standing Committee. ADJOURNMENT Number 2496 CHAIRMAN ROKEBERG adjourned the House Labor and Commerce Standing Committee meeting at 4:02 p.m.