HB 49-EXTEND BOARD OF DIRECT-ENTRY MIDWIVES  1:31:59 PM CHAIR COSTELLO announced the consideration of HB 49. She stated that the intent is to hear from the sponsor, take questions and public testimony, and hold the bill for further consideration. [CSHB 49(FIN) was before the committee.] 1:32:19 PM CRYSTAL KOENEMAN, Staff, Representative Sam Kito, Alaska State Legislature, explained that HB 49 extends the Board of Direct- Entry Midwives for six years, to 2023. Legislative Audit recommended a four-year sunset extension and the House Finance Committee recommended a six-year sunset. The sponsor is comfortable with the finance recommendation with the understanding that the board's deficit will be paid off. Also, extending the audit the additional two years will reduce costs to the state. 1:33:28 PM KRIS CURTIS, Legislative Auditor, Division of Legislative Audit, Legislative Agencies and Offices, stated that the division conducted a sunset audit of the Board of Direct-Entry Midwives to determine whether it is serving the public interest and should be extended. The last sunset audit of this board was conducted in 2014. At that time the division found that the investigative staff of the Division of Corporations, Business and Professional Licensing (DCBPL) was not actively pursuing investigations. This posed a public safety risk and the board was given a two-year extension. The 2016 audit found that the board was serving the public interest and was effectively licensing and regulating direct-entry midwives. A four-year extension was recommended. She said Legislative Audit made three recommendations in the last audit. Recommendation 1: The Division of Corporations, Business and Professional Licensing, in consultation with the board, should increase licensing fees to address the operating deficit. Ms. Curtis noted that in 2014 the deficit was about $115,000 and in 2016 the deficit had grown to just over $183,000. Fees were increased during this time but were insufficient to cover the board's operating costs. Recommendation 2: The director of the Division of Corporations, Business and Professional Licensing should take steps to ensure that license records are accurate. Ms. Curtis explained that audit test work found two errors. The wrong license was listed as on probation in the online database, and a consent agreement that the board had approved had the wrong year listed. Recommendation 3: The legislature should consider alternate forms of regulating the midwifery profession. She said this is an unusual recommendation that is made in light of the rising deficit and the small number of licensees. To address the deficit DCBPL management plans to increase licensing fees significantly. By 2020 fees are expected to be about $4,000 for direct-entry midwives and about $2,000 for apprentice midwives. Legislative Audit believes this fee structure poses a barrier to entry into the profession and could result in a lower number of midwives available to the public. 1:36:51 PM CHAIR COSTELLO asked if this was the first time Legislative Audit the legislature look at alternate forms of licensing a profession. MS. CURTIS said they have made that recommendation in the past and have also recommended terminating due to a large deficit. She directed attention to the Department of Commerce, Community and Economic Development (DCCED) response on page 21 of the audit. DCCED concurred with the first two recommendations and had no position on the third recommendation but did acknowledge that merging the board with a similar profession would improve its fiscal situation. The board's response is on page 23. They concur with recommendations 1 and 2, but strongly disagree with recommendation 3. They point out that midwifery is a unique profession and other boards would have difficulty regulating it. The suggestion to combine with the Board of Nursing or the Physician's Board would be problematic because those boards are in direct competition with the CDM profession. They fear being regulated out of practice and strongly believe that neither of these boards would want midwives to have any role in regulating their profession. 1:37:31 PM SENATOR HUGHES joined the committee. 1:38:38 PM CHAIR COSTELLO said she understands that similar suggestions have not been successful. 1:38:59 PM SENATOR STEVENS joined the committee. CHAIR COSTELLO asked if it is unusual for a board to carry a deficit for a decade, as this board has. MS. CURTIS said she can't confirm that this board has been in deficit for a decade, but prior audits indicate that licensing fees have been a consistent problem. The board has also experienced investigative costs. CHAIR COSTELLO asked Ms. Chambers to comment on the audit and anything else the committee should know. 1:40:47 PM SARA CHAMBERS, Deputy Director, Division of Corporations, Businesses and Professional Licensing, Department of Commerce, Community and Economic Development (DCCED), Juneau, said the division concurred with the first two recommendations and has been working with the board to eliminate the deficit. Statute requires all licensing programs to cover their expenses, including investigations of unlicensed activity. This is a very sensitive public health profession and their investigative and legal costs are quite high relative to the number of licensees. Licensing fees have been increased to about $3,800 to cover costs going forward and to eliminate the debt. CHAIR COSTELLO asked what the licensing fees are for nurses, physicians and chiropractors. MS. CHAMBERS said a physician's license is $300 a nurse's license is $165, and a chiropractor's license is $450. The fees generally reflect the number of people who support the overhead and costs. Physicians and nurses have large boards whereas the chiropractor board is smaller. SENATOR GARDNER commented that if the board objects to being merged with either the Board of Nursing or the State Medical Board, it is deciding that its membership will pay the high fees. MS. CHAMBERS acknowledged the comment. SENATOR HUGHES asked if there had been any conversations with either the Board of Nursing or the State Medical Board. She surmised that those boards wouldn't support the merge. MS. CHAMBERS said there have been no formal conversations but anecdotally the top concern is how the fees would be managed if the program is bringing in a deficit. She added that it isn't unprecedented for multiple professions to be housed under one board. 1:45:52 PM SENATOR MEYER joined the committee. SENATOR GARDNER asked if the committee will hear from members of the board. CHAIR COSTELLO said yes. 1:46:22 PM CHAIR COSTELLO opened public testimony on HB 49. 1:46:45 PM JOHANNA CROSSEH, representing herself, said she is a direct- entry midwife in Juneau who is testifying in support of HB 49. She stated, "We like our board so much that we're willing to pay the $3,800 licensing fee in an effort to get us out of this debt situation we've gotten ourselves into." CHAIR COSTELLO asked her to comment further on the board's willingness to address the deficit within the current membership. MS. CROSSEH maintained that she and other midwives are willing to pay the fees because they understand how unique their profession is. Anecdotal reports from nurses and doctors indicate a lack of support for merging with a board that is operating in a deficit, she said. CHAIR COSTELLO asked the cost of a home birth. MS. CROSSEH said most midwives in Juneau charge $3,500 and Medicaid pays about $1,200 for the same home birth. CHAIR COSTELLO asked what a hospital birth costs. MS. CROSSEH said she didn't have exact figures, but the midwife option certainly saves the state money. SENATOR GARDNER asked if there is an accredited program for midwives in Alaska. MS. CROSSEH said nothing is offered in-state but accredited distance programs are available. The birth center where she works in Juneau offers the internship portion of the accredited training. Many birth centers and private midwives in Anchorage also offer apprenticeships. 1:50:09 PM MADI NOLAN GRIMES said she is a direct-entry midwife and the director of a local birth center in Juneau who is speaking in support of HB 49. She echoed Ms. Crosseh's comments that midwives as a profession acknowledge that they are willing to pay down their debt and will continue to pay the elevated fees. SENATOR GARDNER asked if the $3,800 fee is a barrier to entry for starting midwives. MS. NOLAN GRIMES said the hope is that the licensing fees will even out as the deficit is addressed. 1:51:57 PM DEBORAH SCHNEIDER, Chair, Board of Direct-Entry Midwives, Wasilla, said she is testifying in support of HB 49. She said midwives have been licensed in Alaska for more than 20 years and they have worked hard to provide good, safe care. The licensing fees have fluctuated up and down over the years and the current licensees are committed to paying down their deficit. The board is also working with multiple state agencies to prevent protracted and expensive investigations that the board has faced in the past. The first two recommendations from the audit have been addressed but the board does not agree with the third recommendation to address the deficit by merging with another board. 1:54:34 PM SUSAN TERWILLIGER, President, Midwives Association of Alaska said she is a certified direct-entry midwife who has an office in Eagle River and does home births. She is speaking for the membership in support HB 49. They agree to pay the high fees to eliminate the deficit. The uniqueness of the profession underscores the importance of this board overseeing the midwifery profession and protecting public safety. CHAIR COSTELLO asked if she knows the range of costs for a hospital birth. MS. TERWILLIGER said no, but the packets should have information showing how much direct-entry midwives save the state in Medicaid payments. 1:57:12 PM At ease 1:57:28 PM CHAIR COSTELLO reconvened the meeting and advised that the document is online but not in the packets. MS. TERWILLIGER read from the document she referenced. In 2015, Medicaid payments per birth by CDNs was $1,168 and the Medicaid payment for a low-risk hospital birth was $3,171. CHAIR COSTELLO asked if midwives have adjusted their charges based on their licensing fees. MS. TERWILLIGER said no. 1:59:39 PM CHAIR COSTELLO closed public testimony on HB 49 and held the bill in committee for further review.