Legislature(2019 - 2020)ADAMS 519
03/21/2020 09:00 AM House FINANCE
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| Audio | Topic |
|---|---|
| Start | |
| SB137 | |
| SB120 | |
| HB290 | |
| HB247 | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| + | TELECONFERENCED | ||
| += | SB 137 | TELECONFERENCED | |
| += | SB 120 | TELECONFERENCED | |
| += | HB 290 | TELECONFERENCED | |
| += | HB 247 | TELECONFERENCED | |
HOUSE FINANCE COMMITTEE
March 21, 2020
9:05 a.m.
9:05:44 AM
[Note: continuation of the 3/20/20 1:30 p.m. meeting, see
separate minutes for detail.]
CALL TO ORDER
Co-Chair Johnston called the House Finance Committee
meeting to order at 9:05 a.m.
MEMBERS PRESENT
Representative Neal Foster, Co-Chair
Representative Jennifer Johnston, Co-Chair
Representative Dan Ortiz, Vice-Chair
Representative Ben Carpenter
Representative Andy Josephson
Representative Gary Knopp
Representative Bart LeBon
Representative Colleen Sullivan-Leonard
Representative Cathy Tilton
Representative Adam Wool
MEMBERS ABSENT
Representative Kelly Merrick
ALSO PRESENT
Senator Peter Micciche, Sponsor; Michael Willis, Intern,
Senator Peter Micciche; Kris Curtis, Legislative Auditor,
Alaska Division of Legislative Audit; Jane Conway, Staff,
Senator Cathy Giessel; Representative Matt Claman, Sponsor.
Cynthia Montgomery, Nurse Practitioner, Alaska Psychiatric
Institute.
PRESENT VIA TELECONFERENCE
Andree McLeod, Self, Anchorage; Carrie Doyle, President,
Alaska Advanced Practice of Registered Nurses Alliance,
Anchorage; Marieke Heatwole, Self, Anchorage; Sara Kozup,
Certified Psychiatric Nurse Practitioner, Alaska Advanced
Practice of Registered Nurses Alliance, Anchorage; Michael
Alexander, MD, Director of Psychiatry, Alaska Psychiatric
Institute, Anchorage; Carrie Doyle, Alaska Advanced
Practice of Registered Nurses Alliance; Tom Taube, Deputy
Director, Division of Sport Fisheries, Department of Fish
and Game; David Rutz, Director, Division of Sport
Fisheries, Department of Fish and Game.
SUMMARY
HB 247 SPORT FISHING ENHANCEMENT SURCHARGE
CSHB 247(FSH) was REPORTED out of committee with
seven "do pass" recommendations and three "no
recommendation" recommendations and with one new
fiscal impact note from the Department of Fish
and Game.
HB 290 ALTERNATIVE TO ARREST: MENTAL HEALTH CTR.
CSHB 290(JUD) was REPORTED out of committee out
of committee with six "do pass" recommendations,
three "no recommendation" recommendations, and
one "do not pass" recommendation; and with one
previously published zero impact note: FN1 (LAW);
one previously published indeterminant note: FN2
(DPS); and two previously published fiscal impact
notes: FN3 (DHS) and FN4 (DHS).
CSSB 120(HSS)
ADMINISTRATION OF PSYCHOTROPIC MEDICATION
CSSB 120(HSS) was REPORTED out of committee with
a "do pass" recommendation and with two
previously published zero fiscal notes: FN1 (DHS)
and FN 2 (DHS).
SB 137 EXTEND BOARD OF PAROLE
SB 137 was REPORTED out of committee with a "do
pass" recommendation and with one previously
published fiscal impact note: FN1 (COR).
Co-Chair Johnston reviewed the meeting agenda.
SENATE BILL NO. 137
"An Act extending the termination date of the Board of
Parole; and providing for an effective date."
9:06:41 AM
Co-Chair Johnston OPENED and CLOSED public testimony.
Co-Chair Johnston asked for a brief reintroduction of the
bill.
SENATOR PETER MICCICHE, SPONSOR, the bill would extend the
Board of Parole from 2020 to 2025. He highlighted the
importance of the bill, given the need for a Board of
Parole. He asked his staff to provide additional detail.
MICHAEL WILLIS, INTERN, SENATOR PETER MICCICHE, shared that
the bill would extend the Board of Parole from June 30,
2020 to June 30, 2025. He detailed that the board was
serving the public's interest by effectively evaluating
prisoners' likelihood of recidivism and whether a prisoner
poses a threat to the public. He relayed that Kris Curtis
with the Division of Legislative Audit was available for
additional questions.
9:08:42 AM
Representative Knopp asked if the fiscal note showed an
increased or decreased cost from prior fiscal notes.
Mr. Willis answered that he had not looked at prior fiscal
notes. He deferred the question to the legislative auditor.
Senator Micciche answered that he had reviewed prior fiscal
notes. He highlighted that the auditor's report (copy on
file) showed that the cost had increased because SB 91
[crime reform legislation passed in 2016] had added five
positions. He believed there may be an opportunity to
reduce the members on the board the following year once the
impacts of HB 49 [crime reform legislation passed in 2019]
were understood. He explained that a reduction in board
members would bring the cost down somewhat.
Representative Carpenter directed a question to the
legislative auditor. He asked about the board's ability to
effectively evaluate the likelihood of recidivism. He asked
if it was something the audit was able to evaluate with
statistics the Department of Corrections or board kept on
hand.
KRIS CURTIS, LEGISLATIVE AUDITOR, ALASKA DIVISION OF
LEGISLATIVE AUDIT, replied that what the sunset audit
reviewed was dictated by statute (the 11 various statutes
were included in the appendix of the audit report). The
audit did not look at the quality of a board's decisions in
terms of whether they were making the right decisions. The
background information sections of the audit explained how
a board went about making decisions and the tools it used.
When Legislative Audit did its testing, it made sure a
board was using the tools described in regulation, but it
did not reaffirm a board's decision.
9:11:04 AM
Representative Wool stated that the renewal date had been
pushed back due to HB 49. He thought the board extension
had been reduced from eight to five years. He asked if the
extension was too long considering that SB 91 and HB 49 had
taken place during a short timeframe. He knew that numerous
staff had been added as a result of SB 91. He thought a
reduction may occur sooner than five years.
Ms. Curtis answered that HB 49 had not been considered [in
the audit]. She elaborated that when the audit report had
been written, Legislative Audit did not know what
legislation would pass; therefore, she had recommended a
five-year extension. The last time the board had been
extended was three years earlier. At that time, she had
recommended a six-year extension, which had been cut down
to three years due to uncertainty. The length of the
extension was solely up to policy makers. She reported that
the Board of Parole was very well run and had done an
amazing job with the change they had gone through.
Senator Micciche answered that there would be a parole
board whether or not the extension was made. He elaborated
that whether the board was extended for 3, 5, or 8 years,
the things the legislature would have to adjust were
independent of the board extension. He noted he was on the
Department of Corrections finance subcommittee. He
referenced exhibit 3 on page 2 [of the audit] and
considered whether the legislature had over capitalized the
board with positions now that there was no longer a
requirement for a Board of Parole hearing. He believed the
legislature would have to work through the issue in the
budget process. He explained that the board would still
need to be extended and he did not see the five years as
being a factor in how the legislature adjusted the board's
budget in the next five years.
9:13:30 AM
Co-Chair Foster MOVED to REPORT SB 137 out of committee
with individual recommendations and the accompanying fiscal
note. There being NO OBJECTION, it was so ordered.
SB 137 was REPORTED out of committee with a "do pass"
recommendation and with one previously published fiscal
impact note: FN1 (COR).
CS FOR SENATE BILL NO. 120(HSS)
"An Act relating to administration of psychotropic
medication to a patient without the patient's informed
consent; and providing for an effective date."
9:13:55 AM
Co-Chair Johnston OPENED public testimony.
ANDREE MCLEOD, SELF, ANCHORAGE (via teleconference),
strongly opposed the legislation. She found it stunning to
hear that involuntary medications had been administered
without a physician's determination and authority for
nearly ten years at the Alaska Psychiatric Institute (API).
She was intimately aware of many aspects of the current
mental health system in Alaska because of a family member.
She stated that the current system was broken and needed to
be fixed. She thought the legislation was ill conceived.
Ms. McLeod relayed that one full-time and three part-time
psychiatrists worked at API according to the Department of
Health and Social Services (DHSS) Deputy Commissioner
[Albert] Wall. She believed testimony the past Thursday had
created more questions and raised flags. She asked why Dr.
Alexander was so overworked and why more full-time
psychiatrists had not been hired. She did not believe it
was an acceptable answer to say that it was difficult to
hire psychiatrists. She believed API had been given plenty
of time and resources to hire adequate staff and ramp up
bed capacity. She asked what the hold up was.
Ms. McLeod shared that she had worked for the state long
enough to know that if an administration was serious about
fixing a problem, the red tape easily disintegrated. She
highlighted that the emergency declaration that brought
Wellpath to manage API came with substantial funding. She
asked what had happened to the money and why more
psychiatrists had not been hired to help Dr. Alexander. She
asked what had caused the increase in assaults. She
questioned whether there had been more reports or if
assaults had actually increased. She stated there had been
optimism the previous year when Kevin Huckshorn came from
Wellpath to API because of her expertise in de-escalating
situations. She asked whether Ms. Huckshorn's methods had
been implemented thoroughly.
Ms. McLeod stated that the crux of the legislation was to
allow physician assistants (PAs) and advanced practitioner
registered nurses (APRNs) to have parity with psychiatrists
and physicians. She stressed there was a disparity for a
reason. She underscored that PAs and APRNs were not of the
same caliber, had not had the same training, and did not
have the same depth and breadth as psychiatrists and
physicians. From the perspective of a family member who
often had to give up her family member's rights and
liberties to the state, it was incumbent to trust who her
family member was treated by and where they went at API.
She emphasized that the trust had been breached when she
found there had been malpractice for ten years at API where
PAs had been able to authorize involuntary medication
orders.
Ms. McLeod hoped the committee would not move the bill
forward. She wanted physicians and psychiatrists to be the
ones to determine whether psychotropic medications should
be administered without consent. She implored the committee
to not move the bill forward.
9:19:51 AM
Representative Josephson thanked Ms. McLeod for her
testimony. He recognized that she had a passion and
expertise and good governance on the topic. He noticed that
the bill would delete a section that specified a registered
nurse could make the initial determination about the
administration of a psychotropic drug. He believed the
world functioned because there were registered nurses (RNs)
and he clarified he did not mean any disrespect to the
profession. He believed it seemed inarguable that the bill
would ratchet up the level of training and would no longer
allow an RN to potentially administer the drugs. He noted
that the bill specified the person would be an APRN, PA, or
doctor. He asked if the change made the situation better in
Ms. McLeod's eyes.
Ms. McLeod replied in the negative. She had dealt with many
APRNs and PAs inside and outside of API. She stated that
they had made mistakes. She elaborated that one current
member of the API management team had previously been a
health provider at API and had treated her family member.
She discussed that the provider had made serious mistakes
and when questioned about it, Ms. McLeod found the person's
response shocking. She reported that incorrect medications
had been prescribed to her family member. She recalled
being yelled at by the individual. She did not believe
APRNs had the demeanor to make the decisions when tensions
ran high. She stated that doctors and physicians had been
trained. She did not believe they were the same caliber.
9:23:28 AM
CARRIE DOYLE, PRESIDENT, ALASKA ADVANCED PRACTICE OF
REGISTERED NURSES ALLIANCE, ANCHORAGE (via teleconference),
spoke in strong support of the bill on behalf of the APRN
Alliance. She shared that she had a doctorate in nursing
practice and is an APRN. She read from a prepared
statement:
The APRN Alliance wholeheartedly supports SB 120, as
passed by the Senate. We discussed the bill at a
recent board meeting where all four disciplines of
advanced practice nursing - certified nurse
specialists, certified nurse anesthesiologists,
certified nurse midwives, and certified nurse
practitioners - participated in the discussion. We
note that there have been some strong statements of
support in favor of this bill as written. Providence
Hospital supports the bill as passed by the Senate.
API, who does know a few things about the subject,
supports the bill as passed by the Senate. The State
Medical Association supports the bill as passed by the
Senate. There is a lot of knowledge and expertise
there and yet, based on a few minutes of committee
discussion in the final days of session, it appears
there is an effort to limit an advanced practice
nurse's ability to practice. We applaud Senator
Giessel in trying to remove barriers to practice.
In 2010, the Institute of Medicine's Future of Nursing
Report and more recently, the executive order on
protecting and improving Medicare for our nation's
seniors, both recognize that burdensome supervision
requirements and licensure requirements that limit
professionals from practicing to the top of their
licensure and education. We are concerned that the
amendment to this bill will introduce burdensome and
unnecessary restrictions to practice. APRNs are
educated and trained to administer these medications
and we are ready to do so if this bill is passed and
signed into law.
Madam Chair, nurse practitioners throughout the state
are on the front lines of a global pandemic, working
for you and the citizens of the State of Alaska. We
ask that you do the same for us. I'd be happy to
answer any questions, but I'd like to emphasize that
we do support the bill as passed by the Senate. Thank
you.
Representative Wool believed that one of the issues at hand
was not about the medical knowledge of an APRN. He
highlighted that the bill pertained to an involuntary
medication, which was a constitutional issue where someone
was forced to do something they did not necessarily want to
do. He believed it was the crux of the issue. He believed
the issue went a bit beyond medical. He stated that the
committee had been told that API had one psychiatrist for
50 or more patients, albeit they had heard conflicting
evidence. He asked if Ms. Doyle found it cause for concern.
Ms. Doyle replied that nationwide there was a shortage in
psychiatrists and psychiatric APRNs and in resources for
mental health needs. The bill would help alleviate some of
the burdens.
Representative Wool asked if there was a psychiatric APRN
credential within the State of Alaska. He noted that Ms.
Doyle had listed the four kinds of APRNs on the [APRN
Alliance] board. He observed she had not listed a
psychiatric APRN. He understood that some states had a
credentialed psychiatric APRN.
Ms. Doyle responded that there were four types of APRNs
including nurse practitioners. Within the groups there were
six population foci, which included mental health
psychiatric care. She relayed that it was a certification.
Representative Wool asked if all of the APRNs at API were
psychiatric APRNs. Alternatively, he wondered if a
different subdiscipline could work at API. He observed that
the bill did not require psychiatric APRNs specifically.
Ms. Doyle answered that state statutes and regulations
prohibited nurses from working outside of their
certification. She could not speak about API and who the
facility had on staff, but she assumed they were
psychiatric nurse practitioners.
Co-Chair Johnston noted there were individuals from API
available to answer the question after public testimony.
9:28:54 AM
MARIEKE HEATWOLE, SELF, ANCHORAGE (via teleconference),
shared that she is a registered nurse. She urged unanimous
support and passage of SB 120. She shared that she had
worked as a nurse at API in 2016 and she was currently
studying to become a psychiatric mental health nurse
practitioner. She stated that with all due respect to
earlier testimony, her experience with the patients and
medical professionals at API was top quality. She
elaborated that the bill provided a necessary tool for the
smooth operation of inpatient psychiatric care and mostly
for the safety and comfort of patients. She was available
for any questions.
9:30:12 AM
Representative Josephson asked if in Ms. Heatwole's
experience people at API complied with the law that
required documenting the maximum frequency of
administration and specific conditions under which
medication would be given. Additionally, when the crisis
finished there was a requirement to have and document a
discussion with the patient about precursors to the crisis
and ways to avoid future crises. He asked if Ms. Heatwole
recalled compliance at API with other parts of the existing
law.
Ms. Heatwole answered that she could not stress enough the
importance of documentation. She shared that documentation
was one of the nurses' primary jobs. She emphasized that
all staff members at API were trained in de-escalation and
it had always been the first attempt. She detailed there
had always been an attempt to verbally deescalate and
employees were taught how to physically deescalate. She
relayed that crisis medication was always a last resort.
She underscored that she had never felt uncomfortable when
the situation arose because she knew the attending medical
provider and patient. Staff were licensed, credentialed,
and qualified and there had always been full documentation.
Representative Wool gathered that Ms. Heatwole had worked
at API. He referenced Ms. Heatwole's testimony that she was
currently studying to obtain a psychiatric mental health
nurse practitioner certification. He asked if she had been
an RN or APRN when she had worked at API. He asked for some
history of her work experience at API.
Ms. Heatwole answered that in 2016 she had worked as an RN
at API. She shared that she was currently in a program
pursuing psychiatric mental health nurse practitioner
licensure. As Ms. Doyle had stated, she would be an APRN
with specific credentialing in psychiatric mental health
care across the lifespan. She appreciated the opportunity
to point out the credentialing required 650 direct clinical
hours, not with an employer but with a mentor licensed in
the same field. She noted it was considerably more than
what a physician would require in a general psychiatric
residency.
Representative Wool asked about her experience at API when
situations required an emergency chemical intervention and
the appropriate licensed people were called. He asked if
the person called had typically been a psychiatrist or a PA
or APRN.
Ms. Heatwole replied that at the time, she believed that
every unit had been open, and the units were staffed
perhaps equally by APRNs maybe even more so than
psychiatrists. She did not know the precise answer. She
deferred to Dr. Alexander with API for further detail.
Representative Wool asked if having the licensure of
psychiatric mental health nurse practitioner should be a
prerequisite of the type of APRN responsible for
administering psychotropic intervention.
Ms. Heatwole asked if Representative Wool was referring to
the fact that a physician, not a psychiatrist, was
referenced.
Representative Wool answered in the negative. He explained
that the bill referenced APRN but did not delineate
psychiatric mental health nurse practitioner.
Ms. Heatwole agreed and noted the bill did not use specific
language for a physician either. She stated that if a
change in bill language was considered she would defer to
the bill sponsor. She would be surprised to learn anyone
would hire someone to serve the specific population without
the credentialing. She believed Ms. Doyle had addressed
some state requirements in her testimony. She deferred to
someone with more intimate knowledge of the issue for any
additional detail.
9:36:12 AM
Representative Carpenter asked if changes in the bill were
bringing the law in line with current practice.
Co-Chair Johnston noted the question could be answered by
individuals available online after public testimony.
Ms. Heatwole agreed wholeheartedly. She shared that Alaska
had one of the fullest licensure and credential
recognitions of APRNs. She elaborated that APRNs were
already working with the medications. She added that the
treatment in a crisis situation was the difference of a
combination and dose of medication that nurse practitioners
and PAs were already working with. Furthermore, it would
fall to these professionals to manage patients with
complete follow up care, which was already happening and
within their scope of practice.
9:37:54 AM
AT EASE
9:38:42 AM
RECONVENED
Representative Knopp addressed Ms. Heatwole. He noted that
Ms. Heatwole had stated she had previously worked for API
and that she had administered [psychotropic] drugs. Under
the old statute, Ms. Heatwole had administered the drugs at
the recommendation or approval of a physician after
consultation. He thought the underlying question was
whether, in order to administer the drugs, PAs and APRNs
should be going through the same training that Ms. Heatwole
was currently undertaking.
Ms. Heatwole believed they did [receive the same training],
and she would let others speak to that. She also believed
the issue may be regulated in statute as mentioned by Ms.
Doyle.
9:40:23 AM
SARA KOZUP, CERTIFIED PSYCHIATRIC NURSE PRACTITIONER,
ALASKA ADVANCED PRACTICE OF REGISTERED NURSES ALLIANCE,
ANCHORAGE (via teleconference), spoke in support of SB 120
as passed by the Senate. She read from a prepared
statement:
I appreciated Senator Giessel in trying to remove
barriers to practice. I understand that there have
been concerns raised about the ability of psychiatric
nurse practitioners to order psychotropic medications
during an emergency. Mastering the few psychotropic
medications used in emergency mental health and
knowing what risks to monitor for is a straightforward
part of our job. Advanced practice nurses order these
medications and monitor for their effectiveness every
day. Choosing to forcibly administer a psychotropic
medication is also an ethical and a system decision.
In my undergraduate nursing program, I took the same
ethics course as the medical students. I then had
additional ethical education in my graduate program.
As a former registered nurse, I have participated in
forcibly administering medications and am therefore
more aware of emotional and physical risks to both
patients and staff. Nurses are also the people who
manage the system of the hospital. A forced medication
event pulls caregivers from other units and disrupts
the flow of care hospital wide. Not only am I capable
of ordering emergency psychotropic medications, my
education and background make me the perfect person to
make this clinical decision. I would be very happy to
answer any questions, but I would like to emphasize
that I support the bill as passed by the Senate. Thank
you.
9:42:24 AM
Co-Chair Johnston thanked the testifiers for taking the
time to call in. She CLOSED public testimony.
Co-Chair Johnston asked for a brief reintroduction of the
bill.
JANE CONWAY, STAFF, SENATOR CATHY GIESSEL, relayed that the
bill was designed to help treatment facilities with
existing staff shortages throughout the state and to ensure
safety for the patients and staff who work in the
facilities. She clarified that the bill could help
additional facilities beyond API, including Fairbanks
Memorial, Mat-Su, Bartlett Regional Hospital, and
Providence.
Representative Wool noted that the bill sponsor or her
staff [in a previous hearing on the bill] had stated that
many of the APRNs had ten years of experience at the
facility. He shared that he had worked in "these"
facilities and had been involved in forcible medication
situations in the past. He understood the intent of the
legislation. He remarked that a previous testifier had
highlighted that the practitioners knew the patients and
their history - it was comforting when a practitioner knew
a patient well and understood their behaviors. He asked
about a situation where a temporary or new APRN did not
have the ten years' experience and did not have the
psychiatric mental health nurse practitioner licensure. He
asked if all of the APRNs at API were licensed in
psychiatric health. He recalled that the APRN designation
had been changed in statute recently. He asked if all of
the APRNs envisioned in the bill were psychiatric mental
health nurse practitioners.
MICHAEL ALEXANDER, MD, DIRECTOR OF PSYCHIATRY, ALASKA
PSYCHIATRIC INSTITUTE, ANCHORAGE (via teleconference),
replied in the affirmative. He relayed that at API there
were a number of different nurse practitioners, including
three APRNs working in psychiatry, one physician assistant,
and two physician assistants who worked in family practice
medicine. He stressed that the medical officer who was a
family practice doctor or the other physician assistants
did not have the specific training or experience and were
never contacted regarding the issue [of administering
psychotropic drugs]. He stated it was always the
psychiatric APRN or the psychiatric PA who would be
contacted regarding crisis medications.
9:47:02 AM
Representative Wool asked if the PAs at API were under
licensure of the psychiatrists also at the facility.
Mr. Alexander replied affirmatively. He had a collaborative
association with his PA who worked in psychiatry. The other
two PAs were under the collaboration of the medical
officer.
Representative Wool referenced testimony that Dr. Alexander
was the one full-time psychiatrist at API. He noted a
testifier had stated there were also part-time
psychiatrists. He asked if that was the case. If so, he
surmised that Dr. Alexander was not the psychiatrist for
all of the current API residents.
Mr. Alexander answered that he was the only psychiatrist at
API who worked for the State of Alaska. He elaborated that
apart from his position there were three nurse
practitioners and one PA. Additionally, API tried to
utilize a temporary contract employee as well as utilizing
locum tenens. There was currently one contract employee and
one locum tenens doctor temporarily working at API. He
believed there were six open psychiatrist positions at API.
He had been working hard to try to fill them; however,
getting psychiatrists up to Alaska was extraordinarily
difficult.
Representative Josephson thought there were key two issues.
The first was the practice of making a decision to
administer a psychotropic drug vicariously through the eyes
and ears of information telephonically. He stated that the
current law allowed the practice for doctors but not
others. He asked for verification that a doctor was
responsible for making those types of decisions over the
phone based on what people told them. For example, a doctor
could receive a call while they were shopping or having
dinner.
Mr. Alexander responded affirmatively.
Representative Josephson surmised that the bill was an
expansion of the current law. He remarked that the second
key issue was whether there was confidence in the APRN and
PA community. He noted that Dr. Alexander's testimony was
that he had confidence in the ability of the APRNs and PAs
because most of the institutions would only hire
individuals with the appropriate training and experience.
Dr. Alexander replied in the affirmative. He elaborated
that the individuals were specifically trained to provide
psychiatric care.
9:50:48 AM
Representative Sullivan-Leonard asked if the Alaska State
Medical Board had weighed in on the legislation.
Ms. Conway responded that there had not been correspondence
from the State Medical Board. She believed the board was
currently in a state of flux, which she speculated could be
the reason the bill had not received a letter of support.
She did not know for sure. She relayed there was a letter
from the Alaska State Medical Association.
Representative Sullivan-Leonard requested a copy of any
letters of support.
Ms. Conway agreed. She had thought the committee had the
letters.
Representative Sullivan-Leonard still had concern that the
bill was being considered by the House Finance Committee
instead of the House Health and Social Services (HSS)
Committee. She noted that the HSS Committee typically dug
deeply into the potential ramifications of a change in
licensure, especially with a psychotropic drug
administration. She stressed the medication was very
intensive and meant to be administered against a patient's
will or approval. She stated that she had big concerns
about the bill and thought it needed additional scrutiny.
9:52:33 AM
Co-Chair Johnston asked Ms. Conway to share which
committees heard the bill in the Senate.
Ms. Conway responded that the bill had received an HSS
referral [in the Senate].
Co-Chair Johnston asked for verification that the Senate
HSS Committee had thoroughly reviewed the bill.
Ms. Conway answered affirmatively.
9:53:12 AM
Representative Carpenter shared that he was hesitant to
pass a bill that he did not fully understand. He wondered
how many types of medications had to be prescribed in an
effort to alleviate a mental health crisis situation. He
asked if the same medication was used across the board or
if the type of medication used was specific to the
individual.
Mr. Alexander responded that the number of medications used
varied by state and over time as more medications were
developed. However, a combination of medications was often
used. He elaborated that sometimes an antipsychotic drug
like Olanzapine could be used alone in a liquid form. He
noted that sometimes Olanzapine was not enough on its own.
He shared that in his training they had used a combination
of Haloperidol, Cogentin, or Benadryl along with a
Benzodiazepine valium type of medication. He shared that
multiple hospitals throughout the United States used the
different combinations - the combinations were not unique
to Alaska. The medications used on a particular person
depended on whether there was an allergy list or whether
something had been effective in the past.
Mr. Alexander shared that API looked to the most effective
and least amount of dosing possible. He explained that the
nurse who would be calling for a crisis situation had the
information in a patient's medical record. He summarized
that API typically used Haloperidol,
Chlorpromazine/Thorazine, Zyprexa/Olanzapine,
Benadryl/Diphenhydramine for side effects, and a
benzodiazepine such as Ativan. He stated it was a small
grouping of medications; there were not numerous
medications available in an immediate release liquid form,
which was the reason the specific medications listed were
used.
9:56:14 AM
Representative Carpenter remarked on the complexity of the
issue. He asked Dr. Alexander to provide more information
on API's process for determining which doctors or others
were authorized to administer medications. Alternatively,
he asked if a specific certification was all a person
needed.
Mr. Alexander replied that it was a standard training as
part of a medical residency. He clarified it was not
something unique, it was a regular occurrence for
psychiatrists that began at the start of a residency or
when working in any facility.
Representative Carpenter asked if Dr. Alexander was
speaking about medical doctors only. Alternatively, he
wondered if APRNs were included.
Mr. Alexander explained that he was referring to
psychiatrists. He added that often times emergency room
physicians and nurse practitioners prescribed the
medications. His prior answer applied to psychiatrists and
psychiatric nurse practitioners at API - both received the
training and had experience working in psychiatric
facilities. The medicines used in a psychiatric crisis were
the same medications used on a daily basis for resolution
of psychotic symptoms or otherwise.
9:58:40 AM
Representative Wool asked for clarity. He asked for
verification that an APRN or PA could prescribe an
antipsychotic medication like Thorazine on a daily basis.
Dr. Alexander responded affirmatively.
Representative Wool provided a hypothetical scenario where
a PA, APRN, or someone in the facility determined an
emergency intervention was required for a patient. He
stated that current law required the medical provider to
call a doctor in the situation. He asked for verification
that the bill would enable a PA or APRN at the facility to
decide to use the medications.
Dr. Alexander replied, "Of course."
Representative Wool stated his understanding that the APRN
or PA could prescribe emergency medications against a
patient's will and after the crisis situation was resolved
the patient would take their medicine as prescribed by the
same individual. He wondered about the 24-72 hour period.
He referenced line 11, page 10 of the legislation related
to the quantity of an authorized dose and the method of
administering that dose. He asked if a doctor would be
called in an emergency intervention even if a PA or APRN
prescribed the medication without the doctor.
Dr. Alexander responded in the negative. He explained that
the PA or APRN was considered an independent practitioner
and the doctor would not be called. The PA or APRN would be
managing the different calls and issues throughout the
24-hour period they were on call.
Representative Wool thought that after a certain point the
PA or APRN would inform the doctor about an intervention
that took place.
Dr. Alexander agreed that if the patient was the doctor's,
the PA or APRN would notify the doctor; however, if it was
their own patient, the PA or APRN would be managing the
medication anyway.
Representative Wool thanked the doctor for highlighting the
point.
10:01:53 AM
Representative Carpenter MOVED to ADOPT Amendment 1, 31-
LS0866\K.1 (Marx, 3/19/20) (copy on file):
Page 1, lines 12-13:
Delete ", physician assistant, [OR A REGISTERED]
or advanced practice registered nurse"
Insert "[OR A REGISTERED OR ADVANCED PRACTICE
REGISTERED NURSE]"
Page 2, lines 4 -5:
Delete", physician assistant, or advanced
practice registered nurse"
Page 2, following line 21:
Insert a new bill section to read:
"* Sec. 2. AS 47.30.838 is amended by adding new
subsections to read:
(e)A physician assistant or advanced
practice registered nurse may make a
determination under (a)(l) of this section
or order or renew medication under (a)(2) of
this section only if the evaluation facility
or designated treatment facility has
designated the physician assistant or
advanced practice registered nurse as a
person who may make a determination under
(a)( I) of this section or order or renew
medication under (a)(2) of this section.
(f)Each evaluation facility and
designated treatment facility shall
establish criteria for its designation of
the physician assistants and advanced
practice registered nurses who may make a
determination under (a)( I) of this section
or order or renew medication under (a}(2} of
this section."
Renumber the following bill sections accordingly.
Page 2, line 28:
Delete "Section 2"
Insert "Section 3"
Co-Chair Johnston OBJECTED for discussion.
Representative Carpenter explained that the amendment made
him more comfortable with the oversight and risk management
of the bill. He expressed discomfort at the limited time
the committee had spent on the bill. He believed that if
PAs and APRNs were given the ability to administer
[psychotropic] medication in an emergency situation, the
facility should share in the risk of the decision. The
amendment would require the evaluation facility to
establish criteria for its own use, ensuring that people
were properly trained and authorized to make decisions.
10:03:10 AM
Representative Knopp spoke against the amendment. He
thought the question was whether there was confidence in
the ability of trained and experienced APRNs and PAs to
administer a drug in a crisis intervention situation. He
had complete confidence in the ability of the nursing staff
to administer the drugs. He explained that medical
professionals who lived and breathed the work daily were
qualified to make the decisions. He believed the bill
helped remove unnecessary regulation. He remarked that it
was not that long ago there had not been PAs and numerous
other types of healthcare providers. He believed the
individuals were uniquely skilled and qualified.
Co-Chair Johnston asked one of the testifiers to address
the risk associated with the current bill proposal. She
asked if nurse practitioners carried their own malpractice
insurance. She also wanted to understand the risk or
malpractice carried by API.
CYNTHIA MONTGOMERY, NURSE PRACTITIONER, ALASKA PSYCHIATRIC
INSTITUTE, responded that as a state entity, the facility
was covered by a state provided malpractice insurance. She
added that when she practiced in the community, she was
either covered by a facility's malpractice insurance or her
own malpractice insurance when working independently.
10:05:59 AM
Co-Chair Johnston asked Ms. Doyle to respond to her
question as well.
CARRIE DOYLE, ALASKA ADVANCED PRACTICE OF REGISTERED NURSES
ALLIANCE (via teleconference), replied that it depended on
whether it was a private practice. She elaborated that
occasionally APRNs were covered by a facility provided
malpractice insurance. She relayed that most APRNs also
carried their own malpractice insurance.
10:06:31 AM
Representative Wool read from the amendment. He thought the
designation or criteria sounded like an APRN could be a
psychiatric mental health nurse practitioner and/or that a
PA would work under a psychiatrist at the facility. He
believed it was something that was already taking place. He
asked if he was correct.
Mr. Alexander responded that he did not understand the
question.
Representative Wool asked if Dr. Alexander had seen the
amendment.
Dr. Alexander responded affirmatively.
Representative Wool clarified that Amendment 1 specified
that a facility may make a determination and establish
criteria. He asked if a facility could establish the
criteria specifying that an APRN [working at the facility]
was a psychiatric mental health nurse practitioner.
Dr. Alexander believed the determination that an APRN or PA
could provide the service, should be innate within their
duties and not determined by individual facilities.
10:08:39 AM
AT EASE
10:17:04 AM
RECONVENED
Representative Carpenter appreciated the discussion. He
WITHDREW Amendment 1.
Representative Sullivan-Leonard highlighted the bill's
reference to an evaluation facility or a designated
treatment facility. She asked for additional detail on the
evaluation facility. She wondered, for example, if a prison
could be considered an evaluation facility for patients
with psychiatric issues.
Ms. Conway did not believe a prison would be under the
purview of the legislation. She deferred the question.
10:18:24 AM
Co-Chair Johnston noted that API had a relationship with
the state's correctional system. She asked Dr. Alexander if
the bill would apply to a correctional facility.
Dr. Alexander answered that he did not know whether the
bill would apply to a correctional facility. He was not
certain how correctional facilities mandated medications to
be given to patients or in a crisis situation.
Representative Sullivan-Leonard considered that the bill
would broaden the scope for a PA or APRN to administer
psychotropic medications. She reasoned that if an
evaluation facility was considered within the parameter for
a correctional facility, correctional facilities would have
the same authority as API. She highlighted that the
conversation had been around behavior health and the API
facility; however, the bill may be used in different
facilities. She wondered if her thoughts were accurate.
Ms. Conway believed the bill implied that the terms
evaluation facility or designated treatment facility
pertained to psychiatry. She did not know that a prison
would be considered a facility for psychiatric evaluation.
She remarked that [deputy] Commissioner Wall [deputy
commissioner for Medicaid & Health Care Policy, Department
of Health and Social Services] could have answered the
question if he had been available.
10:20:37 AM
AT EASE
10:25:09 AM
RECONVENED
Ms. Conway relayed that AS 47.30.670 defined a designated
treatment facility as a hospital, clinic, institution,
center, or other healthcare facility that has been
designated by the department for treatment or
rehabilitation of mentally ill persons. She noted that the
list did not include correctional institutions. an
evaluation facility was defined as a healthcare facility
that has been designated or is in operation by the
department to perform the evaluations described in AS
47.30.660 or a medical facility licensed under AS 47.32 or
operated by the federal government.
10:26:30 AM
AT EASE
10:27:15 AM
RECONVENED
Co-Chair Foster MOVED to REPORT CSSB 120(HSS) out of
committee with individual recommendations and the
accompanying fiscal notes.
Representative Carpenter OBJECTED. He found supporting
documentation that did not include a letter from the State
Medical Board. He believed passing the legislation without
a recommendation from the board was ill advised. He did not
support passing the bill.
A roll call vote was taken on the motion.
IN FAVOR: LeBon, Ortiz, Wool, Josephson, Knopp, Johnston,
Foster
OPPOSED: Sullivan-Leonard, Tilton, Carpenter
The MOTION PASSED (7/3). There being NO further OBJECTION,
it was so ordered.
CSSB 120(HSS) was REPORTED out of committee with six "do
pass" recommendations and four "no recommendation"
recommendations and with two previously published zero
fiscal notes: FN1 (DHS) and FN2 (DHS).
HOUSE BILL NO. 290
"An Act establishing an alternative to arrest
procedure for persons in acute episodes of mental
illness; relating to emergency detention for mental
health evaluation; and relating to licensure of crisis
stabilization centers."
10:29:38 AM
Co-Chair Johnston OPENED Public Testimony.
ANDREE MCLEOD, SELF, ANCHORAGE (via teleconference), spoke
in opposition to the bill. She stated the legislation
impacted people who experience acute psychiatric
emergencies and the development of organizations with staff
and it had not been vetted through the Health and Social
Services Committee or the Labor and Commerce Committee. She
stated that "we're all aware and we're all desperate for
easy fixes to our broken mental healthcare system." She
believed there was a tendency to grasp for almost any fix.
She thought the bill was ill conceived. She stressed the
need for a comprehensive package to fix the broken system.
She pointed out that the bills all had impacts on the
system. She opined that bills should not move forward when
they were not vetted by the right committees. She appealed
to members to vote against the bill and to include it in
part of a comprehensive package in the future.
Ms. McLeod stated that the bill criminalized mental
illness. She stressed that the arrest followed the person
who had an acute psychiatric emergency, which had severe
ramifications for the person going forward. She used a
hypothetical scenario where a person was arrested because
they lashed out and hit someone while having a heart attack
or some kind of extreme emergency due to high blood
pressure. She asked members to consider that the symptoms
of a person's illness could create a criminal record. She
mentioned HB 312 sponsored by Representative Matt Claman
that had passed several years earlier. She believed it had
criminalized mental illness. She stated that people in API
or any medical facility who exhibit symptoms that could be
deemed threatening could be arrested and taken to jail. She
emphasized that the court record followed the individuals
and impacted their jobs and future living situations. She
reiterated her desire to see HB 290 brought back in the
future as part of a comprehensive package.
Co-Chair Johnston CLOSED Public Testimony. She asked
Representative Claman to provide a reintroduction of the
bill.
10:33:40 AM
REPRESENTATIVE MATT CLAMAN, SPONSOR, highlighted that there
had been questions at the last hearing about the definition
of acute behavioral health crisis. He read the definition
included in an email from the Department of Health and
Social Services: a situation in which an individual's
behavior or state of mind puts that individual at risk of
hurting themselves or others or prevents them from being
able to care for themselves or function safely in the
community as a result of a mental health diagnosis or a
substance abuse disorder. He explained that the bill did
not include the definition because it was common in the law
for the courts to look at what they refer to as the "plain
meaning rule." He elaborated that from the perspective of
the Department of Law's Civil Division, the plain meaning
rule would take the definition of acute behavioral health
crisis and recognize that it included both substance abuse
and behavioral health issues. The division believed the
bill was inclusive of the broad terms and there was not a
need for a more specific definition in statute. He offered
to provide a longer introduction and/or answer questions.
Co-Chair Johnston asked Representative Claman to address
the concerns raised in public testimony. She stated that
the bill was more about keeping people out of jail as
opposed to putting them in jail.
Representative Claman agreed. The purpose of the bill was
to divert individuals who were appropriate for treatment
away from a repeat cycle where they were not getting
successful treatment in jail. He detailed that many of the
individuals could be stabilized in a short period of time.
He shared that states that used the crisis intervention
model had much better results and police officers found the
method in the bill was a better way to work with repeat
offenders in the community. He explained that they had
actually been able to reduce criminal behavior and achieve
savings in terms of psychiatric care and public safety
expenses.
10:36:28 AM
Co-Chair Foster MOVED to REPORT CSHB 290(JUD) out of
committee with individual recommendations and the
accompanying fiscal notes.
Representative Carpenter OBJECTED.
A roll call vote was taken on the motion.
IN FAVOR: Ortiz, Wool, Josephson, Knopp, LeBon, Foster,
Johnston
OPPOSED: Sullivan-Leonard, Tilton, Carpenter
The MOTION PASSED (7/3). There being NO further OBJECTION,
it was so ordered.
CSHB 290(JUD) was REPORTED out of committee with six "do
pass" recommendations, three "no recommendation"
recommendations, and one "do not pass" recommendation; and
with one previously published zero impact note: FN1 (LAW);
one previously published indeterminant note: FN2 (DPS); and
two previously published fiscal impact notes: FN3 (DHS) and
FN4 (DHS).
HOUSE BILL NO. 247
"An Act relating to the fish and game fund;
establishing the sport fishing enhancement surcharge;
relating to the repeal of the sport fishing facility
surcharge; providing for an effective date by amending
the effective date of sec. 21, ch. 18, SLA 2016; and
providing for an effective date."
10:37:25 AM
Co-Chair Johnston OPENED Public Testimony.
Co-Chair Johnston CLOSED Public Testimony.
Co-Chair Johnston asked for a brief reintroduction to the
bill.
TOM TAUBE, DEPUTY DIRECTOR, DIVISION OF SPORT FISHERIES,
DEPARTMENT OF FISH AND GAME (via teleconference), relayed
that the bill would allow the Department of Fish and Game
(DFG) to continue to collect a reduced sport fishing
license surcharge beyond the date it was set to expire. The
sport fishing surcharge was collected in order to pay off
the bonds issued to construct the Ruth Burnett Sport Fish
Hatchery in Fairbanks and the William Jack Hernandez Sport
Fish Hatchery in Anchorage. The surcharge also funded
Chinook and Coho salmon production in Southeast Alaska,
which would be lost when the surcharge sunset. The statute
authorizing the bonds and surcharge would sunset on
January 1 of the calendar year following the repayment of
the bond obligations (at the end of the current year).
Mr. Taube elaborated that the bill would retain the statute
authorizing DFG to collect the surcharge, but at a reduced
rate. The revenue from the surcharge would be used for
ongoing maintenance and repairs at state sport fish
hatchery facilities as well as continued enhancement of
sport fisheries in Southeast.
10:39:27 AM
Representative Wool asked if there had been discussion
about not reducing the surcharge. He understood the bond
had been paid off. He noted testimony from the previous
hearing on the bill that a reduced number of nonresident
licenses was projected, especially in the current year. He
cited Mr. Taube's testimony that the money would be used
for other maintenance projects and not for the initial
hatcheries that were built. He asked if there had been
discussion about leaving the fee at the current rate.
Mr. Taube responded that at the time the surcharge had been
implemented, DFG had made commitments to discontinue it
after the bonds were paid off. He relayed that when the
bill had been conceived, DFG had realized there were
components of the Fairbanks and Anchorage hatcheries that
were not completed at the time of construction due to
rising construction costs in the mid-2000s. He referenced a
backup well at the Fairbanks hatchery and some effluent
filtering at the Anchorage hatchery as examples. Due to the
high cost of the investment of the hatcheries, the
department had decided to go with a reduced amount to try
to partially remain with the commitment made when the bonds
were first created.
Co-Chair Johnston remarked that in the past the department
had been asked if any of the funds had been used for
operations.
Mr. Taube replied that the entire surcharge had been
directed to paying off the bonds themselves. The component
of the bill would be used for covering maintenance staff,
replacing hatchery vehicles, and for components of the
hatcheries that had not been put in place when the
hatcheries were constructed. He reported that daily
operations were currently being covered by [federal] Dingle
Johnson funds.
10:42:25 AM
Representative Carpenter asked if there had been any
discussion about revenue alternatives in light of the fact
that the fee was scheduled to sunset and the bill would
extend the fee and use the funds for a different purpose
than originally intended. He asked if there were
alternatives about how to continue with maintenance and
repairs at the hatcheries.
Mr. Taube replied that DFG would be continuing to pay for
the operations as it did via Dingle Johnson funds. He
elaborated that for larger components, DFG would likely
come to the legislature for capital improvement project
funds to make necessary upgrades to allow the hatchery to
continue functioning.
Representative Carpenter opined that the conversations
should continue to take place in an operational sense. He
stated that the people had paid a tax via a license fee. He
stated that the purpose for the fee was gone and the
people's money should be returned to them. He believed that
if the legislature needed to fund maintenance, the
conversation should take place.
10:44:22 AM
DAVID RUTZ, DIRECTOR, DIVISION OF SPORT FISHERIES,
DEPARTMENT OF FISH AND GAME (via teleconference), provided
a brief narrative about items that had been left out of the
bill and items included in members' bill packets. He
stressed that the hatcheries were stocking 270 locations
throughout Alaska and they supported hundreds of thousands
of angler-days, a sport fishing effort that generated over
$5,000 to the Alaskan economy. He elaborated that most of
the stocking areas were baren lakes that were once void of
fish population - there had been no fishing opportunities
in those areas previously. The vast majority of the angling
efforts on stocks were Alaskan residents and most of the
stocking locations were within close proximity of major
population centers where anglers could access excellent
fishing for minimal out of pocket cost. He noted it was a
great benefit. The stocking efforts also reduced effects on
wild fish populations, many of which were experiencing
times of low production. He underscored it was a great
driver for reducing the division's dependence on General
Fund monies and would help the department with anticipated
shortfalls caused by reduced non-resident license fees
resulting from COVID-19. He reported that the division was
fully supportive of the legislation.
10:46:02 AM
Co-Chair Foster MOVED to REPORT CSHB 247 (FSH) out of
committee with individual recommendations and the
accompanying fiscal note.
There being NO OBJECTION, it was so ordered.
CSHB 247(FSH) was REPORTED out of committee with seven "do
pass" recommendations and three "no recommendation"
recommendations and with one new fiscal impact note from
the Department of Fish and Game.
10:46:42 AM
Representative Tilton MOVED to bring back HB 259 [2020
legislation proposed by the governor to pay a 2019
supplemental Permanent Fund Dividend] for additional
discussion. She relayed that the bill would pay the past
Permanent Fund Dividend (PFD) back to the people.
10:47:07 AM
AT EASE
10:48:00 AM
RECONVENED
Co-Chair Johnston OBJECTED.
Representative Tilton believed it would be prudent to bring
HB 259 back before the committee because the legislature
was looking at a long-term economic stabilization plan. She
highlighted that the committee heard from businesses the
previous day that talked about the need for an influx of
cash into communities. She elaborated that committee
members had also heard from individuals. She shared that
she had received numerous emails with concerns about how
they would deal with daily living expenses. Additionally,
the governor had come forward with an economic
stabilization plan that included HB 259. She stated it was
dependent on the legislature to make decisions on the
issues. She thought the bill could be used as a vehicle to
consider and discuss the stabilization of the economy.
10:49:16 AM
Representative Sullivan-Leonard concurred with
Representative Tilton. She stated that the committee was
finally not hearing something related to health and social
services and was having a discussion about fiscal policy
and the budget. She elaborated that legislators had heard
loud and clear from across the state that many residents
were looking for back PFD funds for support. She recognized
there had been discussion with regard to federal funds
coming through, but she believed the quickest route to get
funds to the public was through the PFD. She supported
Representative Tilton's motion.
Co-Chair Johnston MAINTAINED her OBJECTION.
10:50:04 AM
AT EASE
10:50:24 AM
RECONVENED
Co-Chair Johnston discussed her objection. She stated that
while she appreciated the comments by Representative Tilton
and Representative Sullivan-Leonard, she objected because
she believed the legislature would be looking at a
comprehensive relief bill that was currently being worked
on. She stated that the subject in HB 259 could be part of
that legislation, but she did not yet know. She did not
believe a supplemental PFD was the only part of relief. She
had concerns about what kind of relief the state would
provide because it was not an issue of a month's time. She
stated it could be an issue of 18 months to two years. She
wanted to make certain the state had the funds and the
tools to accommodate it. She emphasized the importance of
cash for the state's daily needs. She elaborated that most
of the state's retail and service organizations were
currently closed. She was concerned about their economic
stability going forward and she wanted to ensure that any
funding provided by the state went to Alaskan businesses,
and residents in the most need.
Representative Josephson associated himself with Co-Chair
Johnston's remarks. He understood the importance of cash;
however, the numbers were still the numbers. He appreciated
Co-Chair Johnston's thoughtful comments.
10:52:19 AM
Representative Tilton appreciated Co-Chair Johnston's
comments as well and agreed on the importance of being
thoughtful in developing a comprehensive package. She
highlighted that the legislature had a stabilization plan
for consideration, and she had not seen something come from
the legislature itself. She remarked that bringing HB 259
back was not necessarily about the dividend itself, but it
could be used as a vehicle to have the discussion. She
highlighted that the committee had heard testimony from the
business community the previous day and had received
testimony from the public indicating a strong need for
cash. She reasoned that businesses would not remain stable
or open even with innovative ways to alter their business
style. She pointed out that if people did not have cash in
their pockets, businesses would not be stabilized. Her
overall concern was for the state's residents. She
underscored the need to look at how the state would get
money out to the economy during an unprecedented time.
Co-Chair Johnston thanked Representative Tilton for her
remarks. She stated that everyone on the committee was very
concerned about everyone in Alaska. She MAINTAINED her
OBJECTION.
A roll call vote was taken on the motion to bring HB 259
before the committee.
IN FAVOR: Sullivan-Leonard, Tilton, Carpenter,
OPPOSED: Wool, Josephson, Knopp, LeBon, Ortiz, Johnston,
Foster
The MOTION FAILED (3/7).
Co-Chair Johnston indicated the meeting would be Recessed
to a Call of the Chair. [See separate minutes dated 3/23/20
11:33 A.M.]
^RECESSED
10:55:03 AM
| Document Name | Date/Time | Subjects |
|---|---|---|
| SB 120 ver. K Amendment 1 3.19.20.pdf |
HFIN 3/21/2020 9:00:00 AM |
SB 120 |
| HB 120 Testimony Letters 032120.pdf |
HFIN 3/21/2020 9:00:00 AM |
HB 120 |