ALASKA STATE LEGISLATURE  HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE  March 4, 2021 3:09 p.m. MEMBERS PRESENT Representative Liz Snyder, Co-Chair Representative Tiffany Zulkosky, Co-Chair Representative Ivy Spohnholz (via teleconference) Representative Zack Fields (via teleconference) Representative Ken McCarty Representative Mike Prax Representative Christopher Kurka MEMBERS ABSENT  All members present COMMITTEE CALENDAR  HOUSE BILL NO. 76 "An Act extending the January 15, 2021, governor's declaration of a public health disaster emergency in response to the novel coronavirus disease (COVID-19) pandemic; providing for a financing plan; making temporary changes to state law in response to the COVID-19 outbreak in the following areas: occupational and professional licensing, practice, and billing; telehealth; fingerprinting requirements for health care providers; charitable gaming and online ticket sales; access to federal stabilization funds; wills; unfair or deceptive trade practices; and meetings of shareholders; and providing for an effective date." - HEARD & HELD PREVIOUS COMMITTEE ACTION  BILL: HB 76 SHORT TITLE: EXTENDING COVID 19 DISASTER EMERGENCY SPONSOR(s): RULES BY REQUEST OF THE GOVERNOR 02/18/21 (H) READ THE FIRST TIME - REFERRALS 02/18/21 (H) HSS, FIN 02/19/21 (H) HSS REFERRAL REMOVED 02/19/21 (H) BILL REPRINTED 02/26/21 (H) FIN AT 1:30 PM ADAMS 519 03/01/21 (H) HSS REFERRAL ADDED BEFORE FIN 03/01/21 (H) BILL REPRINTED 03/02/21 (H) HSS AT 3:00 PM BY TELECONFERENCE 03/02/21 (H) Heard & Held 03/04/21 (H) HSS AT 3:00 PM DAVIS 106 WITNESS REGISTER JARED KOSIN, President/CEO Alaska State Hospital and Nursing Home Association Anchorage, Alaska POSITION STATEMENT: Testified in support of HB 76. VERNE BERNER, President/CEO Alaska Native Health Board Anchorage, Alaska POSITION STATEMENT: Testified in support of HB 76. PHILLIP HOFSETTER, CEO Petersburg Medical Center Petersburg, Alaska POSITION STATEMENT: Testified in support of HB 76. ELLEN HODGES, MD, Chief of Staff Yukon Kuskokwim Health Corporation Bethel, Alaska POSITION STATEMENT: Testified in support of HB 76. JAMES SWEENEY, Vice President of Hospital Services Yukon Kuskokwim Health Corporation Bethel, Alaska POSITION STATEMENT: Testified in support of HB 76. EMILY FORD, Government Affairs Director Providence Alaska Medical Center Anchorage, Alaska POSITION STATEMENT: Testified in support of HB 76. TOM HENNESSY, MD, MPH College of Health University of Alaska Anchorage Anchorage, Alaska POSITION STATEMENT: Testified in support of HB 76. CARA DURR, Director of Public Engagement Food Bank of Alaska Anchorage, Alaska POSITION STATEMENT: Testified in support of HB 76. LAURIE WOLF, President and CEO The Foraker Group Anchorage, Alaska POSITION STATEMENT: Testified in support of HB 76. SARAH SPENCER, DO, Ninilchik, Alaska POSITION STATEMENT: Testified in support of a renewed emergency declaration during the hearing on HB 76. DOLORES VANBOURGONDIEN, NP Juneau, Alaska POSITION STATEMENT: Testified in support of a renewed emergency declaration during the hearing HB 76. ACTION NARRATIVE 3:09:26 PM CO-CHAIR TIFFANY ZULKOSKY called the House Health and Social Services Standing Committee meeting to order at 3:09 p.m. Representatives Snyder, Kurka, Prax, McCarty, Fields (via teleconference), Spohnholz (via teleconference), and Zulkosky were present at the call to order. HB 76-EXTENDING COVID 19 DISASTER EMERGENCY  [Contains discussion of SB 56.] 3:10:05 PM CO-CHAIR ZULKOSKY announced that the only order of business would be HOUSE BILL NO. 76, "An Act extending the January 15, 2021, governor's declaration of a public health disaster emergency in response to the novel coronavirus disease (COVID- 19) pandemic; providing for a financing plan; making temporary changes to state law in response to the COVID-19 outbreak in the following areas: occupational and professional licensing, practice, and billing; telehealth; fingerprinting requirements for health care providers; charitable gaming and online ticket sales; access to federal stabilization funds; wills; unfair or deceptive trade practices; and meetings of shareholders; and providing for an effective date." 3:10:16 PM CO-CHAIR SNYDER moved to adopt the proposed committee substitute (CS) for HB 76, Version 32-GH1011\B, Dunmire, 3/3/21, as a work draft. 3:10:40 PM CO-CHAIR ZULKOSKY objected for purpose of discussion and requested that Co-Chair Snyder walked the committee through the proposed changes. 3:10:52 PM CO-CHAIR SNYDER informed the committee that the proposed committee substitute for HB 76 ("Version B") is similar to CSSB 56(L&C), a companion bill in the Senate. She explained that it would add a section requiring health care administrators to acquire informed consent before administering a COVID-19 vaccine, allow individuals to object to the administration of a COVID-19 vaccine based on religious, medical, or other grounds, and protects individuals from the liability of an action that does not comply with the order after the expiration of the original declaration, and before the enactment of this one. She said Version B includes legislative findings that it is in the best interest of the state to continue having the appropriate tools and taking the correct steps forward to contain the spread of COVID-19 and distribute COVID-19 vaccines. She shared that it also includes language from Senate Bill 241 of the Thirty- First Alaska State Legislature that limits the governor's appropriation authority to those detailed in the financing plan. It would override (AS) 26.23.050 and make it clear that the governor may only appropriate funds under HB 76. CO-CHAIR SNYDER commented that Version B maintains a September 30, 2021, expiration date. She opined that Alaska has done an excellent job responding to COVID-19, largely due to the flexibility and tools from the original disaster declaration. She emphasized that the state needed to continue having the tools so it could continue to [respond to the COVID-19 pandemic]. She stated that Version B would provide for that. 3:12:45 PM REPRESENTATIVE MCCARTY commented that Commissioner Crum had previously stated that this legislation was no longer needed, because there is no emergency. Representative McCarty asked what Version B is for if there is no longer a disaster. CO-CHAIR ZULKOSKY responded that the intention is to bring alignment from the original bill version to the work that was done in the Senate Health and Social Services Standing Committee and the Senate Labor and Commerce Standing Committee, so that HB 76 remains companion legislation. She explained that later in the meeting the committee would be hearing from healthcare and community stakeholders regarding the ongoing pandemic. She reminded the committee that adoption of Version B as a working document does not give commitment to passage. REPRESENTATIVE MCCARTY asked if CSSB 56(L&C) is still in process. CO-CHAIR ZULKOSKY responded that CSSB 56(L&C) is in the Senate Finance Committee. 3:14:42 PM REPRESENTATIVE PRAX sought understanding on various spending figures throughout the Version B. He asked if there was a total of $30 million in spending authorizations. CO-CHAIR ZULKOSKY asked if he wanted his approximation verified. REPRESENTATIVE PRAX replied, "No." 3:17:00 PM REPRESENTATIVE MCCARTY commented that the language Representative Prax read came from the original version of HB 76, not from Version B. 3:17:29 PM REPRESENTATIVE PRAX expressed concern about language on page 10, line 9, of Version B, concerning personal objections to the administration of the COVID-19 vaccine. He said he was "philosophically uncomfortable with the state permitting someone to do something to which they already have a right." He requested clarification from Legislative Legal Services as to why this language was included. CO-CHAIR SNYDER shared that [Section 11] reflected an amendment to the Senate companion bill, but the committee could have Legislative Legal Services follow up. REPRESENTATIVE PRAX directed attention to page 10, line 18, of Version B, regarding civil liability. He said the exemptions allowed by this section made him uncomfortable. CO-CHAIR ZULKOSKY reiterated that adopting a committee substitute is not the same as passing legislation. Any action in adopting a committee substitute is solely to adopt it as a working document to be amended and considered by this committee, she explained. 3:21:15 PM CO-CHAIR SNYDER commented that Representative Prax's concern was addressed in the Senate companion legislation in the Senate Health and Social Services Standing Committee. 3:21:29 PM CO-CHAIR ZULKOSKY removed her objection to the motion to adopt the proposed CS for HB 76, Version 32-GH1011\B, Dunmire, 3/3/21, as a work draft. 3:22:00 PM REPRESENTATIVE PRAX asked for procedural clarification. 3:22:04 PM The committee took a brief at-ease at 3:22 p.m. 3:22:11 PM CO-CHAIR ZULKOSKY asked if there were any further objections. There being no further objections, Version B was before the committee. 3:22:57 PM CO-CHAIR ZULKOSKY announced the committee would hear invited testimony. 3:23:52 PM JARED KOSIN, President/CEO, Alaska State Hospital and Nursing Home Association (ASHNHA), testified in support of HB 76. He shared that ASHNHA was on record prior to February 14, 2021, with warnings about the impact that could result if the disaster declaration expired. He said Alaska was in "compliance limbo," airport testing had declined, there was a new outbreak in Petersburg, and out-of-state telehealth providers had discontinued care. MR. KOSIN shared that there have been numerous compliance questions from Alaska's hospitals and nursing homes, concerning the authority to use federal waivers for operational flexibility without a state emergency declaration. Without guidance available, ASHNA has had to appeal to the Centers for Medicare and Medicaid Services (CMS) of the federal government for formal guidance. He said that ASHNHA had yet to receive a formal response to a letter sent to CMS on February 19, 2021, [about the blanket waivers]. He said that documentation is key in the healthcare industry, so without a formal answer in writing, it remains an open question [whether providers are in compliance]. Mr. Kosin concluded by arguing that the simplest way to remove compliance doubt, secure federal assistance, allow access to out-of-state telehealth, and maximize Alaska's geographical advantage with airport testing is by passing HB 76. 3:26:49 PM REPRESENTATIVE SPOHNHOLZ asked Mr. Kosin to talk about airport testing and why he thinks it could be problematic to no longer require it. MR. KOSIN answered that the airport testing is Alaska's best line of defense given the state's geography. He commented that once Petersburg stopped testing at the airport, it had one of the largest outbreaks per capita in the country. He argued that considering Petersburg's geography, airport testing is critical. 3:28:44 PM VERNE BERNER, President/CEO, Alaska Native Health Board, stated that the Alaska Native Health Board (ANHB) is supportive of HB 76. She explained that ANHB is a statewide voice for the Alaska Tribal Health System (ATHS). She shared that Alaska Natives are over-represented in Alaska's hospitalizations and deaths due to COVID-19. As of March 3, 2021, hospitalizations were at 26.9 percent, and deaths were at 37.1 percent for Alaska Natives. She stated that rural communities were at continued risk for COVID-19 due to factors such as crowded, multi-generational homes, a lack of running water and sanitation infrastructure, and distance from advanced medical care that often requires air travel to reach hospitals. MS. BERNER said the public health emergency declaration has been critical in ANHB's response to protect Alaska Native communities. Since the beginning of the public health emergency declaration, there has been a 303 percent increase in telehealth related Medicaid services statewide, keeping providers and patients safe. She noted that the majority of this has been delivered through ATHS. This has included expanded access to behavioral health services via telehealth, which has increased by 400 percent. She also shared that access via telehealth has reduced the number of missed and no-show appointments for all services. MS. BERNER stated that travel mandates had helped reduce the spread of COVID-19 in rural Alaska dramatically during the 2020 fishing season. She argued that these types of supports would still be needed as the next fishing season arrived. She noted that the public health emergency declaration provided for swift action during the crisis, which Alaska was still experiencing, and provided the needed time for the legislative process for other initiatives. Further, declaration allowed for rapid procurement and hiring for the vaccine distribution plan and for enabling mass vaccine clinics. She reiterated that it also helped with telehealth and other forms of healthcare delivery and maximized Alaska's workforce by allowing for expedited and courtesy licensing. 3:32:19 PM MS. BERNER spoke about airport testing, noting that it has protected rural communities and has help slow new variants. She highlighted that the public health emergency also allowed the National Guard to assist with testing, contact tracing, and administration of the vaccines. She pointed out that the state disaster declaration allowed the governor to allocate and redistribute food, water, fuel, clothing, medicine, and supplies. MS. BERNER said that since the disaster declaration expired, the state's largest drive-through testing site closed, communities had missed vaccine distribution due to the inability to use the National Guard, and there had been an increase in COVID-19 cases. She closed her testimony with ANHB's strong support of HB 76. 3:33:59 PM REPRESENTATIVE PRAX asked Ms. Brener whether the telehealth providers used were from in-state or out-of-state. MS. BERNER replied that ATHS has a well-established telehealth program that has been developed over several decades. She said ATHS was able to expand and utilize the program during the pandemic, with use in some communities increasing as much as 400 percent. She said she would get information back to the committee regarding whether providers were from in-state or out- of-state. REPRESENTATIVE PRAX asked if all village airports had testing services. MS. BERNER answered that she did not know if all airports had testing sites, but tribal health organizations in the hub communities had put forward testing sites. She pointed out that without the public health emergency declaration in place, the testing is not mandated. The mandated health testing had been successful in capturing positive cases of COVID-16 and protecting the communities out in rural Alaska. REPRESENTATIVE PRAX commented that some rural communities have health powers and have been imposing their own restrictions on travel. He asked if that was still the case now that the emergency declaration had expired. MS. BERNER answered that each of these communities are sovereign and may self-determine the level to which they are willing to open to travelers. However, she argued that some communities are second-class and do not have the same authorities to exercise those measures. 3:38:08 PM REPRESENTATIVE MCCARTY asked if the telehealth and teletherapy that she suggested needed to continue was just because of COVID- 19 or was something ANHB desired throughout the state. MS. BERNER said ANHB is looking for ways to extend telehealth authorities and flexibilities that have been put in place with the disaster declarations. She said this would allow ANHB to maximize its current resources until new statutes are in place. REPRESENTATIVE MCCARTY asked if Ms. Brener was saying that expanded telehealth would be desired and beneficial to the state regardless of the COVID-19 emergency. MS. BERNER responded yes, ANHB has definitely seen the benefits of telehealth in Alaska, particularly in rural communities. She explained that over 80 percent of ANHB's communities are off the road system, accessible only via airplane or boat. Telehealth has allowed for earlier medical interventions to address health conditions before the patient requires higher levels of care, she stated. She concluded that in general there have been benefits which are being realized across the nation. REPRESENTATIVE MCCARTY commented that Ms. Brener had mentioned an increase in COVID-19 cases. He asked if she had data to support that statement. MS. BERNER said yes, ANHB does, but it had been accessing that data through the dashboard on the Department of Health and Social Services (DHSS) webpage. She commented that there is additional data through ATHS that she could follow up with. 3:42:03 PM PHILLIP HOFSETTER, CEO, Petersburg Medical Center, introduced himself and stated that he supports HB 76. He stated that on February 6, 2021, he submitted a letter of support for companion bill SB 56 to the Senate Health and Social Services Standing Committee. He said the letter had cited key provisions the Petersburg Medical Center healthcare facility would lose when the emergency declaration expired. MR. HOFSETTER referred to a graph he sent to the House Health and Social Services Standing Committee. He shared that one week after the disaster declaration expired, Petersburg, Alaska, had over 60 cases in 7 days; more than they had seen the entire year prior. Leading up to the expiration of disaster declaration, he observed a noticeable behavioral difference in the community with increased public and private social activity, reduced masking, and bypassed airport testing. MR. HOFSETTER said after mounting response efforts, the Petersburg Medical Center (PMC) spent over $250,000 towards the outbreak alone. He shared that schools had moved online, and businesses closed. He stated that at that time there had been 4 inpatient admissions, 11 patients were being seen by home- health, and the medical center had used 14 monoclonal antibody treatments and had tested over 700 people. Prior to the outbreak, Petersburg only had two days of school closure. MR. HOFSETTER argued that as an island community, the mandates for testing and intra and interstate travel prevented community spread. He stated that testing travelers is the first line of defense for his community, and an emergency declaration was still needed to stem further outbreaks from occurring. He opined that it was much too soon and a wasted effort to downgrade the pandemic. 3:45:15 PM REPRESENTATIVE KURKA asked for clarification on the number of hospitalizations. MR. HOFSETTER responded that there were four inpatient admissions. In response to follow up questions, he related there are [a limited number] of COVID-19 beds, which differ from traditional hospital beds. He explained that there is one room allocated for COVID-19 treatment, a negative pressure room, but the four hospitalizations did not occur at once. He stated that the medical center is limited in how it can treat COVID-19 patients. CO-CHAIR ZULKOSKY offered her understanding that Petersburg had the resources to treat one inpatient COVID-19 positive individual. She said beyond that, the hospital staff would be working in "not-ideal" healthcare standards. MR. HOFSETTER clarified that the Petersburg Medical Center has 12 inpatient beds. He explained that bed capacity did not dictate the level of treatment or care. He said the hospital has one dedicated room with safeguards in place for a COVID-19 patient. Those rooms can be extended as needed, however, he explained, the biggest limiting factor is staffing. He said that COVID-19 patients take twice the staffing and time as other admissions. He shared that the room itself is not a good picture of the breadth of how patients are taken care of, and if there were more than two or three admissions, the patient would need to be medevacked out. 3:48:46 PM REPRESENTATIVE SPOHNHOLZ asked Mr. Hofsetter to discuss how no longer requiring people to get tested has impacted the Petersburg community, so individuals who don't live on an island could better understand what the testing means. MR. HOFSETTER answered by providing an anecdote about his wife who worked in the airport testing tent. He shared that his wife observed that people now bypass the test because it is not mandated by the state. He clarified that even though it is locally mandated by the city, it isn't enforced. He said the lack of state enforcement has had a behavioral effect on travelers, which has extended out into the community. He said the lack of compliance [coincided with the expiration of the disaster declaration]. REPRESENTATIVE SPOHNHOLZ asked whether the perceived change in people's behavior in the community when they heard there was no longer a public health emergency resulted in the school closure. MR. HOFSETTER commented that the hospital worked with the Division of Public Health to backtrack the sequence of events. He shared that travelers with COVID-19 bypassed the testing tents. He said there was an increase in social activity, both private and public, that had a spreading factor. He emphasized that once the expiration occurred, the lax behavior became obvious. The infected people then went to bars and events within the community, he stated, on sequential days, which had an effect in daycare and schools. He explained that once COVID- 19 gets into a congregate setting there is no way to prevent spread without closing down the vector or moving online. REPRESENTATIVE SPOHNHOLZ commented that she is sorry to hear about the school and Mr. Hofsetter's frustrations. 3:53:11 PM REPRESENTATIVE MCCARTY noted that during the emergency order many communities expanded their COVID-19 response abilities. He asked if there was always only one bed available in Petersburg for that purpose, or if there had been several beds that were now downsized since the emergency order had expired. MR. HOFSETTER responded that he didn't feel the bed capacity was the primary issue, and the hospital was able to allocate rooms as needed. He shared that the home health program has enabled patients to be discharged into home health and these patients have been managed by supplying oxygen, checking oxygen saturation, and determining when and if patients needed to come in for treatment. REPRESENTATIVE MCCARTY asked if schools had been closed since the COVID-19 case count had increased in Petersburg or if that had been during the time of the emergency. MR. HOFSETTER answered that he was trying to explain that when the expiration of the emergency disaster declaration happened, [Petersburg lost] the protections that kept its schools open and kept people safe, [which] involved testing as the first line of defense. He said without the testing, Petersburg's defenses crumbled. He said it was how COVID-19 was detected and how the city had infected persons isolate. Without detection COVID-19 just spreads and there is no way to stop it other than closing down schools and [performing mass] testing, isolating, and quarantining, which is difficult and time consuming. He summarized his point that once the mandate fell, there was a correlation with behavior and with the city's frontline defense of testing crumbling; and once a few [undetected] cases came into the community, there was an exponential effect. REPRESENTATIVE MCCARTY offered his understanding that with freedom of behavior, there was more mobility within the community, and that there was an increase in numbers of people that contracted COVID-19, and this affected the schools. He said he did not understand the demographics of the numbers, and whether the information was anecdotal, or whether there was another testing mechanism. MR. HOFSETTER answered that the anecdotal aspect was the behavioral observation; the objectivity is the testing. He explained that now the hospital was testing the community and symptomatic patients. He noted that the Petersburg Medical Center was also assisting public health with contact tracing, which was in turn assisting with testing, follow-up testing, and making certain people were quarantining and isolating. He explained that once [COVID-19] is spread in the community, it goes everywhere. He offered that Petersburg has age ranges of 1 year old all the way up to 83 years old [having tested positive]. He explained this is why the schools had to be closed until the COVID-19 infectious period ran its course. 3:59:15 PM CO-CHAIR ZULKOSKY asked Mr. Hofsetter to summarize the public health risk within his community of the virus that poses unforeseen impacts on an individual who contracts it. She asked where he would suggest that Petersburg, the region, and the state are in terms of the risk posed by the pandemic on the hospital system. MR. HOFSETTER shared that Petersburg was very proud to have a good portion of its community vaccinated. He explained the vaccines have prevented transmission and pointed out on his graph that only two people who had been vaccinated were then infected with COVID-19 during the Petersburg outbreak. He said he supported vaccination and testing, which he didn't think could be done without mandates. He opined it was too early to let the disaster declaration expire. 4:00:58 PM ELLEN HODGES, MD, Chief of Staff, Yukon Kuskokwim Health Corporation, expressed her support for HB 76. She shared that the Yukon Kuskokwim (Y-K) Delta region's COVID-19 case rates were the highest in the state until recently, and for a few weeks, the highest in the nation. While she attested that there are many stories that she could tell about the desperate fight against the outbreak, she divulged that the most heartbreaking ones are those of her holding the hands of people dying of COVID-19 because their families couldn't be there or explaining to families that they must hastily bury their loved ones with out the usual comfort of cultural tradition, meant to support grieving families because of the risk of holding funerals in villages ravaged by COVID-19. She emphasized her hope to never have to have those conversations in the future. DR. HODGES asserted that while case rates were dropping, the pandemic was far from over, and shared that the Y-K Delta lost two more elders the past weekend. She said the Y-K Delta has had young people die or have their lives permanently altered by COVID-19. She stated that many patients have been sent to intensive care units, and the Yukon Kuskokwim Health Corporation (YKHC) has seen many people die. She explained the Y-K Delta's rural population lives in crowded, multi-generational homes, and that many of the communities do not have access to water or sewer, which is a known risk factor for the spread of respiratory infections. DR. HODGES observed that with the expiration of the public health emergency declaration, many Alaskans seemed to feel like the pandemic was over, but she countered that there were ongoing outbreaks in 12 of the region's 46 villages, and YKHC was diagnosing new cases every day. She said the impact of the emergency declaration in the Y-K Delta region was immense, with improved access to telehealth, flexibility to deliver needed care and testing, the ability to require testing and quarantine for people arriving in the region's airports, and access to funding to care for patients. She asserted that with the presence of variants in the state, she was highly concerned that she would lose ground in the desperate fight against the deadly disease. She cautioned that cases grow exponentially, not linearly, with the increased infectious rates of the new variants being possibly 50 percent higher than the current circulating virus, communities would be even more devastated than they already are. She concluded that support is needed in order to continue vaccination efforts and the broad-based testing strategy. 4:04:07 PM JAMES SWEENEY, Vice President of Hospital Services, Yukon Kuskokwim Health Corporation, testified in support of HB 76. He explained the tools the YKHC was using to manage not only COVID- 19, but healthcare in general. He recounted that early in the pandemic the Y-K Delta region lost much of its air access, both by Raven Air shutting down, and by the restrictions in travel that were put in place. He shared that telehealth became a real tool for the YKHC to use, and it was rapidly set up and expanded to the villages. He explained that YKHC has about 30,000 individuals in its service area, many of whom depend on telehealth and remote services to receive healthcare. He remarked that COVID-19 is important, but when people cannot address regular healthcare, things get worse. So, he stated, telehealth helped YKHC to maintain patients' health and to understand before a patient gets very bad. In order to do this, he insisted, this program must be maintained, which is an important piece of HB 76. 4:05:41 PM REPRESENTATIVE PRAX asked for context on which are the hub communities in the Y-K district. DR. HODGES answered that Bethel is the main hub community. REPRESENTATIVE PRAX asked if the communities have their own health powers, as far as imposing their own restrictions. DR. HODGES answered that many of the villages do have the ability as tribal entities to set their own health restrictions. She explained that Bethel is a second-class city [and does not]. REPRESENTATIVE PRAX offered his understanding that there are several dozen small communities that are spread out a long way from each other. DR. HODGES specified that there are 46 villages. 4:07:15 PM REPRESENTATIVE MCCARTY asked how many villages self-quarantined and didn't want travelers. DR. HODGES answered that every village had some version of restrictions or recommendations for people coming in. She said it varied greatly from some that required pre-approval to even book a ticket, to villages that just had recommendations. REPRESENTATIVE MCCARTY asked regarding telehealth, how YKHC was able to reach the villages or if there was already some degree of medical support assistance. DR. HODGES answered that the villages are staffed mostly by community health aides, who can provide basic medical care and can communicate with the providers in Bethal or in one of the five regional sub-clinics. She explained that once air service became limited, YKHC had to heavily rely on telehealth to provide basic services for the villages. She said that as the pandemic expanded and the number of positive COVID-19 cases increased, many did not feel safe traveling, so telehealth was important. She also noted that the only way to transport COVID- 19 positive patients was to medivac them, which was one more reason that YKHC relied heavily on telehealth to care for COVID- 19 patients who weren't sick enough for medivac, but still required care. 4:09:50 PM CO-CHAIR ZULKOSKY asked for confirmation that YKHC had ceased telehealth services in the absence of the disaster declaration and on what date that was effective. MR. SWEENEY responded that YKHC has not yet ceased them but is considering it now. He explained that telehealth services are important, so they are trying to maintain them, but without receiving reimbursement they will be curtailed. CO-CHAIR ZULKOSKY asked about the strain on medical resources experienced at the height [of COVID-19 cases in the Y-K Delta] and the region's and the state's current risk levels. DR. HODGES responded that YKHC's medical system was stressed immensely at the height of the outbreak. She said YKHC had 10 people with COVID-19 at one time in its hospital, which required a level of care and respiratory support it did not normally provide. She explained that ICU beds in Anchorage were "non- existent," so YKHC had to medivac patients out of state. She emphasized that it was an incredible amount of stress on the nursing staff and respiratory staff, and that the pressure was intense. She acknowledged, however, that the pressure had lessened, citing only one hospitalized patient [in Bethel] at the time of the meeting, along with a few patients in intensive care in Anchorage, Alaska. She shared that the region still had over 20 cases per 100,000, with 41 new cases in the past 7 days. She said she still considered the Y-K Delta region to be on high alert, and therefore needed to continue testing and vaccination efforts. She said the state, according to the DHSS website, had many regions still in "red," where they had not dropped below 10 cases per 100,000. CO-CHAIR ZULKOSKY asked how many cases per 100,000 in the region were at the height of the pandemic, and how that compared to numbers statewide. DR. HODGES answered close to 400 cases per 100,000 and commented that for many months the region had the highest case rates across Alaska. She again mentioned that for a few weeks, the region had the highest case rate in the nation. CO-CHAIR ZULKOSKY referenced Commissioner Crum's presentation on Tuesday which discussed a drop in cases. She asked Dr. Hodges to discuss the level of public health risk that remains to necessitate a disaster declaration. DR. HODGES responded that she thought the level of public health risk was still high. She said that although cases have dropped considerably, 20 cases per 100,000 was still a lot, especially in a region with a fragile healthcare system that could be easily overwhelmed. She mentioned that she was extremely concerned about the variants, which had already shown up in Alaska and were potentially more infectious and resistant to the vaccines. She asserted her concern that the new variants could lead to another wave of outbreak in the Y-K Delta region and mentioned possible re-infection. She concluded that the disaster declaration was needed to quickly vaccinate the population and to prevent a new wave of cases and deaths. 4:15:32 PM EMILY FORD, Government Affairs Director, Providence Alaska Medical Center, testified in support of HB 76. She told the committee members that roughly one year ago the first COVID-19 patient in the United States was treated at a Providence Hospital in Washington State, and in the year since, Providence hospitals have worked tirelessly during the pandemic. She said that the promising rate of vaccination in Alaska allows Alaskans to look towards positive days ahead, but she cautioned that [the administration] cannot lose sight of the policies that would get the state there. MS. FORD stated that the COVID-19 response has required the healthcare community to act nimbly and creatively while delivering care and protecting vulnerable patients. She said that the state and federal government acted swiftly at the beginning of the pandemic to provide hospitals and the healthcare community with the tools necessary to deliver care and save lives through legislation and a series of waivers and flexibility with a response framework that was built upon the state and federal disaster declarations and allowed the Providence Alaska Medical Center to adapt to changing community needs. MS. FORD shared that because of the government response, the medical center was able to make many adjustments in response to COVID-19. She explained that the hospital modified its ventilation systems in the emergency department and created negative pressure rooms to protect patients and caregivers. She said it partnered on alternative care sites and drive through testing, examined supply chain processes, and [increased] personal protective equipment (PPE). It also set up a program to safely monitor patients at home, thereby augmenting critical capacity and reducing potential exposure. She shared that these flexibilities impacted more than the COVID-19 response, helped many Alaskans facing illness, and allowed for help from out of state providers with specialties not offered in the state through telehealth. MS. FORD commented that healthcare is a highly regulated industry. She discussed audits and compliance departments. She argued that ending the disaster declaration shifted the risk of interpreting the network of flexibilities onto hospitals and providers. She explained that the regulatory structure from the past year created a high volume of regulatory change in a compressed timeline. Without the disaster declaration, the medical center faces legal uncertainty in how to operate during the pandemic. She argued that ending the disaster declaration doesn't end the pandemic. 4:20:08 PM TOM HENNESSY, MD, MPH, College of Health, University of Alaska Anchorage, testified in support of HB 76 with a PowerPoint presentation. He said that from his perspective as a public health specialist, he was very disappointed to see the disaster declaration expire. He argued that the declaration provided many of the tools that are needed to fight COVID-19. He acknowledged the good news about lower case counts and increased vaccine supplies and the desire to "get back to normal." He stated that the Center for Disease Control (CDC) just issued a warning that lowering the nation's guard could result in a surge of cases, undoing months of progress. DR. HENNESSY directed attention to slide 2, a graph of national COVID-19 trends. He explained that the red line showed the rate of COVID-19 cases nationally. He observed that there has been a downward trend since January 9, 2021, nationwide. He directed attention to slide 3 and indicated that circled in red was the drop off in cases which had since leveled off. He moved to slide 4 and explained that the likely reasons for this leveling off were decreased vigilance on the part of the public, not following through in public health recommendations, and the new variants. DR. HENNESSY presented slide 5, which showed the rates in Alaska during the pandemic. He pointed out that although rates had declined substantially since the end of December, Alaska's numbers had stabilized and flattened in the high "red zone." He said that was the state picture. He moved to slide 6 which showed four regions of concern with increasing COVID-19 rates. He pointed out the increase in case rates in Fairbanks, the Matanuska-Susitna area, the northern area of Southeast Alaska, which includes Petersburg, and the Southeast region where there was an outbreak in Ketchikan. He said this showed that the epidemic was not over in Alaska, as there were continued increased surges in cases. 4:24:26 PM DR. HENNESSY moved to slide 7 and opined that it was important to think about emergency declarations in. He directed attention to a graph that showed the infection waves from the 2009 H1N1 swine flu. He pointed out that case rates declined once the vaccine was administered, and that it took half a year for the public emergency to end after case rates dropped. He shared this was because public health officials knew the virus was better capable of spreading during summer months. He said this was the type of caution he felt that Alaska should exhibit at this time. DR. HENNESSY presented slide 8 which showed the graph of the United States COVID-19 case rates with three distinct waves highlighted, showing transmission in the spring, the summer, and a late winter peak. He said the virus was not seasonal and could be transmitted any time; therefore, it wasn't safe to assume it would go away because of declining rates. DR. HENESSY presented slide 9, which read as follows [original punctuation provided]: What did we lose when the Emergency lapsed? - Required traveler testing at airports ? Decreased participation in voluntary program ? Increases chances of introducing virus variants into Alaska - Flexibility and speed in response ? Contracting, purchasing, alternative cares sites for testing, vaccination, treatment ? Medical licensing and reciprocity ? Telehealth from providers outside of Alaska - Official recognition of urgency and concern about COVID epidemic ? Sends signal that "All is well" to Alaskans when we need continued vigilance ? Most Alaskans are not vaccinated or immune ? Likely to result in people lowering their guard and increased case counts DR. HENNESSY elaborated on a few points and mentioned that the virus only enters Alaska through airports, so without testing it can't be caught or contained. 4:28:49 PM DR. HENNESSY concluded by stating that it was too soon for Alaska to let down its guard and pack away its tools. CO-CHAIR ZULKOSKY referred to the four regions on slide 6 with rising case counts. She asked what the boundaries of those regions were. DR. HENNESSY responded that those were the behavioral health regions defined by the State of Alaska in order not to single out any one community, thus protecting privacy. 4:29:46 PM CARA DURR, Director of Public Engagement, Food Bank of Alaska, testified in support of HB 76. She informed the committee members she would be speaking to the potential loss of the Supplemental Nutrition Assistance Program (SNAP) emergency allotments (EAs). She stated that failure to extend the public health disaster declaration or something comparable would result in the loss of EAs, which provide critical, 100 percent federally funded benefit boosts to individuals in need. MS. DURR stated that hunger during the pandemic has increased dramatically. She cited estimates that food insecurity in Alaska had increased 30 percent in 2020; looking at children specifically, this rate is 44 percent, she shared. She explained that areas in the state with food insecurity continue to see increased need. She further stated that areas that tended to have low rates of food insecurity experienced huge increases. She remarked that Skagway had seen an estimated 72 percent increase in child food insecurity during the pandemic. MS. DURR said that in order to meet these needs, food banks have had to distribute more food than ever before. She said that last month was Food Bank of Alaska's biggest weekly distribution ever at its Anchorage drive-through sight, and the SNAP outreach team's busiest months ever were December, 2020, and January and February, 2021. She shared that partner associations had also seen higher numbers. She explained that SNAP benefits are calculated based on household size, income, and geographic region, and EAs supplement existing SNAP benefits by providing all individuals and families with the maximum benefit for their household size. She related that EAs are worth about $8 million each month to the State of Alaska, equivalent to about 2.2 million meals each month. She pointed out that these benefits have a broad economic impact and help regenerate more wealth within communities where the money is spent. She concluded that EA benefits are essential to Alaska's hunger response and HB 76 provides a clear path forward to continuing them. 4:34:21 PM LAURIE WOLF, President and CEO, The Foraker Group, spoke in support of HB 76. She stated while there may be hope on the horizon, Alaska is not there yet. She likened ending the declaration to stopping a penicillin regiment three days early because the patient is starting to feel better. She explained that science and doctors wouldn't support that action because of the unnecessary risk. She argued that no one is untouched by the pandemic and said, "While we are all in the same ocean, we are not in the same boat." She said The Foraker Group was hearing from non-profit organizations around the state that needed more certainty in order to meet the essential needs of Alaskans. She emphasized the need for wide-spread testing for Alaskans and mandatory testing of travelers into the state to protect the economy the Alaskan people. She also expressed the need for accessible vaccinations to be delivered efficiently and equitably statewide, for the ability to provide direct care through telehealth, and to safeguard Alaska's food-safety net through SNAP. MS. WOLF argued that all these issues must remain a top priority for Alaska in order to focus on the intersection of public health and the economy. She acknowledged that some issues were being addressed by individual legislation in both bodies but contended that taking each action one by one puts all Alaskans at risk unnecessarily and burdens the non-profits, local governments, and the state, which are all responsible for the safety and care of every Alaskan. She emphasized that the state did not have weeks or months to respond to the unprecedented public health and subsequent economic crisis and insisted that the urgency of an immediate solution remained paramount. MS. WOLF encouraged the committee members to reinstitute an emergency declaration of at least 90 days to meet the needs of non-profits and communities. She explained that 90 days would allow for a bridge for service, continuity, and greater stability to the state's safety net to help Alaskans impacted by the crisis. She suggested that this bridge would give lawmakers time to codify the additional longer-term relief that was sought. Additionally, she felt the bridge would allow understanding for which regulations would be useful in a non- pandemic world, such as access to telehealth and flexibility in remote work. She summarized her testimony saying that in short, extending the disaster declaration is essential in responding to the pandemic and in establishing a foundation for a long recovery. 4:39:27 PM CO-CHAIR ZULKOSKY informed the committee members that she wished to move to public testimony after limited questioning of the invited testifiers. REPRESENTATIVE MCCARTY asked if there would be further discussion outside of committee with testifiers. CO-CHAIR ZULKOSKY clarified that her office could provide contact information for the testifiers if he wished to connect with them after the committee adjourned. 4:40:57 PM CHAIR ZULKOSKY commented that the end of Dr. Hennessey's presentation was about what Alaska loses without a disaster declaration. She asked him how quickly the downward trends could change with the introduction of new variants. DR. HENNESSEY answered that he had not done any modeling on that, but the CDC has on a national level. He said that a lot of the factors have to do with how quickly the population gets vaccinated, and at what rate transmission is occurring in the community. He explained that there is little data in Alaska to help inform such a discussion, but the State of Alaska Division of Public Health just came up with a report on variants of concern, but it was too early to say. CO-CHAIR ZULKOSKY thanked the testifiers. 4:43:27 PM CO-CHAIR ZULKOSKY opened public testimony on HB 76. 4:43:46 PM SARAH SPENCER, DO, told the committee that she is an addiction medication specialist. She informed the committee that during the pandemic, the U.S. had seen the worst year ever for drug overdose deaths. She commented that there is effective treatment for opioid use disorder, and that medication for addiction treatment can reduce mortality rates by over 80 percent. She said the spike in deaths was likely related to the difficulty of accessing treatment during times of COVID-19. She said providers were able to start patients on treatment without meeting them in person first, but only during the state mandated declaration, and if providers were to follow current federal regulations, it would be in violation of state statutes. She argued that without telemedicine access for people in remote areas, addiction is disproportionately affecting people in poverty. She summarized that quarantine and remote access issues limit access for many to treatment, and she hopes the emergency declaration is extended so she can treat patients. 4:47:58 PM DOLORES VANBOURGONDIEN, NP, said she treats substance abuse disorders. She said since the beginning of the pandemic, nearly 300 Alaskans have lost their lives due to COVID-19. She expressed fear that many Alaskans would die in the aftermath of the pandemic from substance abuse disorder. She said the pandemic has resulted in increased substance abuse disorders because of factors like isolation, depression, job loss, and uncertainty. She said CDC reported an acceleration of overdose deaths, with nearly 81,000 overdose deaths through May 2020. She said Alaska reported more overdoses during the pandemic than each of the two previous years. She said the emergency declaration allowed providers to meet patients where they were, waiving the requirements for an in-person, face-to-face exam for the initial encounter. She said this allowed access to life saving medications. She said the expiration of the emergency declaration order means that those who are most vulnerable will be denied access to life saving medications when they are needed most. She requested the extension of the declaration. 4:50:30 PM CO-CHAIR ZULKOSKY stated that the committee would return to public testimony on Saturday, March 6, 2021. CO-CHAIR ZULKOSKY announced that HB 76 was held over. 4:51:34 PM ADJOURNMENT  There being no further business before the committee, the House Health and Social Services Standing Committee meeting was adjourned at 4:52 p.m.