ALASKA STATE LEGISLATURE  SENATE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE  February 23, 2021 1:33 p.m. MEMBERS PRESENT Senator David Wilson, Chair Senator Shelley Hughes, Vice Chair Senator Mia Costello Senator Lora Reinbold Senator Tom Begich MEMBERS ABSENT  All members present COMMITTEE CALENDAR  SENATE BILL NO. 67 "An Act relating to the licensure of nursing professionals; relating to a multistate nurse licensure compact; and providing for an effective date." - HEARD & HELD PREVIOUS COMMITTEE ACTION  BILL: SB 67 SHORT TITLE: NURSING: LICENSURE; MULTISTATE COMPACT SPONSOR(s): RULES BY REQUEST OF THE GOVERNOR 02/03/21 (S) READ THE FIRST TIME - REFERRALS 02/03/21 (S) HSS, L&C 02/23/21 (S) HSS AT 1:30 PM BUTROVICH 205 WITNESS REGISTER JULIE ANDERSON, Commissioner Department of Commerce, Community, and Economic Development (DCCED) Anchorage, Alaska POSITION STATEMENT: Introduced SB 67 on behalf of the Senate Rules Committee, sponsor by request. SARA CHAMBERS, Director Division of Corporations, Business, and Professional Licensing Department of Commerce, Community and Economic Development (DCCED) POSITION STATEMENT: Introduced SB 67 on behalf of the Senate Rules Committee, sponsor by request. ROSE LAWHORNE, Chief Nursing Officer Bartlett Regional Hospital Juneau, Alaska POSITION STATEMENT: Testified in support of SB 67. DANETTE SCHLOEDER, Chair Alaska Board of Nursing Anchorage, Alaska POSITION STATEMENT: Testified in support of SB 67. TAMMIE PERREAULT, Northwest Regional Liaison U.S. Department of Defense Washington, D.C. POSITION STATEMENT: Testified in support of SB 67. BRIAN NORTON, R.N., Manager Cook Inlet Dialysis Fresenius Kidney Care Anchorage, Alaska POSITION STATEMENT: Testified in support of SB 67. REBECCA FOTSCH, Director State Advocacy & Legislative Affairs National Council of State Boards of Nursing Chicago, Illinois POSITION STATEMENT: Offered to answer questions about the Nurse Licensure Compact. ACTION NARRATIVE 1:33:14 PM CHAIR DAVID WILSON called the Senate Health and Social Services Standing Committee meeting to order at 1:33 p.m. Present at the call to order were Senators Begich, Costello, Hughes, and Chair Wilson. Senator Reinbold joined shortly thereafter. SB 67-NURSING: LICENSURE; MULTISTATE COMPACT  1:33:38 PM CHAIR WILSON announced the consideration of SENATE BILL NO. 67 "An Act relating to the licensure of nursing professionals; relating to a multistate nurse licensure compact; and providing for an effective date." He stated his intent to hear an overview of the bill and take invited testimony. He called on Commissioner Anderson and Director Chambers to introduce the bill. 1:35:23 PM JULIE ANDERSON, Commissioner, Department of Commerce, Community, and Economic Development (DCCED), Anchorage, Alaska, said that SB 67 will allow Alaska to become part of the Nurse Licensure Compact (NLC). SB 67 is a pro healthcare, pro military, bipartisan piece of legislation. By joining the NLC, registered and practical nurses are able to practice in any of the participating states in the NLC. The standards to obtain a multistate license are high. Alaska has hundreds of nursing vacancies and projections show that the vacancy rate will only increase over the next decade. The Board of Nursing will retain full regulatory authority over nurses practicing in the state. Alaska nurses and healthcare facilities across the state support this legislation, as does the U.S. Department of Defense. The military has clearly stated that license reciprocity for military spouses is a key factor in basing decisions. Nursing is one of the most common professions for military spouses. Enacting the NLC in Alaska will not only improve Alaskan access to healthcare and allow mobility for Alaskan nurses but will also increase economic opportunities for the state through potential military expansion. MS. ANDERSON said her team did a wonderful job handling the hundreds of applications for new nurse licenses that were necessary once COVID-19 hit Alaska, but had the NLC been in place at that time, the response efforts could have been quicker and more cost effective for all parties involved. This legislation is win-win for Alaska. 1:38:29 PM SARA CHAMBERS, Director, Division of Corporations, Business, and Professional Licensing, Department of Commerce, Community and Economic Development (DCCED), said the NLC is a voluntary, multistate agreement that allows highly qualified practical and registered nurses to practice nursing in any member jurisdiction. Becoming a member of the NLC would be especially timely for Alaska because it solves several problems. MS. CHAMBERS said that the NLC eliminates additional costs, delays and bureaucracy from the delivery of healthcare services. The purpose of occupational licensure is to ensure that individuals meet minimal, jurisdictional requirements to perform a professional service. The licensing takes time, money, and a lot of paperwork. In Alaska an initial nursing license can cost up to $500 and take many weeks to complete. During this time, the applicant cannot work as a nurse in the state. The applicant loses income and a clinic or hospital cannot provide a certain level of care to its patients while the position goes unfilled. When emergencies like an earthquake or pandemic affect the state, the demand for nurses goes up, creating additional delays in processing licenses and delaying the delivery of healthcare. When the state needs nurses the most, they are more difficult to obtain. MS. CHAMBERS said that failure to participate in the NLC affects the state's military community. The U.S. Department of Defense recognizes the difficulty military families face when relocating and has declared that economic decisions such as base location and expansion will rely heavily on state policies toward military spouse employment. The NLC is considered the gold standard in license reciprocity. 1:41:15 PM MS. CHAMBERS said that Alaska's ability to keep up with the demand for healthcare has been at crisis levels even before the pandemic. The Alaska State Hospital and Nursing Home Association (ASHNHA) reported 670 nursing vacancies in 2019. Even before the pandemic there were not enough skilled nurses to meet Alaska's healthcare needs. Since July 2020, the Alaska Board of Nursing issued 324 emergency courtesy licenses to keep up with the COVID pandemic. These licenses were created by emergency regulations by the board last year and represent the additional help needed to keep up with the crisis. The Bureau of Health Workforce estimates that Alaska will need 23 percent more nurses by 2030. That is 5,400 more registered nurses (RN) when the state already has vacancies for almost 700 nurses. An additional measure of concern is that RN and APRN (Advanced Practice Registered Nurse) licenses expire this Sunday in Alaska and 25 percent of nurses, more than 4,500 nurses, have not renewed their licenses. MS. CHAMBERS said that the NLC is a voluntary agreement among state legislatures that sets high, mutual standards for nurses who wish to receive a multistate license. The multistate license is optional for resident nurses, but it allows nurses to work in any member state without having to apply for licensure each time. Each state board of nursing retains authority over the practice of nursing in its state. The practice standards don't change. Violations of practice standards prohibit offenders from further practice in the state and any violation is reported to the home state board of nursing for disciplinary action. Healthcare vacancies can be filled quickly at little expense for the facility, the nurse, or the state government. The multistate license is attractive to Alaska nurses. The ability to work in member states is attractive to Alaska nurse graduates who are leaving the state because of lack of this automatic reciprocity. So far, 35 states and territories have adopted the NLC and another 11 have introduced legislation to join. 1:44:16 PM SENATOR HUGHES asked of the 324 emergency courtesy licenses, how many were coming from out of state. MS. CHAMBERS replied that they were all from out of state. CHAIR WILSON asked how many nurses were expedited to graduate early through the University of Alaska. MS. CHAMBERS answered that she would get that information. MS. CHAMBERS said that the benefits joining the NLC are many. If Alaska had joined the NLC when legislation was introduced in January 2020, expenses to healthcare facilities, private individuals, and state government could have been reduced. Alaska nurses would not have had to bear the great burden during the COVID surge last fall. An Anchorage Daily News article from November 28 captured the desperation and burnout faced by Alaskan nurses during the height of the surge. In the article, the labor representative for the Alaska Nursing Association urged administrators to do more to increase nurse numbers. The NLC is one of the tools facilities need most in their employment toolbox. MS. CHAMBERS said that the NLC requirements to obtain a multistate license are rigorous and exceed the current standards under Alaska law. The Board of Nursing retains jurisdiction to oversee and enforce nursing practice in Alaska. The board does not lose any ability to defend the public's right to a safe nursing workforce. Alaska would have a vote on the NLC commission and multistate license fees will pay for their own program expenses. A single state Alaska license will continue to function as it currently does. Perhaps most importantly, the standards enacted in the NLC cannot be changed without the agreement of the Alaska State Legislature. It is a contract among state leaders. 1:47:41 PM SENATOR BEGICH said that Director Chambers stated that NCL requirements are rigorous and exceed Alaska's. He asked about the possibility that someone who might have had a multistate license before the NLC changed could be grandfathered in and not have to meet the current NLC standards. MS. CHAMBERS replied that there is no grandfathering in this agreement. All states have to meet the same standards. Several years ago there was a first attempt at a compact that did not have that same level of agreement, but it was abandoned and states have to agree through their legislatures on the same standards. There is no one who will hold a multistate license who does not meet these high standards. SENATOR BEGICH asked if that is why Pennsylvania endorsed the NLC. MS. CHAMBERS responded that at least one state had been working from the past NLC language and is working to rejoin because its legislature would finally agree to those higher standards. There were states that would not join the original compact but who are determining that now is the time because some of these old problems have been addressed. MS. CHAMBERS reviewed the many benefits for Alaska joining NLC on slide 7: • Reduces cost and burden on employers in Alaska. • Expedites disaster relief. • Increases access to care for Alaskans. • Increases telehealth options for Alaskans. • Adds options to keep Alaskan-trained nurses in state. • Expands employment opportunities for Alaskan nurses. • Facilitates online education. • Offers seasonal employee flexibility. • Eases costs and burden for military families. • Increases economic opportunities for military base selections or expansions. • Reduces cost and burden on nurses moving or transferring to Alaska. MS. CHAMBERS presented a table on slide 8 illustrating how NCL requirements exceed Alaska requirements. The Alaska Board of Nursing has flexibility considering past civil or criminal violations, the NLC has zero tolerance for risks to public safety. Alaska nurses could keep the single state license, but any nurse who holds a multistate license would be subject to this rigorous level of scrutiny. MS. CHAMBERS said that holding a multistate license would be optional if Alaska entered the compact, but nurses overwhelming want that opportunity to make that decision. In a December 2019 survey, 92 percent of Alaska licensed respondents said they support Alaska joining the NLC; 89 percent of these respondents have primary residency in Alaska and 87 percent of supporters of the NLC are members of a nursing union. The NLC is good for residents and the workforce and Alaska nurses want this employment option. SENATOR BEGICH commented that it is good to see the survey results. He asked if any of the unions responded directly to her in support of the legislation. MS. CHAMBERS replied that her department has not been in touch with the union this year on this bill. CHAIR WILSON asked which union as there are several nursing unions. SENATOR BEGICH clarified that he was asking about any union, but he thinks that Director Chambers is stating that no union has submitted a letter of support. MS. CHAMBERS replied that the department has not been in contact with any of the unions of any type about the NLC this year. Last year a union representing a fraction of nurses, the Alaska Nurses Association, had some concerns about the proposed legislation, and the department addressed all those concerns with them in hearings. The department is happy to do so again if concerns are raised. SENATOR BEGICH clarified that he meant to ask if they had received any opposition from unions and the answer he is hearing is no. MS. CHAMBERS answered that they have not. 1:54:54 PM SENATOR COSTELLO asked what percentage of the total nurse population responded to the survey. MS. CHAMBERS answered about 22 percent of nurses responded. A standard survey response is 2 or 3 percent. The department surveyed over 16,000 nurses and received over 3,500 responses. MS. CHAMBERS presented a list on slide 10 of supporters of Alaska joining the NLC. The list includes economic development organizations, military stakeholders, and healthcare providers. This is just a partial list of Alaska groups supporting the NLC. The list of national supporters is much longer and a link is available from the Alaska Board of Nursing's NLC web page. MS. CHAMBERS thanked the committee for the opportunity to present and asked for their support. 1:56:31 PM At ease 1:57:11 PM SENATOR BEGICH thanked DCCED legislative liaison Glen Hoskinson and Sara Chambers for meeting with him to address concerns he had last year about a similar bill. The department's interests and his are fundamentally the same. They want to ensure that Alaskan are safe and getting the highest level of care. It appears that the compact has a high level of care for those in it, but there is a potential economic impact for the state because the $500 will not come to the state. He asked how to address the impact of the bill on the Board of Nursing funding. MS. CHAMBERS replied that all professional licensing programs are self-funded. State law requires that. Now the state has single state licenses. As the board receives funding to cover the cost for single license, the state will see similar funding for multistate applications. A fee is shifting to a different type of license. Applicants will pay for either a single state license or the multistate license. This is a fundamental question that many states have had. None of the 35 states and territories that have joined the compact have seen an economic downturn because of the shift in cost. The administration is committed to making sure entering the NLC will not have a detrimental impact on any other nursing license type and will continue to follow state law to make sure licenses pay for themselves. SENATOR BEGICH said that the initial nurse license fee can cost up to $500. He asked what the cost is for the NLC license. MS. CHAMBERS responded that the $500 is the ceiling for a new RN license. That accounts for several costs such as fingerprinting. The multistate license will be set by the board and department using the same economic fee-setting structure that is used now to determine the license cost. There is not a set national cost for the NLC. That fee is set at the state level. SENATOR BEGICH asked if it is reasonable to assume that the NLC license will be around $500. MS. CHAMBERS responded that it is highly likely. The department has to take into account many factors, including how many nurses will want multistate licenses. Once the legislature adopts the NLC, that will be done through the public regulation process. It should be about the same as a regular license because a lot of the processes are similar. The savings comes when people who hold a multistate license come to Alaska to work or when Alaskans want to use a multistate license outside of the state. They only pay a fee one time and do not have to accumulate licenses from various states. 2:03:28 PM SENATOR BEGICH said that it should say that an initial Alaska nurse license can cost over $500 for those already holding a multistate license, but the consequence would if they are already holding a multistate license they will not pay the Alaska fee. MS. CHAMBERS answered that is correct. SENATOR COSTELLO said that a federal law requires that if nurses change facilities, in the same state or a different state, that they are responsible for getting a new set of fingerprints processed. She asked who would pay for the fingerprinting that is required by federal law for those nurses who come from out of state to take a position. MS. CHAMBERS replied that her agency and the Board of Nursing are responsible for state licensing and are not responsible for employment-related requirements for fingerprinting. People in healthcare facilities often have to get multiple sets of fingerprints because federal law prohibits sharing that fingerprinting. That is between employees and employers. SENATOR COSTELLO said that in the governor disaster declaration, he asked for a six-month delay for fingerprinting for those coming into the state in the nursing profession. The argument is that this brings nurses on more quickly, but the committee needs to learn more about the fingerprinting process. If there will be a delay anyway, then it may not be accurate to say this will get nurses on the frontlines more quickly. MS. CHAMBERS responded that they are different topics and different types of fingerprinting. As a licensing agency, her department used the provision in SB 241 that then was carried through the governor's health orders. It was hard to get fingerprints done in person during COVID; it was difficult to get hand-rolled fingerprints. The agency worked through the National Fingerprinting Compact to get a grace period to do name-only checks and followed up with fingerprints later. There is no delay in fingerprinting at this time. 2:07:03 PM SENATOR HUGHES asked if there is a nursing shortage here in Alaska, is there is a national shortage. MS. CHAMBERS replied that it depends on the state. Many states have an increasing older population, which increases nursing needs. Some states are projected to have a surplus of nurses and some are projected to have a deficit. It is nuanced. It depends on location, age, and availability. SENATOR HUGHES asked if Alaska nurses want to be part of the compact, will they need the Alaska and the multistate licenses or just the multistate license. MS. CHAMBERS answered that they would only need the multistate license. That would be their pass to all states, including Alaska. SENATOR HUGHES asked if enforcement by the Board of Nursing would only be for Alaska nurses, whether they have only an Alaskan or multistate license, or would the board have jurisdiction when an out-of-state nurse comes to Alaska with a multistate license and action must be taken against the nurse. MS. CHAMBERS said that is an important question. The Alaska Board of Nursing would retain jurisdiction over nurses whose home state is Alaska and the practice of nursing in Alaska that occurs in Alaska. That would include multistate licensees who are practicing in Alaska. It depends on the location of where services are being delivered. If someone with a multistate license is not an Alaskan came to Alaska and did something to violate state statutes or regulations or state practice act, then the Board of Nursing would have a responsibility under the compact to take action to prohibit that person from continuing to practice. The board would also have to report the violation to the compact administration. Then the commission reports that to the home state and the multistate license is suspended in all states until it is unencumbered again. It maintains the same level of governance over anyone practicing nursing in Alaska. SENATOR HUGHES commented that that is helpful because she was hearing misinformation which said that the Board of Nursing would not have that jurisdiction. 2:12:07 PM SENATOR REINBOLD asked if any nurses have been furloughed because of COVID. The unemployment numbers are high. She wants to get that information about what nurses are unemployed at this time before the state gets people from Outside. MS. CHAMBERS replied that the Board of Nursing does not employ nurses and does not have those numbers. Employment numbers would need to come from employers. SENATOR REINBOLD said that she wants to see those numbers before engaging in this discussion about this bill. She wants to know if there is a surplus of nurses anywhere in the state. Local hire is important. MS. CHAMBERS said the ASHNHA survey showed 670 vacancies in 2019 prior to COVID and the board issued almost 400 emergency licenses during COVID. The numbers show it is heading in the other direction. CHAIR WILSON said someone from ASHNHA is online and perhaps could provide that information. SENATOR REINBOLD said that she has heard that many nurses have been laid off and that some offices and clinics have closed. She wants to look at the landscape of who is already out there before making any significant changes. CHAIR WILSON called on Rose Lawhorne to address the unemployment question. 2:14:45 PM ROSE LAWHORNE, Chief Nursing Officer, Bartlett Regional Hospital, Juneau, Alaska, said she was also speaking on behalf of ASHNHA. Multiple nurses are working in various environments. She is not aware of any furloughed nurses, especially in Southeast, who were not repurposed in other jobs. Bartlett Hospital worked hard to provide employment to nurses whose jobs were temporarily suspended because of the pandemic. Training needs to be in place prior to repurposing a nurse from one area to another. The licensure requirements are the same, but there are specialty certifications required before a nurse can work safely in specialty areas. Her colleagues in Anchorage said the facilities worked hard to provide jobs to nurses whose jobs were affected by the pandemic. SENATOR REINBOLD said she wants to make sure no one is unemployed. She prefers Alaska preference. SENATOR BEGICH said he had a question about page 26 of the bill about indemnity but responded to the chair's suggestion to wait until the sectional. SENATOR COSTELLO asked about the nurse hotline. A nurse in Alaska who wants to help administer the COVID vaccine can call the hotline to find a position. She asked how many nurses are waiting to administer the vaccine. MS. CHAMBERS replied that the hotline would be administered by the Department of Health and Social Services (DHSS). The Board of Nursing is not engaged with the hotline but will get that information. CHAIR WILSON asked Director Chambers to present the sectional. MS. CHAMBERS said that before going into the sectional, she wanted to point out that Sections 1-22 and 24-36 are all conforming amendments. She will go through the sectional for the new parts of the law, AS 08.69. She will focus on Section 23, which would establish the compact. These articles are uniform to all states in the compact and are mandatory for participation. Section 23 is not flexible language. All states must agree to that language if they want to adopt the compact. 2:20:24 PM MS. CHAMBERS began the sectional analysis: Section 23: Creates AS 08.69, Multistate Nurse Licensure Compact. These articles are uniform to all 34 other states within the compact and mandatory for participation. Article 1: Establishes the legislature's findings of the need for the compact and its declaration of the compact's purpose in Alaska. Article 2: Establishes definitions and terminology for use in this section. Article 3: Establishes the general provisions for multistate licensure common across all participating states: • It clarifies that partner states have jurisdiction to take adverse action against multistate licensure privilege and requires states to notify the administrator of the coordinated licensure system when adverse action against a multistate license occurs. • It enforces that a nurse practicing in a partner state must comply with the practice laws of the state in which the client is located at the time the service is provided. • It clarifies that nothing in the compact shall affect the requirements established by a partner state for the issuance of a single-state license. • Article 4: Creates uniform standards for applications for multistate licensure. Article 5: Provides licensing boards with the power to: • Take action against a nurse's privilege to practice in that partner state; • Complete pending investigations of a nurse who changes primary residency and to report those actions to the administrator of the coordinated licensure system; • Obtain and submit fingerprints to the FBI for criminal background checks and to use those results for the purpose of licensure; • If permitted by state law, to recover from the affected nurse the costs of investigations and disposition of cases resulting from adverse action taken against that nurse; and • Deactivate the multistate privilege if adverse action is taken in the home state until such time that all encumbrances are removed from the license. Article 6: Establishes the rules for a coordinated licensure information system and provides for exchange of information among partner states, including provisions for ensuring the privacy of information contained in such system. Article 7: Creates the Interstate Commission of Nurse Licensure Compact Administrators, which is the body overseeing the function of the multistate license. • Each state shall have only one administrator, who is a voting member of the Commission. • With few exceptions as allowed by law, meetings will be open to the public and publicly noticed. Meetings held in executive session will be noticed, the cause for a closed meeting will be stated, and all resulting actions will be taken in public. • This article confers certain administrative powers to the Commission, which do not impinge upon the sovereignty of partner states. 2:24:00 PM SENATOR BEGICH said that he wanted clarification about Sections 2 and 3 on page 26, Qualified Immunity, Defense and Indemnification, "the administrators, officers, executive director, employees and representatives of the Commission shall be immune from suit and liability." He described that as standard language, but he asked if Alaska would then be potentially liable if the commission were to pass down fines or settlements to individual states. MS. CHAMBERS replied that she will explore that question with the Department of Law. This indemnification language is similar for board members in Alaska. If acting within the reasonable scope of state law they are protected by Alaska state law and not held personally responsible. To her this language seems similar to that. She will ask the Department of Law for a response. SENATOR BEGICH said a simple response from the Department of Law would be satisfactory. MS. CHAMBERS continued the sectional: Article 8: Establishes a transparent and public rulemaking process to carry out the powers in the previous article. Article 9: Establishes the agreement for oversight, dispute resolution, and enforcement of the compact. Article 10: Sets an effective date for the compact, the process for a state legislature's withdrawal from the compact, and the process of amendment of the compact through statutory changes in each member state. Article 11: Reinforces the primacy of the constitutions of each party state and codifies additional interpretation of the construction and severability of the compact. Sections 24-36: Amend statutes to add AS 08.69 (created by Section 23 of this Act) to the definitions of nursing as found throughout state law: Section 37: Allows the department to adopt regulations necessary to implement the changes made by this Act, to take effect under AS 44.62 on the effective date as noted in Section 38. Section 38: Makes Section 37 (Transition Regulations) effective immediately once the bill is signed. Section 39: Makes Sections 1-36 of this Act effective as of July 1, 2022. CHAIR WILSON asked if the compact would create any obstacles for state auditors to complete their functions. 2:27:42 PM MS. CHAMBERS replied that she did not think so because this compact and its agreements will be in Alaska state law and auditors could perform the same fiduciary responsibilities and have access to the same information as they do now. SENATOR BEGICH commented this has been a very thorough overview and gave him a greater idea than last year about what the compact does. He appreciated that. She mentioned something in passing about the expiration of licenses all on the same day, this coming Sunday. He asked if nursing licenses expire on a particular date. MS. CHAMBERS replied that all of Alaska licenses in all professions are two-year licenses. Each profession expires on the same date. This allows the agency efficiency in helping licensees to know that date and to streamline processes. SENATOR BEGICH commented that he recognizes that is good for notification but he guesses that creates a huge crunch for approval of licenses on her staff. He clarified that on any weekend in a two-year period the state can lose up to 23 percent of its nurses. 2:29:47 PM MS. CHAMBERS responded that the agency starts the process more than three months ahead of time. The renewal is all online. The renewal is less onerous than the initial license. Nurses have had at least five months to renew their licenses. The data point is interesting because it speaks to nurses who apparently do not intend to renew their licenses because they have had plenty of opportunities to do so. The agency looks to the system to be efficient to keep staffing numbers low. All facilities and nurses know when those licenses expire. It allows fees to be consistent and keep costs lower. The agency is always open to new ideas and improvement, but this process seems to have worked best for everyone. No nurse is unaware of the licenses expiring on Sunday. SENATOR BEGICH said these have been extraordinary times with tremendous burdens on the health system. Extraordinary actions have been demanded of nurses and other medical practitioners. He hoped there would be some effort at assessing that 23 percent and whether the process should be more lenient at this time. SENATOR HUGHES asked what has happened in other states with a shortage of nurses that have entered into the compact in terms of in-state nurses. For example, Alaska had 670 openings. Alaska is graduating nurses from the university system. If the state were to do this and bring in nurses with multistate licenses from out of state, she asked if there will still be plenty of jobs for Alaska nurses. She wondered how that might impact salaries. She assumed a hospital would not pay less to a nurse from out of state. Even though the survey indicated an overwhelming number of nurses support the compact, she has heard some concern about that. MS. CHAMBERS replied that she did not want to leave the impression that there are no out-of-state nurses in Alaska now. That 22 percent of nonrenewing nurses could very well be all of the out-of-state nurses who have been working in Alaska who don't intend to renew in Alaska. Out-of-state nurses provide a bulk of employment in the state now and they always have. Her agency licenses anyone who meets the criteria set in law and regulation. Residency is not a factor in their employment. This bill reduces government barriers to hospitals and clinics bringing in the nurses they are already bringing in. They could do that with less paperwork and expense. The nurses wouldn't need to go through her office. They could just get to work That is good for healthcare in Alaska. These are nurses who are going come to Alaska one way or another. It is not a recruitment to suddenly pull a lot of nurses from other states. It reduces government barriers if someone wants to come to work in Alaska. SENATOR REINBOLD said that she and Senator Hughes have been saying the same thing about the impact to Alaska nurses. She would like to know the unemployment numbers for those in the medical profession, especially nurses, and changes in licensure from 2019 to 2020 because COVID has changed the landscape. She would prefer the 2020 numbers. She wants to know the impact for Alaska nurses because unemployment is high in the state. CHAIR WILSON asked if Director Chambers could help the committee get the 2020 data on licensure. MS. CHAMBERS said her agency maintains the licensure data and will work with the Department of Labor, DHSS, ASHNHA, and private agencies to locate the unemployment numbers for the nursing sector. SENATOR HUGHES asked that Director Chambers listen to the meeting recording to fully understand her question and provide an answer in writing. Senator Hughes would like to know what has happened with states that have had shortages and whether that will make it tough for Alaska nurse graduates as well as nurses in the state. She wants to understand the impact of the NLC on in-state nurses and would like the answer in writing. Director Chambers mentioned the bulk of nurses are from out of state. She asked if that meant the nurses picked up to fill these vacancies or, at any one point in time, are more nurses working in the state from out of state than in state. MS. CHAMBERS replied that she will follow up in writing. 2:38:35 PM CHAIR WILSON moved to invited testimony. 2:38:55 PM DANETTE SCHLOEDER, Chair, Alaska Board of Nursing, Anchorage, Alaska, said one of the duties of the board is licensing. A common belief is that only the best nurses get Alaska licenses. In reality, a license of any type is awarded to someone who meets the minimum qualifications as established by law. All nurses graduate from accredited programs and sit for the exact same national licensing examination. Licensing and competency are not synonymous. The licensing requirements under the NLC are stricter than Alaska's current requirements. In August of 2019 the board voted to support the NLC after listening to nurses and employers. The board examined the current evidence-based literature and nursing practice trends in Alaska and across the nation. The board also considered the experiences of boards of nursing that enacted the NLC. MS. SCHLOEDER said that the previous version of the NLC may not have been a good fit for Alaska, but the current NLC with its uniform licensing requirements is a good fit. The federal government projects over 200,000 new nurse positions will be created in the years 2016-2026. The committee has heard information about the current vacancies in Alaska. Nationally about 33 percent of nurses engage in telehealth activities across state lines. The Alaska Board of Nursing met a nurse who holds 17 single state licenses to do her job. Holding multiple licenses does not make her a better nurse but adds an unnecessary barrier to nursing practice. The NLC was first heard by this committee in February 2020. At that time no one could have predicted the events that unfolded. The Board of Nursing issued emergency regulation for the courtesy licensing. That emergency regulation allowed courtesy licenses to be issued to any nurse with an unencumbered nursing license in any state. Although the board issued almost 400, it was not enough to meet the ongoing need. MS. SCHLOEDER said that nurses have choices of where to work, whether it is a permanent move or a temporary assignment. Nurses are drawn to NLC states because they can immediately practice nursing without delay or cost. Nurses have been at the frontlines of this pandemic. They are asked to work extra shifts every day. They have all seen images of these nurses in the media. The pandemic has shown the skill, compassion, and resiliency of these amazing nurses. In February 2021, the Board of Nursing unanimously reaffirmed its complete support for the NLC. The bill will help the mobility of the profession, simplify the licensing process, and help healthcare move forward. 2:43:48 PM TAMMIE PERREAULT, Northwest Regional Liaison, U.S. Department of Defense, Washington, D.C., said that on behalf of military families and the Department of Defense (DOD), she is supporting SB 67. One of the DOD key quality of life issues is working to help enact interstate compacts to improve licensure options for military spouses, veterans, and service members. Easy licensure transition is very important for military spouses as 68 percent of service members reported that the ability of their spouses to maintain a career impacts their decision to remain in the military. Compacts such as the NLC are beneficial for the 53 percent of military spouses who work in healthcare professions. The DOD has partnered with the National Council of State Boards of Nursing to support the NCL, which allows military spouses to use their state of legal resident as their home state for the privilege to practice. Joining the NLC is a benefit to those military spouses who are Alaska residents. By joining the compact, Alaska spouses have the benefit to practice in 34 states when stationed away from their homes. These allows military spouses from Alaska a seamless way of maintaining careers when changing duty stations and then returning to Alaska. Many service members retain multistate license allowing them to work in a federal facility. However, they cannot conduct training, seamlessly support emergencies, or provide additional hours of service to maintain their skills in a nonfederal facility. By joining the NLC, Alaska would benefit from military members being available to train and provide care in their communities. The percentage of military spouses in Alaska is the second highest in the nation with nearly 8,000 active duty spouses. Thirty-four percent of those spouses in the workforce are in licensed occupations. Seventy percent of surveyed military spouses who hold an occupational licenses have encountered challenges maintaining them. SB 67 is a tremendous step forward for the state to ease the burden of licensure for military spouses, military members, and veterans. 2:47:26 PM MS. LAWHORNE said that healthcare facilities in Alaska, particularly those in isolated areas, would benefit from the NLC. Bartlett Hospital is a small community hospital with limited resources that experiences staffing challenges. The prepandemic healthcare burnout was real. Currently nursing staff is experiencing postpandemic burnout. Bartlett has 10 open nursing positions. The cost of filling these with travelers is double that of permanent nurses. Their contracts typically extend for 13 weeks. That is much time and effort for 13 weeks of nursing care. Bartlett hired 12 travelers last year when volumes were down due to restrictions on elective procedures and the hesitancy of patients to seek medical care. In the two years prior, Bartlett hired 20 travelers per year. Cumbersome licensing processes reduce Bartlett's ability to provide uninterrupted care to patients without overloading existing staff. Exhausted staff trying to fill staffing gaps leads to reductions in quality of care, increased errors, susceptibility to illness, and creates additional vacancies. Patient flow and safety and hospital capacity are negatively impacted with typical licensure processing time. Temporary licensing still causes delays. Maintaining multiple licenses is costly and a deterrent for nurses selecting work destinations. Specialty areas experience additional recruitment challenges related to certification requirements. During disasters and disease outbreaks, like COVID-19, rapid mobilization of qualified nursing staff is essential for continuity of operations. The NLC will help fill gaps in nursing resources and serve as a recruitment tool. It is not uncommon for nurses to come to Juneau temporarily and decide to stay. In the growing world of telemedicine, licensure compacts facilitate effective and efficient use of nursing resources. The NLC promotes interstate educational opportunities in hospitals that wish to collaborate but don't due to licensure restrictions. The demand for nurses is expected to increase in coming years. The nursing workforce deficit will grow and jeopardize patient care unless the state acts now to draw nurses to Alaska. The NLC supports healthy workforce and offers a broad resource pool for recruitment and selection of nurses. 2:51:44 PM BRIAN NORTON, R.N., Manager, Cook Inlet Dialysis Fresenius Kidney Care, Anchorage, Alaska, said that Fresnius Kidney Care serves 330 patients in Anchorage, Fairbanks, Juneau, Soldotna, and Wasilla. Dialysis nursing is a very specialized field. Because Fresenius is a large company, it relies on the ability to bring dialysis-trained nurses from other states in times of need. The Centers for Medicare and Medicaid Services have strict requirements for registered nurses in the dialysis setting that make it difficult to use nurses who do not have experience to fill in during shortages. If nurses give two-week notice when they are leaving, the clinic can go from stable staffing to instability quickly. Fresenius currently has 10 openings for permanent RN positions. It takes an average of 75 days to fill them. According to a study, by 2030 Alaska will have the highest percentage of nursing vacancies at 23 precent. Twelve Fresenius dialysis nurses used emergency temporary licensing allowed by the Board of Nursing. For dialysis patients, interruptions and delays in treatment schedules are more than just an inconvenience, it is critical. It is vital to have a permanent way to bring dialysis nurses from other states immediately during any disaster. The compact has a history of working well. In 2018 the original 26 states passed the enhanced Nurse Licensing Compact. Additional states have joined. In 2020, the Pennsylvania state nurses association surveyed 15 compact states and found that concerns such as lost revenue to state boards of nursing and public safety concerns had not materialized. The association changed from opposing the compact to supporting it. He asked the committee to support the NLC. SENATOR BEGICH shared that he had met some of his staff last year who talked about Fresenius efforts to develop local workforce. He asked Mr. Norton to share the work his company has done with local workers. MR. NORTON replied that work frequently in community to promote ways of helping patients who receive dialysis. The company engages nurses in other facilities to coordinate care. 2:55:46 PM REBECCA FOTSCH, Director, State Advocacy & Legislative Affairs, National Council of State Boards of Nursing, Chicago, Illinois, said she had called in to answer any technical questions about the compact or any other questions. CHAIR WILSON responded that there were no questions at this time. He clarified with Director Chambers that any changes to the compact must be approved by the legislature. He asked if any there were any anticipated changes with the compact that would need action from the legislature that would possibly hinder participation in the compact. MS. CHAMBERS asked for clarification. CHAIR WILSON said perhaps Ms. Fotsch could answer whether there have been any changes to the compact that all the states had to agree to. MS. CHAMBERS responded that her understanding is that if there is a change that must happen to Section 23, all of the states would have to ratify the same kind of change. That would only be for the multistate license and not affect any changes to the state license. MS. FOTSCH said that has happened once. All of the states came together because they knew they needed to make a change in the language. That old compact was in existence for 15 years and had 25 members. The old NLC language stalled at 25 members, so the NLC states changed it so that all states could be members. All the compact states had to agree to it. She hopes there will be no change any time soon. The intent of the compact states is not to have to do that. SENATOR COSTELLO said that is important to her that Alaska grow its own in Alaska, such as engineers, teachers, and nurses. She has observed nurse graduation ceremonies in Anchorage. If the NLC requirements are more stringent than the state license requirements, the multistate license gives individuals more flexibility, she asked if that license will be valued more than an Alaska license. She asked if there any concerns about displacing Alaskans who are committed to living here with nurses from outside of the state. MS. CHAMBERS responded that the intent is to provide more flexibility and mobility for nurses to meet healthcare needs. Her agency has talked one constituency group, those graduating nurses, who are leaving the state because Alaska does not have the compact. They want to pay for one license and have flexibility to travel. The agency is responding to the desire of graduating nurses to have that flexibility. The question of whether a multistate is more valuable than an Alaska license is an interesting question. That is a question for each employer. There is no change in what a registered nurse or licensed practical nurse could do with either an Alaska license or the multistate license. The Alaska Practice Act governs the practice of nursing. The agency is trying to retain Alaskan homegrown nurses and make sure they don't want to leave Alaska by adding this attractive tool in their toolbox. 3:04:00 PM CHAIR WILSON held SB 67 in committee. He encouraged written testimony be sent to shss@akleg.gov. 3:04:29 PM There being no further business to come before the committee, Chair Wilson adjourned the Senate Health and Social Services Standing Committee meeting at 3:04 p.m.