ALASKA STATE LEGISLATURE  HOUSE LABOR AND COMMERCE STANDING COMMITTEE  February 4, 2026 3:18 p.m. DRAFT MEMBERS PRESENT Representative Zack Fields, Co-Chair Representative Carolyn Hall, Co-Chair Representative Ashley Carrick Representative Robyn Niayuq Frier Representative Dan Saddler Representative Julie Coulombe Representative David Nelson MEMBERS ABSENT  All members present COMMITTEE CALENDAR  PRESENTATION(S): LICENSING FOR GENETIC COUNSELORS - HEARD PRESENTATION(S): THE RISING COST OF HEALTH CARE (PART 2) - HEARD PREVIOUS COMMITTEE ACTION  No previous action to record WITNESS REGISTER MONTY WORTHINGTON, Certified Genetic Counselor Providence Cancer Center Anchorage, Alaska POSITION STATEMENT: Gave testimony during the presentation on licensing for genetic counselors. APRIL O'CONNOR, Certified Genetic Counselor Providence Cancer Center Anchorage, Alaska POSITION STATEMENT: Answered questions during the presentation on licensing for genetic counselors. GARY STRANNIGAN, Vice President Congressional and Legislative Affairs Premera Blue Cross Blue Sheild of Alaska Anchorage, Alaska POSITION STATEMENT: Gave the Rising Cost of Health Care (Part 2) presentation and answered questions. JOSEPH FONG, Administrator Medical Park Family Care Anchorage, Alaska POSITION STATEMENT: Gave testimony during the Rising Cost of Health Care (Part 2) presentation. JILL GASKILL, MD Medical Park Family Care Anchorage, Alaska POSITION STATEMENT: Gave testimony during the Rising Cost of Health Care (Part 2) presentation. ACTION NARRATIVE 3:18:33 PM CO-CHAIR CAROLYN HALL called the House Labor and Commerce Standing Committee meeting to order at 3:18 p.m. Representatives Nelson, Coulombe, Saddler, Frier, Carrick, Fields, and Hall were present at the call to order. ^PRESENTATION(S): LICENSING FOR GENETIC COUNSELORS PRESENTATION(S): LICENSING FOR GENETIC COUNSELORS  [Includes discussion of HB 293.] 3:19:40 PM CO-CHAIR HALL announced that the first order of business would be the Licensing for Genetic Counselors presentation. 3:20:04 PM MONTY WORTHINGTON, Certified Genetic Counselor, Providence Cancer Center, noted that he was a lifelong Alaskan and certified genetic counselor who holds a master's in genetic counseling from Stanford University. He noted that he was speaking on behalf of himself as well as his colleagues at the Providence Cancer Center. He appreciated the opportunity to speak about genetic counseling and licensing. MR. WORTHINGTON noted that Alaska was one of twelve states that has not passed legislation to establish licensure for genetic counselors. He said that there are several reasons that licensure for genetic counselors would be valuable. He said these include reduction in harm to patients due to services being provided by unqualified individuals, increasing access to genetic counselling services for Alaskans, and economic benefits that licensure would bring. MR. WORTHINGTON said that before speaking about licensure, he wanted to speak about what genetic counselors do. He said that he provides care to individuals with personal or family histories of cancer. He said that with these patients, he gathers a detailed family history as it relates to cancer and assesses the likelihood of there being an inheritable component of the cancer. He provides education on familial and hereditary risks of cancer and then enters a shared decision-making process with his patients to determine if genetic testing is warranted. He said that this involves discussing what types of genetic testing would be most appropriate. He discloses and interprets genetic test results and provides up-to-date risk assessment and cancer screening guidelines for patients and their family members. Furthermore, counseling and psychosocial support are provided to patients during their visits, particularly as it pertains to genetic tests and their impact on patients and families. He remarked that he sits on multi-disciplinary tumor boards to provide input on appropriate genetic testing matching to patients and its utility. He noted that in some cases, results of genetic testing can provide information to proactively manage cancer risk for patients and their families. He said in other cases it can open treatment modalities that are more appropriate than standard treatment types. MR. WORTHINGTON remarked that genetic counselors are employed by a wide range of institutions including clinical care, academic institutions, laboratories, research, and biotechnology ("biotech") settings. He stated that genetic counselors are health care providers with significant training and expertise in human and medical genetics, patient education, psychosocial counseling, which is obtained in a two-year master's program. In a clinical care setting, genetic counselors are found in health care specialties that include prenatal, pediatrics, oncology, cardiology, neurology, and many other specialties. Genetic counselors are key players in appropriately applying genetics into health care, they provide expertise in genetics to patients and provide expertise to their other clinical providers. He said that genetic counselors work "hand in hand" with physicians and other clinical providers to identify individuals most appropriate for consideration for genetic testing or hereditary conditions and to provide interpretations of test results to help guide providers in managing identifiable genetic conditions. MR. WORTHINGTON noted that there are currently seven genetic counselors who work and live in Alaska. He said that at least one genetic counselor provides services to patients living in other states. He noted that these counselors work by providing specialty care in a variety of other instances. He said that there are several genetic counselors who work for testing labs or consultancies and provide care to patients in Alaska but reside in other states. He said that a single hereditary cancer testing lab has at least sixty genetic counselors who provide these types of services. MR. WORTHINGTON explained that Alaska currently has no legal standard for anyone who can represent themselves as a genetic counselor. He said that licensure would provide a standard for practice and by doing so it would provide value in a variety of ways. This includes protection of patients from harm by ensuring minimum standards for practice. He said that as the field of medical genetics grows, there is and will be a need to provide the residents of Alaska with accurate information regarding genetic risk. He said that a few decades ago genetic information was utilized in only a few clinical specialties; today it is hard to find an area of medicine where genetics does not have a role to play. Furthermore, the complexity of genetic tests has continued to increase. He said that genetic counselling fills this space in the medical field. 3:26:05 PM MR. WORTHINGTON explained that without a standard that qualifies who can practice, significant harm can occur. He remarked that residents of Alaska deserve access to professionals who have been qualified by the state to help understand the potential and actual impact of genetic information on their health. He noted that licensure requirements would provide this qualification. Furthermore, licensure for genetic counselors would make services more easily billable and reimbursable from both private payers and Medicaid. He said that the states lacking licensing standards have challenges regarding what procedures can and cannot be billed. This makes many services not worth the effort for reimbursement. He said that states without licensure do not qualify genetic counselors as rolling providers with Medicaid. He said that licensure in Alaska would facilitate Medicaid recognition and facilitate access to health care for Medicaid beneficiaries. He reiterated that licensing would facilitate access for counseling services. MR. WORTHINGTON noted that recent changes to billing codes for genetic counselors and ongoing efforts at the federal level with the Access to Genetic Counselor Services Act of 2025, efforts have been made to facilitate Medicare access to these services. He said that state licensing would enhance opportunities for reimbursement and increase access for patients in Alaska. MR. WORTHINGTON said that this bill would enable genetic counselors to order genetic tests. He said that genetic counselors refer to physician referrals and other licensed advanced practice providers and orders are placed under those providers names. He said that licensure would allow counselors to fully perform the scope of practice by eliminating barriers. This legislation is important to Alaska for maintaining a high- quality genetic testing workforce. He raised concern about genetic counselors looking for other opportunities in other states due to licensing complications and the difficulty in attracting genetic counselors from other states. He urged the committee to consider legislation to create licensing requirements for this profession. 3:30:21 PM CO-CHAIR HALL mentioned that the committee would hear an introductory hearing of HB 293 in an upcoming meeting. The bill would install licensing requirements for genetic counselors in Alaska and was the bill of reference during Mr. Worthington's presentation. 3:30:56 PM REPRESENTATIVE SADDLER said that he had never heard of genetic counselling prior to seeing the bill in development. He asked what credentials were in the field of genetic counselling and how many counselors were practicing in Alaska. MR. WORTHINGTON responded that at a national level there is certification process for genetic counsellors. 3:31:32 PM APRIL O'CONNOR, Certified Genetic Counselor, Providence Cancer Center, noted that the national certifying body for genetic counselors was the American Board of Genetic Counselling. MR. WORTHINGTON noted that currently thirty-five states have licensures in place for genetic counselors. Furthermore, two other states have passed legislation that would establish licensing. 3:31:57 PM REPRESENTATIVE SADDLER asked how many genetic counselors were practicing in Alaska. MR. WORTHINGTON responded that there were seven who work and live in Alaska and one who lives in Alaska and provides care to patients living in other states. 3:32:13 PM REPRESENTATIVE CARRICK noted that she also had not heard about genetic counselling before today and appreciated the introduction. She asked whether all seven genetic counselors were working in Anchorage or were spread to other parts of the state. MR. WORTHINGTON responded that three work at Providence Cancer Center, three provide care through the Southcentral Foundation and the Alaska Native Medical Center (ANMC), and one works in Juneau and provides care for people in other states. He was unsure about the placement of one other genetic counsellor. REPRESENTATIVE CARRICK said that generally when licensing a profession, it is common to assay any issues with people operating outside the scope of licensing. She asked whether people were calling themselves genetic counsellors without credentials. MR. WORTHINGTON responded that Ms. O'Connor had more experience working in other states and working with licensing credentials. 3:34:26 PM CO-CHAIR HALL asked Mr. Worthington to follow testimony protocol. 3:34:52 PM MR. O'CONNOR responded that she has been a genetic counselor for 21 years and in the 4 years that she has practiced in Alaska, she has come across a scenario where a patient has been misinformed of the inheritance pattern with test results and this misinformation may have been provided by a provider who was not trained in genetics. She said that she also practices cardiology for a hospital in Tennessee and said that this type of misinterpretation happens there as well. She said that this creates problems with treatment options. Overall, she said that she has seen problems associated with genetic care by individuals without appropriate credentials. 3:36:30 PM REPRESENTATIVE COULOMBE asked why someone would get a genetic counselor and asked what types of conditions would warrant this type of counselling. MR. WORTHINGTON responded that the way that the medical systems work is typically a provider or specialist evaluates somebody with a condition such as cancer or cardiac condition, and they would recognize that there may be a heritable component. At this point they would refer to genetic counsellors. He noted that oncologists would send patients to a genetic counselor specializing in cancer risk whereas a cardiologist may refer a patient to a genetic counselor specializing in cardiology. He said a counselor's role is to step in and assay the family history and the likelihood or a heritable component to the condition. REPRESENTATIVE COULOMBE asked about the error rate associated with testing and asked whether there was a percentage error rate. MR. WORTHINGTON responded that as far as the tests themselves operate, they are highly accurate and the only way to receive errors from the actual test is that there is a classification of genetic variance and it ranges from pathogenic to benign. He said that genetic tests themselves, counsellors look at this type of variance and make determinations. He said that the actual DNA test is around 100 percent accurate but how it is interpreted requires training and evaluation. REPRESENTATIVE COULOMBE said that there is an interpretation level associated with it much like x-rays and sometimes it can be misinterpreted. MR. WORTHINGTON responded that there is a level of interpretation involved. 3:39:57 PM REPRESENTATIVE FIELDS asked Mr. Worthington whether the absence of a sustainable billing model due to lack of licensure would cause complications for genetic counselors operating in smaller clinical organizations that cannot pay the costs. MR. WORTHINGTON responded that licensing would increase employment opportunities and said that Ms. O'Connor could comment as well. 3:40:39 PM MR. O'CONNOR added that currently not having licensure there was complications with downstream revenue. She noted that if services could get billed at a professional level, then that could open the doors. She said that states that contained licensing had more billable operations and more businesses could employ genetic counsellors. REPRESENTATIVE FIELDS asked whether Ms. O'Connor could comment on the technological advancements regarding people's genetic information and how it generates more efficient patient care. 3:42:06 PM MS. O'CONNOR responded that much of the field is evolving into targeted therapies. She said this has opened a large role for genetic counsellors to provide counseling for patients. Depending on the results of the gene screening, it can assist with driving care and targeted therapeutics. She described the process of isolating a gene factor and specific patient focused care. 3:42:59 PM MR. WORTHINGTON added that in terms of genetic testing technology, there is a wide array of different ways to test the genome. He said that knowing which test is appropriate is a constant learning curve and ensuring that appropriate test deployment is a matter of continuing education. 3:43:42 PM REPRESENTATIVE SADDLER said that he was hung-up on the counselor aspect of things and was curious to what degree genetic considerations are made during a routine physical check-up when patients are seeing a physician. He said that he still would like to hear the case for why genetic counselling needs its own practice. MR. WORTHINGTON responded that the title of genetic counselor has been established for more than 50 years, it occurred when genetic specialists working in the medical field were termed "genetic counselors." He said that they provide counselling primarily to their patients. He noted that the work is complex and it does not simply involve individuals but often patient families. He reiterated that psychosocial concerns were common and they were trained to address these. 3:45:15 PM REPRESENTATIVE COULOMBE asked whether most people getting genetic counselling were adults and whether the practice was common with children. MR. WORTHINGTON responded that there are specialists who work in pediatrics. He said that when there are complicated health conditions in children, genetic counsellors can be part of the diagnostic process. He said that it is also important to recognize when counselling would be appropriate. He said that most conditions he works with lead to adult onset of cancer risk as opposed to child onset of cancer risk. He said that sometimes family members are keen to test their children for things that would not change health care until adulthood. He said that genetic counsellors try to counsel parents that autonomy might be a better approach. He said that families are families and make their own decisions, but counsellors try to guide them through pitfalls and benefits. 3:46:45 PM REPRESENTATIVE SADDLER said that he was still trying to understand the practice, he asked where in the medical chain genetic counsellors operate and who pays for their services. MR. WORTHINGTON responded that he works for the Providence medical system and is paid through the Providence Cancer Center. He reiterated that since many of the genetic counselling services were not billable, it is one of the reasons that licensure is important. He said that this creates challenges in recouping costs from unbillable services. He said that genetic counsellors sit in the overhead of the cancer center. He said that one reason Providence does this is that it allows credentialing as a comprehensive cancer care center. This certification requires genetic counsellors working at an institution. He reiterated that they were paid by the overhead. 3:48:02 PM REPRESENTATIVE CARRICK asked whether there was a demand for prenatal genetic counselling so potential parents can understand risk factors. Furthermore, she asked whether there was an understanding of what volume of counsellors work in oncology as opposed to another field. MR. WORTHINGTON deferred the question to Ms. O'Connor. 3:49:08 PM MS. O'CONNOR said that she has worked as a prenatal genetic counselor for the entirety of her career. She said that she is currently working remotely as a maternal fetal medicine specialist in Arizona. She said that when she graduated in 2005, most genetic counsellors were in prenatal space, or around 60-70 percent of counsellors at the time. She noted that genetic screening in oncology is still in its infancy. She said today things have shifted and most genetic counsellors practice oncology and make-up over half of the workspace. She reiterated that there is a role of prenatal genetic counselling that involves meeting with families to discuss prenatal conditions that could affect an unborn challenge. She said work is closely conducted with prenatal medicine specialists. 3:50:46 PM REPRESENTATIVE FIELDS said that his understanding is that sometimes an older couple may worry that they have a heritable condition and could talk with a genetic counselor to determine risk. He asked whether Ms. O'Connor could elaborate on this. MS. O'CONNOR responded that in states with licensure, maternal fetal medicine specialists have determined that patients in a high-risk group should be referred to genetic counselling. She described instances in which couples might get referred to genetic counsellors. REPRESENTATIVE FIELDS commented that one of his motivations in introducing the bill is to provide consulting services for couples engaged in family planning. 3:53:17 PM The committee took an at-ease from 3:53 P.M. to 4:10 P.M. ^PRESENTATION(S): THE RISING COST OF HEALTH CARE (PART 2) PRESENTATION(S): THE RISING COST OF HEALTH CARE (PART 2)    4:10:05 PM CO-CHAIR HALL announced that the final order of business would be The Rising Cost of Health Care (Part 2) presentation. 4:10:46 PM GARY STRANNIGAN, Vice President, Congressional and Legislative Affairs, Premera Blue Cross Blue Sheild of Alaska ("Premera"), began the Rising Cost of Health Care (Part 2) presentation via PowerPoint [hard copy included in committee file]. He noted that Premera is a not-for-profit institution that has operated in Alaska prior to the establishment of statehood. He said the aim of Premera is to make health care work better by placing the customer at the forefront of everything the company does. He noted that insurance is a heavily regulated business and the products are reviewed and prices are approved before plans can be sold. He noted that Premera is subject to financial and regulatory supervision and accountability in the marketplace. MR. STRANNIGAN explained that insurance commissioners were created to address a problem where unscrupulous operators would come into a town and sell different types of insurance at low cost and were never seen again. He said that because of this, insurance commissions were put into place to provide market supervision. In essence, insurance commissioners were created to be sure that insurers were charging enough. He said that it is often not possible to do business in a successful way in an environment that is prone to legislative and public input. MR. STRANNIGAN noted that one key role of insurers in the construct of the United States health care marketplace is to put downward pressure on health care costs. He said that without a doubt, this puts insurers at odds with some provider partners. MR. STRANNIGAN, on slide 2, pointed to a pie chart that illustrated Premera dollars in the small and large group marketplace. He said that what is interesting is that the insurance side is small, about 8 percent. He noted other data points pertaining to commission, taxes, and other factors. He said that there was a "little sliver" on the pie chart pertaining to profits. He continued to elaborate on the various points on the pie chart. He said that the reason the pie chart was important was that for decades lawmakers have focused the bulk of their attention on the 8 percent of the pie chart. He said that given that Premera was 8 percent of the overall picture, there is not a lot of "fruit left on the tree." He said the American health care system is about twice as costly as most other industrialized nations, with outcomes that are not better, and often worse. He said that it seems to him that there would be better service regarding innovation to improve the pre-existing health care system. He acknowledged that tremendous investments have been made and successes have been made in health improvement despite this. He remarked that the pie chart underscores where opportunities lie. 4:16:43 PM MR. STRANNIGAN proceeded to slide 3 of the presentation, which displays a few common procedures and cost differentials between Washington and Alaska. He said that Primera does business exclusively in both these states. He said that they are licensed with the Blue Cross Blue Sheild Association (BCBSA). He said that these comparisons were good since the data was readily available and costs for in-network and out-of-network care are available. He said that the chart on the slide has been similar for quite some time. MR. STRANNIGAN proceeded to slide 4, which showed a chart of "new" information from the U.S. Bureau of Economic Analysis (BEA). He explained that it was a 2024 report on the cost of living in every state. He said that several states have exceeded Alaska regarding the cost of living. He pointed out that Washington has a 6 percent higher cost of living than Alaska. He said that a few years ago he could eat at a nice dining area in Alaska for less money than the same type of establishment in Washington. The factors pushing cost of living higher than Alaska are taxes, cost of housing, childcare, and restaurants. He said it is interesting how cost of living has flipped and it is important to make these considerations when thinking about the cost of health care. People often conflate health insurance and health care and the costs of each. He said that health insurance is primarily driven by the cost of health care but there is a fine distinction. In Alaska, the affordability is driven by the cost of care. 4:20:12 PM MR. STRANNIGAN proceeded to slide 5, the final slide of the presentation which provided information on recommendations for sustainable affordability. He said there are not a lot of proactive things listed but, rather, cautions. He said that the repeal of the eightieth percentile from a few years ago had some positive impacts on the individual market in the state of Washington, meaning reductions in premiums. He said that these were mostly concealed by increases in the cost of care which outpaced reductions. He said that this year, apart from the expiration of the advanced premium tax credits, the individual market premiums went down 3 percent. Consumers are seeing higher prices due to the expiration of the credits. He said that Premera was a strong supporter of continuation of the tax credits and was disappointed to see their expiration, especially considering the market in Alaska. He said that customers need help since the insurance has become costly. MR. STRANNIGAN pointed out that the slide listed a few other pieces of legislation that pertain to health insurance premiums. He described a few of the pieces of legislation and cautioned against specific legislative approaches to change reimbursements and the floor. He noted that last year a bill was passed that Premera and Jared Kosin with the Alaska Hospital and Healthcare Association (AHHA)supported, and it was a great example of health insurance and health associations working together to support Alaskans. He recommended that it could be modeled by other states. MR. STRANNIGAN noted that the final recommendation on the slide pertains to value-based care arrangements to provide provider incentives with good patient outcomes. He noted that people are paid to "pull a crank" and this does not always align with good patient outcomes. He noted that care arrangements are intended to address the wellness of the patient and not just the symptoms of a current condition. He stated that there is difficulty in convincing providers to sign up for this for a variety of reasons, but it is something that warrants more exploration. He concluded the presentation and noted that he was happy to listen to additional testimonies and answer any potential questions. 4:24:41 PM JOSEPH FONG, Administrator, Medical Park Family Care, gave testimony during the Rising Cost of Health Care (Part 2) presentation. He noted that Medical Park Family Care is a physician owned and locally owned primary care practice located in Anchorage. It has been operating for around 52 years, and the current owners are all long-time Alaskans. He said that the organization has cared for Alaska residents for years and wants to continue to do so. He said that pressures on both cost and reimbursement are making it challenging to provide services. He said that the clinic is in the process of renewing its health insurance plan, and the 2026 prices were increased by 37 percent. He noted that it was not reasonable, and he does not understand the price increases. He said that Medical Park Family Clinic pays most of the costs for health insurance and, in prior years, it has paid 82 percent of the total cost of health care. He noted that if the cost of insurance for the year was $10,000, then the organization paid for $8,200 of the employee health insurance costs. He said that the 37 percent increase translates to an additional $340,000 that needs to be covered by the organization to continue providing health insurance for the employees. He said that the employees would experience price increases as well. He discussed the payments and changes the clinic made to accommodate price increases and noted that employees were still seeing double the cost than that of previous years. He said that price increases are hard to understand and justify. MR. FONG said that being a health care provider allows the clinic to get perspectives from the patients as a recipient of payments from insurance companies. He said that over the last several years, more patients are coming in and asking for services that are 100 percent covered by their health insurance provider. He said that this is not a good way to provide health care, and others could testify to this. Not only is it not a good way to approach health care but it is something that is challenging since patients' health insurance coverage varies. He said it can be challenging for the clinic to understand what insurance plans cover what services for what patients. He said that the clinic asks patients to determine what is and what is not covered, it is something that the clinic is unable to do. He said that in 2025 the clinic saw 13,000 individual patients and it is not possible to keep track of this type of information. He noted that it was challenging to provide care rather than deal with an "administrative burden." MR. FONG noted an additional observation in 2026 is that a lot of patients are opting not to carry health insurance. He said that the clinic conducts health insurance verification prior to visits, and the clinic has found an increased number of patients who no longer carry health insurance. Furthermore, even if the patients do have insurance, they are asking whether they can pay for health care services in cash. He said that the clinic offers uninsured patients a cash pay discount and, in some instances, this can be less than what the insurance reimbursement is with patient deductibles. He said that it is hard to understand and navigate this. MR. FONG noted that another factor for consideration is the reimbursement side. He explained that all the costs continue to rise with insurance but as a provider that bills insurance and gets reimbursed, the reimbursements have not increased. He said that reimbursement rates have not changed in almost 10 years. He said that given these pressures, it is becoming harder to provide good quality care from a clinical perspective as well as being able to have a viable business. 4:32:45 PM MR. FONG said that the clinic participates in a few value-based care projects, and it requires careful design to ensure the value of that care. He also mentioned that the clinic is part of an integrated network comprising over thirty practices. He noted that the clinic has spoken with Premera regarding expansion of the value-based care program, but there has been no movement in that direction after two years of conversation. He reiterated that it was hard to understand how the health care billing was a sustainable model and the clinics' opinion is that it was not. 4:34:28 PM JILL GASKILL, MD, Medical Park Family Care, gave testimony during the Rising Cost of Health Care (Part 2) presentation. She said that she has been concerned regarding the decision- making for employee health insurance. The clinic has realized that the health insurance bill has gone from around $1 million to approximately $1.35 million. She pointed out that this is for a business that covers 48 employees and their families, which she said is not a "huge" number of people. She related that $1 million dollars just gets premiums and not necessarily health care. She raised concern that small businesses in Anchorage working in the private sector are struggling with recruitment and as a health care provider she needs nurses and other clinicians to provide care. 4:40:55 PM DR. GASKILL asked the committee to consider the way small businesses are being taken advantage of by private insurance companies to provide meaningful health care to employees. She said that people in the private sector need access to health insurance and for businesses to remain in place. 4:41:33 PM CO-CHAIR FIELDS said that one of his concerns when Congress gutted Medicaid and the enhanced premium tax credits is that it would end access to affordable private insurance, and the effects were already observed. He asked Dr. Gaskill to keep the committee in the loop as she sees the downstream impacts. 4:42:09 PM DR. GASKILL, in response to Representative Saddler, confirmed that medical assistants are called MAs and perform a variety of clinical tasks. 4:42:24 PM MR. FONG, in response to Representative Saddler, explained that value-based programs utilize payments based on the value of care received. He discussed the incentives to provide this type of care and some programs on the backend; if savings are demonstrated, then savings can be shared between insurance and the provider. In response to a follow-up question, he clarified that rather than paying for results or service, value-based programs focus on "paying for outcomes." 4:43:56 PM DR. GASKILL, in response to Co-Chair Fields, replied that she did not know the exact number of local, family-oriented facilities like Medical Park Family Care, but estimated there may be around 10. She noted that most people in Anchorage would likely be seeing a clinician in private practice. She described a few examples of private practice providers. She said that the ones that are not private tend to serve a niche group of patients. 4:45:37 PM REPRESENTATIVE SADDLER referred to the pie chart slide of Mr. Strannigan's presentation and asked if he could clarify the numbers associated with it. MR. STRANNIGAN responded that he could not expand on the pie chart at this time, but he could follow up with an answer. He asked if there was a specific service he was interested in. REPRESENTATIVE SADDLER said that he was trying to understand the net amount of premium dollars associated with the chart. He asked whether Premera was only operating with a .9 percent profit and if that's what the chart suggested. MR. STRANNIGAN, in response to a query from Representative Saddler regarding a pie chart on a previous slide, confirmed that it represents the insured group business. He said that this is the data that he can send with follow up. He noted that it is not the entire amount of revenue from the State of Alaska. REPRESENTATIVE SADDLER asked for a layman's understanding of the chart. MR. STRANNIGAN responded that the State of Alaska does not regulate self-insured business since that is not actually insurance and those businesses operate their health plans for companies themselves and pay the claims themselves. They do so under the federal Employee Retirement Income Security Act of 1974 (ERISA) laws. He said that they are governed by the U.S. Department of Labor. REPRESENTATIVE SADDLER asked again for the clarification of the chart and how it ties into discussions. MR. STRANNIGAN responded that the state-regulated business is fully insured and Premera assumes the risk of the claims that the employees bring for the large group and small group. 4:49:10 PM REPRESENTATIVE COULOMBE, referring to previous testimony, asked Mr. Strannigan to respond to the claims of premiums going up to the point of unaffordability. She noted that there was not much mention of the cost of care going up but the premiums have. MR. STRANNIGAN responded that it is not uncommon and is part of why Premera advocated so aggressively for the extension of the premium tax credits. He said that this is especially important when considering the small business and individual markets. He confirmed that the premiums were "sky high" and affirmed that 85 percent of the premium cost is from health care and the cost of health care is "sky high." MR. STRANNIGAN noted that GLP-1s were referenced and most Premera plans for businesses do not cover this type of medication. He said Premera was aware of only one small business member that opted for coverage for GLP-1s. He said that the per member per month cost is over $50. He said these costs were spread amongst the group. For context, around half of this was paid for through primary care. He said that it is a "big" expense to opt into this kind of coverage. He noted that most plans do not cover weight loss medications. He said there are lot of unknowns for GLP-1s from a clinical and actuarial perspective. 4:52:58 PM REPRESENTATIVE COULOMBE said that the termination of tax credits could be blamed but she believed that there is a bigger problem with this. She said the problem was just being masked by the tax credits. She said that if her premium is $100 and she had the tax credits and was able to pay $50, the insurance company would still get $100 for the premium. She wanted to determine what is driving the premiums up "so high" and why they are staying so high. She noted that high premiums have been unmasked since the government is not helping. She asked whether Mr. Strannigan had any thoughts on this. MR. STRANNIGAN responded that Premera would suggest that any changes in prices of health insurance are not necessarily associated with insurance but the cost of care. He said that virtually every hospital system that has been part of negotiations has requested a 15 percent price increase year after year. He reiterated that the cost of care and the hospital side of things is the biggest piece. 4:54:50 PM CO-CHAIR HALL remarked that she was having a hard time analyzing this. She asked for clarification that the premium increases are a result of a cost of care and wished to hear from Family Park Medical Clinic regarding this. She said that if the providers are not receiving increases in the reimbursement rates and if it is flat over years, she is not understanding the what is being said. DR. GASKILL responded that when it comes to the reimbursements for primary care, these have been flat. She has not received any increase in compensated care over the last decade, and the dollar amounts are the same. She noted the Premera's reimbursement has not gone up in 10 years. She said that the clinic is seeing a similar, if not fewer, number of patients and there is not another way to do the math. She said that she has been engaging with value-based contracting through clinically integrated networks and Premera has not been interested in participation. The clinic is seeing higher costs, higher plans, and higher deductions. 4:57:18 PM CO-CHAIR HALL asked whether Mr. Strannigan had any comments on this. She asked for insights into why reimbursements for primary care have remained flat. MR. STRANNIGAN responded that he did not have any illuminating information on the flat reimbursements for primary care, and he agreed with the comments regarding primary care that helps address health care cost inflation. He said an interesting study he recently came across indicated that people who have a relationship with a primary care physician have 30 percent lower health care costs. He said that primary care is something that Premera has tried to prioritize and there is a network of primary care facilities in Washington State. He said that there is a primary care crisis that has many waiting six months to meet with a physician. He reiterated that flat line reimbursements were something that Premera needs to look review. He suspects that most cost increases have come from private equity firms buying up clinical practices. 5:00:58 PM REPRESENTATIVE SADDLER said he has observed what seems to be finger pointing regarding who is responsible, with the clinicians pointing at health insurance costs and the insurance providers pointing at rising health care costs. He questioned how he could explain this to constituents. He asked for an easy answer as to why health costs and insurance costs are increasing, offering his understanding that Mr. Strannigan noted that it was private equity. DR. GASKILL said that the question regarding increasing health care premiums going up was something that she could not answer easily since these cost increases were not necessarily associated with the primary care settings. She noted that the expenses may be associated with other clinical settings that provide the highest levels of care. 5:02:42 PM MR. FONG added that he agreed with Dr. Gaskill and that rising costs were not coming from primary care facilities but specialty care facilities. 5:03:06 PM MR. STRANIGGAN said that it is the cost of care, and it is important to note that insurance companies are regulated and the books are checked. He said that none of these things are true for clinical providers. CO-CHAIR HALL asked if Mr. Strannigan agreed with Mr. Fong's comments on costs associated with specialty care facilities. MR. STRANNIGAN responded that he agrees with Mr. Fong regarding specialty care costs. 5:03:57 PM REPRESENTATIVE SADDLER asked for clarification of the cost of care. MR. STRANNIGAN responded that it runs the gamut and features a wide range of services. He said the price of these services is going up. REPRESENTATIVE SADDLER asked for clarification. MR. STRANNIGAN responded that the number of widgets and cost of widgets has gone up. 5:05:27 PM ADJOURNMENT  There being no further business before the committee, the House Labor and Commerce Standing Committee meeting was adjourned at 5:05 p.m.