Legislature(2021 - 2022)ANCH LIO DENALI Rm

09/02/2021 03:00 PM House HEALTH & SOCIAL SERVICES

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Audio Topic
03:05:25 PM Start
03:06:16 PM Overview: Covid-19 Update
05:12:32 PM Adjourn
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
-- Testimony <Invitation Only> --
                    ALASKA STATE LEGISLATURE                                                                                  
      HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE                                                                     
                       Anchorage, Alaska                                                                                        
                       September 2, 2021                                                                                        
                           3:05 p.m.                                                                                            
MEMBERS PRESENT                                                                                                               
Representative Liz Snyder, Co-Chair                                                                                             
Representative Tiffany Zulkosky, Co-Chair                                                                                       
Representative Ivy Spohnholz                                                                                                    
Representative Ken McCarty                                                                                                      
Representative Mike Prax (via teleconference)                                                                                   
Representative Christopher Kurka (via teleconference)                                                                           
MEMBERS ABSENT                                                                                                                
Representative Zack Fields                                                                                                      
OTHER LEGISLATORS PRESENT                                                                                                     
Representative Andy Josephson                                                                                                   
COMMITTEE CALENDAR                                                                                                            
OVERVIEW: COVID-19 UPDATE                                                                                                       
     - HEARD                                                                                                                    
PREVIOUS COMMITTEE ACTION                                                                                                     
No previous action to record                                                                                                    
WITNESS REGISTER                                                                                                              
ANNE ZINK, MD, Chief Medical Officer                                                                                            
Division of Public Health                                                                                                       
Department of Health and Social Services (DHSS)                                                                                 
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  Co-provided a PowerPoint presentation                                                                    
titled, "COVID-19 Update", dated 9/2/21.                                                                                        
HEIDI HEDBERG, Director                                                                                                         
Division of Public Health                                                                                                       
Department of Health and Social Services (DHSS)                                                                                 
Juneau, Alaska                                                                                                                  
POSITION STATEMENT:  Co-provided a PowerPoint presentation                                                                    
titled, "COVID-19 Update", dated 9/2/21.                                                                                        
ADAM CRUM, Commissioner                                                                                                         
Department of Health and Social Services (DHSS)                                                                                 
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  Spoke during the PowerPoint presentation                                                                 
titled, "COVID-19 Update", dated 9/2/21.                                                                                        
JOSEPH MCLAUGHLIN, MD, Epidemiologist, Chief                                                                                    
Section of Epidemiology                                                                                                         
Division of Public Health                                                                                                       
Department of Health and Social Services (DHSS)                                                                                 
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  Co-provided a PowerPoint presentation                                                                    
titled, "COVID-19 Update", dated 9/2/21.                                                                                        
COLEMAN CUTCHINS, PharmD, BCPS, State Pharmacist                                                                                
Office of Substance Misuse and Addiction Prevention                                                                             
Division of Public Health                                                                                                       
Department of Health and Social Services (DHSS)                                                                                 
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  Co-provided a PowerPoint presentation                                                                    
titled, "COVID-19 Update", dated 9/2/21.                                                                                        
MATTHEW BOBO, Immunization Program Manager                                                                                      
Section of Epidemiology                                                                                                         
Division of Public Health                                                                                                       
Department of Health and Social Services (DHSS)                                                                                 
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  Co-provided a PowerPoint presentation                                                                    
titled, "COVID-19 Update", dated 9/2/21.                                                                                        
GENE WISEMAN, Section Chief                                                                                                     
Rural and Community Health Systems Bureau                                                                                       
Office of Emergency Medical Services                                                                                            
Division of Public Health                                                                                                       
Department of Health and Social Services (DHSS)                                                                                 
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  Co-provided a PowerPoint presentation                                                                    
titled, "COVID-19 Update", dated 9/2/21.                                                                                        
MICHAEL SAVITT, MD, Chief Medical Officer                                                                                       
Anchorage Health Department                                                                                                     
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:   Provided invited  testimony on  the current                                                             
status of COVID-19 in Anchorage.                                                                                                
JARED KOSIN, President and CEO                                                                                                  
Alaska State Hospital and Nursing Home Association (ASHNHA)                                                                     
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:   Provided invited  testimony on  the current                                                             
status of COVID-19 in Alaska.                                                                                                   
PRESTON SIMMONS, Chief Executive Officer                                                                                        
Providence Alaska Medical Center                                                                                                
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:   Provided invited  testimony on  the current                                                             
status of COVID-19 at his hospital.                                                                                             
ELLEN HODGES, MD, Chief of Staff                                                                                                
Yukon-Kuskokwim Health Corporation (YKHC)                                                                                       
Bethel, Alaska                                                                                                                  
POSITION STATEMENT:   Provided invited  testimony on  the current                                                             
status of COVID-19 in rural Alaska.                                                                                             
DAVID WALLACE, Chief Executive Officer                                                                                          
Mat-Su Regional Medical Center                                                                                                  
Palmer, Alaska                                                                                                                  
POSITION STATEMENT:   Provided invited  testimony on  the current                                                             
status of COVID-19 at his facility.                                                                                             
ROBERT ONDERS, MD, Administrator                                                                                                
Alaska Native Medical Center                                                                                                    
Alaska Native Tribal Health Consortium                                                                                          
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:   Provided invited  testimony on  the current                                                             
status of COVID-19 at his facility.                                                                                             
ACTION NARRATIVE                                                                                                              
3:05:25 PM                                                                                                                    
CO-CHAIR LIZ SNYDER  called the House Health  and Social Services                                                             
Standing   Committee    meeting   to    order   at    3:05   p.m.                                                               
Representatives  Prax (via  teleconference), McCarty,  Spohnholz,                                                               
Zulkosky,  and  Snyder  were  present   at  the  call  to  order.                                                               
Representative Kurka (via teleconference)  arrived as the meeting                                                               
was in progress.                                                                                                                
^OVERVIEW: COVID-19 Update                                                                                                      
                   OVERVIEW: COVID-19 Update                                                                                
3:06:16 PM                                                                                                                    
CO-CHAIR SNYDER announced  that the only order  of business would                                                               
be a COVID-19 update.                                                                                                           
CO-CHAIR SNYDER reported  that the COVID-19 Delta  variant is now                                                               
causing spikes  in cases  and deaths, and  that this  week Alaska                                                               
tied its  record for the  most patients hospitalized  with COVID-                                                               
19.  She further reported that  Alaska's hospitals are at or near                                                               
capacity.  She invited Dr. Anne Zink to begin the presentation.                                                                 
3:10:41 PM                                                                                                                    
ANNE ZINK, MD, Chief Medical  Officer, Division of Public Health,                                                               
Department of  Health and Social  Services (DHSS),  co-provided a                                                               
PowerPoint presentation titled,  "COVID-19 Update", dated 9/2/21.                                                               
She displayed  the first slide  and related that over  99 percent                                                               
of the COVID-19  cases in Alaska are the Delta  variant, which is                                                               
spreading  quickly across  the  state.   She  said an  increasing                                                               
number of  cases is being  seen, along with an  increasing strain                                                               
on  hospital   capacity.    Early  on   with  COVID-19,  Alaskans                                                               
collectively worked  together, which saved lives  and reduced the                                                               
number of COVID-19 cases and  hospitalizations, and DHSS hopes to                                                               
continue working together for this current surge.                                                                               
3:11:52 PM                                                                                                                    
HEIDI HEDBERG,  Director, Division  of Public  Health, Department                                                               
of Health and Social Services  (DHSS), co-provided the PowerPoint                                                               
presentation  titled,  "COVID-19  Update",  dated  9/2/21.    She                                                               
proceeded to  slide 2, "Continuing  COVID-19 Response",  and said                                                               
DHSS  has been  meeting weekly  with tribal  health organizations                                                               
organized  by the  Alaska  Native Health  board  and the  [Alaska                                                               
State Hospital and Nursing Home  Association (ASHNHA) has another                                                               
meeting with  all its  hospital members.   Additionally,  DHSS is                                                               
conversing  daily with  hospitals and  clinicians, and  as issues                                                               
are identified  DHSS is quickly  finding solutions to  respond to                                                               
those  issues  so  that  support can  be  provided  to  Alaskans,                                                               
patients, providers,  and the  state system.   The  public health                                                               
order, HB 76,  is allowing DHSS to  use additional flexibilities.                                                               
The department's  focus is prevention and  supporting the state's                                                               
hospitals during this surge.                                                                                                    
MS.  HEDBERG related  that  this morning  the  Alaska Chamber  of                                                               
Commerce  launched  "Give  AK  a Shot",  a  strategy  focused  on                                                               
motivating the unvaccinated to become  vaccinated.  She explained                                                               
that it  is a weekly drawing  for eight weeks with  an option for                                                               
those who  are currently vaccinated  to enter their name  if they                                                               
so choose, and that over  3,000 people have already entered their                                                               
name into the sweepstakes.                                                                                                      
3:13:50 PM                                                                                                                    
ADAM  CRUM,   Commissioner,  Department  of  Health   and  Social                                                               
Services (DHSS),  announced that earlier today  Governor Dunleavy                                                               
changed  the call  of the  special session  by reintroducing  the                                                               
Nurse  Licensure Compact,  which had  been previously  introduced                                                               
under SB 67 and  HB 83, as well as a new bill  [SB 3006] which is                                                               
in direct response towards the  COVID-19 response in working with                                                               
the  Alaska State  Hospital &  Nursing Home  Association (ASHNHA)                                                               
[now  called   the  Alaska  Hospital  &   Healthcare  Association                                                               
(AHHA)].    This  new bill  includes  items  about  telemedicine,                                                               
telehealth, prior  authorizations, and background checks,  and is                                                               
a  tool that  will enhance  the state's  response to  open health                                                               
care  capacity.   Internally,  the  commissioner's public  health                                                               
emergency powers  or authorities  under HB 76  have been  used to                                                               
waive   background  checks   for  ASHNHA   facilities  personnel,                                                               
including non-healthcare  providers like cooks  and environmental                                                               
services personnel.                                                                                                             
3:15:42 PM                                                                                                                    
JOSEPH   MCLAUGHLIN,  MD,   Epidemiologist,  Chief,   Section  of                                                               
Epidemiology,  Division of  Public Health,  Department of  Health                                                               
and   Social   Services   (DHSS),  co-provided   the   PowerPoint                                                               
presentation  titled,  "COVID-19  Update",   dated  9/2/21.    He                                                               
briefly displayed  slide 3 and  then moved to slide  4, "COVID-19                                                               
Statewide  Dashboard, Sept.  1, 2021".   He  reported that  every                                                               
region in  Alaska is currently  at the  high alert level,  with a                                                               
rate of  504.7 cases per 100,000  people.  A high  alert level is                                                               
reached  when the  rate is  greater  than 100  cases per  100,000                                                               
people on  average over the past  seven days.  Over  85,000 cases                                                               
have  been reported  to  the Section  of  Epidemiology since  the                                                               
pandemic's start,  and during the  last week the number  of cases                                                               
has  increased by  13 percent.   The  number of  hospitalizations                                                               
since the pandemic's  start is just over 2,000  and 435 residents                                                               
have died.                                                                                                                      
DR. MCLAUGHLIN turned to slide  5, "COVID-19 Cases by Onset Date,                                                               
Statewide, March  2020    August 31,  2021".   He said  the graph                                                               
depicts the  epidemic curve  in Alaska,  with the  increase since                                                               
July [2021] mirroring what is happening on the national level.                                                                  
DR. MCLAUGHLIN  addressed slide 6, "COVID-19  Variants of Concern                                                               
in Alaska, Weekly  COVID Genomics Surveillance Report  - Sept. 1,                                                               
2021".    He related  that  this  recent  surge is  being  driven                                                               
primarily by  the Delta variant, and  that, nationally, according                                                               
to  the federal  government, 99  percent of  all sequenced  cases                                                               
have been positive for the Delta strain.                                                                                        
DR.  MCLAUGHLIN spoke  to slide  7, "Alaska  Vaccine Breakthrough                                                               
Cases,  Vaccinated vs.  Unvaccinated Cases  and Hospitalization".                                                               
He  said  this slide  illustrates  the  changing epidemiology  of                                                               
vaccine breakthrough cases in Alaska.   The top figure shows that                                                               
from January-July 2021, 10 percent of  the cases and 8 percent of                                                               
the  hospitalizations  were  fully   vaccinated  people,  and  90                                                               
percent of the cases and  92 percent of the hospitalizations were                                                               
unvaccinated.   For the  month of  July 2021,  30 percent  of the                                                               
cases  and   20  percent  of  the   hospitalizations  were  fully                                                               
vaccinated people, and 70 percent of  the cases and 80 percent of                                                               
the  hospitalizations were  unvaccinated.   First among  multiple                                                               
reasons for the  breakthrough vaccination rate is  that the Delta                                                               
strain is much more transmissible  than prior strains.  Second is                                                               
that the  Delta strain  evades prior  immunity better  than other                                                               
strains of virus.                                                                                                               
DR.   MCLAUGHLIN   displayed   slide   8,   "Hospitalization   By                                                               
Vaccination Status".  He pointed  out that from January-June 2021                                                               
the risk  of hospitalization increased  16-fold among  people who                                                               
were  not  vaccinated  as  compared   to  those  who  were  fully                                                               
vaccinated.  In July 2021 the increased risk was 7.5-fold.                                                                      
3:19:55 PM                                                                                                                    
COLEMAN  CUTCHINS,  PharmD,  BCPS, State  Pharmacist,  Office  of                                                               
Substance  Misuse and  Addiction Prevention,  Division of  Public                                                               
Health,  Department of  Health and  Social  Services (DHSS),  co-                                                               
provided the  PowerPoint presentation titled,  "COVID-19 Update",                                                               
dated 9/2/21.   He briefly showed  slide 9 and then  proceeded to                                                               
slide 10,  "Alaska's Testing Update".   He said Alaska is  one of                                                               
the most  tested states and  is doing  well in relation  to other                                                               
states,  although  certain  things  are getting  stressed.    For                                                               
example,  there  are  longer  lines   in  Anchorage,  Kenai,  the                                                               
Matanuska-Susitna  Valley, and  Fairbanks.   The turnaround  time                                                               
for  results is  24-72 hours,  which  is good  compared to  other                                                               
states that  have turnaround  times of  5-10 days.   A  year ago,                                                               
Alaska's two  public health  labs were handling  the bulk  of the                                                               
processing, but today two commercial  labs and three hospitals in                                                               
Alaska  are handling  processing,  so Alaska's  capacity for  lab                                                               
testing remains quite  high.  [The state  warehouse] continues to                                                               
supply rapid molecular tests by Cue  Health and ID NOW, and rapid                                                               
antigen tests  by [BinaxNOW], and  is actively trying  to acquire                                                               
more.  A new group of tests are  also being looked at that can be                                                               
done in the  home; they have some limitations but  offer a lot of                                                               
benefit for  certain things.   The state  is continuing  to offer                                                               
airport testing for as long as it can.                                                                                          
DR. CUTCHINS  proceeded to  slide 11,  "Rapid Antigen  Testing by                                                               
YKHC".  He  stated that in outbreak  response the Yukon-Kuskokwim                                                               
Health Corporation  (YKHC) took the  lead in using  rapid antigen                                                               
testing and  was able to  get ahead of  the outbreaks.   This was                                                               
the  first good  data,  and it  was published  in  a Centers  for                                                               
Disease  Control and  Prevention  (CDC)  Morbidity and  Mortality                                                               
Weekly Report  (MMWR), a  high impact  national publication.   He                                                               
noted  that the  downward  slope  on the  graph  began once  YKHC                                                               
started using  these tests, then  another decrease  occurred once                                                               
the vaccine  became available, and yet  another decrease occurred                                                               
when the vaccine became widely available.                                                                                       
DR.  CUTCHINS moved  to  slide 12,  "Diverse  Testing Partners  +                                                               
Locations".   He  reported  that DHSS  has  worked with  schools,                                                               
university   sports  teams,   fishing  boats,   fishing  industry                                                               
processors,  [television]  reality  show  production  sites,  the                                                               
Iditarod Sled Dog Race, churches,  remote lodges, and the tourism                                                               
industry by  supporting their testing  and offering  them support                                                               
from clinical considerations to testing supplies.                                                                               
3:23:25 PM                                                                                                                    
DR.  CUTCHINS   discussed  slide   13,  "Disease   Progression  +                                                               
Treatment".   He  specified that  the graph,  which looks  at the                                                               
phases of how COVID-19 progresses,  is based on the evidence that                                                               
is known  and the treatment  options available that  evidence and                                                               
guidelines support.   He  said the  prevention phase  consists of                                                               
mitigation  not medication,  given  there  aren't good  treatment                                                               
options for most viruses and the  body is the best at eliminating                                                               
these type things.   Vaccine is the best option  because it is 90                                                               
percent  effective  at  preventing severe  disease.    Monoclonal                                                               
antibodies  are a  synthetic  antibody given  by  IV infusion  or                                                               
subcutaneous injections  and can be preventative  in infection if                                                               
given at  a specific time in  a specific person and  are the only                                                               
treatment option for patients not  admitted to the hospital.  The                                                               
earlier  monoclonal antibodies  are  given in  the infection  the                                                               
better, which  is why people  are encouraged  to test.   If given                                                               
early  before  patients start  to  get  very  sick, they  are  70                                                               
percent  effective  in reducing  the  patient's  risk for  severe                                                               
disease.   Once hospitalized the  treatment options  are systemic                                                               
steroids,  but vaccine  and monoclonal  antibodies  are the  best                                                               
tools for preventing people from getting severely sick.                                                                         
DR. CUTCHINS proceeded to slide  14, "Monoclonal Antibodies".  He                                                               
noted that [DHSS]  changed its vaccine call line  to a monoclonal                                                               
antibody call line to help people  get access to these drugs.  He                                                               
said DHSS is  working with health care providers  and the federal                                                               
government is still supplying most of these drugs for free.                                                                     
3:26:38 PM                                                                                                                    
MATTHEW   BOBO,   Immunization   Program  Manager,   Section   of                                                               
Epidemiology,  Division of  Public Health,  Department of  Health                                                               
and   Social   Services   (DHSS),  co-provided   the   PowerPoint                                                               
presentation  titled,  "COVID-19  Update",   dated  9/2/21.    He                                                               
briefly displayed  slide 15,  then moved  to slide  16, "COVID-19                                                               
Vaccine Summary Dashboard, September 1,  2021".  He reported that                                                               
as of 9/1/21,  60.9 percent of residents 12 years  and older have                                                               
received  one  dose  of  vaccine   and  55.1  percent  are  fully                                                               
vaccinated.  He  further reported that 16,749  vaccine doses were                                                               
administered  between   8/18/21  and  8/31/21,  a   43.6  percent                                                               
increase compared to the week of 7/21/22 through 8/3/21.                                                                        
MR.  BOBO next  reviewed the  list  on slide  17, "COVID  Vaccine                                                               
Rates by  Age Group, August 31,  2021".  He noted  that residents                                                               
with one  dose are broken out  on the list by  [age group] within                                                               
each borough  census area.  Overall,  for 12 years and  older the                                                               
coverage  rate  is 60.7  percent,  for  65  years and  older  the                                                               
coverage rate is  76 percent, and for all ages  the coverage rate                                                               
is 50.6 percent.                                                                                                                
3:28:18 PM                                                                                                                    
MR.   BOBO   spoke   from  slide   18,   "Additional   Dose   for                                                               
Immunocompromised  People",  which   read  [original  punctuation                                                               
   • CDC's Advisory Committee on Immunization Practices                                                                         
     (ACIP)  recently recommended  that people  whose immune                                                                    
     systems are moderately  to severely compromised receive                                                                    
     an additional  dose of mRNA  COVID-19 vaccine  at least                                                                    
     four weeks after an initial two-dose mRNA series.                                                                          
   • CDC's recommendation includes people with a range of                                                                       
      conditions, such as recipients of organ or stem cell                                                                      
       transplants, people with advanced or untreated HIV                                                                       
     infection, active  recipients of treatment  for cancer,                                                                    
     people who are taking  some medications that weaken the                                                                    
     immune system, and others.                                                                                                 
   • Vaccine providers should administer vaccine in                                                                             
     accordance    with    the   updated    emergency    use                                                                    
     authorization (EUA)  per the COVID-19  vaccine provider                                                                    
MR.  BOBO paraphrased  from slide  19,  "Pending Booster  Doses",                                                               
which read [original punctuation provided]:                                                                                     
   • COVID-19 vaccines continue to be highly effective in                                                                       
     reducing risk  of severe disease,  hospitalization, and                                                                    
     death,  even  against   the  widely  circulating  delta                                                                    
   • However, we are seeing a decrease in vaccine                                                                               
     effectiveness against infection.                                                                                           
   • Nearly  all   the    cases    of   severe    disease,                                                                      
     hospitalization,  and  death  continue to  occur  among                                                                    
     those not yet vaccinated at all.                                                                                           
   • [Health and Human Services] HHS has developed a plan                                                                       
     to  begin  offering  these   booster  shots  this  fall                                                                    
     subject   to  FDA   [Food   and  Drug   Administration]                                                                    
     authorization   and   CDC's   Advisory   Committee   on                                                                    
     Immunization  Practices  (ACIP)  issuing  booster  dose                                                                    
     recommendations  based  on  a thorough  review  of  the                                                                    
3:30:14 PM                                                                                                                    
GENE WISEMAN,  Section Chief, Rural and  Community Health Systems                                                               
Bureau, Division  of Public Health,  Office of  Emergency Medical                                                               
Services, Department  of Health  and Social Services  (DHSS), co-                                                               
provided the  PowerPoint presentation titled,  "COVID-19 Update",                                                               
dated 9/2/21.  He briefly showed  slide 20, and then continued to                                                               
slide 21,  "COVID-19 Hospitalizations Dashboard, Sept.  1, 2021".                                                               
He drew  attention to the  graph at the  bottom of the  slide and                                                               
noted that the  curve for the number of  confirmed COVID hospital                                                               
beds occupied in  2021 is similar to November  and December 2020.                                                               
Currently, 164 people are hospitalized  and 16.9 percent of total                                                               
hospitalizations are COVID patients.                                                                                            
MR. WISEMAN  moved to  the graph  on slide  22, "Alaska  COVID 19                                                               
Hospital  Admissions  By  Age".   He  specified  that  the  graph                                                               
demonstrates  admissions  by  age  group and  the  mean  age  has                                                               
changed.  In  October, November, and December 2020  the age group                                                               
of 60-69  years was  the mean  age for  the most  admissions, but                                                               
currently 50-59  years is  the mean  age group.   He  pointed out                                                               
that the pediatrics age group is also increasing.                                                                               
MR.  WISEMAN discussed  slide 23,  "Covid-19  Update on  Hospital                                                               
Capacity".  He stated that  there are other differences from last                                                               
year's surge, one being that  Alaska is currently experiencing an                                                               
exhausted workforce from 18 months  of this pandemic and staffing                                                               
shortages.  He  said it isn't uncommon for  Alaska's hospitals to                                                               
have traveling nurses  as a part of their  augmentation for staff                                                               
year to year,  but this year those professions are  not there due                                                               
to a  nationwide or  global shortage for  those professions.   On                                                               
top of that,  summers are the busy season  and Alaska   hospitals                                                               
are  still   treating  heart   attacks,  strokes,   and  traumas,                                                               
resulting  in a  bottleneck  that decreases  access to  specialty                                                               
care  and urgent  care,  and  making it  difficult  to find  beds                                                               
throughout the state for placing patients where they need to be.                                                                
3:33:25 PM                                                                                                                    
MR. WISEMAN addressed slide 24,  "Supporting Alaska's Health Care                                                               
System".   He related that  DHSS meets regularly with  its ASHNHA                                                               
hospital partners  to work through  the problems and issues.   He                                                               
said steps  have been  taken to  expedite license  and background                                                               
checks for providers.   The department is  working with emergency                                                               
medical  services  (EMS)  partners  on  ways  to  decompress  the                                                               
hospital through  avoiding potentially unnecessary  transports to                                                               
the emergency room  (ER), or by supporting  early discharge which                                                               
is  done  through  [Centers  for   Medicare  and  Medicaid]  1135                                                               
waivers.   The  department  has partnered  with  the [US  General                                                               
Services  Administration   (GSA)]  and   Region  10,   which  has                                                               
established  four contractors  to specifically  provide staff  to                                                               
the  region    four  states of  Oregon,  Idaho,  Washington,  and                                                               
Alaska, and for  which there is currently a deficit  of about 500                                                               
medical workers.                                                                                                                
MR. WISEMAN spoke to slide  25, "Hospital Situational Awareness".                                                               
He said the dashboard shown on  the slide was established in 2020                                                               
and is  currently based  on hospitals  with intensive  care units                                                               
(ICUs).    He explained  that  the  dashboard  is used  for  load                                                               
leveling  between  hospitals  and  is in  the  process  of  being                                                               
expanded to include  all hospitals.  A  morning situational brief                                                               
is going  to be started where  each hospital will talk  about its                                                               
capacity  so patients  can be  sent to  those hospitals  that can                                                               
give them the care they need.                                                                                                   
3:36:56 PM                                                                                                                    
DR. ZINK briefly displayed slide  26, "The Next Few Months", then                                                               
proceeded to  slide 27, "Supporting  Alaskans".   She highlighted                                                               
that DHSS  is continuing to  support Alaska's public  schools and                                                               
health care workers.  She  emphasized that children learn best in                                                               
school,  so DHSS  has an  ongoing school  health and  safety team                                                               
that works  with schools  to help each  district with  what makes                                                               
sense to keep their schools open  and safe and the protocols that                                                               
may be used; DHSS also  supports them with testing, supplies, and                                                               
resources.   To support schools  to stay in-person and  help kids                                                               
be   healthy    and   resilient,   DHSS   regularly    holds   [a                                                               
videoconference  called Extension  for  the Community  Healthcare                                                               
Outcomes (ECHO)].   The department  continues to hold  a parents                                                                
night to help  parents with difficult decisions and  to get their                                                               
kids in school.   The department continues to  support the public                                                               
via a  weekly ECHO every  Wednesday where  the team is  online to                                                               
take questions.   The  department further  supports a  variety of                                                               
healthcare providers with  popup ECHOs to support  them in better                                                               
understanding how COVID-19 is affecting  kids and to collectively                                                               
work together in moving forward.                                                                                                
MS. HEDBERG  closed the  presentation with slide  28, "We  can do                                                               
this, Alaska!"   She underscored that this  is about partnerships                                                               
and that  DHSS works with communities,  hospitals, and clinicians                                                               
every day seven days a week.                                                                                                    
3:40:42 PM                                                                                                                    
CO-CHAIR ZULKOSKY,  in relation  to epidemiology,  requested that                                                               
someone speak to the curve in  Alaska about where the state is in                                                               
terms of case rates, hospitalization trajectories, and peaking.                                                                 
DR.  MCLAUGHLIN replied  that Alaska  is still  in an  increasing                                                               
trajectory   with  a   13  percent   increase  from   last  week.                                                               
Nationally, the  week-to-week increase  in cases is  slowing down                                                               
with the last  report being a 3 percent increase  in cases, which                                                               
could  be an  indication that  things are  starting to  level off                                                               
potentially in the US.   Something learned early on with COVID-19                                                               
is  that  it is  difficult  to  predict  the  future.   In  other                                                               
countries,  such  as  the United  Kingdom  (UK),  the  trajectory                                                               
recently had a sharp rise that  peaked, then it fell, and then it                                                               
started to  rise again.   In  general, this  pattern seems  to go                                                               
over a period  of two to three months in  other countries, but at                                                               
this time  it cannot be  said whether that  will occur in  the US                                                               
and Alaska.                                                                                                                     
DR.  ZINK added  that when  the world  and the  US surge,  Alaska                                                               
tends to surge  as well.  She noted that  the vaccination rate in                                                               
rural communities is better in  general than in communities along                                                               
the road  system, and that  increased access to rapid  testing is                                                               
even  more important  with the  Delta variant  than before.   She                                                               
predicted that Alaska  would see a series of outbreaks  on top of                                                               
each other for some time before it comes down.                                                                                  
3:44:32 PM                                                                                                                    
CO-CHAIR   ZULKOSKY  shared   her   understanding  that   several                                                               
hospitals statewide are working with  the state to centralize ICU                                                               
transfer requests.  She inquired  about the status of making this                                                               
effort happen and whether it is included on slide 25.                                                                           
MR. WISEMAN  responded that  slide 25  represents a  component of                                                               
that.  He said DHSS has  been working with the hospitals to bring                                                               
a mechanism together for that  visual aspect of load leveling and                                                               
moving ICU patients appropriately.   Transfers and transports are                                                               
different  now than  what  was  normally seen  in  the past;  for                                                               
example, a critical  patient was moved from Bethel to  the ICU at                                                               
Fairbanks Memorial Hospital rather  than to Alaska Native Medical                                                               
Center (ANMC) where that patient would normally have gone.                                                                      
3:46:11 PM                                                                                                                    
CO-CHAIR ZULKOSKY  recalled that early  in the pandemic  DHSS was                                                               
reporting  ICU  capacity  in  terms   of  bed  availability,  but                                                               
providers  pointed  out  that  ICU  capacity  was  based  on  the                                                               
[availability of] expert  staff rather than number of  beds.  She                                                               
asked  whether  staffing  capacity,  not just  bed  capacity,  is                                                               
layered into this new reporting.                                                                                                
DR.  ZINK answered  that  it has  to  some degree.    One set  of                                                               
numbers, she  explained, looks at  the population as a  whole and                                                               
considers the  chance/risk of someone getting  COVID-19 and being                                                               
hospitalized.   However,  she continued,  several things  must be                                                               
considered when  the team  is thinking  about capacity,  need for                                                               
care, and how much the state's  hospitals take on.  The available                                                               
beds  reported by  hospitals are  their  available staffed  beds.                                                               
She pointed  out that  the number displayed  on the  dashboard is                                                               
the  number of  hospitalized people  who are  actively infectious                                                               
with  COVID-19  that   the  hospital  is  reporting   to  the  US                                                               
Department of  Health and  Human Services  (HHS), and  which DHSS                                                               
then sees.   Not reflected in the overall  dashboard numbers, but                                                               
still  a continued  burden  on  the hospital,  is  the number  of                                                               
patients requiring  hospital stays of  1-2 months and who  are no                                                               
longer  infectious  beyond their  first  10-15  days.   Also  not                                                               
necessarily reflected  in the  dashboard are  patients infectious                                                               
with COVID-19 who  start to recover but then must  be treated for                                                               
a  complication  such  as  a  pulmonary  embolism  or  myocardial                                                               
infarction, which occur at higher  rates in people with COVID-19.                                                               
Further, there is  a pivot point in the first  five to seven days                                                               
of either  people do much  better or they  do much worse  and are                                                               
hospitalized for  a very long  time.   So, Dr. Zink  advised, the                                                               
dashboard  doesn't represent  the  overall  burden on  hospitals;                                                               
numerous points  need to be  considered when looking  at hospital                                                               
capacity and the impact of COVID-19 on the hospitals.                                                                           
3:48:57 PM                                                                                                                    
REPRESENTATIVE  SPOHNHOLZ  asked  whether  the  governor  or  the                                                               
commissioner  considered utilizing  the  public health  emergency                                                               
disaster declaration  to cut  through the red  tape and  speed up                                                               
the implementation  of some of the  licensing suspending elements                                                               
to make it easier for  telehealth and to eliminate the background                                                               
checks requirement without needing to pass legislation.                                                                         
MR. CRUM  replied that  these are specific  items that  were laid                                                               
out  by ASHNHA  in  conversation and  in writing.    He said  the                                                               
disaster  declaration is  so  overly broad  that  it would  still                                                               
require legislative  action to  go beyond 30  days.   Fine tuning                                                               
and tools are being looked at  to deal with the large spikes that                                                               
seem  to be  occurring every  six to  seven months.   These  very                                                               
specific items  need to be  moved forward, and  since legislative                                                               
action is  going to be required  anyway it was thought  that this                                                               
narrow aspect was the best way to move that forward.                                                                            
REPRESENTATIVE  SPOHNHOLZ  recalled   that  the  Nurse  Licensure                                                               
Compact wasn't well-received in the  House when it was introduced                                                               
earlier.   She said it focuses  only on nurses and  not any other                                                               
healthcare professionals,  and she  is concerned  that it  is too                                                               
narrow  and does  not  respond  to ASHNHA    request  for a  much                                                               
broader public health emergency disaster.                                                                                       
3:51:50 PM                                                                                                                    
REPRESENTATIVE  SPOHNHOLZ asked  whether  at-home  testing is  as                                                               
reliable and  of the same  standard as the rapid  tests available                                                               
through a healthcare provider.                                                                                                  
DR.  CUTCHINS responded  that there  is a  wide variety  of these                                                               
tests, and  some are appropriate  for people who want  to travel.                                                               
He said  the most  important thing  is for  people to  follow the                                                               
test's directions and to reach  out to their health care provider                                                               
with  any questions  on the  results.   Overall, over-the-counter                                                               
tests are  very good at detecting  positive, but the chance  of a                                                               
negative result being real is only 50-75 percent.                                                                               
3:54:05 PM                                                                                                                    
REPRESENTATIVE   SPOHNHOLZ  drew   attention   to  the   hospital                                                               
dashboard  and  remarked that  it  is  alarming  to see  so  many                                                               
hospitals  at capacity.    She noted,  however,  that Joint  Base                                                               
Elmendorf-Richardson  (JBER)  Hospital   appears  to  still  have                                                               
capacity  and asked  whether people  could be  sent there  rather                                                               
than to Washington state.                                                                                                       
MS. HEDBERG  answered that  DHSS continues  to encourage  all the                                                               
hospitals  to update  the divert  page,  which is  what is  being                                                               
referenced.   But, she explained,  not all hospitals  update that                                                               
page on a timely fashion and  that is being worked on.  Hospitals                                                               
are  asking patients  if  they have  [US  Department of  Veterans                                                               
Affairs  (VA)] benefits  and, if  they  do, whether  they can  be                                                               
transported to Fort  Lehi or to the 673d  Medical Group Hospital.                                                               
She  advised that  she therefore  doesn't think  it reflects  bed                                                               
availability at the JBER hospital.                                                                                              
REPRESENTATIVE SPOHNHOLZ asked whether  Ms. Hedberg is suggesting                                                               
that there is a higher utilization  than what is reflected in the                                                               
MS.  HEDBERG  confirmed  that  JBER's   hospital  status  is  not                                                               
accurately reflected but that the hospital does have patients.                                                                  
3:56:21 PM                                                                                                                    
REPRESENTATIVE  MCCARTY inquired  whether the  dashboard variance                                                               
is a  standard deviation variance of  days or weeks or  a lack of                                                               
DR. ZINK  replied that it is  a combination of lack  of reporting                                                               
results  and the  dashboard  not being  regularly  updated.   She                                                               
noted that the Anchorage Fire  Department has a diversion website                                                               
so Anchorage hospitals can see who  is full.  She emphasized that                                                               
if [the  dashboard] shows an  emergency department is  closed, it                                                               
doesn't mean that  that department isn't delivering  care as they                                                               
are still open  to walk-ins and will treat people  with a medical                                                               
emergency.   She explained that  this was initially made  for the                                                               
Anchorage area  EMS to  be able to  round-robin.   The department                                                               
then stepped  in to  add additional  hospitals to  provide better                                                               
visibility of what was happening.   Not all hospitals are used to                                                               
the system,  but they are  getting more comfortable with  it over                                                               
time.   The  department is  meeting with  hospitals and  transfer                                                               
centers  on a  regular basis  to have  a better  understanding of                                                               
their capacity.   Not every  patient can  go to every  place, not                                                               
every bed  is equal.   For example,  no dialysis is  available at                                                               
JBER so  a bed  would not  be available there  for a  patient who                                                               
needs  dialysis.   Complex  decision  making  is happening  at  a                                                               
critical  level  for  many  of  these  patient  transfers.    The                                                               
dashboard is  a rough  tool used internally  to give  hospitals a                                                               
place to start calling other hospitals in the state.                                                                            
MR. WISEMAN  added that the  dashboard is  a capture in  time and                                                               
hospitals under  stress are entering  when they can.   Typically,                                                               
it is 24  hours, sometimes a couple days, but  that is recognized                                                               
and is  why DHSS is  also putting  emphasis on working  through a                                                               
daily  oral standup  with  each hospital,  which  will provide  a                                                               
situational picture within the state.   While that will only be a                                                               
piece  of time  when  that briefing  occurs,  it should  increase                                                               
4:00:20 PM                                                                                                                    
REPRESENTATIVE MCCARTY  stated he  would like a  copy of  slide 4                                                               
along  with data  that shows  what has  happened between  July 1,                                                               
2021, and  now.  Regarding  slide 7,  he asked whether  there are                                                               
studies of what  has happened with school  starting and influenza                                                               
and  how  that compares  over  the  years  to  what is  going  on                                                               
currently, i.e.,  whether this is  an anomaly or a  standard type                                                               
thing?   Relative to slide 10,  he asked whether there  have been                                                               
studies on antigen longevity within  people who are known to have                                                               
had COVID-19.   Relative  to slide  13, he  said some  places are                                                               
offering  monoclonal  antibodies and  some  are  not.   He  asked                                                               
whether regulation difficulties or  accessibility are the reasons                                                               
why outpatient clinics are not participating in this therapy.                                                                   
DR. ZINK  answered that DHSS  does a monthly  hospitalization and                                                               
vaccine  breakthrough report,  but  since it  takes  a while  for                                                               
those  reports to  come in  the most  recent report  is for  July                                                               
[2021] data.   A comparison is made  to 2020 and she  is happy to                                                               
provide it.  Addressing vaccine  breakthrough, she explained that                                                               
it is  a matter of  understanding timing because when  looking at                                                               
fully vaccinated  individuals and  those who get  COVID-19, there                                                               
is not a perfect marker  to understand whether someone exposed to                                                               
COVID-19 had full protection against the virus.                                                                                 
4:04:18 PM                                                                                                                    
DR.  ZINK continued  her response  and  addressed the  difference                                                               
between antibodies  and antigens.   Antibodies are what  the body                                                               
makes in response to either  natural infection or to vaccination.                                                               
With vaccination,  the body gets a  signal that it needs  to make                                                               
antibodies and  ideally a longer-term response  to that pathogen.                                                               
Because viruses  replicate themselves  by taking over  the normal                                                               
cellular structure,  they are not  very responsive  to treatment,                                                               
and as  a result they are  best prevented.  The  immune system is                                                               
the best way to  take viruses down and the best  way to take them                                                               
down is  when the immune system  knows how to do  it efficiently.                                                               
Vaccines teach the immune system to  take down a virus as quickly                                                               
as  possible.    Antibodies  are   the  [immune  system's]  first                                                               
response.   There are different ones    IgG, IgM, IgA    and they                                                               
last for  different periods  of time and  are found  in different                                                               
parts of  the body in  general.   Additional parts of  the immune                                                               
system are  also important, including  B cells and T  cells which                                                               
play a key  role in natural infection as well  as vaccine induced                                                               
protection.  Dr. Zinc further  explained that there isn't a great                                                               
test  to say  that  someone  previously had  COVID  and are  they                                                               
getting reinfected.  According to  national data, people who have                                                               
previously had COVID-19  are 2.5 times more likely  to get COVID-                                                               
19 again with the Delta variant  if they are not vaccinated.  She                                                               
said antigens are  small molecules that are tested for  to see if                                                               
someone currently has a virus.   Antigen testing looks for active                                                               
infections,  it   is  not  looking  for   past  infections  which                                                               
antibodies look at.                                                                                                             
DR. ZINC  continued further and addressed  monoclonal antibodies.                                                               
She explained  that it can be  challenging to the workflow  of an                                                               
infusion  center   or  outpatient   clinic  -  where   there  are                                                               
immunocompromised or sick  people - to bring  in a COVID-positive                                                               
patient.   The health care  system has been stretched  for months                                                               
now, but more  providers are stepping into that  space.  Alaskans                                                               
are encouraged to phone the DHSS  call line for where they may be                                                               
able to access monoclonal antibodies in their community.                                                                        
4:08:23 PM                                                                                                                    
MICHAEL  SAVITT,  MD,  Chief Medical  Officer,  Anchorage  Health                                                               
Department, provided  invited testimony on the  current status of                                                               
COVID-19 in Anchorage.   He said city of Anchorage  is in a high-                                                               
risk  situation with  a  7 percent  positivity  and 37,700  total                                                               
cases as  of today.   As of today,  the total number  of COVID-19                                                               
deaths is  215, and the  number of new cases  today is 251.   The                                                               
city's  14-day rate  average is  64.8 per  100,000.   The highest                                                               
number  of  tests  done  across  Anchorage  is  1,900.    Current                                                               
hospitalizations  today   include  93   confirmed  cases   and  5                                                               
suspected.  Vaccination  rate for the first dose  is 67.1 percent                                                               
and  the completed  series  is 59.3  percent,  this includes  the                                                               
municipality  and JBER  totaled together.   Right  now, Anchorage                                                               
has three staffed adult ICU beds available.                                                                                     
DR.  SAVITT  emphasized  that this  battle  against  COVID-19  is                                                               
really against the Delta variant and  that it is not just for the                                                               
health care  system to  fight.   He said  the public  must become                                                               
fully engaged and  partner with the health care  system to defeat                                                               
this  virus.   The  health  care  system encourages  vaccinations                                                               
because that is the single  best weapon against the Delta variant                                                               
and COVID in general.                                                                                                           
4:11:23 PM                                                                                                                    
DR.  SAVITT  encouraged  the  public  to  follow  all  the  CDC                                                                 
recommendations and to  get early testing for COVID-19.   He said                                                               
anyone exposed or experiencing symptoms  should be tested because                                                               
the  only way  to make  the diagnosis  is with  testing.   Anyone                                                               
testing  positive  should  call  their health  care  provider  as                                                               
quickly as  possible to  see what treatment  is appropriate.   If                                                               
eligible for  monoclonal antibody treatment,  try to get  it done                                                               
as  quickly as  possible  because the  sooner  the treatment  the                                                               
better it works.                                                                                                                
DR. SAVITT  stressed that monoclonal  antibody therapy is  not in                                                               
place  of vaccinations.   If  you  are unvaccinated  and have  no                                                               
natural   immunity   your   chance    of   severe   disease   and                                                               
hospitalization and  death are  much higher.   Why  put yourself,                                                               
family, friends, and  neighbors at greater risk?   Get vaccinated                                                               
and  follow all  the  recommendations for  proper  use of  masks,                                                               
handwashing, physical  distancing, and adequate ventilation.   In                                                               
addition  to  helping  family, friends,  and  neighbors  you  are                                                               
helping hospitals  by decreasing the  need to go to  the hospital                                                               
to begin  with.  Vaccines are  safe and protective even  if there                                                               
is decreased  effectiveness against Delta, they  still reduce the                                                               
severity of the disease and help to prevent death.                                                                              
4:14:45 PM                                                                                                                    
CO-CHAIR SNYDER said she understands  that the administration has                                                               
no intention to  require masking or reduction  of gathering sizes                                                               
or social  distancing.   She asked whether  there is  a threshold                                                               
where the  administration would  consider implementing  orders to                                                               
minimize the impacts that are being seen from the Delta variant.                                                                
DR. SAVITT deferred to the administration to provide an answer.                                                                 
CO-CHAIR  SNYDER  asked  whether  Dr. Savitt,  as  Chief  Medical                                                               
Officer, has a sense of what that threshold should be.                                                                          
DR.  SAVITT answered,  "We have  made recommendations  as to  the                                                               
necessity  for  the  vaccinations for  the  CDC  recommendations;                                                               
going forward that would be up to the administration."                                                                          
4:16:03 PM                                                                                                                    
REPRESENTATIVE MCCARTY  pointed out  that some people  cannot get                                                               
vaccinated due  to medical  reasons.   He requested  Dr. Savitt's                                                               
suggestions for what these people can do to protect themselves.                                                                 
DR. SAVITT replied  that those who can't be  vaccinated should be                                                               
surrounded by  family members  and close  contacts who  have been                                                               
vaccinated.  Also,  they should wash their hands,  wear masks, do                                                               
physical distancing,  limit their  circle of  friends, and  be in                                                               
well-ventilated  indoor spaces,  and limit  gatherings to  people                                                               
who are not sick or have been vaccinated.                                                                                       
4:17:35 PM                                                                                                                    
REPRESENTATIVE  SPOHNHOLZ  noted  that  while  Anchorage  has  40                                                               
percent  of the  state's  population  it has  60  percent of  the                                                               
hospitalizations.   She asked whether  this is  because Anchorage                                                               
is  receiving folks  from  outside the  municipality  who need  a                                                               
level of care that cannot be gotten in other communities.                                                                       
DR. SAVITT responded that the  hospitals have a primary catchment                                                               
area of Anchorage, but second  and tertiary catchment areas could                                                               
be  from anywhere  in the  state.   Many  of the  cases are  from                                                               
Anchorage, he  said, but there  has been the influx  from outside                                                               
of  the municipality  as well.    Regarding ICU  capacity, it  is                                                               
important to note that not every bed  in the ICU is filled with a                                                               
COVID patient,  it is  probably 30 percent  COVID, which  puts an                                                               
additional  strain  on  already  near capacity  hospitals.    So,                                                               
prevention is much  more important than ever.   Patients from all                                                               
over  the  state  are  taken,   but  a  further  strain  is  that                                                               
Washington  state and  Oregon,  [Anchorage's]  usual avenues  for                                                               
transfer, are also at capacity and  have been unable to help with                                                               
transfers to the extent that would be hoped.                                                                                    
4:19:54 PM                                                                                                                    
CO-CHAIR  SNYDER opened  invited testimony  from the  health care                                                               
4:21:01 PM                                                                                                                    
JARED  KOSIN,  President  and  CEO,  Alaska  State  Hospital  and                                                               
Nursing Home Association (ASHNHA),  provided invited testimony on                                                               
the current  status of COVID-19.   He offered his  recognition to                                                               
all the caregivers on the frontline  and said this is and will be                                                               
the single biggest  health care crisis of their  lifetimes.  What                                                               
these caregivers are witnessing,  enduring, and returning to day-                                                               
after-day is  unbelievable and they are  owed support, especially                                                               
right now.   He  thanked Commissioner Crum  and his  health team,                                                               
and ASHNHA's  health team, who  are all exhausted from  trying to                                                               
clear the way for facilities to respond.                                                                                        
MR. KOSIN explained  that normally ASHNHA [now  called the Alaska                                                               
Hospital  &  Healthcare  Association  (AHHA)]  is  a  policy  and                                                               
advocacy-based organization.  But today  ASHNHA is, and has been,                                                               
functioning as  an operational support  team solely  dedicated to                                                               
getting resources to its facilities  on the frontline.  Yesterday                                                               
169  Alaskans were  in the  hospital with  a COVID-19  diagnosis.                                                               
Anchorage  is  full, units  are  closed,  people are  waiting  in                                                               
parking  lots,  and  surgeries  are  being  postponed.    Outlier                                                               
hospitals are full.   Mat-Su Regional [Medical  Center in Palmer]                                                               
and Central  Peninsula Hospital  in Kenai  are carrying  50 COVID                                                               
patients.   Nursing homes are  closed to admission and  have been                                                               
for weeks  due to  severe staffing shortages.   The  situation is                                                               
intense and  nearing desperation, [ASHNHA's members]  are on fire                                                               
and need help.                                                                                                                  
MR.  KOSIN related  that yesterday  ASHNHA sent  a letter  to the                                                               
governor asking  him to  declare a  disaster for  Alaska's health                                                               
care system.   Since  then, he said,  his understanding  that the                                                               
special session call has been amended  to include a set of health                                                               
care relief  bills.  It is  a crisis and ASHNHA's  sole focus and                                                               
interest is getting  resources and support to  its facilities and                                                               
caregivers as fast  as possible.  It doesn't  matter whether it's                                                               
a  disaster declaration  or legislation  or  neither, all  ASHNHA                                                               
wants is support - now.                                                                                                         
4:24:21 PM                                                                                                                    
PRESTON  SIMMONS,  Chief  Executive  Officer,  Providence  Alaska                                                               
Medical Center, provided invited  testimony on the current status                                                               
of COVID-19 at  his hospital.  He said he  echoes the comments of                                                               
his colleagues  and today's co-presenters.   Alaskans continue to                                                               
expect high quality care, but  the state's health care safety net                                                               
is strained  and being  tested like never  before.   Patients are                                                               
coming  to the  hospital  with more  serious illnesses  requiring                                                               
higher level acuity  care; these cases require  a skilled medical                                                               
team,  including  skilled  nurses.   Hospitals  are  consistently                                                               
operating near or  at capacity and available staffed  beds are at                                                               
a premium.   Yesterday Providence had 30 patients  holding in its                                                               
emergency  department, a  record number.   The  waiting room  was                                                               
beyond its capacity  to safely distance people,  so people waited                                                               
in their cars to be triaged.   This is not the care that Alaskans                                                               
deserve,  and it  has taken  emotional and  physical toll  on the                                                               
DR. SIMMONS  said he was  going to focus  his remarks on  some of                                                               
the regulatory flexibilities and  increased policy tools that are                                                               
needed  to   continue  battling  this  pandemic.     However,  he                                                               
continued,  he is  instead going  to  a focus  on caregivers  and                                                               
recognize  Alaska's health  care workers  for their  unbelievable                                                               
strength and compassion.  The  mental and physical toll on health                                                               
care workers will  have lasting impacts.  There  is concern about                                                               
the ongoing  stress and  demands placed  on caregivers,  they are                                                               
tired  and burned  out.   A  day doesn't  go  by without  several                                                               
headlines  and op-eds  from caregivers  begging  for relief  with                                                               
none  in sight.   Many  are called  to work  in this  field by  a                                                               
desire to help  people who are sick and care  for the vulnerable.                                                               
Wave  after wave  of COVID-19  has  been faced.   Caregivers  are                                                               
retiring and  leaving health  care at  record rates.   Retirement                                                               
rates  at  Providence Alaska  Medical  Center  are more  than  19                                                               
percent higher than they were a  year ago.  Vacancy rates for all                                                               
positions  across Providence  are  more than  double the  target.                                                               
Providence  has record  job postings  that are  hiring at  record                                                               
levels, yet  Providence is struggling  to keep up  with attrition                                                               
even while implementing targeted bonuses and other incentives.                                                                  
4:27:17 PM                                                                                                                    
DR.  SIMMONS  stated  that  there are  things  that  can  provide                                                               
relief.  Good public health  measures save lives, he pointed out.                                                               
Masking,  social  distancing,  washing hands,  and  vaccines  are                                                               
effective.  Alaskans  need to wear masks indoors  and he supports                                                               
any statewide  measures that  result in  increased use  of masks,                                                               
which  provide a  layer of  protection for  Alaska's communities,                                                               
families, and  workforce.  Everyone  hopes that relief is  on the                                                               
horizon,  especially  as  more   Alaskans  receive  the  vaccine.                                                               
However, he  stressed, hope is  not a strategy and  there remains                                                               
opportunity.  There  are the ongoing partnerships  with the state                                                               
and  the suite  of tools  announced by  Commissioner Crum  today.                                                               
This  ongoing  dialogue and  collaboration  are  critical to  the                                                               
ability to care for Alaskans  and working together must continue.                                                               
To  continue  adapting  to   the  changing  environment,  lessons                                                               
learned along the  way can be used  as a road map  towards a more                                                               
effective and  efficient process.   The disaster  declaration, SB
241, and the additional  flexibilities provided through executive                                                               
action   can   provide   a   roadmap   towards   more   permanent                                                               
modernization  for  Alaska's  health   care  environment.    This                                                               
package of  regulatory waivers and  relief has  allowed hospitals                                                               
to implement  strategies to  help flatten  the curve  and provide                                                               
more  efficient   care.    Providence  quickly   ramped  up  full                                                               
telehealth programs, including  home monitoring, and professional                                                               
licensing  flexibilities brought  caregivers  to  the bedside  as                                                               
quickly  as possible.   These  efforts  have proven  to be  safe,                                                               
effective, efficient,  and popular with patients  and clinicians.                                                               
Providence pledges its partnership efforts  to make some of these                                                               
measures a permanent part of the health care in Alaska.                                                                         
DR.  SIMMONS addressed  the Nurse  Licensure  Compact [indisc.                                                                  
audio  interruption].   He said  the current  process discourages                                                               
caregivers from working  in Alaska and is  driving away Alaskans,                                                               
especially newer  graduates.  [The  Nurse Licensure  Compact] may                                                               
not  provide immediate  relief but  can be  a powerful  long-term                                                               
tool.   Every  option available  is needed  to hire  Alaskans and                                                               
attract the nation's  health care workers to the state.   He said                                                               
he looks forward to continuing these conversations.                                                                             
4:30:32 PM                                                                                                                    
ELLEN  HODGES,   MD,  Chief  of  Staff,   Yukon-Kuskokwim  Health                                                               
Corporation  (YKHC), provided  invited testimony  on the  current                                                               
status  of  COVID-19 in  rural  Alaska.    She  stated she  is  a                                                               
practicing family  medicine physician and has  served this region                                                               
for 17  years.  She noted  that YKHC is a  tribal health facility                                                               
that provides health  care to a region of  about 28,000 primarily                                                               
Alaska Native residents from 56 tribes  in 46 villages.  Over the                                                               
past  month, the  region  has  seen a  dramatic  increase in  the                                                               
number   of  COVID-19   cases   with   subsequent  increases   in                                                               
hospitalizations and  deaths.   These rates  are being  driven by                                                               
the Delta variant and are  occurring in the region's unvaccinated                                                               
population.   She  said situation  is dire  - 50  percent of  the                                                               
region's current  active cases are  in children under the  age of                                                               
12  who are  ineligible for  vaccination  and 60  percent of  the                                                               
region's active cases are in children under the age of 18.                                                                      
DR. HODGES  related the recent story  of a patient in  the region                                                               
who  was  desperately  ill,  not with  COVID,  but  with  another                                                               
serious illness.  Upon arrival  by air medivac at YKHC's hospital                                                               
in Bethel it became immediately  apparent that this person needed                                                               
intensive  care treatment  not available  at  the YKHC  hospital.                                                               
Using the dashboard, the physician  reached out to every hospital                                                               
in Alaska,  all the while  providing ongoing care at  the bedside                                                               
of this desperately ill person  who was deteriorating as precious                                                               
time went  by.  Hours  later a bed  was secured, and  the patient                                                               
left the  YKHC facility.   Dr. Hodges urged committee  members to                                                               
put themselves in the shoes of  this patient, his family, and the                                                               
doctor as time ticked by.                                                                                                       
DR. HODGES  discussed how everyone  is connected in Alaska.   She                                                               
pointed  out that  choices made  by each  person affect  the care                                                               
that others  are able to access.   The choice of  an unvaccinated                                                               
person to  go maskless in  a crowded venue  causes a person  in a                                                               
village  hundreds  of miles  away  to  go without  the  resources                                                               
needed to  simply survive  regardless of  that person  making the                                                               
choice  to  get  vaccinated  and  wear   a  mask.    A  mask  and                                                               
vaccination  against  COVID  do  not  protect  a  person  against                                                               
strokes,  heart attacks,  sepsis, traumatic  injuries, or  any of                                                               
the  other reasons  a person  might need  an intensive  care unit                                                               
bed.  No one is safe until everyone is safe.                                                                                    
DR.  HODGES  stressed that  immediate  action  must be  taken  to                                                               
protect the lives of Alaskans.   She said Alaskans should be able                                                               
to  rely on  their leaders  in  government to  fully support  and                                                               
tirelessly   promote  each   of   the  following   evidence-based                                                               
measures:  1) All eligible  persons need to be vaccinated against                                                               
COVID-19; there  should be  no equivocation  on this  matter; the                                                               
vaccines are  safe and effective;  the way to end  this seemingly                                                               
endless pandemic  is through  vaccination.   2) All  persons over                                                               
the age  of two need to  be masked in all  public settings; there                                                               
should  be no  equivocation  on  this; it  is  a  safe and  cost-                                                               
effective method of preventing the  transmission of the virus, as                                                               
shown  by multiple  studies; all  politics must  be taken  out of                                                               
that  discussion immediately;  if  this  commonsense measure  was                                                               
universally   applied   it   would  dramatically   decrease   the                                                               
transmission  of  disease.   3)  Telehealth  needs to  be  widely                                                               
available,  and all  measures need  to  be taken  to ensure  this                                                               
highly valuable  tool is  available to  all Alaskans  without any                                                               
barriers; this  is especially true for  behavioral health clients                                                               
who have fared poorly in  pandemic society.  Dr. Hodges concluded                                                               
by urging legislators  to do everything in their  power to reduce                                                               
the  transmission of  COVID-19  in Alaska  because  the lives  of                                                               
everyone depend on everything legislators do.                                                                                   
4:35:50 PM                                                                                                                    
DAVID WALLACE,  Chief Executive Officer, Mat-Su  Regional Medical                                                               
Center,  provided  invited testimony  on  the  current status  of                                                               
COVID-19 at his facility.   He expressed his appreciation for the                                                               
teamwork  between  the government  entities  and  his heath  care                                                               
colleagues represented at this presentation.   He stated that the                                                               
burnout being felt is not just  a little burnout.  The paradox is                                                               
the high  levels of  COVID-19 hitting the  system and  staying in                                                               
the  system for  a long  time, plus  the highest  need for  other                                                               
services simultaneously,  which is a very  difficult landscape to                                                               
navigate.   Concern started to  get high at Mat-Su  Regional when                                                               
it was  one of the  last hospitals with  ICU capacity to  fill up                                                               
that  capacity because  it meant  that a  patient in  an outlying                                                               
community   with  no   ICU  or   ventilator   was  being   bagged                                                               
indefinitely  while a  transfer  was being  sorted  out.   Mat-Su                                                               
Regional,  at  125  beds,  has  an ICU  and  the  same  level  of                                                               
intensivists  available at  Providence,  although Providence  has                                                               
quite a  bit more subspecialties.   Mat-Su Regional has  the same                                                               
intensivist  group, so  the same  high-quality physicians  and an                                                               
outstanding staff, and wants to help anybody it can.                                                                            
MR.  WALLACE reported  that  two weeks  ago  Mat-Su Regional  had                                                               
unprecedented  transfers  in  and  reached  full  capacity,  with                                                               
patients  received from  Homer, Ketchikan,  Barrow, and  Cordova.                                                               
However, with  the nature of  this pandemic, beds then  opened as                                                               
some  of  those  patients  got  better  and  some  expired.    He                                                               
explained  that receiving  transfers  puts Mat-Su  Regional at  a                                                               
position of making decisions on how  long that can be done.  With                                                               
all respect  to the capacity  dashboards that use the  numbers of                                                               
ICU  beds  available,  Mat-Su  Regional   is  in  disaster  mode.                                                               
Because the hospital is in the  situation of not wanting to close                                                               
or  not accepting  the next  patient, a  step-down unit  has been                                                               
made available  on the second  floor for those patients  that are                                                               
just under ICU status.  They are  moved to the second floor if we                                                               
are at full capacity in our ICU.                                                                                                
4:40:34 PM                                                                                                                    
MR. WALLACE related that he  rounds on the hospital's departments                                                               
to see how they are doing.   He recounted that several months ago                                                               
a ward  clerk in ICU  told him that every  nurse in the  ward was                                                               
going to  counseling of one kind  or another.  When  an ICU nurse                                                               
with  critical care  training and  20 years  of experience  says,                                                               
 Last week was the worst week  in my entire career, I didn't know                                                               
what was  going to happen  but I just  wanted to make  it through                                                               
the week"  because she is  watching the desperation on  the faces                                                               
of patients  that are far  too young to  be dying from  a disease                                                               
that could be prevented by  immunization, and when looking at the                                                               
faces of  nurses who are ready  to throw up their  hands and walk                                                               
away,  [administrators] find  themselves  begging  this staff  to                                                               
please come  back for  the next shift  because [the  hospital] is                                                               
stretched so  thin.  Staffing is  in a grim situation.   When the                                                               
ER director says, "I cry on the way  to work and I cry on the way                                                               
home and  I try and  hold it together the  rest of the  day   one                                                               
knows that things are at an unprecedented level of stress.                                                                      
MR. WALLACE  pointed out that this  disaster is now a  year and a                                                               
half old  and now at its  very worst state but  ironically no one                                                               
seems to want  to talk about it anymore let  alone recognize that                                                               
the hospital  safety net is  starting to  fray and very  close to                                                               
breaking.  He implored the  governor's office, the committee, and                                                               
DHSS to work  together to help provide resources  that should not                                                               
be a  part of  politics at  this time.   Working together  is how                                                               
things get done and a difference  is made, and the list of things                                                               
provided in the presentation are a good start.                                                                                  
4:44:22 PM                                                                                                                    
ROBERT ONDERS,  MD, Administrator, Alaska Native  Medical Center,                                                               
Alaska   Native  Tribal   Health  Consortium,   provided  invited                                                               
testimony on the current status of  COVID-19 at his facility.  He                                                               
related  that there  is a  general feeling  of the  staff at  his                                                               
hospital  that  the  public and  governmental  entities  are  not                                                               
recognizing  how  strained  the  system  is,  combined  with  the                                                               
emotional and  physical toll that this  has taken.  In  the fall,                                                               
direct  actions were  taken related  to mitigation  measures that                                                               
helped   decrease  the   case   counts;   right  now,   immediate                                                               
governmental  interventions  are  needed  to  decrease  the  case                                                               
counts.   The current COVID  surge is impacting  his organization                                                               
and everywhere.   The  long road out  is vaccination,  but short-                                                               
term relief is needed and needed  now.  Things are much worse off                                                               
than [last]  fall, both from  a combination of all  the hospitals                                                               
feeling this stress and the  long standing emotional and physical                                                               
toll.  [Alaska Native Medical Center]  is not doing well, and the                                                               
general perception is that no action is being taken.                                                                            
4:47:05 PM                                                                                                                    
CO-CHAIR ZULKOSKY expressed her  recognition of the very sobering                                                               
testimony heard  by the committee.   She asked Mr.  Kosin whether                                                               
the  temporary   30-day  disaster  declarations  issued   by  the                                                               
governor in November-January would  give Alaska's hospital system                                                               
all the tools that would be needed now.                                                                                         
MR. KOSIN  answered yes, it got  resources fast.  It  allowed for                                                               
reciprocal licensing,  people could  come in quicker  and easier,                                                               
and it had telehealth.                                                                                                          
4:48:22 PM                                                                                                                    
REPRESENTATIVE  SPOHNHOLZ  stated  that   the  tenor  of  today's                                                               
testimony was heartbreaking,  and the committee wants  to do what                                                               
it can to  provide support quickly.  She said  it sounds like the                                                               
emergency  disaster  declaration  allowed all  the  flexibilities                                                               
that   were   very  useful   for   hospitals   and  health   care                                                               
organizations  to be  able to  recruit people  and get  access to                                                               
out-of-state   resources,  including   technical  expertise   and                                                               
consultation.   She  asked whether  there is  anything else  that                                                               
would urgently make a significant difference right now.                                                                         
MR. KOSIN  responded that  right now  the time  is now.   Another                                                               
second should not be wasted  in getting resources to [facilities]                                                               
as  fast as  possible.   A disaster  declaration is  fast because                                                               
it's immediate and  he understands there is  legislation in play.                                                               
Whatever way  this gets done, ASHNHA  just wants it done  as fast                                                               
as possible.   Regarding whether there is anything  else, he said                                                               
he  commends the  commissioner  and his  team  for the  expedited                                                               
background check workaround that  was created for facilities, and                                                               
which is  a huge help.   Immediate impacts  that would go  a long                                                               
way  are  anything  around  background  checks,  standing  up  an                                                               
emergency  and  aid program,  and  telehealth.   Everything  else                                                               
starts to get into the mid- and long-term stuff.                                                                                
4:51:21 PM                                                                                                                    
REPRESENTATIVE  MCCARTY, regarding  the Nurse  Licensure Compact,                                                               
said  he hears  from  health care  professionals  that boots  are                                                               
needed on the ground now so  that people can be touched, but that                                                               
they are not so plentiful.  He  said he also hears of not getting                                                               
background checks  done fast enough,  so he  is glad to  hear the                                                               
resolve  for that.    He  asked what  things  are inhibiting  the                                                               
process and whether people in  the health industry not wanting to                                                               
get vaccinated is an element.                                                                                                   
MR. KOSIN answered that what  the commissioner did for background                                                               
checks has  been very impactful, and  it is correct that  what is                                                               
needed is  physical people and  that is  the challenge.   He said                                                               
the Nurse  Licensure Compact is  ASHNHA's top priority  in normal                                                               
times,  has been  for several  years, and  will be  next year  as                                                               
workforce is  focused on.  However,  it takes time to  stand that                                                               
up,  so  in  ranking  these  it  is  the  smaller  levels  around                                                               
background  checks,  trying to  get  CNAs  here, and  telehealth.                                                               
[The association]  wants everybody  vaccinated.   Masking indoors                                                               
needs to  be done,  so ASHNHA  is completely  behind that.    The                                                               
world is breaking  before our eyes and were   asking for anything                                                               
you can do," he added.                                                                                                          
4:54:20 PM                                                                                                                    
CO-CHAIR  SNYDER   stated  that  one  benefit   of  the  disaster                                                               
declaration is the streamlining  of professional and occupational                                                               
licensing,  which has  been offered  up  in a  separate piece  of                                                               
legislation that may  or may not be necessary.   For much of this                                                               
time, she continued,  the focus has been on the  need to increase                                                               
capacity to  respond and what  [health care providers]  need from                                                               
the state to  make that happen.   The other side of  that coin is                                                               
efforts to  reduce the number  of infections, which  then reduces                                                               
the pressure  on health care  providers.   She asked what  can be                                                               
done from  the state's  side to reduce  the number  of infections                                                               
and whether  directives for mask wearing,  social distancing, and                                                               
gathering size be helpful at this point.                                                                                        
DR. ONDERS replied  that as a tribal facility,  the Alaska Native                                                               
Medical Center can  accept licenses from other  states related to                                                               
nursing staffing.  He cautioned  against thinking that this alone                                                               
will provide  an immediate  solution because  there is  a limited                                                               
number of traveling  nurses.  Since that solution  is unlikely to                                                               
be as robust as needed, the  prevention of infection is even more                                                               
critical than  the hope of  staffing coming in via  a streamlined                                                               
process.  A  key component of mitigating spread  is public indoor                                                               
masking, and  this is needed.   When this measure  was previously                                                               
in place in the Anchorage area, case counts rapidly went down.                                                                  
4:57:24 PM                                                                                                                    
CO-CHAIR ZULKOSKY recalled it being  said that Alaska is seeing a                                                               
growth phase  of cases and there  is no guarantee it  is peaking.                                                               
She  asked  what this  means  for  how  health care  delivery  is                                                               
provided  to all  patients,  COVID or  otherwise,  in the  coming                                                               
weeks and how long before Alaska starts to see those impacts.                                                                   
MR.  SIMMONS responded  that  he would  say  [Alaska] is  already                                                               
starting  into  alternative provisions  of  care.   He  said  the                                                               
nursing to  staffing ratio at Providence  as well as many  of the                                                               
hospitals that  are at  capacity around  the state  are different                                                               
than they  normally would be.   The system of care  within Alaska                                                               
is designed such that Anchorage  is the referrable hub throughout                                                               
the state for the quaternary  and tertiary services.  Capacity is                                                               
backing  up into  the communities  so right  now communities  are                                                               
having to  care for patients  that they  normally would not.   As                                                               
that continues to  back up it will eventually  start causing harm                                                               
to patients.   The normal channels  in the system of  care aren't                                                               
there and  it's going to  get backed up,  which is being  seen in                                                               
other states.  Many hospitals  in Washington state don't have the                                                               
referral sources  into typical tertiary  and quaternary  hubs and                                                               
some  of  the smaller  hospitals  are  seeing  as much  as  30-50                                                               
percent  COVID populations.   It  will get  worse before  it gets                                                               
better.  The health care industry  will do its best, but a change                                                               
to ratios of nursing to patients  will be seen, along with levels                                                               
of having to care for  patients beyond [staff's] typical scope of                                                               
practice as [the pandemic] continues.                                                                                           
MR. SIMMONS continued  his response.  He  recalled Dr. McLaughlin                                                               
stating that Alaska will follow the  pattern that was seen in the                                                               
United  Kingdom, India,  and  other  areas.   He  said Alaska  is                                                               
likely  to see  this continue  to escalate  through probably  the                                                               
latter part of this month and  then towards the end of October it                                                               
will go back  down.  Alaska is  far from seeing the  peak of this                                                               
yet.  What helps  in the immediate is just to  quit the spread of                                                               
the virus and the way to do  that is through masking.  He pointed                                                               
out that children  have a lower acuity when they  get the disease                                                               
but  are good  vectors for  spreading.   Last year  when all  the                                                               
school   districts  were   masking,   Alaska   had  very   little                                                               
transmission within  the school  districts.   But this  year when                                                               
school started up  and some of the school  districts didn't mask,                                                               
there were  massive numbers  of infections  right away,  with 300                                                               
cases in the  Mat-Su in the last week.   There isn't outside help                                                               
coming in,  Alaska needs to  immediately tamp down the  spread to                                                               
get through this.                                                                                                               
5:03:00 PM                                                                                                                    
REPRESENTATIVE KURKA  stated that this hearing  feels politically                                                               
manipulated.   He  stated that  right now  Israel is  the world's                                                               
most vaccinated  country at 85  percent vaccinated.   Conversely,                                                               
some of the  COVID-19 variants are running rampant  in Israel and                                                               
the  hospitals   are  full  of   vaccinated  patients   who  have                                                               
breakthrough COVID.   He asked  how that is reconciled  with what                                                               
has been heard today about those who are in hospitals.                                                                          
DR.  MCLAUGHLIN answered  that  the Delta  variant  is more  than                                                               
twice  as  transmissible as  the  original  Wuhan strain  of  the                                                               
severe acute  respiratory syndrome  corona virus  2 (SARS-CoV-2),                                                               
so  transmission of  cases is  occurring  at a  much faster  rate                                                               
across the  globe.   Regarding the proportion  of cases  that are                                                               
vaccine breakthrough  cases, he explained that  the Delta variant                                                               
has mutations that  allow it to evade prior  immunity better than                                                               
other variants.   That  is part  of why  the vaccine  efficacy is                                                               
dropping  from an  original  range of  90  percent prevention  of                                                               
cases to  the currently much  lower vaccine efficacy  with Delta.                                                               
It  is still  quite good  in terms  of vaccines  in general.   In                                                               
terms  of  preventing  SARS-CoV-2  infection  it  is  probably  a                                                               
vaccine  efficacy  of 66  percent  or  higher against  infection,                                                               
which  means quite  a few  vaccine breakthrough  cases are  being                                                               
seen.    The other  factor  is  that  as  the proportion  of  the                                                               
population  becoming fully  vaccinated increases,  the number  of                                                               
vaccine breakthrough cases also increases.   For example, if only                                                               
100  people in  the whole  population of  Israel are  vaccinated,                                                               
probably 1-2 cases of vaccine  breakthrough over a 2-month period                                                               
would be seen.  If  1000 people are vaccinated, more breakthrough                                                               
cases  would  be seen.    If  80  percent  of the  population  is                                                               
vaccinated,   the   proportion   of  cases   that   are   vaccine                                                               
breakthrough  compared  to  non-vaccine  breakthrough  is  really                                                               
going to increase  because the proportion of  the population that                                                               
is vaccinated  increases.   If 100 percent  of the  population is                                                               
vaccinated,  then  100 percent  of  the  cases  are going  to  be                                                               
vaccine breakthrough  cases.  So,  when looking at  these numbers                                                               
one must think through the proportions.                                                                                         
CO-CHAIR  SNYDER stated  that the  primary focus  of the  hearing                                                               
today is hospital capacity.                                                                                                     
5:09:21 PM                                                                                                                    
REPRESENTATIVE  PRAX related  that people  are still  sending him                                                               
questions about  efficacy and  side effects of  the vaccine.   He                                                               
requested the  DHSS phone  number for people  to call  with their                                                               
questions and for receiving answers.                                                                                            
MS. HEDBERG responded that the  phone number is 907-646-3322.  In                                                               
further   response,    she   said   the   website    address   is                                                               
5:11:36 PM                                                                                                                    
CO-CHAIR SNYDER  summarized that  what was  heard today  from the                                                               
health  care  sector  is  that   an  increase  in  resources  and                                                               
flexibility  [is  needed]  to   increase  the  sector's  response                                                               
capability  and  to  address  the   burnout  being  seen  in  the                                                               
overburdened  health care  providers.   Also  needed are  renewed                                                               
efforts  at reducing  the number  of infections  to then  in turn                                                               
reduce the  pressure on  the health  care sector.   A  variety of                                                               
individuals  from the  health care  sector  testified today  that                                                               
they need relief  immediately and they need  the flexibility that                                                               
was  previously provided  in the  disaster  declaration and  that                                                               
flexibility is  needed now.   She implored committee  members and                                                               
members of the administration to heed  that call and take a close                                                               
look at the quickest way to provide that relief.                                                                                
5:12:32 PM                                                                                                                    
There being no  further business before the  committee, the House                                                               
Health  and  Social  Services   Standing  Committee  meeting  was                                                               
adjourned at [5:12] p.m.                                                                                                        

Document Name Date/Time Subjects
House HSS Sept2_2021 FINAL.pdf HHSS 9/2/2021 3:00:00 PM
DHSS Presentation 9-2-21