ALASKA STATE LEGISLATURE  HOUSE LABOR AND COMMERCE STANDING COMMITTEE  April 20, 2022 3:17 p.m. MEMBERS PRESENT Representative Zack Fields, Co-Chair Representative Ivy Spohnholz, Co-Chair Representative Calvin Schrage Representative Liz Snyder Representative David Nelson Representative James Kaufman MEMBERS ABSENT  Representative Ken McCarty COMMITTEE CALENDAR  SENATE BILL NO. 131(TITLE AM) "An Act relating to the presumption of compensability for a disability resulting from certain cancers in firefighters." - MOVED HCS SB 131(L&C) OUT OF COMMITTEE CS FOR SENATE BILL NO. 174(EDC) "An Act relating to dress codes and natural hairstyles." - MOVED HCS CSSB 174(L&C) OUT OF COMMITTEE SENATE BILL NO. 151 "An Act extending the termination date of the Alcoholic Beverage Control Board; and providing for an effective date." - MOVED HCS SB 151(L&C) OUT OF COMMITTEE HOUSE BILL NO. 276 "An Act relating to licensing of psychologists and psychological associates; and relating to the practice of psychology." - MOVED CSHB 276(L&C) OUT OF COMMITTEE HOUSE BILL NO. 176 "An Act relating to insurance; relating to direct health care agreements; and relating to unfair trade practices." - MOVED CSHB 176(L&C) OUT OF COMMITTEE HOUSE BILL NO. 392 "An Act relating to advanced practice registered nurses; and relating to death certificates, do not resuscitate orders, and life sustaining treatment." - HEARD & HELD CONFIRMATION HEARING(S): Workers' Compensation Board Matthew Barth Anchorage Sara Faulkner Homer Brad Austin Juneau Randy Beltz Anchorage Sarah Lefebvre - Fairbanks Christopher Dean Fairbanks - CONFIRMATION(S) HELD Workers' Compensation Appeals Commission Stephen Hagedorn Anchorage - CONFIRMATION(S) HELD Workers' Compensation Appeals Commission PREVIOUS COMMITTEE ACTION  BILL: SB 131 SHORT TITLE: WORKERS' COMP DISABILITY FOR FIREFIGHTER SPONSOR(s): SENATOR(s) HOLLAND 04/28/21 (S) READ THE FIRST TIME - REFERRALS 04/28/21 (S) CRA, L&C 05/06/21 (S) CRA AT 3:30 PM BELTZ 105 (TSBldg) 05/06/21 (S) Heard & Held 05/06/21 (S) MINUTE(CRA) 05/11/21 (S) CRA AT 3:30 PM BELTZ 105 (TSBldg) 05/11/21 (S) -- MEETING CANCELED -- 05/13/21 (S) CRA AT 3:30 PM BELTZ 105 (TSBldg) 05/13/21 (S) Moved SB 131 Out of Committee 05/13/21 (S) MINUTE(CRA) 05/14/21 (S) CRA RPT 2DP 2NR 05/14/21 (S) DP: HUGHES, GRAY-JACKSON 05/14/21 (S) NR: MYERS, WILSON 05/14/21 (S) L&C AT 1:30 PM BELTZ 105 (TSBldg) 05/14/21 (S) Moved SB 131 Out of Committee 05/14/21 (S) MINUTE(L&C) 05/17/21 (S) L&C RPT 4DP 05/17/21 (S) DP: COSTELLO, MICCICHE, GRAY-JACKSON, STEVENS 05/18/21 (S) TRANSMITTED TO (H) 05/18/21 (S) VERSION: SB 131(TITLE AM) 05/19/21 (H) READ THE FIRST TIME - REFERRALS 05/19/21 (H) L&C 02/02/22 (H) L&C AT 5:15 PM BARNES 124 02/02/22 (H) Heard & Held 02/02/22 (H) MINUTE(L&C) 04/13/22 (H) L&C AT 3:15 PM BARNES 124 04/13/22 (H) Heard & Held 04/13/22 (H) MINUTE(L&C) 04/20/22 (H) L&C AT 3:15 PM BARNES 124 BILL: SB 174 SHORT TITLE: ALLOW NATURAL HAIRSTYLES SPONSOR(s): SENATOR(s) WILSON 02/01/22 (S) READ THE FIRST TIME - REFERRALS 02/01/22 (S) EDC, L&C 02/16/22 (S) EDC AT 9:00 AM BUTROVICH 205 02/16/22 (S) Heard & Held 02/16/22 (S) MINUTE(EDC) 02/23/22 (S) EDC AT 9:00 AM BUTROVICH 205 02/23/22 (S) Moved CSSB 174(EDC) Out of Committee 02/23/22 (S) MINUTE(EDC) 02/25/22 (S) EDC RPT CS 1DP 4NR SAME TITLE 02/25/22 (S) DP: HOLLAND 02/25/22 (S) NR: HUGHES, STEVENS, BEGICH, MICCICHE 02/28/22 (S) L&C AT 1:30 PM BELTZ 105 (TSBldg) 02/28/22 (S) Heard & Held 02/28/22 (S) MINUTE(L&C) 03/23/22 (S) L&C AT 1:30 PM BELTZ 105 (TSBldg) 03/23/22 (S) Moved CSSB 174(EDC) Out of Committee 03/23/22 (S) MINUTE(L&C) 03/25/22 (S) L&C RPT CS(EDC) 3DP SAME TITLE 03/25/22 (S) DP: COSTELLO, GRAY-JACKSON, MICCICHE 03/30/22 (S) TRANSMITTED TO (H) 03/30/22 (S) VERSION: CSSB 174(EDC) 04/04/22 (H) READ THE FIRST TIME - REFERRALS 04/04/22 (H) L&C 04/11/22 (H) L&C AT 3:15 PM BARNES 124 04/11/22 (H) Heard & Held 04/11/22 (H) MINUTE(L&C) 04/15/22 (H) L&C AT 9:00 AM BARNES 124 04/15/22 (H) Scheduled but Not Heard 04/18/22 (H) L&C AT 3:15 PM BARNES 124 04/18/22 (H) 04/20/22 (H) L&C AT 3:15 PM BARNES 124 BILL: SB 151 SHORT TITLE: EXTEND ALCOHOLIC BEVERAGE CONTROL BOARD SPONSOR(s): SENATOR(s) MICCICHE 01/18/22 (S) PREFILE RELEASED 1/7/22 01/18/22 (S) READ THE FIRST TIME - REFERRALS 01/18/22 (S) L&C, FIN 02/09/22 (S) L&C AT 1:30 PM BELTZ 105 (TSBldg) 02/09/22 (S) Moved SB 151 Out of Committee 02/09/22 (S) MINUTE(L&C) 02/11/22 (S) L&C RPT 3DP 02/11/22 (S) DP: STEVENS, MICCICHE, GRAY-JACKSON 02/24/22 (S) FIN AT 9:00 AM SENATE FINANCE 532 02/24/22 (S) Heard & Held 02/24/22 (S) MINUTE(FIN) 03/01/22 (S) FIN AT 9:00 AM SENATE FINANCE 532 03/01/22 (S) Moved SB 151 Out of Committee 03/01/22 (S) MINUTE(FIN) 03/04/22 (S) FIN RPT 3DP 3NR 03/04/22 (S) DP: STEDMAN, BISHOP, HOFFMAN 03/04/22 (S) NR: WILSON, WIELECHOWSKI, OLSON 03/09/22 (S) TRANSMITTED TO (H) 03/09/22 (S) VERSION: SB 151 03/14/22 (H) READ THE FIRST TIME - REFERRALS 03/14/22 (H) L&C, FIN 04/06/22 (H) L&C AT 3:15 PM BARNES 124 04/06/22 (H) -- MEETING CANCELED -- 04/13/22 (H) L&C AT 3:15 PM BARNES 124 04/13/22 (H) Heard & Held 04/13/22 (H) MINUTE(L&C) 04/20/22 (H) L&C AT 3:15 PM BARNES 124 BILL: HB 276 SHORT TITLE: PSYCHOLOGISTS: LICENSING AND PRACTICE SPONSOR(s): LABOR & COMMERCE 01/18/22 (H) READ THE FIRST TIME - REFERRALS 01/18/22 (H) L&C, FIN 02/07/22 (H) L&C AT 4:30 PM BARNES 124 02/07/22 (H) -- MEETING CANCELED -- 02/09/22 (H) L&C AT 4:30 PM BARNES 124 02/09/22 (H) Heard & Held 02/09/22 (H) MINUTE(L&C) 02/14/22 (H) L&C AT 3:15 PM BARNES 124 02/14/22 (H) 04/11/22 (H) L&C AT 3:15 PM BARNES 124 04/11/22 (H) Heard & Held 04/11/22 (H) MINUTE(L&C) 04/13/22 (H) FIN REFERRAL REMOVED 04/13/22 (H) BILL REPRINTED 04/20/22 (H) L&C AT 3:15 PM BARNES 124 BILL: HB 176 SHORT TITLE: DIRECT HEALTH AGREEMENT: NOT INSURANCE SPONSOR(s): RASMUSSEN 04/16/21 (H) READ THE FIRST TIME - REFERRALS 04/16/21 (H) L&C, HSS 05/03/21 (H) L&C AT 3:15 PM BARNES 124 05/03/21 (H) Heard & Held 05/03/21 (H) MINUTE(L&C) 05/07/21 (H) L&C AT 8:00 AM GRUENBERG 120 05/07/21 (H) Heard & Held 05/07/21 (H) MINUTE(L&C) 05/12/21 (H) L&C AT 3:15 PM BARNES 124 05/12/21 (H) 03/23/22 (H) L&C AT 3:15 PM BARNES 124 03/23/22 (H) Heard & Held 03/23/22 (H) MINUTE(L&C) 04/06/22 (H) L&C AT 3:15 PM BARNES 124 04/06/22 (H) -- MEETING CANCELED -- 04/11/22 (H) L&C AT 3:15 PM BARNES 124 04/11/22 (H) Heard & Held 04/11/22 (H) MINUTE(L&C) 04/20/22 (H) L&C AT 3:15 PM BARNES 124 BILL: HB 392 SHORT TITLE: EXPAND ADV. PRAC. REG. NURSE AUTHORITY SPONSOR(s): SNYDER 02/22/22 (H) READ THE FIRST TIME - REFERRALS 02/22/22 (H) HSS, L&C 03/24/22 (H) HSS AT 3:00 PM DAVIS 106 03/24/22 (H) -- MEETING CANCELED -- 03/29/22 (H) HSS AT 3:00 PM DAVIS 106 03/29/22 (H) Heard & Held 03/29/22 (H) MINUTE(HSS) 03/31/22 (H) HSS AT 3:00 PM DAVIS 106 03/31/22 (H) -- MEETING CANCELED -- 04/14/22 (H) HSS AT 3:00 PM DAVIS 106 04/14/22 (H) Moved CSHB 392(HSS) Out of Committee 04/14/22 (H) MINUTE(HSS) 04/20/22 (H) L&C AT 3:15 PM BARNES 124 WITNESS REGISTER RICH ETHERIDGE, Fire Chief Alaska Fire Chiefs Association Juneau, Alaska POSITION STATEMENT: Testified in support of SB 131. ED KING, Staff Senator Roger Holland Alaska State Legislature Juneau, Alaska POSITION STATEMENT: During the hearing on SB 131, answered a question on behalf of Senator Holland, prime sponsor. SENATOR DAVID WILSON Alaska State Legislature Juneau, Alaska POSITION STATEMENT: As prime sponsor, answered questions related to CSSB 174(EDC). MORGAN LIM, Government Relations Manager Planned Parenthood Alliance Advocates Juneau, Alaska POSITION STATEMENT: Testified in support of CSSB 174(EDC). SENATOR PETER MICCICHE Alaska State Legislature Juneau, Alaska POSITION STATEMENT: As prime sponsor, provided testimony during the hearing on SB 151. CRYSTAL KOENEMAN, Staff Representative Sara Rasmussen Alaska State Legislature Juneau, Alaska POSITION STATEMENT: During the hearing on HB 176, answered questions on behalf of Representative Rasmussen, prime sponsor. HEATHER CARPENTER, Health Care Policy Advisor Office of the Commissioner Department of Health and Social Services Juneau, Alaska POSITION STATEMENT: During the hearing on HB 176, answered questions. LORI WING-HEIER, Director Division of Insurance Alaska Department of Commerce, Community, and Economic Development Anchorage, Alaska POSITION STATEMENT: During the hearing on HB 176, answered questions. ALLIANA SALANGUIT, Staff Representative Liz Snyder Alaska State Legislature Juneau, Alaska POSITION STATEMENT: On behalf of Representative Snyder, prime sponsor, provided the sectional analysis for CSHB 392(HSS). MARIANNE JOHNSTONE-PETTY, DNP, APRN, FNP-C, ACHPN Alaska APRN Alliance Anchorage, Alaska POSITION STATEMENT: Provided invited testimony in support of CSHB 392(HSS). SHANNON HILTON, DNP, AGACNP American Association of Nurse Practitioners Anchorage, Alaska POSITION STATEMENT: Provided invited testimony in support of CSHB 392(HSS). MATTHEW BARTH, Appointee Workers' Compensation Board Division of Workers' Compensation Department of Labor and Workforce Development (DLWD) Anchorage, Alaska POSITION STATEMENT: Testified as appointee to the Workers' Compensation Board. SARA FAULKNER, Appointee Workers' Compensation Board Division of Workers' Compensation Department of Labor and Workforce Development Homer, Alaska POSITION STATEMENT: Testified as appointee to the Workers' Compensation Board. BRAD AUSTIN, Appointee Workers' Compensation Board Division of Workers' Compensation Department of Labor and Workforce Development Juneau, Alaska POSITION STATEMENT: Testified as appointee to the Workers' Compensation Board. RANDY BELTZ, Appointee Workers' Compensation Board Division of Workers' Compensation Department of Labor and Workforce Development Anchorage, Alaska POSITION STATEMENT: Testified as appointee to the Workers' Compensation Board. SARAH LEFEBVRE, Appointee Workers' Compensation Board Division of Workers' Compensation Department of Labor and Workforce Development Fairbanks, Alaska POSITION STATEMENT: Testified as appointee to the Workers' Compensation Board. CHRISTOPHER DEAN, Appointee Workers' Compensation Board Division of Workers' Compensation Department of Labor and Workforce Development Fairbanks, Alaska POSITION STATEMENT: Testified as appointee to the Workers' Compensation Board. STEPHEN HAGEDORN, Appointee Workers' Compensation Appeals Commission Department of Labor and Workforce Development (DLWD) Anchorage, Alaska POSITION STATEMENT: Testified as appointee to the Workers' Compensation Appeals Commission. ACTION NARRATIVE 3:17:31 PM CO-CHAIR ZACK FIELDS called the House Labor and Commerce Standing Committee meeting to order at 3:17 p.m. Representatives Nelson, Snyder, and Fields were present at the call to order. Representatives Schrage, Kaufman, and Spohnholz arrived as the meeting was in progress. SB 131-WORKERS' COMP DISABILITY FOR FIREFIGHTER  3:17:52 PM CO-CHAIR FIELDS announced that the first order of business would be SENATE BILL NO. 131(title am), "An Act relating to the presumption of compensability for a disability resulting from certain cancers in firefighters." [Before the committee was Version I, the proposed House committee substitute (HCS) for SB 131(title am), Version 32-LS0598\I, Marx, 2/23/22, adopted as the working document on 4/13/22.] 3:17:58 PM CO-CHAIR FIELDS opened public testimony on SB 131. 3:18:11 PM RICH ETHERIDGE, Fire Chief, Alaska Fire Chiefs Association, testified in support of SB 131. He stated that SB 131 is a monumental bill for improving safety for all firefighters. 3:18:34 PM CO-CHAIR FIELDS closed public testimony after ascertaining that no one else wished to testify. 3:19:07 PM REPRESENTATIVE KAUFMAN moved to adopt Amendment 1 to Version I of SB 131, labeled 32-LS0598\I.2, Marx, 4/15/22, which read: Page 2, line 11: Delete "and" Page 2, line 12, following "cancer;": Insert "and (xvi) ovarian cancer;" 3:19:10 PM CO-CHAIR FIELDS objected for the purpose of discussion. 3:19:15 PM REPRESENTATIVE KAUFMAN explained that the purpose of Amendment 1 is to add "ovarian cancer", which is currently missing from SB 131 (title am) but is known to be amongst the cancers that this bill is addressing. 3:19:38 PM ED KING, Staff, Senator Roger Holland, Alaska State Legislature, answered on behalf of Senator Holland, prime sponsor of SB 131 (title am). He stated that Senator Holland is supportive of Amendment 1. 3:19:52 PM CO-CHAIR FIELDS removed his objection to Amendment 1. There being no further objection, Amendment 1 was adopted. 3:20:13 PM CO-CHAIR FIELDS moved to report the proposed HCS for SB 131(title am), Version 32-LS0598\I, Marx, 2/23/22, as amended, out of committee with individual recommendations and the accompanying fiscal notes. 3:20:35 PM The committee took a brief at-ease. 3:20:57 PM CO-CHAIR FIELDS announced that there being no objection, HCS SB 131(L&C) was reported out of the House Labor and Commerce Standing Committee. SB 174-ALLOW NATURAL HAIRSTYLES  3:21:08 PM CO-CHAIR FIELDS announced that the next order of business would be CS FOR SENATE BILL NO. 174(EDC), "An Act relating to dress codes and natural hairstyles." 3:21:34 PM The committee took an at-ease from 3:21 p.m. to 3:22 p.m. 3:22:05 PM CHAIR SPOHNHOLZ, on behalf of Representative McCarty, moved to adopt Amendment 1 to CSSB 174(EDC), labeled 32-LS1298\W.1, Marx, 4/8/22, which read: Page 1, lines 6 - 7: Delete "commonly or historically" Page 2, lines 4 - 5: Delete "commonly or historically" 3:22:19 PM CO-CHAIR FIELDS objected for the purpose of discussion. 3:22:23 PM CO-CHAIR SPOHNHOLZ explained that Amendment 1 would delete the language "commonly or historically" from within the bill, which are terms used to describe hairstyles. She noted that the amendment was drafted in consultation with the bill sponsor. 3:22:42 PM SENATOR DAVID WILSON, Alaska State Legislature, as prime sponsor of CSSB 174(EDC), stated he is supportive of Amendment 1. He explained that there is confusion nationally when looking at other states that have passed a CROWN Act [Create a Respectful and Open World for Natural Hair Act], and it was felt that deleting this language would make the bill a cleaner version. 3:23:00 PM CO-CHAIR FIELDS removed his objection to Amendment 1. There being no further objection, Amendment 1 was adopted. 3:23:09 PM CO-CHAIR SPOHNHOLZ, on behalf of Representative McCarty, moved to adopt Amendment 2 to CSSB 174(EDC), labeled 32-LS1298\W.2, Marx, 4/12/22, which read: Page 1, line 7: Delete ", including wearing headwraps" Page 2, line 5: Delete ", including wearing headwraps" 3:23:12 PM CO-CHAIR FIELDS objected for the purpose of discussion. 3:23:13 PM CO-CHAIR SPOHNHOLZ explained that Amendment 2 would delete in two sections of the bill the language "including wearing headwraps". She stated that the amendment was done in consultation with the bill sponsor. 3:23:24 PM SENATOR WILSON stated he is supportive of Amendment 2 because headwraps do not pertain to hair necessarily. He said "including wearing headwraps" was added in a Senate committee and he would like to keep the bill related to hair and not hair accessories. In response to Co-Chair Fields, he clarified that he does support adopting Amendment 2. 3:24:32 PM CO-CHAIR FIELDS removed his objection to Amendment 2. There being no further objection, Amendment 2 was adopted. 3:24:54 PM CO-CHAIR FIELDS opened public testimony on CSSB 174(EDC). 3:25:04 PM MORGAN LIM, Government Relations Manager, Planned Parenthood Alliance Advocates (PPAA), testified in support of CSSB 174(EDC). He stated that PPAA is committed to creating a world in which all people have autonomy over their bodies and health. He said dress codes banning certain hairstyles perpetuate racist stereotypes and lead to over-policing and over-discipling of BIPOC people [Black, Indigenous, and people of color], which has real world consequences on educational, professional, and health outcomes. He explained that, for many, Afrocentric and Indigenous are an expression of identity and hold historic, cultural, and spiritual significance. Over time hair has become a link between history and current identities, he said, and represents a rejection of Eurocentric notions that the texture of white or European hair is inherently professional and beautiful while the texture and styling of nonwhite hair is inherently unprofessional and undesirable. He related that extensive research shows that schools discriminatorily enforce dress codes against Black students, especially Black girls due to race and gender base stereotypes. Dress codes that police hairstyles lead educators to discipline Black students and students of color more often and more harshly than they do white students. This discipline causes students to lose class time which can deny equal opportunities and impact graduation rates and access to higher education. He urged the bill's passage from committee. 3:27:07 PM CO-CHAIR FIELDS closed public testimony after ascertaining no one else wished to testify. 3:27:26 PM CO-CHAIR SPOHNHOLZ moved to report CSSB 174(EDC), as amended, out of committee with individual recommendations and the accompanying [zero] fiscal notes. There being no objection, HCS CSSB 174(L&C) was reported out of the House Labor and Commerce Standing Committee. SB 151-EXTEND ALCOHOLIC BEVERAGE CONTROL BOARD  3:27:47 PM CO-CHAIR FIELDS announced that the next order of business would be SENATE BILL NO. 151, "An Act extending the termination date of the Alcoholic Beverage Control Board; and providing for an effective date." CO-CHAIR FIELDS recounted that the committee heard a recommendation that the Alcoholic Beverage Control Board (ABC Board) be extended by four years and industry testimony asked that the extension be longer. He said he is going to offer an amendment that is an attempt to strike a balance with the two recommendations. 3:28:37 PM CO-CHAIR FIELDS moved to adopt Amendment 1 to SB 151, labeled 32-LS1280\A.2, Dunmire, 4/14/22, which read: Page 1, line 5: Delete "2026" Insert "2027" 3:28:39 PM CO-CHAIR SPOHNHOLZ objected for the purpose of discussion. 3:28:40 PM CO-CHAIR FIELDS explained that Amendment 1 attempts a compromise between the different positions offered by the Division of Legislative Audit and industry. If adopted, the ABC Board would be extended by five years and, if not adopted, the ABC Board would be extended by four years. He said either way he will support the bill. 3:29:08 PM CO-CHAIR SPOHNHOLZ removed her objection to Amendment 1. There being no further objection, Amendment 1 was adopted. 3:29:22 PM CO-CHAIR FIELDS opened public testimony on SB 151, then closed it after ascertaining that no one wished to testify. 3:30:03 PM SENATOR PETER MICCICHE, Alaska State Legislature, as prime sponsor of SB 151, stated that Amendment 1 is fair because it listens to the concerns of the ABC Board yet respects the concerns of the auditors. 3:30:55 PM CO-CHAIR SPOHNHOLZ moved to report SB 151, as amended, out of committee with individual recommendations and the accompanying fiscal notes. There being no objection, HCS SB 151(L&C) was reported out of the House Labor and Commerce Standing Committee. HB 276-PSYCHOLOGISTS: LICENSING AND PRACTICE  3:31:20 PM CO-CHAIR FIELDS announced that the next order of business would be HOUSE BILL NO. 276, "An Act relating to licensing of psychologists and psychological associates; and relating to the practice of psychology." CO-CHAIR FIELDS reminded members that HB 276 is a committee bill and that the proposed committee substitute (CS), labeled 32- LS0963\I, Ambrose, 3/30/22, "Version I," was adopted as the working document on 4/11/22. He said Version I reflects a consensus with the industry and no amendments have been offered. 3:32:12 PM CO-CHAIR FIELDS opened public testimony on HB 276, then closed it after ascertaining that no one wished to testify. 3:32:25 PM CO-CHAIR SPOHNHOLZ moved to report the proposed CS for HB 276, version 32-LS0963\I, Ambrose, 3/30/22, out of committee with individual recommendations and the accompanying [zero] fiscal note. There being no objection, CSHB 276(L&C) was moved out of the House Labor and Commerce Standing Committee. HB 176-DIRECT HEALTH AGREEMENT: NOT INSURANCE  3:32:45 PM CO-CHAIR FIELDS announced that the next order of business would be HOUSE BILL NO. 176, "An Act relating to insurance; relating to direct health care agreements; and relating to unfair trade practices." [The proposed committee substitute (CS), Version 32-LS0784\B, Marx, 4/7/22 ("Version B"), was adopted as the working document on 4/11/22.] 3:33:14 PM REPRESENTATIVE SNYDER moved to adopt Amendment 1 to Version B of HB 176, labeled 32-LS0784\B.1, Marx, 4/13/22, which read: Page 2, line 17: Delete the second occurrence of "and" Page 2, line 23, following "sex": Insert "; and (7) specify the number of patients the health care provider has the capacity to serve and the number of patients the health care provider is currently serving" 3:33:17 PM CO-CHAIR FIELDS objected for the purpose of discussion. 3:33:20 PM REPRESENTATIVE SNYDER explained that Amendment 1, for purposes of consumer protection, would require the provider to specify the number of patients that the health care provider has the capacity to serve and the number of patients the health care provider is currently serving. She said this would give an individual considering a health care agreement an understanding of the level of care and amount of attention that might reasonably be expected from the health care provider. 3:34:16 PM CRYSTAL KOENEMAN, Staff, Representative Sara Rasmussen, Alaska State Legislature, on behalf of Representative Rasmussen, prime sponsor of HB 176, related that the prime sponsor has no objection to Amendment 1. 3:34:39 PM CO-CHAIR FIELDS removed his objection to Amendment 1. There being no further objection, Amendment 1 was adopted. 3:34:49 PM REPRESENTATIVE SNYDER moved to adopt Amendment 2 to Version B of HB 176, labeled 32-LS0784\B.3, Marx, 4/13/22, which read: Page 4, line 19: Delete "and" Page 4, following line 19: Insert a new paragraph to read: "(4) the percentage of the patients that entered into or maintained a direct health care agreement with the health care practice in the preceding calendar year who are paying fees and costs under a direct health care agreement through (A) the federal Medicare program; and (B) medical assistance under AS 47.07;" Renumber the following paragraph accordingly. 3:34:52 PM CO-CHAIR FIELDS objected for the purpose of discussion. 3:34:54 PM REPRESENTATIVE SNYDER noted that Version B, the proposed CS, includes a reporting requirement so it can be determined how well this new approach is working and whether any areas need to be improved. She explained that Amendment 2 would add to the short list of information that would be tracked by requiring the percentage of patients who are paying fees under a direct health care agreement through the federal Medicare program or through medical assistance under AS 47.07. She said this would provide a sense of the spectrum of patients who are receiving care under a direct health care agreement. 3:35:50 PM REPRESENTATIVE KAUFMAN inquired about the end purpose of gathering this information. REPRESENTATIVE SNYDER replied that early research is showing a trend that health care providers adopting the direct health care agreement model are reducing the percentage of patients under Medicare or Medicaid that they serve. There isn't a firm understanding nationally on the extent of that trend, she said, so if this is adopted in Alaska, it would help in understanding what happens. REPRESENTATIVE KAUFMAN said it sounds like the intent of the amendment's sponsor is to have a quota system. REPRESENTATIVE SNYDER responded not necessarily, it is for assessing what is happening and whether this is or isn't a good thing for Alaska, or whether other requirements are needed in the future for direct health care agreements. She said she isn't suggesting what the solution might be, but just getting the information to ensure that all Alaskans regardless of financial situation are able to access care consistently. REPRESENTATIVE KAUFMAN reiterated that it sounds like it may be for the purposes of a quota system. REPRESENTATIVE SNYDER answered that someone advocating for a quota system may be able to utilize this data to support that argument, depending on what the data show. It may not support a quota, she continued, and that is not something she has thought beyond this amendment, only that the information would inform the legislature's decisions moving forward. 3:37:58 PM CO-CHAIR SPOHNHOLZ commented that different iterations of this bill have been heard over the years, and an earlier version in a previous legislature did have a required percentage of people on Medicaid. She offered her understanding that Amendment 2 is not a quota system but a transparency element to be able to understand the way that this new approach intersects with other important populations - seniors covered by Medicare and low- income and disabled people on Medicaid. She stated that Alaska has a crisis in access to care, particularly for people on Medicare trying to find providers because the Medicare rates are so low. Information is needed to understand whether this is helping to meet the shortfall in Alaska or creating an unintended consequence that may need to be remedied. REPRESENTATIVE SNYDER confirmed that that's a fair description of the intent with Amendment 2. She said the purpose of HB 176 is to improve access to care and to monitor how that is going to ensure that improvement is happening. If other issues are instead being opened, she continued, then information will be had for informed decisions on how to fix that. 3:40:05 PM CO-CHAIR FIELDS said this is an important amendment to ensure that affordability is being maintained for diverse care groups. MS. KOENEMAN specified that the prime sponsor is still analyzing Amendment 2 and the impacts that it will have, and that there is a level of concern with including those on federal programs. One thought with having a direct primary care system, she explained, is to potentially pull retired doctors or doctors close to retirement because they would not be inundated; a direct primary care system would allow more doctors to keep providing care instead of leaving the workforce. She said the prime sponsor will, as the bill moves forward, continue to analyze whether it is a quota system or just reporting, given they are distinctly different. CO-CHAIR FIELDS invited comment from the Department of Health and Social Services. 3:42:06 PM HEATHER CARPENTER, Health Care Policy Advisor, Office of the Commissioner, Department of Health and Social Services (DHSS), answered that the department's main concern is including Medicaid beneficiaries as individuals who can access direct primary care agreements. She explained that that is in part because there are limitations with Medicaid a provider must be an enrolled Medicaid provider to serve a Medicaid beneficiary. The department is reimbursing in a fee-for-service Medicaid environment so the department doesn't have the same flexibility that managed care might have. Additionally, she said, Medicaid is the payor of last resort, which means DHSS must chase and require any other third party in a third-party liability situation to pay first. So, if Medicaid were allowed to access these direct primary care agreements, there would be lots of difficulty and bureaucracy and increased cost to the Medicaid program. Ms. Carpenter further explained that individuals who are on the Medicaid program have limited co-pays based on the rules of the federal program, making it a very affordable program for those who are enrolled. She offered to talk with Representative Snyder offline to determine language that would address both the representative's and the department's concerns at the same time. 3:44:03 PM CO-CHAIR FIELDS offered his understanding that under HB 176 a Medicaid recipient could pay out of pocket for his or her direct primary care. MS. CARPENTER replied that the department also interprets the bill that way. But, she noted, Medicaid covers a large breadth of services, so DHSS would be concerned about what services might be outside of that scope for which the individual would want a direct primary care [agreement], and he or she would be paying out of pocket for those services. Therefore, she pointed out, the fiscal note includes indeterminate because the department is unsure of the full implications to the Medicaid program. CO-CHAIR SPOHNHOLZ asked whether there is any prohibition within federal Medicaid statute about participating in a direct health care agreement. MS. CARPENTER responded that she has received mixed signals on that, so she will get back to the committee after more research. REPRESENTATIVE SNYDER clarified that Amendment 2 does not make any requirement for Medicare or Medicaid to be eligible for direct care agreements, it would simply be a reporting requirement for monitoring the success of the legislation. 3:45:54 PM CO-CHAIR FIELDS withdrew his objection to Amendment 2. There being no further objection, Amendment 2 was adopted. 3:46:05 PM CO-CHAIR FIELDS moved to adopt Amendment 3 to Version B of HB 176, labeled 32-LS0784\B.4, Marx, 4/13/22, which read: Page 1, line 1: Delete "and" Page 1, line 2, following "practices": Insert "; and providing for an effective date" Page 5, following line 29: Insert new bill sections to read: "* Sec. 4. The uncodified law of the State of Alaska is amended by adding a new section to read: TRANSITION: REGULATIONS. The director of the division of insurance may adopt regulations necessary to implement the changes made by this Act. The regulations take effect under AS 44.62 (Administrative Procedure Act), but not before the effective date of the law implemented by the regulations. * Sec. 5. Section 4 of this Act takes effect immediately under AS 01.10.070(c). * Sec. 6. Except as provided in sec. 5 of this Act, this Act takes effect January 1, 2023." 3:46:06 PM CO-CHAIR SPOHNHOLZ objected for the purpose of explanation. 3:46:08 PM CO-CHAIR FIELDS explained that Amendment 3 was drafted in consultation with the Division of Insurance and would provide clarity that the Division of Insurance may adopt such regulations as are necessary to implement the changes within HB 176. He said the amendment has value because a whole new type of health care is being legalized and it must be ensured that the appropriate department has appropriate regulatory authority. MS. KOENEMAN, on behalf of the prime sponsor, stated that Amendment 3 is important for the division, and the prime sponsor considers the benefit necessary. CO-CHAIR FIELDS invited the Division of Insurance to provide comment. 3:47:30 PM LORI WING-HEIER, Director, Division of Insurance, Alaska Department of Commerce, Community, and Economic Development (DCCED), thanked Co-Chair Fields for talking to the division and sponsoring Amendment 3. She related that as the division reviewed the bill, it was thought that in time the division may need to fine tune it through regulation, such as some of the reporting requirements and transparency at which the committee is looking. 3:47:51 PM CO-CHAIR SPOHNHOLZ removed her objection to Amendment 3. There being no further objection, Amendment 3 was adopted. CO-CHAIR FIELDS stated that this makes more sense than having to legislate fine tuning provisions later. 3:48:23 PM The committee took a brief at-ease. 3:48:36 PM CO-CHAIR FIELDS stated that Amendment 4 would not be offered due to Representative McCarty not being present. 3:48:44 PM REPRESENTATIVE KAUFMAN moved to adopt Amendment 5 to Version B, HB 176, labeled 32-LS0784\B.5, Marx, 4/14/22, which read: Page 5, lines 14 - 19: Delete "Before terminating a direct health care agreement with an existing patient, a health care provider shall ensure that the patient is transferred to a health care provider who (1) is able to provide the level or type of care the patient requires; and (2) agrees to provide to the patient the level or type of care the patient requires." 3:48:46 PM CO-CHAIR FIELDS objected for the purpose of discussion. 3:48:48 PM REPRESENTATIVE KAUFMAN explained that Amendment 5 would delete the language requiring a health care provider to transfer a patient if the provider can no longer serve that patient. He said he fears that providers who are aware of that liability may choose to not engage in the service and therefore Amendment 5 is a well-intentioned amendment to make this a better opportunity. MS. KOENEMAN, on behalf of the prime sponsor, stated that the prime sponsor understands the concern and the burden this may put on providers and will defer to the will of the committee. 3:50:06 PM REPRESENTATIVE SNYDER requested more context as to whether this is typical language seen in other states or something uniquely developed here. MS. KOENEMAN replied that the language was included in the original bill and is to ensure that a person is not "left out to dry by a provider." For example, she related, her own primary care provider ran some tests and discovered that the level of care she needed was outside his scope of practice, so he referred her to another provider to take on that level of care. Had he not made that referral she would have not known what to do and would have had to search for a provider on her own. This language, she continued, is to ease that burden from the patient while understanding that it may throw an additional burden on the provider. She said she doesn't know if a referral instead of a transfer would achieve the same thing or whether it is better to remove the language. 3:52:00 PM REPRESENTATIVE KAUFMAN offered his belief that there are ethical responsibilities to refer and that that is implicit in the oath under which providers operate. He related that that was the case when his own provider retired. It is a well-intentioned clause, he said, but he fears it will inhibit and that the code of ethics under which doctors operate should be relied upon to provide referrals. CO-CHAIR SPOHNHOLZ said she is conflicted because it may take a while for a handoff to occur and therefore a simple referral may not meet the need; a handoff may be needed to meet the Hippocratic oath. She is conflicted, she continued, because of the importance of ensuring ongoing patient management for certain chronic issues; for example, people with diabetes could lose their vision or limbs. REPRESENTATIVE KAUFMAN responded that he understands the concern, but that if attractive legislation is not created then doctors will not sign up for the program. He cautioned that requiring doctors to sign up for placement rather than referral could be a bar that may limit the number of providers willing to engage in the program. 3:55:00 PM REPRESENTATIVE SNYDER asked whether any providers are available online to answer questions. CO-CHAIR FIELDS noted that no providers are online. He asked Ms. Wing-Heier to provide perspective. MS. WING-HEIER responded that the division believes Amendment 5 would help the bill because it has the same concern as Representative Kaufman. The division agrees with referral, she said, but transfer is problematic. There will be providers who can give a referral but cannot guarantee a transfer, she advised, a provider may be full and unable to take a new patient. Or it might create stumbling blocks for providers when someone's condition gets to a point where the provider is not qualified to treat and does not know anybody because it is a condition for which the patient must go out of state. 3:56:23 PM CO-CHAIR SPOHNHOLZ stated that Amendment 5 applies only to people who are already in a current direct care agreement and is about a "warm handoff" to another provider. She offered her understanding that the division believes that requiring a warm handoff could potentially be a barrier to providers entering into direct care agreements and creating more market capacity. MS. WING-HEIER confirmed that that is right. She said the division looked at it as if the first direct care provider is trying to transfer a patient, or handoff a patient, to a second direct care provider and the other one is at capacity and cannot take any additional new patients, then a barrier has been created for that person to transfer on. Referrals are one thing, she continued, but the division thinks that ensuring they are transferred is problematic. 3:57:36 PM CO-CHAIR FIELDS stated he is hesitant to remove his objection to Amendment 5 when language has not been agreed to by the bill sponsor and personally he is supportive of some consumer protection. He asked whether Ms. Koeneman has suggestions for how to have some degree of protection for referrals or transfers without an unnecessary barrier. MS. KOENEMAN responded that she understands the Hippocratic oath and the desire that there be a referral. She suggested that on page 5 of Version B, line 15, the word "transferred" be changed to "referred" to provide some overarching language in the statute that directs providers to refer. She said the prime sponsor would defer to the committee, however. 3:58:58 PM REPRESENTATIVE SNYDER stated she was going to offer two possible alternatives, one being to [change "transferred" to "referred"]. Another alternative, she said, could be removing the language here as a requirement and instead require the [direct care] agreement itself to specify yes or no regarding whether transfer assistance is part of the agreement. 3:59:45 PM REPRESENTATIVE KAUFMAN stated that the issue is still with placing that obligation of placement. He said referral is within the control of the physician, but transfer is not; placing an obligation on someone for something on which they have no control creates an untenable situation. He said he could withdraw Amendment 5 and suggest a conceptual amendment that states "referred" or "directed" rather than "transferred", which would achieve more of a consensus agreement around what is being looking for. 4:00:34 PM CO-CHAIR FIELDS agreed with withdrawal of the amendment. 4:00:37 PM REPRESENTATIVE KAUFMAN withdrew Amendment 5. 4:00:45 PM The committee took a brief at-ease. 4:01:34 PM CO-CHAIR SPOHNHOLZ moved to adopt Conceptual Amendment 1 to Version B of HB 176. 4:01:52 PM CO-CHAIR FIELDS objected for the purpose of discussion. 4:01:53 PM CO-CHAIR SPOHNHOLZ described Conceptual Amendment 1 as follows: Page 5, line 15: Delete "transferred" Replace with "referred" 4:02:13 PM REPRESENTATIVE KAUFMAN agreed with Conceptual Amendment 1. 4:02:20 PM CO-CHAIR FIELDS removed his objection to Conceptual Amendment 1. There being no further objection, Conceptual Amendment 1 was adopted. 4:02:31 PM REPRESENTATIVE KAUFMAN moved to adopt Amendment 6 to Version B of HB 176, labeled 32-LS0784\B.7, Marx, 4/14/22, which read: Page 1, line 8: Delete "an annual" Insert "a periodic" Page 1, line 10: Delete "annual" Insert "periodic" Page 1, line 11: Delete "annual" in both places Insert "periodic" in both places Page 2, line 1: Delete "annual" Insert "periodic" Page 2, line 9: Delete "annual" Insert "periodic" Page 2, line 10: Delete "annual" Insert "periodic" Page 2, line 18: Delete "annual" Insert "periodic" Page 2, line 19: Delete "annual" Insert "periodic" Page 3, line 11: Delete "annual" Insert "periodic" Page 3, line 13: Delete "annual" Insert "periodic" Page 4, line 17: Delete "annual" Insert "periodic" 4:02:36 PM CO-CHAIR FIELDS objected for the purpose of discussion. 4:02:38 PM REPRESENTATIVE KAUFMAN said Amendment 6 would create greater flexibility in the time period to allow agreements that are not necessarily annual. He explained that by striking "annual" and allowing "periodic" there could be six-month, monthly, or other agreements to provide a structure that is most beneficial for both a provider and the patient. 4:03:11 PM MS. KOENEMAN, on behalf of the prime sponsor, stated that this is the language which was contained in the original version of the bill, so the prime sponsor is supportive of this language. MS. WING-HEIER related that the division had asked for "periodic" to be changed to "annual" simply because insurance policies are annual. She posed a scenario of someone choosing to buy a health care policy with a high deductible of $20,000 and buying a direct health care agreement at $100 a month. If that changed in three months, she pointed out, then the person's decision for the $20,000 deductible health care policy might not have been the best one. That is the only reason the division had asked for annual, she stated, but it is not a huge deal. CO-CHAIR SPOHNHOLZ said she appreciates the intent to be more flexible but since insurance is done on an annual basis, direct care agreements should also be made on an annual basis. Periodic is an undefined term whereas annual is clear, she stated, and passage of this bill is to ensure access to this kind of care as well as provide clarity, transparency, and protection. She said she cannot support Amendment 6 as drafted. 4:05:37 PM CO-CHAIR FIELDS maintained his objection. 4:05:42 PM A roll call vote was taken. Representative Kaufman voted in favor of Amendment 6 to HB 176, Version B. Representatives Schrage, Snyder, Nelson, Fields, and Spohnholz voted against it. Therefore, Amendment 6 to HB 176 failed to be adopted by a vote of 1-5. 4:06:25 PM The committee took a brief at-ease. 4:06:30 PM CO-CHAIR SPOHNHOLZ moved to report the proposed CS to HB 176, version 32-LS0784\B, Marx, 4/7/22, as amended, out of committee with individual recommendations and the accompanying fiscal notes. There being no objection, CSHB 176(L&C) was moved out of the House Labor and Commerce Standing Committee. 4:06:58 PM CO-CHAIR FIELDS stated that he gives the Legislative Legal Services the ability to make any necessary and conforming changes. HB 392-EXPAND ADV. PRAC. REG. NURSE AUTHORITY  4:07:14 PM CO-CHAIR FIELDS announced that the next order of business would be HOUSE BILL NO. 392, "An Act relating to advanced practice registered nurses and physician assistants; and relating to death certificates, do not resuscitate orders, and life sustaining treatment." [Before the committee was CSHB 392(HSS).] 4:07:55 PM REPRESENTATIVE SNYDER, as the prime sponsor, introduced HB 392. She stated that CSHB 392(HSS) would give advanced practice registered nurses (APRNs) and physician assistants (PAs) the signature authority for death certificates, do not resuscitate (DNR) orders, and physician orders of life sustaining treatment (POLST). She explained that APRNs are registered nurses with additional education and specialized training that adequately prepares them for this authority. She said APRNs have had the authority to practice independently in Alaska since 1984 and are recognized as primary care providers. Similarly, she continued, PAs have master's degrees, plus additional clinical training, and work as part of a health care team to examine, diagnose, and treat patients. She stated that both APRNs and PAs frequently oversee end of life care, but current statute does not allow APRNs or PAs to sign the official papers documenting and finalizing these decisions, only physicians can do so. This creates an unnecessary paperwork bottleneck that can cause additional delays and stress for families during an already stressful time, she pointed out. She noted that the bill has received broad support since its introduction, is narrow in scope in that it simply allows APRNs and PAs to sign off on the care they have provided, and it helps a vulnerable population through difficult times. 4:10:22 PM ALLIANA SALANGUIT, Staff, Representative Liz Snyder, Alaska State Legislature, on behalf of Representative Snyder, prime sponsor, provided the sectional analysis for CSHB 392(HSS). She paraphrased from the document in the committee packet titled "SECTIONAL ANALYSIS HB 392: EXPAND ADV. PRAC. REG. NURSE AUTHORITY Ver. B," which read as follows [original punctuation provided]: Sec. 1: Amends AS 08.68.700(a) Determination of death by registered nurse by allowing a Registered Nurse (RN) to pronounce or determine a death of a person if a physician or an advanced practice registered nurse (APRN) or physician assistant (PA) has documented in the person's medical or clinical record that the person's death is anticipated. Sec. 2: Amends AS 08.68.700(b) by allowing an RN to sign a determination of death if a physician, APRN, or PA has previously documented the person's condition. Sec. 3: Amends AS 08.68.700(c) by allowing an APRN or PA to certify a death determined by an RN within 24 hours of the determination of death. Sec. 4: Amends to 08.68.700(d) by adding "an advanced practice registered nurse, or a physician assistant" and physician assistant as a conforming change to statute regarding health care facilities' policies and procedures for determination and pronouncement of death by a registered nurse. Sec. 5: Amends AS 13.62.065 Do not resuscitate protocol and identification requirements (a) by allowing APRNs and PAs to issue a do not resuscitate order. Sec. 6 & 7: Adds conforming language to AS 13.62.065 Do not resuscitate protocol and identification requirements to ensure APRNs and PAs are subject to the same rules and protocols as physicians. Sec. 8: Adds language to AS 13.62.065(f) Do not resuscitate protocol and identification requirements allowing APRNS and PAs to revoke a do not resuscitate order. Sec. 9: Adds "or an advanced practice registered nurse, or a physician assistant" to 13.52.080(a)(5) Immunities as a conforming change. Sec. 10: Amends AS 13.52.100(c) Capacity by adding "an advanced practice registered nurse, or a physician assistant" to language regarding protocols and how do not resuscitate orders govern decisions regarding cardiopulmonary resuscitation and other life- sustaining procedures. Sec. 11: Amends AS 13.52.300 Optional Form by adding "an advanced practice registered nurse, or physician assistant" to the Advanced Health Care Directive Form. Sec. 12: Amends AS 13.52.390(12) Definitions by adding "an advanced practice registered nurse, or physician assistant" to language defining "do not resuscitate order." Sec. 13: Amends AS 13.52.390(23) Definitions by adding "an advanced practice registered nurse, or physician assistant" to language defining "life-sustaining procedures." Sec. 14: Adds a new paragraph to AS 13.52.390(38) defining an "advanced practice registered nurse" and "physician assistant" by referring to the definition in AS 08.68 Nursing and AS 08.64.107 Regulation of Physician Assistants and Intensive Care Paramedic respectively. Sec. 15: Amends AS 18.15.230(c) by adding "advanced practice registered nurse, or the physician assistant" to the instructions for completing a death certificate. 4:12:12 PM REPRESENTATIVE SNYDER explained that the bill does not break new ground, it updates Alaska statute to reflect current practices elsewhere to improve access to care. The bill would bring Alaska in line with 34 other states and the District of Columbia where APRNs have full practice authority and are allowed to sign DNR and POLST forms; 37 other states and the District of Columbia where APRNs have full practice authority and can sign death certificates; 30 states where PAs can sign DNR and POLST forms; and 28 other states where PAs can sign a death certificate. She added that nothing in the bill would change practice protocol or guidelines with respect to patients wishes for any of these actions, it would simply add APRNs and PAs to the list of medical professionals who can sign the final paperwork reflecting a patient's wishes. 4:13:20 PM CO-CHAIR FIELDS opened invited testimony on CSHB 392(HSS). 4:13:38 PM MARIANNE JOHNSTONE-PETTY, DNP, APRN, FNP-C, ACHPN, Alaska APRN [advance practice registered nurse] Alliance, provided invited testimony in support of CSHB 392 (HSS). She noted that she holds a doctorate degree and specializes as an advanced certified hospice and palliative nurse (ACHPN). She stated that the bill would decrease costs, barriers, obstructions, and inefficiencies in the care of the seriously ill. She said the bill would simply update Alaska statutes to align with the APRN state practice and licensing laws. She noted that APRN is an umbrella term that includes certified nurse mid-wives, clinical nurse specialists, certified registered nurse anesthetists, and certified nurse practitioners, but that today's focus is specifically on nurse practitioners. DR. JOHNSTONE-PETTY pointed out that since 1984 nurse practitioners in Alaska have had full practice authority as independent practitioners. She said Alaska's practice and licensing laws permit independent practitioners to diagnose, order, and interpret diagnostic tests, and initiate and manage treatments, including prescribing medications, meaning independent practitioners do all this without having to have a collaborative or supervisory agreement. In being able to do this, she explained, APRNs have serious illness conversations with patients and their families to help better care for them. Part of those conversations need to lead to the completion of forms, including POLST forms, death at home forms, DNR forms, and death certificates. But at this time, she continued, APRNs must rely on physician colleagues to come in and review what they've done to take care of their patients. DR. JOHNSTONE-PETTY conveyed that this is ongoing across the nation - it is to align current practice with the statute and ensure that APRNs can complete the forms for the practice that they are providing for their patients. The best care of the seriously ill, she said, requires that APRNs have signature authority for medical orders and forms, such as DNR orders and Alaska POLST and death certificates. That signature authority is lacking right now, and the bill would simply update the statutes to better align current practice. 4:16:26 PM SHANNON HILTON, DNP, AGACNP, American Association of Nurse Practitioners, provided invited testimony in support of CSHB 392 (HSS). She noted that she holds a doctorate degree in nursing practice and is a board-certified adult gerontology acute care nurse practitioner (AGACNP) and board-certified adult health nurse practitioner. She stated that with their advanced education, APRNs provide a tremendous amount of care for Alaskans throughout the state. But, she continued, the statutes that were written before nurse practitioners were providing the level of care that they are today have not been updated to include APRN signature on these very important documents. These challenges for nurse practitioners and patients have caused significant delays in care and unnecessary conversations during very sensitive times in patient care, she related. DR. HILTON pointed out that the documents in CSHB 392(HSS) serve as an important guide and source of communication between health care providers and their patients and the families of their patients prior to a patient's advanced illness. For example, she related, she may be the clinician directing the course of treatment for a patient and facilitating difficult conversations with family members, but the law does not recognize her extensive knowledge and advanced care planning discussions on this necessary paperwork. As a result of that, patients are left with alternatives. The first is to locate and establish a new patient relationship with another health care provider who is recognized to complete these standard patient care forms. Or, in the instance of critical care, [Alaska's] current health care system is obligated to provide care that patients did not want initially and that patients had prior indicated to their primary care nurse practitioner that they did not want. The disconnect between treating patients and signing paperwork, she advised, contributes to costly unnecessary interruptions in care and to delays at a very trying time. DR. HILTON urged support for the bill because it would authorize APRNs who are already treating the patients to also treat the paperwork and to protect the autonomy of patients and respect patient choices. She reiterated that similar reforms have already been successfully implemented in other states. 4:19:59 PM REPRESENTATIVE KAUFMAN, regarding the forms embedded in the bill, stated that there is probably a variety of ways to create the templates for the forms. He inquired whether the prime sponsor wants these forms embedded in the bill. REPRESENTATIVE SNYDER replied that those forms are already in statute and are not embedded [in the bill]. REPRESENTATIVE KAUFMAN asked whether the prime sponsor is sure that that is how to do this. REPRESENTATIVE SNYDER deferred to the medical professionals to answer the question. 4:21:04 PM CO-CHAIR FIELDS relayed Representative Kaufman's question to the witnesses and asked whether there should be further changes to the underlying statute that CSHB 392(HSS) would change. DR. JOHNSTONE-PETTY responded that as a hospice and palliative care nurse practitioner she doesn't have a strong opinion one way or another whether it is in statute, but her understanding is to minimize statutes as much as possible. She said there are multiple templates for advanced care planning documents in the community that can be used and are readily available. REPRESENTATIVE SNYDER drew attention to page 5, Section 11, of the bill and said the form provided there is an optional sample form that may be used. She agreed it may be worth having discussion on the necessity of that since it isn't something that is addressed in this specific bill. MS. SALANGUIT related that in conversations with Legislative Legal Services during the bill's drafting, the form was added as a conforming change to make it line up with the rest of the statutory changes. 4:22:51 PM CO-CHAIR SPOHNHOLZ noted that her own advanced healthcare directive is included with her legal documents, including her will, which have been submitted to the court system to have on file. She said a confidential paper copy has also been submitted to local hospitals in Anchorage so her wishes can be known should she arrive at the hospital while unconscious. REPRESENTATIVE KAUFMAN responded that he understands the function and that it is optional, but he is trying to determine whether there is a more optimal place to park a template. 4:24:11 PM REPRESENTATIVE NELSON inquired about the conversations that happen in relation to a DNR. DR. JOHNSON-PETTY replied that she has these conversations every day as a hospice and palliative nurse practitioner. She said it is not a situation of a patient wanting DNR and the practitioner just hands the paper to the patient. Rather, she explained, it is an in-depth conversation discussing who the patient is, what the patient hopes to gain from it, what are the goals of the patient's medical care, and why the patient would want something like a DNR. Then it is a conversation about the forms that are to be used and that are the legal forms in Alaska to protect the patient from having procedures that the patient does not want. The POLST form, she stated, is to ensure that the patient's and family's wishes are abided. 4:25:36 PM REPRESENTATIVE NELSON noted that not all APRNs specialize in hospice care. He asked whether other APRNs would be qualified to have that in-depth conversation about the various options, especially the DNR option. DR. JOHNSON-PETTY answered that she believes they do. She pointed out that there are many nurse practitioners and PAs across Alaska who are caring for patients and families, including patients in rural and remote settings. She noted that there is a lengthy amount of training through the website of akpolst.org. She further pointed out that all physicians, not just physicians with hospice training, are able to complete these forms and there haven't been issues with that. She also noted that other states have not made it just for a specific type of APRN, it has been for all APRNs to ensure that the patient has access to these documents. REPRESENTATIVE NELSON related his understanding that while in medical school physicians must take classes in ethics, end of life care, and DNR. He inquired about the training for APRNs. DR. JOHNSON-PETTY replied that nurse practitioners receive extensive training in advanced physiology, ethics, and pharmacology, along with completing clinical hours, to become an APRN. She said APRNs therefore have the training to have these types of conversations. 4:28:06 PM CO-CHAIR SPOHNHOLZ pointed out that advanced health care directives are developed in consultation with health care practitioners and in estate planning conversations. She said it is a form used by many professionals who have this expertise so it can be acted upon if the person becomes unable to make those decisions for himself or herself. The bill, she continued, is referencing a form that is used by a broad group of providers who are trained in having these conversations with folks. [CSHB 392(HSS) was held over.] ^CONFIRMATION HEARING(S): ^CONFIRMATION HEARING(S):    ^Workers' Compensation Board Workers' Compensation Board    ^Workers' Compensation Appeals Commission Workers' Compensation Appeals Commission    4:29:29 PM CO-CHAIR FIELDS announced that the final order of business would be consideration of the governor's appointees to two boards. 4:29:44 PM MATTHEW BARTH, Appointee, Workers' Compensation Board, Division of Workers' Compensation, Department of Labor and Workforce Development (DLWD), testified as appointee to the Workers' Compensation Board. He stated he has been a police officer in Anchorage for about 15 years and is excited to apply his skills and abilities as a member of this board. He said he was appointed to the board earlier this year and has worked as a board member attending multiple hearings to date. 4:30:57 PM CO-CHAIR FIELDS asked whether Mr. Barth is a member of the Anchorage Police Department Employees Association (APDEA). MR. BARTH replied that he has been an APDEA member for about 15 years. He said he is also an APDEA trustee and a member on multiple committees for the APDEA. 4:31:40 PM SARA FAULKNER, Appointee, Workers' Compensation Board, Division of Workers' Compensation, Department of Labor and Workforce Development, testified as appointee to the Workers' Compensation Board, Southcentral Panel industry seat. She stated that she worked for ARCO in the 1980s, then in 1990 she and her husband moved to Homer after having purchased Land's End Resort in 1988. She noted that she has served on the board since 2019 and enjoys serving because of the positive impact that the board's work has in the life of the injured worker and in improving business practices. She said listening is one of her skills and she respects her fellow board members and collaborates with them during deliberations. 4:32:57 PM BRAD AUSTIN, Appointee, Workers' Compensation Board, Division of Workers' Compensation, Department of Labor and Workforce Development, testified as appointee to the Workers' Compensation Board. He stated that he works for the Plumbers and Pipefitters Local Union 262. He said he is the labor member of the board's two-person Southeast Panel and has served on the board since October 2010. Longevity on the board is important, he added, because of sometimes dealing with complex legal and medical issues. He noted that the Southeast Panel approves the self- insurance for employers that provide their own workers' compensation insurance. He said the board also takes care of the regulations for the Division of Workers' Compensation, sits as panel members for quasi-judicial hearings, and reviews and approves or disallows settlement agreements. 4:34:40 PM RANDY BELTZ, Appointee, Workers' Compensation Board, Division of Workers' Compensation, Department of Labor and Workforce Development, testified as appointee to the Workers' Compensation Board. He stated he is currently the North Slope manager for North Star Equipment Services/North Star Terminal and Stevedore Company, and incoming president of the Alaska Support Industry Alliance. He said this would be his second three-year appointment on the board and added that he concurs with Mr. Austin about the importance of longevity on the board. He said he is a good listener and a fair and impartial board member. 4:36:04 PM SARAH LEFEBVRE, Appointee, Workers' Compensation Board, Division of Workers' Compensation, Department of Labor and Workforce Development, testified as appointee to the Workers' Compensation Board. She said she is up for re-appointment to the industry seat of the board's Northern Panel. She stated she has been on the board since about 2008 and has worked in heavy civil construction since 1998. She said she agrees that longevity on the board is important and that the work done by the board is important because lives are at stake. 4:37:10 PM CHRISTOPHER DEAN, Appointee, Workers' Compensation Board, Division of Workers' Compensation, Department of Labor and Workforce Development, testified as appointee to the Workers' Compensation Board. He said his background is health care related, both in care delivery and administration, that he currently works for Foundation Health Partners, and that he is a licensed athletic trainer. He stated that he has a long history of professional and civic service and enjoys the opportunity to serve his profession and the community, having served on boards and committees at the local, state, and national levels. He said he understands and respects the responsibility that his appointment to this board represents. 4:38:26 PM CO-CHAIR SPOHNHOLZ observed from Mr. Dean's application that he originally applied to serve on two other boards. She asked how he came to apply to serve on the Workers' Compensation Board. MR. DEAN responded that when he applied last spring there was an opening on the Physical Therapy and Occupational Therapy Board, but it was determined that he was ineligible to serve on that board because his organization owns a physical therapy and occupational therapy practice. The governor's office asked him whether he would be interested in serving on the Workers' Compensation Board given his experience with administrative work in his practice, he continued, and that is how he applied. He said he has already attended some hearings and is excited to serve because the board provides a much-needed service to the state and to injured workers. 4:40:11 PM STEPHEN HAGEDORN, Appointee, Workers' Compensation Appeals Commission, Department of Labor and Workforce Development (DLWD), testified as appointee to the Workers' Compensation Appeals Commission. He said he worked for the Alaska Railroad Corporation from 1975-2009 and was the Corporate Risk Manager for the last 24 years of his career. He noted that he was first appointed to the board in 1991 by Governor Walter Hickel where he served for a little over 15 years before accepting an appointment to the Workers' Compensation Appeals Commission, on which he has served since 2008. He said he has enjoyed the task of appeals that come from the Workers' Compensation Board as it keeps him very involved with the law and the caseload. 4:41:55 PM CO-CHAIR FIELDS opened public testimony on the governor's appointees to the two boards, then closed it after ascertaining that no one wished to testify. [The confirmation hearings were held over.] 4:42:38 PM ADJOURNMENT  There being no further business before the committee, the House Labor and Commerce Standing Committee meeting was adjourned at 4:42 p.m.