03/15/2024 01:30 PM Senate LABOR & COMMERCE
| Audio | Topic |
|---|---|
| Start | |
| SB44 | |
| SB225 | |
| SB237 | |
| Adjourn |
+ teleconferenced
= bill was previously heard/scheduled
| += | SB 44 | TELECONFERENCED | |
| *+ | SB 225 | TELECONFERENCED | |
| *+ | SB 237 | TELECONFERENCED | |
ALASKA STATE LEGISLATURE
SENATE LABOR AND COMMERCE STANDING COMMITTEE
March 15, 2024
1:34 p.m.
MEMBERS PRESENT
Senator Jesse Bjorkman, Chair
Senator Click Bishop, Vice Chair
Senator Elvi Gray-Jackson
Senator Kelly Merrick
Senator Forrest Dunbar
MEMBERS ABSENT
All members present
COMMITTEE CALENDAR
SENATE BILL NO. 44
"An Act relating to the practice of naturopathy; establishing
the Naturopathy Advisory Board; relating to the licensure of
naturopaths; relating to disciplinary sanctions for naturopaths;
relating to the Department of Commerce, Community, and Economic
Development; and providing for an effective date."
- HEARD & HELD
SENATE BILL NO. 225
"An Act relating to occupational licensing fees; and providing
for an effective date."
- HEARD & HELD
SENATE BILL NO. 237
"An Act establishing a corporate income tax credit for certain
expenditures on child care services, utility rates, residential
housing, and food security and availability; and providing for
an effective date."
- HEARD & HELD
PREVIOUS COMMITTEE ACTION
BILL: SB 44
SHORT TITLE: NATUROPATHS: LICENSING; PRACTICE
SPONSOR(s): SENATOR(s) GIESSEL BY REQUEST
01/25/23 (S) READ THE FIRST TIME - REFERRALS
01/25/23 (S) HSS, L&C, FIN
02/23/23 (S) HSS AT 3:30 PM BUTROVICH 205
02/23/23 (S) Heard & Held
02/23/23 (S) MINUTE(HSS)
03/07/23 (S) HSS AT 3:30 PM BUTROVICH 205
03/07/23 (S) Moved CSSB 44(HSS) Out of Committee
03/07/23 (S) MINUTE(HSS)
03/08/23 (S) HSS RPT CS 1DP 4NR SAME TITLE
03/08/23 (S) NR: WILSON, TOBIN, KAUFMAN, DUNBAR
03/08/23 (S) DP: GIESSEL
05/15/23 (S) L&C AT 1:30 PM BELTZ 105 (TSBldg)
05/15/23 (S) -- Invited & Public Testimony --
03/04/24 (S) L&C AT 1:30 PM BELTZ 105 (TSBldg)
03/04/24 (S) <Bill Hearing Canceled>
03/15/24 (S) L&C AT 1:30 PM BELTZ 105 (TSBldg)
BILL: SB 225
SHORT TITLE: OCCUPATIONAL LICENSING FEES
SPONSOR(s): RULES BY REQUEST OF THE GOVERNOR
02/12/24 (S) READ THE FIRST TIME - REFERRALS
02/12/24 (S) L&C, FIN
03/15/24 (S) L&C AT 1:30 PM BELTZ 105 (TSBldg)
BILL: SB 237
SHORT TITLE: TAX CREDIT CHILD CARE/UTILITY/HOUSE/FOOD
SPONSOR(s): RULES BY REQUEST OF THE GOVERNOR
02/19/24 (S) READ THE FIRST TIME - REFERRALS
02/19/24 (S) L&C, FIN
03/15/24 (S) L&C AT 1:30 PM BELTZ 105 (TSBldg)
WITNESS REGISTER
SENATOR CATHY GIESSEL, District E
Alaska State Legislature
Juneau, Alaska
POSITION STATEMENT: Sponsor of SB 44.
JANE CONWAY, Staff
Senator Cathy Giessel
Alaska State Legislature
Juneau, Alaska
POSITION STATEMENT: Offered a presentation on SB 44.
TIMOTHY BIRDSALL, ND
Avante Medical Center, LLC
Anchorage, Alaska
POSITION STATEMENT: Testified by invitation on SB 44.
CARRIE BALDWIN-SAYRE, ND, Associate Vice President
Advancement and Community Engagement
National University of Natural Medicine
Portland, Oregon
POSITION STATEMENT: Testified by invitation on SB 44.
CLYDE JENSEN, PhD, representing self
Saint George, Utah
POSITION STATEMENT: Testified by invitation on SB 44
ROB DOWNEY, MD, Founder
Seaworthy Functional Medicine
Homer, Alaska
POSITION STATEMENT: Testified by invitation on SB 44.
CHRISTINE SAGAN, NP, Owner
Vitae Integrative Medical Center
Anchorage, Alaska
POSITION STATEMENT: Testified by invitation on SB 44.
NATALIE WIGGINS, ND
Vitae Integrative Medical Center
Anchorage, Alaska
POSITION STATEMENT: Testified by invitation on SB 44.
SYLVAN ROBB, Director
Corporations, Business & Professional Licensing
Department of Commerce, Community and Economic Development
(DCCED)
Juneau, Alaska
POSITION STATEMENT: Introduced SB 225 on behalf of the
administration.
FADIL LIMANI, Deputy Commissioner
Department of Revenue
Juneau, Alaska
POSITION STATEMENT: Introduced SB 237 on behalf of the
administration.
MICHAEL WILLIAMS, Acting Deputy Director
Tax Division
Department of Revenue
Anchorage, Alaska
POSITION STATEMENT: Presented the sectional analysis for SB 237
and answered questions.
ACTION NARRATIVE
1:34:13 PM
CHAIR JESSE BJORKMAN called the Senate Labor and Commerce
Standing Committee meeting to order at 1:34 p.m. Present at the
call to order were Senators Bishop, Dunbar, Gray-Jackson,
Merrick, and Chair Bjorkman.
SB 44-NATUROPATHS: LICENSING; PRACTICE
1:35:10 PM
CHAIR BJORKMAN announced the consideration of SENATE BILL NO.
44, "An Act relating to the practice of naturopathy;
establishing the Naturopathy Advisory Board; relating to the
licensure of naturopaths; relating to disciplinary sanctions for
naturopaths; relating to the Department of Commerce, Community,
and Economic Development; and providing for an effective date."
[Before the committee is CSSB 44 (HSS), work order 33-LS0297\S.]
1:35:30 PM
SENATOR CATHY GIESSEL, District E, Alaska State Legislature,
Juneau, Alaska, sponsor of SB 44, said she is an advanced nurse
practitioner with a national board certification in family
practice. She briefly described her educational experience
obtaining a master's degree at the University of Alaska
Anchorage, which included study of naturopathic medicine. She
explained that after graduation she spent time working in an
alternative medicine clinic alongside a physician, nurse
practitioners, and several naturopathic doctors (ND). She
emphasized the degree of knowledge that she gained as a result
of working alongside naturopaths and briefly described their
method of patient care. She explained that naturopaths are not
able to prescribe medications and would bring patient cases to
her and request prescriptions (typically for thyroid or hormone
replacement medications). She pointed out that naturopaths tend
toward a limited use of prescription medications. She commented
that many Alaskans seek out naturopathic care. She acknowledged
that she has sponsored SB 44 by request; however, she emphasized
that naturopathic doctors are credible healthcare providers.
1:39:56 PM
JANE CONWAY, Staff, Senator Cathy Giessel, Alaska State
Legislature, Juneau, Alaska, offered a presentation on SB 44 and
advanced to slide 2:
[Original punctuation provided.]
WHAT IS A NATUROPATHIC DOCTOR?
• A primary care provider with a four-year post
graduate medical degree who:
• practices evidence-based primary care, with
a patient-centered focus,
• prioritizes disease prevention and
discovering root cause of illness,
• whose treatments focus on lifestyle
modifications, nutrition and low-risk
intervention
MS. CONWAY explained that NDs attempt to answer the question
"why?" and directed attention to recent Health Resources and
Services Administration (HRSA) data indicating that, in the next
decade, Alaska will need 237 primary care doctors. In addition,
HRSA recommended creating interdisciplinary care teams. She
pointed out that Alaska currently has 48-50 NDs who could help
fill this requirement and SB 44 would make them primary care
doctors in the state.
1:42:11 PM
MS. CONWAY advanced to slide 3:
[Original punctuation provided.]
WHAT ABOUT THEIR EDUCATION?
Education
4-Year Medical School Program accredited by the
Council of Naturopathic Medical Education with
• 2 years of medical sciences (anatomy, physiology,
microbiology, immunology, etc.)
Pre-requisites
• 4-yr undergraduate degree and additional pre-med
coursework
Residency
• Less common because they are not trained as
hospitalists
• 1-3 year residency options available; nationwide
there's a shortage
• Note that residencies are not required for
independent primary care providers who hold
prescriptive privileges
Licensing
Naturopaths must pass the two-part Naturopathic
Physicians Licensing Examination (NPLEX) before being
licensed to practice
MS. CONWAY noted that Dr. Carrie Baldwin, who is an authority on
ND education, is available for questions on this topic.
1:43:33 PM
MS. CONWAY advanced to slide 4:
[Original punctuation provided.]
WHO IS NOT A NATUROPATHIC DOCTOR?
• Other conventionally-trained or allied health
care providers practicing integrative,
functional, or holistic healthcare such as
Medical Doctors (MD), Doctors of Osteopathy (DO),
Chiropractors (DC), Nurse Practitioners (NP),
Physicians Assistants (PA), or Massage Therapists
(LMT)
• Other licensed or unlicensed providers marketing
themselves as natural care providers, holistic
healthcare providers or healers
• Health food store employees
• Essential oil sales representatives
• Someone who completed an online certificate
course
1:44:12 PM
MS. CONWAY advanced to slide 5, displaying a multi-colored US
map with the heading, "Regulation of Naturopathic Doctors in the
United States." She explained that 24 states regulated NDs while
10 states have active licensure initiatives. Texas and Wyoming
have active advocacy initiatives; there is growing interest in
the practice of naturopathy across the country.
1:44:59 PM
MS. CONWAY advanced to slide 6, displaying a multi-colored US
map with the heading, "Scope of Practice by State: Prescriptive
Authority." She pointed out that Alaska is among the 10 states
that do not allow NDs prescriptive authority. 12 states do give
NDs prescriptive authority and California gives limited
prescriptive authority. She noted that Dr. Clyde Jenson is
available to answer related questions.
1:45:42 PM
MS. CONWAY advanced to slide 7, displaying a multi-colored map
titled, "Scope of Practice by State: Controlled Substances." She
pointed out that six states allow NDs to prescribe controlled
substances. She clarified that SB 44 would not allow NDs to
prescribe controlled substances.
1:46:09 PM
MS. CONWAY advanced to slide 8:
[Original punctuation provided.]
SENATE BILL 44
• Modernizes statutes for Naturopaths
• Cleans up outdated language
• Imposes the same public health duties on
Naturopaths as other medical providers
• Updates scope of practice for Naturopaths that
includes limited prescriptive authority
• Allows minor office procedures
• NO MORE duplicative office visits
• Improved access to care for Alaskans
• More choice for patients
MS. CONWAY emphasized that NDs would most likely prescribe basic
medications as a last resort. This would be more convenient and
less costly for patients. She gave examples of minor office
procedures.
1:48:02 PM
MS. CONWAY stated that increasingly, people are seeking
alternative healthcare options that can help them understand why
they feel a certain way - without relying heavily on
prescription medications.
1:48:43 PM
SENATOR BISHOP asked for clarification that Senator Giessel had
worked in a facility with a ND and a medical doctor (MD) and
asked if this is a common practice.
1:49:10 PM
SENATOR GIESSEL replied that this is correct and explained that
it was an integrative healthcare facility, meaning that
practitioners of allopathic (conventional medicine) and
alternative medicine worked alongside one another in an
"alternative medicine" clinic. She shared that she visits a
clinic that is owned by a nurse practitioner who employs
naturopaths.
1:49:47 PM
SENATOR BISHOP asked for an example of what is considered
"limited prescriptive authority."
SENATOR GIESSEL explained that NDs may need to prescribe thyroid
hormones (a common medication for women over 40) or hormone
replacement therapy (HRT). Occasionally, they may need to
prescribe antibiotics (most often a last resort). She stated
that these were the main prescriptions she wrote for NDs while
working at the aforementioned clinic.
1:50:45 PM
SENATOR BISHOP shared his understanding that NDs would not be
able to write prescriptions for schedule class III drugs and
asked if this is correct.
SENATOR GIESSEL agreed that this is correct - NDs would not be
able to write prescriptions for controlled substances. She
explained that the ability to write prescriptions for controlled
substances is limited - even for conventional healthcare
providers - and briefly explained the requirements. She offered
to provide a handout describing the five categories of
controlled substances (e.g. oxycodone and certain sleeping
pills). She explained that medications on this list are commonly
addictive.
1:52:03 PM
TIMOTHY BIRDSALL, ND, Avante Medical Center, LLC, Anchorage,
Alaska gave a brief overview of his educational and work
experience. He explained that NDs have worked in Alaska for over
35 years and in the US for over 100. He described the
educational requirements and clinical hours needed to become an
ND and noted that there is an immense about of oversight by NDs,
MDs, and Doctors of Osteopathy (DO) during training. He stated
that ND training programs are subject to the same accreditation
and oversight as other medical training programs. He named
Bastyr University and the National University of Health Sciences
as the two oldest Naturopathic medical schools in the US. They
are accredited by the same agency that accredits the University
of Alaska. He noted that the naturopathic programs each have
additional accreditation through the Council on Naturopathic
Medical Education. Once students have graduated from an
accredited program, they sit for the national board exam, which
includes an exam on pharmacology. He stated that the education
received by ND is comparable to that of nurse practitioners, who
have broader prescriptive authority than what is proposed by SB
44.
1:55:08 PM
DR. BIRDSALL asserted that, with this level of training, NDs
have shown themselves to be safe and effective providers. SB 44
allows NDs to practice to the extent of their education,
experience, and training. He said that this education training
includes the use of minor office procedures and prescriptions
when appropriate. He stated that he would personally prescribe
less than 10 percent of the time. He gave an example of a
patient who needed an antibiotic for strep but he couldn't
prescribe due to restrictions on his ND license in Alaska. He
added that he had to refer this patient to a nurse practitioner
for the prescription and reiterated that his ND training is as
extensive as a nurse practitioner's. He said that being unable
to prescribe necessary medications results in treatment delays,
added costs, and some patients do not follow through to receive
the necessary care. He pointed out that Alaska has a shortage of
primary care providers that NDs can help to fill. He asserted
that NDs are safe primary care providers who are trained to
understand their scope of practice and will refer patients to
other providers when necessary. He shared a story of a patient
he recently referred to a specialist and emphasized his desire
for his patients to have the best care and the most positive
outcome, regardless of the therapies employed.
1:58:22 PM
DR. BIRDSALL discussed the safety of an ND scope of practice
that includes limited prescriptive authority. He referred to the
rate of disciplinary action and directed attention to a document
from the Federation of Naturopathic Medicine Regulatory
Authorities to gain perspective on the rates of disciplinary
action in all states that regulate NDs. The rate of disciplinary
action for NDs is one tenth of that for MDs and half of that for
DOs. He then turned his attention to malpractice insurance
claims against NDs nationwide, the rate of which is 0.0001
percent. He emphasized that this is a very low number and added
that this is reflected in the premiums, which are also low. He
pointed out that currently, NDs are not required to report
malpractice claims and added that SB 44 closes this reporting
loophole. He reiterated that NDs receive formal education and
training that is comparable to nurse practitioners and supports
independent prescribing rights. He stated that SB 44 is a
comprehensive rewrite that adds additional responsibilities and
expressed his support for these changes. He asserted that these
changes would allow NDs to practice as trained while ensuring
the safety of Alaskans and requested support.
2:01:15 PM
SENATOR BISHOP asked if NDs have the ability to do physicals for
Federal Aviation Administration (FAA) flight exams and
Commercial Driver's License (CDL) exams.
DR. BIRDSALL replied that he does not know the answer and
offered to find out. He shared his understanding that this is
not currently done by NDs and stated that he is not aware that
SB 44 would address this.
2:02:40 PM
CARRIE BALDWIN-SAYRE, ND, Associate Vice President, Advancement
and Community Engagement, National University of Natural
Medicine, Portland, Oregon, gave a brief work history. She
stated she can speak to the education and training that NDs
receive - and how this is overseen and regulated by national
accreditation organizations. She explained that all NDs attend
accredited naturopathic medical schools. The National University
of Natural Medicine has both a program accreditation (via the
Council on Naturopathic Medical Education (CNME)) and an
institutional accreditation (via the Northwest Commission on
Colleges and Universities (NWCCU))- both are overseen by the US
Department of Education. CNME sets the standard for the
naturopathic program, ensuring that graduates are well-trained
to provide excellent and safe patient care. NWCCU is the same
accreditor for the state's allopathic medical school (Oregon
Health Sciences University) and the University of Alaska. She
stated that the processes are rigorous and expressed pride that
NUNM meets the same high standards as these institutions.
2:04:32 PM
DR. BALDWIN-SAYRE discussed the content of Naturopathic Medical
training programs, which are four-year graduate training
programs. NUMN's program includes 5047 hours of total education,
including 1254 hours of direct student involvement in clinical
care. She detailed the admissions requirements, pointing out
that the prerequisite requirements are nearly identical to DO
and MD programs throughout the US. She emphasized that the 1254
clinical training hours are comparable to the requirements for
many other medical programs and exceed the 1000-hour requirement
for the two-year nurse practitioner program at OHSU. She pointed
out that, though they have less training than naturopathic
doctors, nurse practitioners have fully autonomous prescription
authority - including controlled substances. She added that
nurse practitioners do not have a post-graduate residency
requirement, yet they play a vital role in Alaska's healthcare
system.
2:05:36 PM
DR. BALDWIN-SAYRE explained that ND Education covers the
following areas of study:
Years 1-2
Biomedical Sciences and Diagnostic Training, courses
include:
• Anatomy
• Physiology
• Biochemistry
• Histology
• Pathology
• Microbiology
Diagnostic methods and procedures, courses include:
• Physical examination
• Laboratory diagnosis
• Diagnostic imaging
Years 3-4
Translating basic scientific knowledge into clinical
application, courses include:
• Cardiology
• Gastroenterology
• Gynecology
• Endocrinology
• Disease management & prevention
• Nutrition
• Lifestyle medicine
• Botanical medicine
• Pharmaceutical prescribing
• Minor surgical procedures
• And more
DR. BALDWIN-SAYRE emphasized that, in years 3-4, students
receive education specific to prescribing pharmaceuticals
throughout 15 courses. This is in addition to the prescribing
they do in a primary care clinical setting during their
internship. They receive extensive didactic and hands-on
clinical training in dermatologic and minor surgical procedures
during their final two years. This includes suturing techniques,
biopsies, cryotherapy, and laceration repair. Students receive
hands-on training in a variety of clinical settings, with
increasing levels of responsibility as they progress. They must
pass three hands-on clinical examinations to graduate. The final
exam occurs after a full year of their own supervised patient
load in a state credentialed, primary care medical home -
serving mostly Medicaid patients with complicated medical needs.
2:07:15 PM
DR. BALDWIN-SAYRE said that following the completion of their
education, all NDs must pass two board examinations. She
asserted that this medical training ensures that NDs are
competent, safe, effective healthcare providers and are prepared
to care for patients. She stated that allowing NDs to perform
minor surgeries and giving them prescriptive authority for non-
schedule C drugs is a very low risk addition to their current
scope of practice. She added that this is well within the
confines of their training.
2:08:29 PM
CLYDE JENSEN, PhD, representing self, Saint George, Utah, gave a
brief overview of his work history in pharmacology and teaching
MDs, DOs, NDs, among others. As a result, he is in a position to
compare the pharmacology education received by these
professions. He added that he is currently a professor of
pharmacology at an osteopathic medical school with campuses in
Colorado, Utah, and Montana. He stated that when he has taught
and designed pharmacology courses for naturopathic medical
students, he has ensured that the number of pharmacology contact
hours - along with the content of the hours - is identical to
what is taught in MD and DO schools. He has done this in order
to ensure that naturopathic physician graduates are prepared to
prescribe in jurisdictions where they have pharmaceutical
prescription authority. He explained that this also ensures that
NDs can collaborate with their MD and DO colleagues to provide
patient care. In addition, teaching NDs to the same level as MDs
and DOs ensures that naturopathic medical graduates are aware of
important drug/herb and drug/nutrient interactions. He stated
that he testifies at hearings like this one because
professionals need to be allowed to work to the level that they
have been trained.
2:13:37 PM
ROB DOWNEY, MD, Founder, Seaworthy Functional Medicine, Homer,
Alaska, gave a brief education and work history and stated that
the education he received is similar to what is taught at
naturopathic universities. He stated that he has worked in both
Montana and Alaska and is a strong advocate for SB 44. He shared
an account of an ND who treated a patient with an auto immune
difficulties that had not responded to conventional medical
treatment. The patient suffered from psoriatic arthritis and
responded well to naturopathic treatment. He shared that this
inspired him to seek additional training at the Institute for
Functional Medicine. He continues to work alongside NDs and he
expressed great respect for these doctors. He expressed his
belief that NDs are well-trained and perfectly suited to provide
much needed primary care to patients in Alaska. He said that the
NDs he works with are very well trained in the use of
pharmacologic agents. He said that he is not surprised by
testimony that the curriculum used for ND education is the same
as that of MDs and DOs. He stated that concerns related to the
ND scope of practice proposed by SB 44 are unfounded and added
that no evidence supports claims of harm. He pointed out that
many states have an expanded scope of practice for NDs - and
there is a low incidence of malpractice allegations.
2:17:13 PM
DR. DOWNEY stated that nurse practitioners do a wonderful job
prescribing for Alaskans and pointed out that NDs receive post
graduate education that that is equal to - or that exceeds -
that of nurse practitioners. He opined that it is a dark irony
that naturopathic physicians are not prescribing in Alaska
already and added that this is an understatement. He commented
that, while NDs tend to use medications as a last resort, they
are very well-trained to know when a medication is necessary -
and offered examples. However, patients must seek secondary
appointments in order to receive treatment - which can have dire
consequences. He explained that currently, there can be a lag of
many days between appointments. He referred to the chain of
treatment and stated that more links mean more delay - and more
points for the chain to break. In this scenario, many suffer. He
noted that NDs are trained to work with patients to determine
when lifestyle changes can mitigate underlying health problems -
and if ongoing medication is necessary. This is no different
from a good MD or nurse practitioner would provide. He compared
restricting NDs to restricting mechanics or tax accountants and
recommended that common sense be used when determining the
appropriate regulations. He stated that Alaska's primary care
shortage limits access to affordable care and asserted that NDs
who have graduated from accredited programs, passed post-
graduate exams, and passed the new exam required by SB 44 should
be able to prescribe the medications allowed by this
legislation.
2:19:57 PM
CHRISTINE SAGAN, NP, Owner, Vitae Integrative Medical Center,
Anchorage, Alaska, stated that her clinic serves patients all
over the state and has a large demand for primary care
providers. The clinic's ND has openings to see patients but not
the ability to prescribe, which precludes patients from
establishing care. This delays access to primary care - the
demand for which is significantly higher post Covid-19. She
stated that nurse practitioners and naturopaths are filling this
role. She added that access to healthcare is an urgent issue in
Alaska and pointed out that many healthcare providers retired
during the Covid-19 pandemic. Patients may wait up to a year for
an office visit and some clinics are not accepting new patients.
Primary care providers see an average of 2100 visits per year
and NDs could take up 1000 of these visits.
MS. SAGAN stated that she has worked alongside NDs for the
entirety of her 17 years in the field and added that her
experience working with NDs puts her in a position to speak to
their competency and training. She explained that this includes
a knowledge of pharmaceutical medications and said that she
often consults her ND colleagues for their expertise in this
area. She has attended naturopathic continuing education courses
- including pharmacology courses - and learned a great deal
which she was then able to apply to her medical practice. She
said that it is common for her ND colleagues to request that she
see one of their patients in order to prescribe medications. She
explained that this requires her to duplicate exams - only to
prescribe the same medication that her colleague would have
prescribed. She asserted that seeing multiple providers is not
in the patient's best interest, as it wastes resources,
finances, and time. She pointed out that nurse practitioners
faced this issue 40 years ago when they updated their scope of
practice to include prescriptive authority. She explained that
some argued against this change, claiming that nurse
practitioner education was inadequate because it does not
include a post-graduate residency. However, the legislature
decided to extend their scope of practice in spite of this,
which has allowed nurse practitioners to serve a vital role in
Alaska's healthcare system. She asserted that this work is done
safely, in spite of the concerns raised previously. She pointed
out that NDs receive extensive training; however some argue that
they are not adequately trained since, like nurse practitioners,
they are not required to complete a residency. She emphasized
that currently, NDs - who have a four-year doctorate degree -
must turn to nurse practitioners to complete a component of
their patient's care and opined that this situation defies
logic. She urged support of SB 44 to extend NDs scope of
practice.
2:24:32 PM
DR. NATALIE WIGGINS, ND, Vitae Integrative Medical Center,
Anchorage, Alaska, urged support of the SB 44 for the benefit of
Alaskans. She stated that the changes proposed by this
legislation mirror what has been done in many other states for
years. She shared a brief work history in Arizona, which
included prescriptive authority, superficial wound repair, and
biopsies; while there she worked alongside an MD and supervised
students. She gave an overview of her education, which gave her
the knowledge to perform these tasks. She said that when she
came to Alaska, she had to give up the ability to work to the
extent of her knowledge - a disservice to herself and to
Alaskans. She pointed out that she is entrusted to perform the
same tasks as a primary care provider and gave examples.
However, when the treatment protocol includes prescribing
medications, she is must refer them to other providers. She
shared examples from her practice when medications were needed.
She pointed to her experience in Arizona as proof that the
expanded scope of practice proposed by SB 44 is both safe and
essential for comprehensive patient care.
2:29:05 PM
CHAIR BJORKMAN referred to page 6 of SB 44, which describes the
proposed scope of practice - including minor surgery. He asked
what types of surgery are considered minor.
DR. WIGGINS replied that this would include stitches,
superficial wound repair, and superficial lesions.
SENATOR BJORKMAN said that he has heard reports of NDs
performing liposuctions in Arizona and asked if Dr. Wiggins is
familiar with this.
DR. WIGGINS stated she had also heard this report and emphasized
that she does not consider that to be a minor office procedure.
She surmised that the ND had received additional training. She
added that liposuction is not routinely included in ND training
and would therefore would not be included in the expanded scope
of practice.
2:31:44 PM
CHAIR BJORKMAN held SB 44 in committee.
#
2:31:50 PM
At ease
SB 225-OCCUPATIONAL LICENSING FEES
2:33:14 PM
CHAIR BJORKMAN reconvened the meeting and announced the
consideration of SENATE BILL NO. 225, "An Act relating to
occupational licensing fees; and providing for an effective
date."
2:33:54 PM
SYLVAN ROBB, Director, Corporations, Business & Professional
Licensing, Department of Commerce, Community and Economic
Development (DCCED), Juneau, Alaska, introduced SB 225 on behalf
of the administration. She began a presentation and advanced to
slide 2:
[Original punctuation provided.]
What Does SB 225 Do?
• Removes investigation, legal, and hearing costs
from the "regulatory costs" covered by
professional license fees as required under AS
08.01.065.
• Shifts funding for investigations and hearings
from professional licensing fees (1156) to
corporations' fees (1005) so the division remains
self-sufficient.
MS. ROBB explained that the division collects more from
corporate filings than is needed to fund the program. This
change does not require an increase in corporate fees (the
division currently diverts lapses funds to the general fund from
these fees).
2:35:12 PM
CHAIR BJORKMAN referred to SB 203, which would increase fees. He
asked what those fees are for and where they would go.
MS. ROBB replied that this is another bill by the Governor that
proposes to return business license fees to 2008 levels. She
explained that licensing fees were reduced in 2009.
CHAIR BJORKMAN asked what account these fees go in to.
MS. ROBB replied that the collections come in as DGF collections
and excess funds flow into the general fund. She noted that
these are the funds referred to in slide 2. She explained that
collectively - between corporations and business licensing - the
division lapses over $8 million to the general fund in a typical
year. SB 225 proposes that some of these funds be used to help
pay for investigations for professional licensing.
2:36:36 PM
MS. ROBB advanced to slide 3 and stated the important language
regarding the calculation of professional licensing fees on the
slide is bold print:
[Original punctuation provided.]
AS 08.01.065(a) & (c) Currently
(a) Except for business licenses, the department shall
adopt regulations that establish the amount and manner
of payment of application fees, examination fees,
license fees, registration fees, permit fees,
investigation fees, and all other fees as appropriate
for the occupations covered by this chapter.
(c) Except as provided in (f) (k) of this section,
the department shall establish fee levels under (a) of
this section so that the total amount of fees
collected for an occupation approximately equals the
actual regulatory costs for the occupation. The
department shall annually review each fee level to
determine whether the regulatory costs of each
occupation are approximately equal to fee collections
related to that occupation. If the review indicates
that an occupation's fee collections and regulatory
costs are not approximately equal, the department
shall calculate fee adjustments and adopt regulations
under (a) of this section to implement the
adjustments. In January of each year, the department
shall report on all fee levels and revisions for the
previous year under this subsection to the office of
management and budget. If a board regulates an
occupation covered by this chapter, the department
shall consider the board's recommendations concerning
the occupation's fee levels and regulatory costs
before revising fee schedules to comply with this
subsection?.
MS. ROBB said that "investigation fees" includes the cost of
certified investigators as well as legal costs for the
Department of Law and hearing costs at the Office of
Administrative Hearings, superior court, and supreme court. She
explained that this will impact licensing fees for the
associated professions in years with a high number of complaints
or complex cases. SB 225 is an attempt to mitigate this.
2:37:27 PM
SENATOR GRAY-JACKSON asked for clarification that the lapsed
money would cover the fees.
MS. ROBB returned to slide 3 and replied that currently, the
professional licensing fees must cover the costs of regulating
the program. She explained that the money that is lapsed to the
general fund comes from dues paid for business license fees and
corporate filing fees.
2:38:15 PM
SENATOR GRAY-JACKSON said that SB 225 removes investigation,
legal, and hearing cost and clarified that these are the costs
that her question is referring to. She asked if the money that
lapses to the general fund would cover these costs.
MS. ROBB replied yes. She added that it does not take all the
funds that currently lapse to the general fund as it would only
require $4.7 million.
SENATOR GRAY-JACKSON asked what would happen in the event that
the division does not have enough lapsed funds to cover the
costs.
MS. ROBB replied that the division would need to seek an
additional source of funding. She added that the number of
corporate filings and business licenses purchased have increased
consistently over the years and this growth is expected to
continue.
2:39:37 PM
MS. ROBB advanced to slide 4:
[Original punctuation provided.]
Primary Reasons for SB 225
• Currently volatile license fee rates would
stabilize, as investigations, legal, and hearing
costs are the most variable element of the fee
setting equation.
• Licensing fees would be reduced for many
programs, helping in the effort to attract
professionals to Alaska.
• This would be fairer to Alaska's professional
licensees who comply with the laws regulating
their profession as law-abiding professionals
would no longer bear the cost of investigations
of licensees who have potentially violated
licensing laws and/or on individuals practicing
without a license.
• Remove a potential disincentive to report members
of their profession.
MS. ROBB explained that investigations are the most volatile
aspect of the equation for setting licensing fees as there is no
way to determine what the costs will be. This can cause large
swings in licensing fees from year to year. She reiterated that
licensing fees are based on the costs to run the program and
removing investigatory and hearing costs from this equation
would reduce program costs and therefore reduce licensing fees.
She clarified that this would not be the same across the board
but would depend on how many investigations a particular
profession has seen - and how complex the investigations are.
However, no profession would be negatively impacted by the
change. Lower licensing fees would also help to recruit
professionals to work in much needed areas like veterinary
medicine and nursing (both of which have high licensing fees
relative to other states).
2:41:19 PM
SENATOR DUNBAR shared his previous understanding that SB 203 and
SB 225 impacted the same kinds of fees. He asked for
clarification that SB 203 impacts a flat fee while the fees in
SB 225 are variable. He asked for more information on the fees
and how they are calculated.
2:42:02 PM
MS. ROBB explained the difference between corporation, business
licensing, and professional licensing fees. She said that
corporation fees are set in regulation - there are 64 different
corporate fees depending on the type of filing and the type f
corporation. These fees are not impacted by SB 225. However, SB
225 proposes to use the funds collected to offset the costs of
investigations for professional licensing. She clarified that
[SB 203] applies to business licensing, the fees for which are
set in statute. She explained that "professional licensing"
refers to 45 programs, including doctors, dentists, naturopaths,
midwives, construction contractors, etc. Professional licensing
fees must cover the cost of regulating the program. SB 225
proposes to remove investigatory fees from the calculations of
the cost of regulating the program.
2:43:20 PM
SENATOR DUNBAR commented that transferring less money to the
general fund results in a large fiscal note for the state as a
whole. He pointed out that SB 203 raises more money by
increasing licensing fees. He commented that this is causing a
lot of volatility and asked if there is a way to stabilize at a
slightly higher number so that the cost of SB 225 is roughly
equivalent to the net raised in SB 203.
MS. ROBB replied she understands the question and surmised that
the cost of investigations could potentially be parsed out
further. She said that SB 225 only covers part of investigatory
costs and acknowledged that the legislature could agree to cover
a set amount from corporation fees to offset investigations. She
added that the rest of the investigatory costs would remain a
part of the fee setting equation. She commented that there are a
number of ways to achieve what he is suggesting.
SENATOR DUNBAR clarified that he is wondering if it would be
possible to reduce volatility by removing the investigatory fees
from the equation and setting the licensing fees a bit higher
(while still lowering them from their current amount) in order
to cause less fiscal harm to the state.
2:45:27 PM
MS. ROBB expressed her understanding. She stated that part of
the argument for SB 225 is that investigations into professional
licensees and unlicensed practice is a public safety issue. She
explained that, as currently structured, the onus to pay for
this falls on licensees. She emphasized that these individuals
are licensed and following the rules are paying for those who do
not. She stated that professional licenses are intended to
mitigate harm that can be done by those who are not trained in a
particular profession.
SENATOR DUNBAR expressed his agreement. He commented that bad
actors in these professions are imposing the costs on the state.
2:46:27 PM
MS. ROBB returned to speaking to slide 4 and reiterated that
those following the rules are paying for the "bad apples." In
addition, an understanding of how the fees are set could act as
a disincentive for someone to report a member of their
profession. SB 225 would remove this potential disincentive.
2:47:09 PM
MS. ROBB advanced to slide 5:
[Original punctuation provided.]
Example of Substantial Fee Increases in Past Years
• Certified Direct-Entry Midwife Certificate Fees:
• In FY2017 initial and renewal application
fee increased from $1,750 to $3,800.
• That was after an increase from $1,450 to
$1,750 in 2016.
• Fees have since been reduced to $2,800.
• Midwife Apprentices in 2015:
• Initial and Biennial Renewal Certification
Fees increased from $125 to $825.
• Initial and Biennial Renewal Certification
Fees increased from $825 to $1,275.
• Fees have since been reduced to $550.
MS. ROBB gave another example of a dentist who is currently
involved in an Alaska Supreme Court case for performing a
procedure while on a hoverboard. She said all other licensed
dentists are paying for the ongoing investigation and court
costs.
2:48:40 PM
MS. ROBB advanced to slide 6, displaying FY 2023 investigative
stats. She explained that, in a typical year, anywhere from
1,200 to 1,600 investigations may be conducted by the division.
2:49:03 PM
MS. ROBB advanced to slide 7, displaying the top complaints
received by the division. She noted that the second most common
complaint is individuals operating without a license and
reiterated that those who are operating lawfully (i.e. licensed
professionals) are paying for those who choose to operate
without a license. The top complaints are listed as follows:
• Continuing Education Violations (303)
• Unlicensed Practice or Activity (178)
• License Application Reviews (146)
• Violation of Licensing Regulation (144)
• Unprofessional Conduct (77)
• Falsified Application (53)
• Standard of Care (28)
2:49:27 PM
SENATOR BISHOP asked if the department interacts with every
licensed business once a year or once every two years.
MS. ROBB replied that licenses are good for two years and all
licenses for a particular profession expire on the same day.
SENATOR BISHOP asked how the department finds a continuing
education violation.
MS. ROBB answered that when continuing education is required for
license renewal, applicants attest to meeting these requirements
on their application. The division selects a sample of
applicants to audit and these individuals are then required to
submit documentation showing that they have completed their
continuing education requirements.
2:50:41 PM
SENATOR BISHOP expressed his understanding that the division
does not check every business but is doing a random sample.
MS. ROBB replied that this is correct. She stated that the
division has 109,000 professional licenses and would require a
lot more staff to check each licensee.
SENATOR BISHOP agreed and compared this to the Occupational
Safety and Health Administration (OSHA), where the large number
of businesses makes it impossible to investigate each one for
possible violations. He surmised that complaints come in and are
then investigated.
2:51:21 PM
MS. ROBB agreed that a majority of investigations are complaint
driven, though they do conduct inspections for some professions.
2:51:37 PM
SENATOR GRAY-JACKSON said that she had the same question as
Senator Bishop.
2:51:47 PM
SENATOR DUNBAR referred to the current license renewal schedule
in which every person in a particular field is renewed on the
same day. He surmised that this would cause a variety of
challenges in certain professions (such as nursing). He asked if
there has been discussion of a rolling application process.
MS. ROBB expressed her understanding and explained that
licensees are required to comply with regulations, which can
frequently change. She stated that without a firm date to
determine compliance, it would be difficult to track expiration
dates. She offered an example of nursing, which has 32,000
licensees. Tracking which had expired - and then notifying those
who need to renew would create a great administrative burden -
especially adding the extra burden of cross-referencing
individual expiration dates with regulation changes. She added
that the division needs to notify licensees in a timely fashion
when renewal is required. She pointed out that the 45 licensing
programs are spread out over the 2-year period in order to
minimize the burden on the division.
2:53:38 PM
SENATOR DUNBAR expressed hope that the technology to automate
this process would someday be available. He commented that if
all nursing licenses expire on January 1 - and someone becomes
licensed on December 30 - this means they would have to complete
the entire process again two day later.
MS. ROBB replied that the renewal process for professional
licenses can be done online, although some things require hands
on consideration or further viewing in order to renew. She added
that those who receive their licenses within three months of the
expiration date are grandfathered in and do not owe a fee for
the subsequent two-year period.
2:54:53 PM
MS. ROBB advanced to slide 8, displaying the top ten programs
that received complaints and number of licensees per program in
FY 2023:
Top 10 Programs Receiving Complaints:
• Board of Nursing (369 complaints; 32,169
licensees)
• State Medical Board (164 complaints; 9,221
licensees)
• Board of Pharmacy (138 complaints; 6,428
licensees)
• Big Game Commercial Services Board (70
complaints; 1,521 licensees
• Board of Barbers and Hairdressers (67 complaints;
7,086 licensees)
• Real Estate Commission (59 complaints; 4,335
licensees)
• Board of Massage Therapists (54 complaints; 1,232
licensees)
• Construction Contractors (43 complaints; 10,290
licensees)
• Board of Social Work Examiners (43 complaints;
1,351 licensees)
• Business Licensing (38 complaints; 99,599
licensees)
• Board of Dental Examiners (38 complaints; 3,355
licensees)
2:55:21 PM
SENATOR BISHOP asked for an example of a Construction
Contractors complaint.
MS. ROBB replied that many of the complaints received about
construction contractors are related to the maintenance of
required bond and insurance. Other complaints are related to
unlicensed practice. She added that the division sometimes
receives complaints that are outside of the division's
jurisdiction (e.g. someone may be unhappy with the way their
construction project looks when completed).
2:56:11 PM
MS. ROBB advanced to slide 9 and discussed the top 10
professions receiving complaints in FY 2023:
Top 10 Professions Receiving Complaints
• Registered Nurse (252)
• Physician (142)
• Massage Therapist (54)
• Certified Nurse Aide (53)
• Pharmacy (43)
• Real Estate Salesperson (42)
• Wholesale Drug Distributer (41)
• Dentist (38)
• Clinical Social Worker (37)
• Advanced Nurse Practitioner (37)
2:56:41 PM
CHAIR BJORKMAN expressed curiosity about the possibility of
adjusting the statute to allow licensing boards to maintain a
larger fund balance in their board account to act as a shock
absorber for large spikes in investigatory costs. He shared his
understanding that boards are required to draw their fund
balance (if they have one) down to nearly zero. He questioned
whether it would be possible to allow these boards to maintain a
larger fund balance to level out their fees.
MS. ROBB stated that this is an excellent idea and explained
that there is carry forward language for all professional
licensing fees that are collected. She added that the division
tries to maintain one year's worth of expenses for the program
in order to provide some amount of shock absorption. The
division tries to keep fees from changing excessively.
Generally, if a program has accrued a significant amount of
surplus, the division is conservative on the number of potential
license renewals and new applications while being generous with
what the potential costs might be. She acknowledged that this
carry-forward ability has allowed the division to smooth the fee
changes somewhat.
2:58:46 PM
At ease
3:00:02 PM
CHAIR BJORKMAN reconvened the meeting.
3:00:10 PM
CHAIR BJORKMAN held SB 225 in committee.
SB 237-TAX CREDIT CHILD CARE/UTILITY/HOUSE/FOOD
3:00:16 PM
CHAIR BJORKMAN announced the consideration of SENATE BILL NO.
237, "An Act establishing a corporate income tax credit for
certain expenditures on child care services, utility rates,
residential housing, and food security and availability; and
providing for an effective date."
3:00:41 PM
FADIL LIMANI, Deputy Commissioner, Department of Revenue,
Juneau, Alaska, introduced SB 237 on behalf of the
administration and explained that this legislation is also
called the Alaska Affordability Act (AAA). He emphasized that
this is a top priority for the Governor, who wants to ensure
families continue to call Alaska home while attracting more
people and families to the state.
3:01:37 PM
MR. LIMANI advanced to slide 2 of the SB 237 Bill Overview:
[Original punctuation provided.]
SB 237 Bill Overview
This proposed legislation focuses on four key areas:
• Childcare
• Housing
• Energy
• Food Security
The idea behind this legislation is that it creates a
tax incentive for Corporations and businesses to
offset their corporate income tax liability for
qualified expenditures in those key areas.
The Department of Revenue will define the qualified
expenditures through regulations.
Further, the tax credits are limited to 50 percent of
qualified expenditures and may not exceed 50 percent
of the Corporation's tax liability for any year.
MR. LIMANI pointed out that the state does not have broad based
taxes; therefore, the corporate income tax is one of the few
levers available to incentivize businesses to develop
communities and provide economic development.
3:02:40 PM
MR. LIMANI advanced to slide 3, showing FY 2023 general fund
(GF) revenue from corporate income tax. He noted that the total
is approximately $436 million and pointed out that 70 percent of
this is tied to oil and gas. He stated that the $436 million
does not include the $7.6 million that is deposited into the
Constitutional Budget Reserve Fund (CBRF).
3:03:14 PM
SENATOR GRAY-JACKSON referred to the chart on slide 3 and asked
why tourism is a negative amount.
MR. LIMANI answered that this is due to the carryover from the
Coronavirus Aid, Relief, and Economic Security Act (CARES Act)
and deferred to Acting Deputy Director Mike Williams.
3:03:43 PM
MICHAEL WILLIAMS, Acting Deputy Director, Tax Division,
Department of Revenue, Anchorage, Alaska, explained that under
the federal CARES Act, corporations that had net losses during
the years of 2018, 2019, and 2020 were allowed - under federal
statute - to carry back those losses for up to five years and
claim refunds. There was a process for filing those claims - due
to the timing of filing claims and paying out refunds, some of
this refund process carried over into FY 2023. The roughly $18
million in negative revenue is attributed to those refund
claims.
3:04:37 PM
MR. LIMANI advanced to slide 4:
[Original punctuation provided.]
SB 237 Estimated Revenue Impact
At this time, we don't have clear visibility on the
revenue impact as we can't predict taxpayer behavior
and how much they may contribute to each of these
areas; however, we have run an analysis and determined
the maximum revenue impact to the State on Corporate
Income Tax Revenue would range from ($238) million in
FY25 to ($267) million in FY30.
MR. LIMANI explained that the chart on slide 4 looks at the
maximum impact on both non-petroleum and petroleum corporate
income tax revenue for FY 2025 ($(87.5) million non-petroleum,
$(150.1) million petroleum) through FY 2030 ($(126.3) million
for non-petroleum, $(140.5) million petroleum).
3:05:39 PM
MR. LIMANI advanced to slide 5:
[Original punctuation provided.]
SB 237 Implementation Cost
The department will need to make minor changes to its
Tax Revenue Management System (TRMS) and tax forms to
implement this bill. The Tax Division will use
existing resources to absorb the costs to update tax
forms, TRMS, and other miscellaneous implementation
costs.
3:06:21 PM
MR. WILLIAMS advanced to slide 6 and discussed the sectional
analysis for SB 237:
[Original punctuation provided.]
SB 237 Sectional Analysis
Section 1: Adds a new section at 43.20.022 which
creates a new tax creditthe Alaska affordability tax
credit. The amount of the credit is up to 50 percent
of a corporation's tax liability. The credit is 50
percent of qualifying expenditures for employer-
provided childcare, residential heating and
electricity affordability, housing affordability, and
food affordability. The bill authorizes the department
to adopt regulations that define qualifying
expenditures.
A contribution claimed as an Alaska affordability tax
credit could not also be the basis for a different tax
credit or be allowed as a federal tax deduction, which
is the basis for computing the Alaska corporate income
tax.
The credit is nontransferable and cannot be carried
forward or backwards.
Section 2: The credit takes effect January 1, 2025.
3:07:43 PM
SENATOR DUNBAR presented an example of a large corporation that
used the tax credit to set up a childcare facility for
employees. They offset overhead costs using the tax credit and
charge a fee to their employees (a subsidized rate). He asked
how this would interact with the tax credit and if the
corporation would be prohibited from charging a rate - or if
there would be any restrictions on the rate charged to
employees. He questioned whether the corporation could
potentially make money off of the daycare or if it would be
revenue neutral.
3:09:07 PM
MR. WILLIAMS said that this is a complex question, some of which
would require follow-up. He explained that under Section 129 of
the Internal Revenue Code an employer can provide a certain
amount of childcare to employees before it is considered
"compensation" to the employee. Likewise, the employee can make
elected, tax-free deferrals for childcare after a certain amount
(typically $5,000) of provided childcare for employer or
employee. He stated that anything beyond this could be
considered compensation to the employee. If an employer is
charging the employee for childcare, up to $5,000 could be
excluded but anything beyond this amount would be considered
taxable. He stated that there is no prohibition on how much an
employer can charge an employee for the daycare (other than
market factors). He opined that charging above market prices
would not benefit employee retention.
3:10:48 PM
SENATOR DUNBAR asked - if the employer is free to continue
charging for the daycare while taking advantage of the tax - how
50 percent is the "right number". He surmised that the intention
is to tip the daycare into affordability and questioned why not
use 20 or 30 percent.
MR. WILLIAMS stated that this would be a policy call and added
that he does not know what would incentivize corporations to
provide this service.
3:11:56 PM
MR. LIMANI stated that childcare is a critical need across the
state, particularly since emerging from the Covid-19 pandemic.
Parents returning to the workforce are facing difficulty finding
affordable childcare and often choose to stay home, causing a
reduction in the workforce in some areas. He explained that 50
percent was chosen to incentivize corporations and provide
affordable childcare for employees.
3:13:01 PM
SENATOR DUNBAR stated that, while he understands this, over $200
million is a lot. He pointed out that the Governor vetoed $7.5
million out of Head Start, which functions as daycare for many
low-income families. SB 237 would benefit middle-class and upper
middle-class families. He acknowledged that childcare support is
needed and suggested that adjusting the fiscal note to $150
million would still tip childcare into affordability. The
remaining $50 million could be used to expand head start
programs. He opined that, without additional data, 50 percent
appears to be an arbitrary number. He requested additional data
utilizing different percentages and information from other
states that have implemented something similar.
3:14:20 PM
MR. LIMANI stated that from that perspective - and considering
the education component, where there are contributions - the
maximum contribution is not reached. He reiterated that the
intention of SB 237 is to make it worthwhile for corporations to
do offer these services. He stated that even at 50 percent, it
is not known whether businesses would entertain the necessary
infrastructure to consider this. He indicated that this may be
even more difficult to ascertain for energy and housing, which
are much more complex and costly than childcare.
3:15:38 PM
CHAIR BJORKMAN held SB 237 in committee.
3:16:22 PM
There being no further business to come before the committee,
Chair Bjorkman adjourned the Senate Labor and Commerce Standing
Committee meeting at 3:16 p.m.