House Standing Committee on Health

Good morning everyone and Kungi Fat Choi. Welcome to this first hearing of the House Health Committee in 2025. Let me introduce myself. I'm Greg Takayama and this is my very first time as Chair of the House Health Committee.

So looking forward with nervous anticipation, I'd like to introduce my Vice Chair, Representative Lee Loy, and it's as well, her first Vice Chair hearing. So thank you all for being here. Thank you Members for all attending as well.

I do want to get over some housekeeping notes this hearing will because we have many testifiers, we're going to try and limit testifiers to a 2 minute time limit if you would, because morning hearings must adjourn before our noon floor session.

Not all testifiers may have the chance to testify if it goes long, but please know that we've reviewed all of your written testimony if it was submitted on time and we have all thoroughly studied, so be assured. This next note applies to those on Zoom as probably those in the audience as well.

Please keep yourself muted and keep your video off while waiting to testify and after your testimony is complete. For those on Zoom, you can chat with our technical staff and not with members. If you're disconnected, we'll try and connect you.

In the event of a catastrophic network failure, we may need to reschedule meeting because we are required to be on Zoom. Please avoid holding or using any trademark or copyrighted images. And finally, please refrain from profanity or uncivil behavior. Please practice the Aloha Spirit as we all will.

So with that, let me begin our first measure which is HB303 relating to health care preceptors. And first up, we have the State Department of Health.

Aloha Mai, Chair Takayama, Vice Chair Keoho Kapuliloi and Committee Members. My name is Wanda Anae-Onishi. I'm with the Department of Health. We stand in support of our testimony for HB303 and we defer to the Hawaii State Center for Nursing for comments.

But findings from the five year evaluation of the Preceptor Tax Credit Program showed growth in the number of preceptors providing training and in the number of professionals becoming preceptors locally. So therefore, by expanding the eligibility criteria for healthcare professionals and students, it could address our healthcare workforce shortage.

I am available for questions and mahalo for allowing me to testify.

Thank you. Department of Taxation.

Good morning, Chair, Vice Chair and Members of the Committee, Garrison Kurth, Department of Taxation. The Department stands on its written testimony providing comments and I'm available if you have any questions. Thank you.

Thank you. Hawaii Health Systems Corporation. Edward Chu. Not present. University of Hawaii System. UH.

Sorry. Chair, Kalbert Young, University of Hawaii. We can stand on our testimony in strong support of this measure. Thank you.

Thank you. Hawaii State Center for Nursing.

Good morning, Chair, Vice Chair, Members of the Committee, My name is Laura Reichhardt I'm the Director of the Hawaii State Center for Nursing, and I, in addition with the JABSOM Area Health Education Center, administered this program.

I just want to let you know that in addition to the successful program that we've been running for the past five years, we have reviewed the professions that are being recommended to be added to this program, and we've determined that they meet all of the same kind of criteria and structures that are existing in place.

So we'd be able to successfully add them, and we would look forward to furthering our support of healthcare in the state. Thank you very much.

Thank you. Thank you, Laura. Hawaii Primary Care Association. Eric Copy. Thank you, Eric. Healthcare Association of Hawaii. Paige Choi. Let's see. Michael Robinson, Hawaii Pacific Health, in support. Hawaii Association of. Sorry, let me go to those in person first. Queens Health Systems.

We'll stand in strong support.

Thank you Chase.

Hawaii Medical Association, HMA in support. Kaiser Permanente in support. Kahala Clinic for Children and Family in support. Let me go to a couple people on zoom. Let's see, we have Tax Foundation of Hawaii, Tom Yamachika.

Aloha. Chair, and Members of the Committee, this is Jade McMillen. On behalf of Tom Yamachika for the Tax Foundation of Hawaii. We have submitted some comments on the measure and we will stand on our written comment. Thank you.

Thank you. Hawaii Association of Professional Nurses. Not present. In support. Hawaii Academy of PAs. Leocadia Conlon.

Yes. Good morning and thank you. Chair, Vice Chair and Committee Members. I'm the representative of the Hawaii Academy of Physician Assistants. We support this bill and stand by our testimony and all the comments in our testimony. And I'm available to answer any questions. Thank you.

Okay. Hawaii American Nurses Association. Elizabeth Kahakua. Not present. We have a couple. Let's see, 10 or so individuals offering comment and support. Let me ask if there's anyone else present in this room who wishes to testify on this bill, please step forward. If not, anyone else on Zoom that wishes to testify on this bill? None.

Okay, thank you very much. Members, let's open up for questions of any of the testifiers. Yes.

Representative, quick question for Department of Health, I think, or maybe anyone who referenced the report.

Were there numbers attached about how many people would be entering into the program for each of these professions or anyone have any kind of estimates about like how many more people we might be expecting to do the to enter into fields. Center for Nursing?

Would you like to.

Sorry. I saw several people mention the report, but I didn't see the exact numbers if it was available.

Thank you representative. So the maximum tax credit is $1.5 million a year annually. So 1500 tax credits. So we would not be able to exceed that amount. We were a- we have been providing credits at we've about 650 to 670 tax credits annually.

And so that remaining amount would be allocated to those professions when we did an assessment two years ago. The PA program is relatively small. HPU is just launching their program now and there is one in Kona. The social work program also is relatively small in size, particularly as comparison to nursing and medicine.

And then the registered dietician program again is very small. So I don't have the exact numbers, but when we did the analysis they would not exceed the 1500 and there would still be plenty of room for growth for a APRNs, physicians and pharmacists.

Oh, great. So everyone could probably be covered if we were to extend it to all these.

Exactly. Yes.

Perfect. Thank you.

Oh, Laura, while you're up there, just to clarify that this tax credit only applies to unpaid preceptors.

Absolutely correct. So if a person is getting compensated for being a preceptor above and beyond their clinical job. So as a clinician, you're seeing your patients all day long right now, the normal circumstances that in addition to your patients, you have a student or a resident and you're finding time to teach them.

In some instances they don't have any patients and that would be considered compensated. In other instances, a school will pay them directly, that would be considered compensated. And in those two examples, they would not be eligible for this tax credit.

Thank you. Thank you very much. Any other questions? If not, let's move on to the next Bill up, which is HB 441 raising our cigarette taxes. First up, we have the Attorney General.

Morning Chair, Vice Chair, Members of the Committee. My name is Chelsea Okamoto, a Deputy Attorney General assigned to the Tobacco Enforcement Unit. Thanks for hearing this Bill. Our Tobacco Enforcement Special Fund is primarily funded through a stamp fee which is tied directly to the cost of the cigarette stamp.

So our revenue and our special fund has been dropping alongside the cigarette tax revenue. And so as stated in our testimony, it's important to keep our unit funded to protect that annual MSA Payment that comes to the state.

Our Department also wanted to thank the Chair and Vice Chair for scheduling HB 1085, which we also recommended this Committee take a look at. As you know, cigarette taxes have been plummeting and we're seeing that it's not sustainable to keep continuing on that route to just using cigarette tax stamp money.

So that Bill, HB 1085, which is set for a hearing on Friday, looks to expand outside of just cigarette taxes to encompass all tobacco products that are now being taxed by the state. So thank you again for hearing this Bill. We ask you to pass it. And thank you again for setting the other hearing for measure.

Thank you very much. Department of Health.

Good morning. I'm Lola Irvin representing Director Kenny Fink with the Department of Health. Happy New Year. The Department of Health supports HB441 and thanks you for hearing it on principle. We have a vision that all people have the opportunity to experience optimal health and quality of life.

Well, we also know that if we increase the price of cigarettes that it will reduce youth consumption. Right. Youth don't have as much accessible cash. And so it would deter their initiation. It also helps people think about whether they should quit. And we are here to support them if they're ready to quit because we.

Have free services through the Hawaii Tobacco Quit line. We also Fund community programs to help them quit. And we have really fantastic tobacco treatment. Specialists who help people quit. But the problem is we still have 1,400 people a year who die from smoking-related deaths.

If we were to ask for people to raise their hands of loved ones they've lost from smoking related deaths, I would run out of hands to raise for myself of loved ones, my dad in particular. So it is still a big problem. In Hawaii and for Native Hawaiians.

We were targeted in Hawaii as known as a menthol friendly state. According to their documents where the smoking rate in Hawaii is 10% for native Hawaiians, it's close to 18% of smoking rate. We're here to help people quit smoking. We thank you for this Bill and we support it fully knowing that it's.

A proven method to help people quit and to prevent youth from starting up. So we do support the tax increase, which would be 18 cents per cigarette, which is about $3.60 per pack. So thank you so much for the. Opportunity to provide testimony.

Thank you. Department of Taxation offering comments University of Hawaii System.

Good morning, Dear Chair and the Vice Chair and the Committee Member. I'm Naoto Ueno, the Director of University Hawaii Cancer Center. So we stand on this Bill, HB441 and as stated by other Members that this does. It is important to reduce the overall cigarette smoking and it has been affected by increasing the tax.

But not only that, the cancer center is in the hub of providing the effective policy as well as research and clinical activities. As you know that the cancer center has a significant debt service and with multiple multifaceted approach, there's a significant decline on the cigarette tax.

And this is important to really infuse additional funding that would help the debt service as well as future investment so that we could be more effective. And this is not just only about smoking related cancer, but there are many other people who are suffering from cancer and we think that this Bill is important for our future.

So thank you very much for the opportunity to testify.

Thank you, Doctor. Let's see. Hawaii Pacific Health in support. Alan Johnson, Hawaii Substance Abuse Coalition in support. Tax foundation of Hawaii on zoom.

Yes. Good morning Chair, Members of the Committee, this is Jade McMillan on behalf of Tuamchika for the SACS foundation of Hawaii. We've submitted some comments on the measure. We'll stand on our written comments. Thank you very much.

Thank you. Let's see, we have Hina Mauka in support. Hawaii Primary Care Association. Eric. Abe. Thank you, Eric. Let's see. Hawaii. I'm sorry, The Queen's Health Systems. J.C. thank you. In support. Hawaii Medical Association in support. Let's see. Cigar Association of Hawaii in opposition. Retail merchants of Hawaii not present in opposition. See Hawaii Public Health Institute. Kevin Ramirez.

Aloha. Good morning, Chair, Vice Chair and Members of the Committee. My name is Kevin Ramirez. I'm the program manager for the Coalition for Tobacco Free Hawaii Program of the Hawaii Public Health Institute. Here to testify in support with amendments for HB 441.

We respectfully request the Bill be amended to raise the tax by at least $1 per pack to maximize potential public health benefits for youth prevention and adult cessation. And we have more details on the public health benefits in our written testimony. Recent polling shows voter support.

According to an independent poll conducted by Ward Research on behalf of our coalition, 78% of registered Hawaii voters support an increase in cigarette tax and 89% feel that it is important for the state to dedicate part of its tobacco tax revenue to support tobacco prevention and cessation programs.

Thank you for the opportunity to provide testimony in support of HB441. We respectfully ask you to pass this measure out of Committee with the requested amendments. Mahalo.

Thank you. Let's see. Campaign for Tobacco Free Kids Hawaii in support American Cancer Society Cancer Action Network.

Thank you. Chairs and Joint Committee Members. My name is Cynthia Au. I'm with American Cancer Society Cancer Action Network or ACS can as a Government Relations Director. We support the Bill with amendments. ACS can supports increased funding for the UH Cancer Center. Cancer is the second leading cause of death in the state.

More than 9,000 residents will be diagnosed with cancer this year and more than 2,000 residents will be expected to die from the disease. Projections in 2025 mark an uptick in cases but a decline in deaths compared to 2024.

That is because of institutions like the UH Cancer center which provides important cancer research, access to life saving treatment, including clinical trials which play a critical role in reducing the cancer burden for our unique population in the State of Hawaii. We our amendment is to increase the cigarette tax to a dollar or five cents per pack.

And we look forward to the Bill that's going to be heard on Friday as well. So thank you so much for this time to testify.

Thank you. Let's see on zoom we have Taxpayers Protection Alliance.

Yes. Hello, Chairman, Vice Chairman, Chairwoman, Members of the Committee, thank you for your time today. My name is Lindsey Stroud. I'm a senior fellow at the Taxpayers Protection Alliance.

I do submit written testimony, but I wanted to highlight some of the numbers I went over and all of the numbers come from the Centers for Disease Control and Prevention. So cigarette taxes are regressive. They disproportionately impact low income and less educated adults.

They're also unreliable sources of revenue as many adults quit smoking and are move on to safer alternatives. First, smoking rates continue to decline in the aloha state. Only 9% of Hawaiian adults aged 18 years or older were currently smoking in 2023, which was actually a 27.4% decrease from 2022.

Even better, youth combustible cigarette use is at record lows. In 2023, only 3% of Hawaii high school students reported past month cigarette use. But unfortunately, low income and less educated adults are more who are more likely to smoke are burdened by these type of taxes.

In 2023, Hawaiian adults with annual incomes of $25,000 or less were three times more likely to smoke as adults who reported incomes of $50,000 or greater. Among Hawaiians who had not completed high school or its equivalent, 18.7% of them were currently smoking compared to 4.8% of college graduates.

And even with tax increases, you have not seen pronounced declines in these demographic groups. Between 2003 and 2023, smoking rates among higher earning adults decreased by 53.4% compared to only a 16.6 reduction among lower income earners. Among college graduates, rates decreased by 48.9% compared to less educated adults who only saw a 25.5% dec.

And as smoking rates decline, so does tax revenue. While the previous tax increases temporarily boosted revenue, these gains were not sustained. In 2023, Hawaii collected $76.8 million in cigarette tax revenue, which was a 43.4% decrease from 2011.

Raising the state excise tax on cigarettes may seem like a good way to Fund health, but its evidence shows it's unreliable, regressive and harms low income individuals. Thank you for your time today.

Thank you. Let's see. Susan Hirano.

Good morning. My name is Susan Hirano. I am here in support of the Bill and specifically to give you a personal perspective of why it's so important. Forgive my informality and nerves. This is the first time I've done something like this.

That's okay. I'm nervous too.

I'm an advocate for the University of Hawaii Cancer Center. I'm also a cancer patient. I was diagnosed three years ago with stage 4 metastatic breast cancer and I'm now facing clinical trials. So I'm here for myself and others like me who need a clinical trial but can't get them yet here on the island, which is why the passing of the Bill is so important.

The tax will help the cancer center provide these needed clinical trials to me and others like me, not only here on Oahu, but on other islands as well, so that they don't have to travel to the mainland for treatment. And that's what I'm facing right now. I have a 16 year old son.

My husband is the breadwinner, so neither one of them would be able to come with me. So that's sending me to the mainland without my support system, which, as you all know, the family is the most important thing when you're going through a journey like this. So I ask you to consider the Bill in support and I thank you for your time.

Well, thank you. Thank you. That was very effective testimony. Let's see, have I missed anyone? Anyone else in person or on zoom wishing to testify? Seeing none, I might note that we have written comments from about 19 other people, 14 in support and five in opposition. So at this point, let's open up for questions.

Members Any questions of the testifiers? Seeing none. Let me ask Department of Health to step forward. Just want to clarify. This proposal suggests raising cigarette taxes by 2 cents. When is the last time we raised cigarette taxes? 2011.

2011. So 13 years. 14 years ago. Yes. Going on 14 years. Yes. Do you remember then how much we raised it by at that point? I think we may have raised it about 2 cents. We've been stuck at $3.20 since then.

Okay. Alright, thank you very much. Seeing no further questions. Let's move on to the next bill, which is House Bill 557 relating to telehealth. Department of Human Services up first. Thank you. Yeah, I reviewed the testimony. Thank you very much. Department of Health.

Aloha. I'm Wanda Anae-Onishi from the Department of Health. The Department supports HB557 provided that its passage does not replace or adversely affect impact priorities indicated in our executive budget. So mahalo for this opportunity to testify.

Thank you. Insurance Division, DCCA. Standing on your testimony, offering comments. Jack Lewin, Hawaii State Health Planning and Development Agency, SHPDA.

Good morning. Chairman, Vice Chairman, Members, we stand on our testimony and support.

Thank you. UH System. UH System leaves the room. Okay. Thank you. But in support. Okay. Hawaii Primary Care Association.

Morning. My name is Erik Abe and I'm the Public Affairs and Policy Director for the Hawaii Primary Care Association. The HPCA supports House Bill 55- 557. This bill would conform Hawaii's insurance code to recent amendments to the Medicare Physician's Fee schedule that were approved on December 9th, 2024 and went into effect on January 1st, 2025.

These amendments expanded the reimbursability of audio only telehealth services under Medicare for mental health services only to all telehealth services that one are provided at the patient's home, two are designated by the patient, and three is the same service that would be reimbursable if provided in person.

Since the enactment of Act 107, Session Laws of Hawaii 2023, Private insurers in Hawaii are required to reimburse for mental health services provided through telephone- telehealth in the same manner as Medicare. At the time the law was enacted, questions arose as to whether the requirement in Medicare was permanent or temporary.

As such, a sunset of December 31st, 2025 was written into the law. What became Act 107 was a compromise between a hui of approximately 12 provider health care and community organizations and HMSA, the state's largest private insurer. The hui agreed to an 80% cap on reimbursement compared to the reimbursement allot for inpatient services.

HMSA agreed to ease patient provider visit requirements that needed- that were needed before the first audio only visit would be allowed under Medicare. In the two years since that law. In the two years that this law has existed, countless numbers of Hawaii's most isolated patients were provided essential mental health services through audio only telehealth.

These included patients in rural communities, those who are without broadband access, Kupuna who are not well computer versed, and the disabled who experience difficulty commuting to provider facilities.

After extensive hearings and fact finding, the Center for Medicare and Medicaid Services found that throughout the United States states there are vast health care deserts because of the lack of adequate broadband coverage and the lack of health care providers. They determined that the landline telephone is often the only lifeline available for these communities and demographic groups.

Because the definition of the Medicare fee schedule is referenced by citation in Act 107, the HPCA asserts that the expansion under Medicare applies to private insurance in Hawaii at the time the amendments to the Medicare fee schedule went into effect. That would be January 1st, 2025.

Because MedQuest nor the insurance commissioner have formally indicated whether non mental health telehealth services are reimbursable, the HPCA requested both to provide an agency determination on this question. A copy of that letter is attached to our written testimony. We had requested a written response by January 31st, 2025.

We also note that the MedQuest guidance on telehealth implementation dated December 18th, 2024 did not reflect the amendments made in the December 9th final rule and because of that-

Ask you to please summarize.

Sure. The HPC has been negotiating with HMSA on behalf of and in conjunction with the hui of organizations. The hui hopes that a compromise may be reached before adjournment sign die if Act 107 sunsets on December 31st, 2025 everyone loses. If a measure approved by the legislature is contested in the courts, everyone loses.

For these reasons, the HPCA respectfully asks your committee to approve this measure so that discussions can continue. Thanks.

Thank you very much. Let's see Hawaii Pacific Health in support. HMSA.

Good morning, Chair Takayama, Vice Chair Keokapu Lee Loy and Members of the Committee Walden Au on behalf of HMSA. First we just want to state that we fully support the efforts to make behavioral healthcare more readily available across the state.

We're really grateful to have been a part of the 2023 group that came up were able to work on what became Act 107 but however, we respectfully oppose the language as written in House Bill 557 as we believe it strays from the original intent of Act 107.

While the bill aims to better align with Medicare, we believe that it's an incomplete if you just look at the definition of interactive telecommunication system in isolation alone, that definition's change could be seen as an expansion of applicability.

However, in the broader federal regulations as defined by 1834 M of the Social Security Act, once the federal public health emergency flexibilities end on March 31st, 2025, audio only telehealth in the home will only be allowed for services of diagnosis, evaluation or treatment of mental health or substance abuse disorder, as well as monthly ESRD clinical assessments.

We recognize audio only telehealth is an important means of access, but there is no clinical data to justify it being considered as an equal substitute for face to face or audio visual telehealth in terms of quality of care.

We also oppose the changes that are proposed in House Bill 557 that would basically make harder the protocol requirements to establish the use of audio only telehealth by removing audiovisual telehealth as an option.

Considering the intent of Act 107 to help residents with access issues, we believe that this option was agreed upon to eliminate barriers for those unable to participate for in person visits.

I guess in closing, telemedicine is continuously evolving and as the flexibilities and waivers of the public health emergency come to an end, we hope to continue to work with the stakeholders to find solutions that do not sacrifice quality of care.

For those reasons, we would ask that the committee consider amending Act 107 2023 by striking all references of 42 Code of Federal Regulation section 410.78 A and in sections 2 through 6 of Act 107 inserting the interactive telecommunications system definition found in the federal regulations as defined at the time of its passing in 2023 and by removing the sunset language found in Section 8 of Act 107 in order to allow for this access in perpetuity.

We appreciate your consideration and we are committed to working with the various stakeholders to find and ensure that this important means of access for mental health services continues. Mahalo and we're available for questions.

Thank you very much. Let's see on Zoom we have George Mackel, Ohana Psych.

Yes, good morning. Thank you for allowing me to testify. I am an APRN. I am the CEO of Ohana Psych. We are a psychiatric telepsyche practice group in the State of Hawaii. We deliver care to over 6,656 members of Hawaii in 2024 alone. Our practice group has doubled in size for the next last five years.

We anticipate doubling in size this year. We are starting to make an impact in mental health delivery and the care of people in Hawaii. Behind me is a map all those little data points or people we've served in Hawaii. We cover every island in Hawaii.

We do not have any physical locations in the State of Hawaii because of payment disparity between physicians and APRNs. We're looking broader. We would recommend that you all follow the State Oregon and recommend state payment parity across all payers in the State of Hawaii.

The payment for APRNs in the State of Hawaii is reduced by 60s when APRNs became available in care and provider relationships with clients. The same committee that started that recommended in 1998 that there be payment equality between APRNs and physicians. The reality is that my payment is reduced by 85% because I'm an APRN.

We operate on thin margin lines. I cannot open practices in the state like I'd like to because there's not enough economic resources.

With that we know that there's still many who rely on audio only communications.

With a life threatening illness. Cancer is a second leading cause of death in Hawaii.

Access to health care providers is critical to ensure that patients receive- health care providers is critical to ensure that patients receive the best possible care- the best possible care and support that they can get. With telehealth patients in rural and underserved areas can easily access and connect with specialists and receive timely recommendations or answers to questions.

The passage of this bill will make real difference in the lives of cancer patients for our unique island state. Thank you so much for this time to testify.

Thank you. Hawaii Association of Health Plans.

Good morning Chair, Vice Chair, Members of the Committee. Rachel Wilkinson on behalf of the Hawaii Association of Health Plans and we stand our written testimony in opposition.

Thank you. Let's see. We have Aloha Care on Zoom. Mike Nguyen.

Good morning Chair, Vice Chair, Members of the Committee. Thank you for the opportunity to testify. My name is Mike Nguyen providing testimony on behalf of Aloha Care. We have submitted written testimony and support with comments and we'd like to underscore support of this measure on the principle of access to care particularly for the Medicaid population.

We serve over 70,000 Medicaid and Medicaid and Medicare dually eligible members across all islands including Kupuna and residents, in rural and remote areas that benefit from accessing care via telehealth. We support this measure again as a way to improve access to care, especially given our state's provider shortages. We do want to acknowledge the concerns raised by other stakeholders.

And I would also note that while Aloha Care is a member of the Hawaii Association of Health Plans, for which testimony was just shared and also submitted via written testimony with an opposed position, we do appreciate those concerns, but we are not aligned with that opposition stance. Thank you for allowing me to testify.

Okay, thank you. Let's see. Queen's Health System in support. Thank you. Let's see. Alzheimer's Association in support. We have written comments from, let's see, a half dozen other people in support. Have I missed anyone? Anyone else wishing to testify in person or on Zoom that I missed? If not members questions? Oh, I'm sorry, did I miss some? You?

I thought that the National Association of Social Workers, Marriage and Family Counselors and Mental Health Counselors submitted testimony.

They may have. They may have been among half a dozen or so. Well, I ask if anyone here wishing to testify. I see none. Thank you. Members, any questions? Representative Chun.

Question for DHS.

Aloha.

Hello. Thanks for being here. So I got a chance to review your testimony and your concerns. So if the bill were amended to just reflect the intent of Act 107, would that alleviate DHS? DHS's concerns with the bill to be audio only for mental health services.

For mental health service. Thank you. Judy Mohr Peterson, MedQuest Administrator with the Department of Human Services. Thank you for that question. We would be amenable to that. We also recognize, however, that there are other circumstances by which audio only may be.

May be acceptable and helpful as another access point, especially for individuals in the Medicaid program who may not have access to full audio visual technology. At the same time, we do have concerns about it being accessible for as an equivalent, clinical equivalent, as well as we have concerns regarding the equivalency of a payment parity. Thank you. Yeah.

Can I ask another question?

Go ahead. Did you have one question?

Just one more. Oh, not for you.

For me?

White Primary Care Association. Hey, thanks for being here. Just a question about the 80% reimbursement rate. Just want to know how you folks came up with that number.

Yeah. Two years ago, when negotiations between the hui and HMSA kind of came at loggerheads, the idea was broached that we take an approach that was used by the Hawaii State Legislature in work comp reform and also no fault insurance reform that basically in order to reduce costs.

What the legislature did was they linked costs to the Medicare fee schedule and to further provide a disincentive for providers to utilize work comp or no fault insurance, they put a cap of 80% on the reimbursement. That was the crux of that idea.

And when we brought that to the table, HMSA came back to the table and in essence, you know, that was the agreement. That or that's the reason why ultimately it came down to an 80% cap.

Okay, Any other questions?

Okay, thank you. Thank you, Chair.

Yes, question for HMSA. Just this is directed to you guys because you're big and you have a lot of members. So what's been the participation rate in this audio only. Do you guys have numbers? I mean like number of people, frequency of use, maybe even where they are? Because. Right.

We're trying to expand access to our rural areas.

This is Moni Von Nas, she's our senior manager for telehealth and I believe she would have a better answer for you.

Looking at our data, it's about 3% of all of our telehealth claims is audio only. The proportions of where audio only is being used is in alignment with where telehealth claims are actually happening as well. So we're not seeing like a larger percentage of audio only being used in neighbor island communities or rural areas.

Pretty consistent with telehealth as a whole.

And 3%, what is that in numbers? I guess.

I can get back to you on numbers. I just. Sorry, only remember the percentage.

Okay, thank you.

Any other questions? Any other? Representative Amato.

Thank you Chair. Question for Dr. Peterson please. Good morning, Judy. It's nice to see you here.

My question is, is there any risk if Medicare Medicaid rules change that it could ultimately have a chilling effect on telehealth access? Could this could passage potentially make it harder to actually access telehealth medicine if rules change again?

Good morning.

Judy Mohr Peterson, MedQuest Administrator for the Department of Human Services so the rules that were being cited are Medicare rules. The Medicare rules have did change their definition, but they did not change the originating site. Where are the kinds of services that can be in their actual rules?

They didn't change their originating site, meaning the location where the patient is for when those services are being received in the home. Those are still restricted to the three types of services being mental health, substance use and end stage renal disease, home assessments, clinical assessments. For Medicaid.

Our Medicaid rules are different at the national level in that they allow the Medicaid programs to to deviate or we can change from those rules. In our state, we chose to follow for the audio only.

We chose to follow the Medicare rules because at the time, which is a couple of years ago, there was evidence that for mental health and for substance use, there was clinical evidence that there was some clinical equivalency with both the audiovisual in clinic and telephonic.

Since that time, there is expanding evidence, but there's still not sufficient evidence for the whole thing. The waivers that are in place from the pandemic are set to expire at the end of March.

What that will mean is that the way that the law is currently written, without amendments, it would revert to those- to those and it would remain the same essentially off rate. It would remain the same as it is currently, as the world exists currently. It's not going to decrease that.

Okay, thank you so much.

Thank you.

Any other questions? Members seeing none. Let's move on to HB716, establishing a health infrastructure grant program. Jack Lewin, SHPDA.

Aloha good morning, Chair, Vice Chair and Members. Jack Lewin, Administrator of State Health Planning and Development Agency we strongly support this measure. Our testimony goes into the detail there, but as we look at the future, it's a sort of a challenging future for safety net providers and in General rural health providers.

Today, with the change of administrations in Washington, a lot of uncertainties are there. It's very likely that a greater burden of costs and services will be shifted to states in terms of communication and telecommunication interoperability.

This is a critically important piece of our infrastructure to allow those providers in those locations, and particularly those serving safety net disadvantaged persons, to be able to really effectively communicate for care, communication, coordination for quality of care and so forth.

This measure, it's a bold ask because it's probably going to cost 15 to 20 $1.0 million or more to get people up to speed.

But this Bill would create a two year process to bring those entities which are lagging behind in this ability because of the cost to get up to speed, they would be able to maintain their services in the future themselves.

But without this kickstart, if you will, we're not going to have the remaining federally qualified health centers, our DOH programs like the Ryan White clinics and others to really participate. And this also includes some of our critical access hospitals in the safety net across Hawaii. So we strongly support it.

Shipta has the ability to help coordinate the development of this and build this infrastructure out, and we would need a little bit of help for the 24 months that it would take to do it.

But afterwards our state would be in a unique position to be able to provide coordinated quality of care and care coordination in a way that has not occurred ever here or anywhere. So I would urge you to try to find a way to support this. Mahalo.

Thank you. Let's see, we have Hawaii Pacific Health and Support Health Care Association in support. Waikiki Good Morning, Chair.

I'm Jimmy Nelson. On behalf of Alexis Charpentier, who's CEO of Waikiki Health, I will stand on our testimony and support. I'll just note that we are both an FQHC and a Ryan White Part C grantee. So this would be enormously helpful to both of those programs which we operate. And I would echo the sentiments of Dr.

Lewin on how important this would be to organizations such as ourselves. It works for rural clinics, but we're a very urban oriented organization and would be helpful to us as well as we already spend quite a lot of money on information technology that is really a strain on our budget.

So this type of program would be very helpful. Thank you.

Thank you. Hawaii Primary Care Association. Eric Abe in support. Thank you. Let's see. Waianae Coast Comprehensive Health Center in support.

In support. Thank you. Let's see, we have on Zoom Jennifer Stoll, OCHIN.

Good morning, Jennifer Stoll, I'm the Chief of External affairs here. Good morning, Chair, Vice Chair, Members of the Committee and thank you for the opportunity for providing testimony and support of House Bill 716. Naturally, my phone would ring as soon as I get on provide testimony. Ochin is a national, not for profit.

We do health IT innovation and research serving rural and underserved communities in Hawaii and then across the country. We are as a nonprofit.

We provide technology solutions and support for those with the least amount of resources to improve health outcomes and really support them with electronic health records, data analytics and workforce development and other tools that are really important to make sure that they can stay on a level playing field, especially as the regulatory environment continues to change.

And the need to understand data and analytics to support your communities are really, really key.

We are very supportive of House Bill 716 because it does provide the investments that health providers need to get over the initial hump of changing systems to be able to meet, of course, all the demands that are happening and also being cybersecurity relevant and interoperable. Looking at what Shipta provided for testimony.

Also, many of the underserved and rural providers are going to have challenges with some of the data analytics needs of the new AHEAD grant, which the state was awarded and this program would be very supportive in being able to help the state achieve the data and analytics needs because quality data starts from quality systems and making sure that they have modernized health it.

And for all these reasons, we. Ochin respectfully urges you to support the measure. I'm available to answer any questions in Mahalo.

Thank you very much. Let's see. Papa Ola Lōkahi.

Aloha Chair, Vice Chair, Members of the Committee. My name is Keʻōpū Rilitz. I am the Director of Policy and Strategy with Papa Ola Lōkahi. You have our written testimony.

The only thing we wanted to offer as comments is maybe to either replace Native Hawaiian Healthcare center with Native Hawaiian Healthcare Systems or to just add the Native Hawaiian Healthcare systems to the types of entities that are eligible. That's the only comments we had, but I'm here to answer any questions. Mahalo.

Thank you very much. Let's see. We have written comments from about a half dozen other organizations in support at this point. Have I missed anyone in person or on Zoom? Seeing none. Members, any questions? If not, I have a question for Jennifer Stoll on Zoom.

Jennifer, we heard from SHPDA, Jack Lewin that the estimated cost of such a system might be, let's see, 15 to 20 $1.0 million. What would be your estimate?

Well, each provider would make individual decisions on what they are looking to acquire. You know, I think the estimate that Mr. Lewin provided was. Was about. About right.

Thinking about, you know, maybe structuring it in a way that looks at initial onboarding or, you know, some sort of program Administration based on priority will also be important as the agency would be implementing the program.

Okay, thank you. Any other questions? Seeing none. Let's move on. Next Bill HB302, medical cannabis. Let's see. Department of Health.

Good morning. I'm Kyle Brandt with the Department of Health. We stand by a written testimony providing comments and I'm available for any questions.

Thank you.

Thank you.

Department of the Attorney General on Zoom. Oh, you're in person. Okay.

Morning, Chair, Vice Chair and Members. Andrew Goff, Deputy Attorney General. You have our written testimony noting concerns. I do want to point out.

The biggest concern we have is that this bill would allow an applicant or their primary caregiver to purchase up to half of their legal allotment of cannabis prior to the Department of Health approving their application. This means that an applicant or their caregiver could purchase up to 2 ounces of medical cannabis.

And if the Department of Health determines they are ineligible for medical cannabis, those people could be in possession of 2 ounces of medical- of cannabis unlawfully, which could lead to criminal penalties of depending on what product they buy from a misdemeanor all the way up to a class C felony.

Now, given that the DoH turnaround time for applications is around two to three days and sometimes can be within one day, this seems to be a solution without a problem and the risks may outweigh the rewards there. Additionally, the bill repeals the in person consultation requirement.

Right now, telehealth is an option for a medical provider to certify a patient for medical use of cannabis, but it does require an initial in person consultation. This bill would remove that from 329.

But we would note that the Telehealth Law 453-13C explicitly requires for the certification of medical cannabis and in person- in person meeting between the provider. So there'd be a conflict there. I'm available to answer any questions that you have.

Thank you. Hawaii Cannabis Industry Association.

Morning Chair, Vice Chair Blake Oshiro

on behalf of the HICIA, we are in strong support of this bill. We thank you for skills scheduling it today. We do have a proposed amendment which we think takes care of the conflict that was referenced by the Attorney General and its proposed in our testimony. So I would just like to briefly summarize.

You know, the medical dispensary law was passed in 2015, and since that time, the landscape on cannabis has changed dramatically. We've seen adult use in multiple states, we've decriminalized the possession of Marijuana. We've seen the black market only continue to rise and become bigger and stronger.

And what that is directly influenced is the prices and the availability of illicit Marijuana. And so when it comes to registered cardholders, in the last three years, the DoH has seen a 15% drop in qualifying patients of people who actually go and get the cards.

So in order to maintain and support this industry which provides safe products, in order to make sure that our patients and our residents are getting safe products that are tested, we think we need to remove some barriers to access. And that's what this bill does. I'll be available for any questions. Thank you.

Thank you. Let's see. Noa Botanicals.

Aloha Chair, Karlyn Laulusa from Noa Botanicals and I stand in strong support of the bill and will stand on my testimony.

Thank you. In support, Akamai Cannabis Consulting, Clifton Otto on zoom.

Yes. Good morning, Chair, Vice Chair, Members of the Committee, Dr. Clifton Otto in support. You have my written testimony, which is basically a collection of all the suggestions for improvements to our medical cannabis program that I've received from patients and providers.

And I think the end result is very interesting because these changes taken together would expand our medical cannabis program in ways that would drastically improve patient participation and access, making this an alter- an attractive alternative to recreational legalization, but one that would allow for much better regulatory oversight of this Schedule 1 controlled substance while protecting the state's authority over the interstate medical use of cannabis.

So thank you for considering this testimony and I will be available for any questions.

Thank you. Let's see, we have five other groups submitting written testimony and support. Have I missed anyone? Anyone in the yes, please step forward.

Chair Takayama, Vice Chair Keohokapu-Lee Loy, Committee Members, Happy New Year first of all. My name is Tai Cheng. I am founder of Aloha Green Apothecary, a state licensed dispensary here on Oahu. We stand in strong support of HB302.

The first part of HB302 is about allowing telemedicine, and we've already heard today from a number of people how important telemedicine has become after Covid. But unlike the other bills you've heard this morning, the initial qualifying visit is not covered by insurance. It's paid out of pocket by the patient.

And so there is no opposition from anyone saying that this is not allowed. We have the Hawaii Cannabis Dispensary Association has already provided some language to fix the issue that the Attorney General has pointed out. In the second part of this bill

though, you may have some questions about why would we allow patients to access small amounts of cannabis medicine after a physician's qualification?

Patients now, in accordance with the DoH, wait up to three days and sometimes up to one week for a technical check that their name and their address provided by the physician is correct so that a card may be issued and emailed to that patient.

Recent polling of patients that we just conducted yesterday show that four out of 10 cardholders have waited three days or more. The DoH offices are a government office. They're only open on the weekdays and are not open on the weekends. Physicians, on the other hand, work seven days a week and are qualifying patients on Saturday and Sunday.

So even if the turnaround time was two to three days, if a qualified patient is qualified before a holiday or a weekend, they would wait up to five days with their symptoms before they can get access to any medicine.

Is it right to allow for five days for a patient where 83% of all patients have severe pain as a reason for their condition, to be not allowed to access medicine even for pharmacies, they're open seven days a week. Their registry, their computer systems are available so that a patient- a pharmacist can check and dispense medication accordingly.

I think it is cruel to make a patient wait when they are suffering. Actually, I had a story yesterday. The DoH did a very good job. A family friend of ours was diagnosed with terminal brain cancer. She attended a physician.

She went to see a physician and was able to receive a card within 30 minutes because the physician called the registry and told them, this person is dying. They require medicine. And at that point, yes, they were allowed to get the medicine.

But who is it up to and whose choice is it to allow for a physician to have to call into the registry to ask for an immediate card?

Thank you. I'm going to ask you to please summarize.

We again- this change is not novel. There's similar legislation in other states such as California, that allow for small amounts to be purchased during that three day interim period. And to alleviate the concerns of law enforcement, the products that are purchased by the patient are labeled by the dispensary in childproof packaging.

They have a receipt that has the patient's name and the amounts purchased. And the patient themselves would have the physician's qualifying letter approving that they're a qualified patient.

Provider.

Provider.

Yes.

Thank you very much.

Thank you very much.

Big Island Grown Dispensaries.

Good morning. Thank you, Members of the Committee for hearing this bill. We stand on our written testimony. In support. Strong support.

In support. Thank you. Cure Oahu on Zoom. Mihoko Ito. Oh, there you are. Okay.

Good morning. Chair, Vice Chair, Members of the Committee, Mihoko Ito. On behalf. Behalf of Cure Oahu, we also stand on our testimonials.

Thank you. So at this point, I think I've. Have I missed anyone in person or on Zoom wishing to testify, if not members, any questions? I have one question for Department of Health, if I may. Let's see. As I understand it, an application for a medical cannabis card is submitted by a certified

How often do you turn it down?

I couldn't have an exact number turn down a return for.

How do you.

We do occasionally.

How often do you reject them?

Hardly ever.

Okay.

Yeah.

Okay. Thank you very much. Seeing no other questions, let's move on to another. Let's see. Let's move on to HB600, which is another. Another medical cannabis bill. Attorney General.

Morning again Chair Vice Chair Members, Andrew Goff, Deputy Attorney General. Again we've submitted our written testimony and to outline some of our more serious concerns. This is similar to the last Bill.

However, this one would completely remove any registration requirement for an out of state patient and essentially allow them to walk into a dispensary and prove to the dispensary that they are an out of state patient and purchase their full allotment of cannabis. This raises several logistical and legal issues.

The first one is that there will be no way to track the patient's purchase of cannabis. Currently they are tracked through a registration program. They get a number and then the system itself will disallow an out of state patient from purchasing at any dispensary more than their allotment.

So you can go to one dispensary, purchase your full amount, go to another dispensary and if you try to purchase more, the system won't let you. If you don't have registration, then that will not be the case. And a patient could go to multiple dispensaries in one day.

And by exceeding their legal limits, this would also put the dispensary at a disadvantage and potentially a violation for selling a out of state patient incorrectly in excess of what they're allowed to purchase. The dispensary would also be in charge of verifying that the out of state patient is legally authorized in another state to purchase medical cannabis.

We have seen instances where patients from out of state come in with fake cards with incorrect information and the dispensary itself at that point would be selling an unauthorized person medical cannabis, which could also be a violation and that person would be in possession of medical cannabis unauthorized by law and that patient could face criminal liability.

And then we also point out that the issue with telehealth remains in this Bill as well. Section 453-1.3C requires an in person visit. Thank you for the opportunity.

Thank you. Department of Health.

Good morning again, Kyle Brandt with the Department of Health. We stand by written testimony and strong opposition to this Bill. I'm available for questions.

Thank you, Can I ask you, I'm sorry. I know you stand on your testimony, but could you briefly summarize your, because it is in opposition. Summarize your opposition.

I mean, Andrew Goff from the Attorney General's did a great job. I mean I would just echo his comments. We have a lot of concerns about out of state patients coming without having to register. Obviously without funding, we'd have a hard time running our program.

All the public health Initiatives that we're currently conducting and like to continue to conduct in the future would be at risk. Those are the two main key points, along with the telehealth thing that we brought up earlier.

Okay, thank you, Hawaii Cannabis Industry Association.

Morning again, Chair, Vice chairs, Members of the Committee, Blake Oshiro, thank you for also hearing this Bill. Thank you to the introducer for putting it in. There's a lot of overlap with the prior Bill. We support this Bill.

The one thing I would like to point out is the Bill actually proposes to remove the fee for registration of a card. We hear what DOH is saying that they do, may need some funding, so we would propose that instead maybe suspending it.

The information we've looked at is they may be sitting on as much as $11 million in their special fund that's dedicated to the registry as well as overseeing the dispensaries.

We think that's a lot of money that actually would be better served if patients got some relief and didn't have to pay the registration fee for a number of years until some point where DOH can demonstrate they're actually going to be using some of that $11 million. Thank you.

Thank you. Let's see. Aloha Green Apothecary.

Good morning again, Chair. Vice Chair. We stand by our written testimony in support of HB600. We appreciate the intent of the Bill. The only thing that would ask is to amend it to allow for any out of state patient to bring in proof of a medical need or a medical registration.

The issue here is that in California, physicians issue physician letters that qualify the patient with a medical condition. With that letter, they're allowed to enter a dispensary, adult use or medical and purchase cannabis medicine without having to pay the retail tax. They have the option of registering with the state,

and if they register with the state, they receive a physical plastic card. Many Californians decide not to get that physical plastic card and instead just walk around with this physician letter that they're running around with. So if the Committee thinks that this Bill is worthy to move on, then we ask for that amendment. Thank you very much.

Thank you, Noa Botanicals.

Thank you, Chair. Karlyn Laulusa, CEO for Noa Botanicals. So I stand on my written testimony and strong support and further support Mr. Oshiro and Mr. Cheng's comments.

Thank you. I believe on Zoom we have Dr. Clifton Otto.

Aloha Chair, Vice Chair, Members of the Committee, Dr. Clifton Otto, in support of the telehealth portion in hopes of some amendments, you have my written testimony which is essentially the same as the testimony as I offered on HB302. Because of the similarity of these bills and my comments on HB302 apply to this Bill as well.

And I think you'll find in my written testimony that there are solutions for the concerns of the Attorney General and the Department of Health. So thank you for considering this testimony and I'll be available for any questions.

Thank you. Let's see. We have written comments from two individuals in support and one in opposition. Have I missed anyone else wishing to testify in person or on Zoom? Seeing none. Members, any questions? Yeah, go ahead.

Sorry. I'm short and to the side. Question for Department of Health, please. You know the fee that we're talking about potentially waiving, is this fee the same? Is it a processing fee that's applied to both Hawaii residents and for the out of state, or is this a fee just for out of state?

There's a fee for both in state and out of state patients to apply.

It's the same?

No, out of state is actually a little bit more.

How much more?

In state is 35. Out of state is 45. Then with additional small fee for our online processing.

Okay. And I guess so the amounts that was referenced at 11 million. And could you expand a little bit more on what the programming or what you're using those funds for?

And then is there any need in any of that work for like a floor that is there a reason you're just accumulating or do you need to keep some kind of cash balance for certain programs in whatever you're administering?

I'll do my best. I can't do very specific questions because I'm not the fiscal person of the office. I know we are only appropriated a small fraction of that special fund every year.

You know, we would try to use as much as possible that we're allotted, you know, for public health initiatives, for personnel, for, you know, so forth.

So the other uses are contracted out to for education, for whatever else. Is that?

We recently brought on a public health educator. And so we've really started to kick start some of those initiatives and there's a lot more we'd like to do this year and the following years. Yes.

Okay. Thank you.

Welcome.

Thank you. Any other questions? Seeing none. Let's move on to the final bill on the agenda, which is House Bill 434 proposing the registration of doulas. DCCA Director Ando.

Yes, good morning, Chair. Vice Chair, Members of the Committee. And we stand on our testimony opposing.

Could you Step forward? I'm sorry. Because people can't hear you unless you use the mic.

Yeah. We stand on our testimony opposing the measure because as we read this bill, you know, it talks about the registration of certain doulas, but based on what it's asking for, it's requiring any person providing doula services for compensation or who advertises or holds themselves out as a certified doula to register with the dcca, establish rights for certain certified doulas and requires the Director to take in application forms, collect applicable fees, maintain a registry and promulgate rules concerning their requirements needed to be included in the registry.

And so we regard the proposed addition of a new chapter for registration of doulas as essentially seeking regulation for this category of birth attendance not currently regulated under the midwife statute, which is HRS chapter 457J.

And so we believe that it's more appropriate that this matter be referred if it's going to take, if there's going to be any interest in pursuing something like this, that it be referred to the State Auditor for a sunrise analysis pursuant to HRS section 26H6, which requires some analysis of the probable effects of regulation, assess whether or not enactment is consistent with legislative policies, and assess alternative forms of regulation.

And furthermore, if we're going to add another category that this Department has to regulate, this would require additional funding to administer the program, including it upgrades, operational and personnel costs, which would mean added, which we'd have to ask for if anything is going to be set up to regulate this additional profession.

So we request in our opposition that the matter be deferred until the sunrise analysis has been done and has been conducted by the Auditor. I'm available for further questions. Thank you.

Let's see on Zoom. We have Best Birth Hawaii. Kacha Paharma. Not present. Laura Akashio. Not present. Allison Shiozaki.

Chairperson Takayama and Members of the Committee on Health. Aloha Mai Kakou, and Happy Lunar New Year to you all. My name is Allison Shiozaki. I live in the Puna District on the island of Hawaii. I have fully completed my trainings in full spectrum birth work and I'm an active Member of the Birth Workers of Color Collective.

I agree that the matter should be deferred and strongly oppose this bill as it will create further barriers to much needed support around birthing and reproductive health and justice. I also further question the approach of this bill when the federal Administration is very keen to limit access to reproductive health.

While I appreciate the intent of this measure, I stand with other birth workers who voice how deeply flawed this approach is requiring certification when access to such trainings do not exist locally or within means not only limits access, but it's worse than that.

Well informed birth workers who may not have training through the means recognized by the state cannot practice the course that I personally spent thousands of dollars and nearly a year of intense study is not recognized by the state in this way.

And yet the collective I'm a part of provides me ongoing support including one on one mentorship, monthly or more continuing education workshops and Zoom meetings to up to date with vital information regarding birth work and especially analysis of statistics on black and indigenous people of color birthing people.

In fact, my collective specifically chose to give certificate of completion instead of certification because it is problematic to delegitimize traditional and community based birth workers. While also not a significant factor in providing community community accountability.

Personally, I also have connected myself with the local birth working community and make myself available to local community as an early childhood educator and thus professionalism, accountability and accessibility are very important to me.

Studies that I've read and included in my written testimony have shown that Native Hawaiian and Pacific Islanders are four times as likely as white birthing people to receive prenatal care only in the third trimester or none at all. Native Hawaiian and Pacific infants have a two times mortality rate as white peers.

Higher preterm births as well as Native Hawaiian and Pacific birthing people have nearly five times higher pregnancy related deaths. Thank you.

I'm going to ask you to summarize.

Please, please yes. All of this to emphasize the need for increased support and choice for birthing parents. Not more obstacles. I live here on Hawaii island where it is considered 100% rural and only has three major hospitals and many people are outside of the 30 minutes to a hospital. Despite this fact, I cannot legally offer my services.

And I just lastly would like to point out, given the deeply disturbing nature of the federal Administration's approach towards reproductive health care, I want to especially voice opposition to this approach as it doesn't really feel necessary or helpful to protect birthing families and also their right to choice nor birth workers ourselves.

Looking to states like California, we can see other positive examples. Thank you so much.

I appreciate your comments. Penelope Penelope Mckenzie on Zoom not here. Have I missed anyone in person or on Zoom wishing to testify on this bill, if not Members? Any questions? Seeing none, let's move on to decision making. We have all Members here, so let's go straight forward. Give me a Sec.

Our first bill was HB303 relating to healthcare. Preceptors, I'd like to move this forward. I think it's a good bill, not because I introduced it, but because I think it has much merit. I'd like to make a couple of. Well, like a single amendment.

So it'll be a House draft, like to defect the date to July 1st, 3000. For Members of the audience, Just so you know, adding a defective date, it doesn't mean we actually intend the bill to take effect in 3000. It simply provides insurance assurance that we will further the discussion before we finalize the bill.

So with that, any Members, any comments or questions on my recommendation? If not, Vice Chair, would you take the vote?

Yes. Chair, thank you. We're voting on House Bill 303. Chair's recommendation is to pass with amendments. [Roll Call] Chair, your measure passes.

Thank you. Next bill, HB441, raising cigarette taxes. I'd like to move this forward with a defective date. As mentioned in testimony, we'll be hearing another bill on this issue submitted by the Governor. But because of the scheduling, I mean the referral of that bill, we couldn't schedule it at the same time.

So we'll hear that ill in a couple days. But noting that I'd like to move forward, as I said, a House draft with a defective date. Any questions, comments? If not Vice Chair.

Thank you, Chair. Voting on House Bill 441. Chair's recommendation is to pass with amendments recognizing all Members of the Committee. Any Members voting no, with reservations. Chair, your recommendation is adopted.

Thank you for this. Next bill is 557 relating to telehealth. Members, bear with me, it gets a little bit complicated. First of all, I agree with the important intent of the bill. Many kupuna like myself prefer telephone service rather than video conferencing.

I also recognize, however, the concerns raised by the Human Services Director which in essence we're trying to match state law to federal law, which is actually changing. So it's like hitting a moving target. I'd like to thank the author of the measure, Representative Chun, for working with me to find a way forward with that.

I'd like to move a house draft adopting a couple recommendations by HMSA along with some others. First of all, we're going to. We'd like to clarify the definition of interactive communication system to restrict audio only communication to the diagnosis, evaluation and treatment of mental health disorders.

And further requiring providers to amend a CMS designated modifier to verify that the conditions for use of audio only communication has been met. Secondly, remove the sunset language in Section 8 of Act 107. Thirdly, note that the bill references in several places quote distant site physician or practitioner, but practitioner is not defined in the bill.

So we will change that to use the term distant site health provider, which is broader and should accomplish the same thing. Finally, on page 19 reference is made to distant site physician or practitioner. And this part of the Bill really does seem limited to physicians. So we'll delete or practitioner and just leave physicians.

Finally, Members, I'd like to note that this bill has a triple referral. It's a long way to go. I'd like to keep the bill moving forward for further discussion. Any Member, any questions or comments or concerns? Seeing none. Thank you Vice Chair for the vote.

Thank you Chair. Voting on House Bill 557, chair recommends to pass with amendments as defined, noting all Members present. Any Members voting no with reservation over here. Thank you Chair. Your measure is adopted.

Thank you. Next bill is HB 716 relating to health Infrastructure Grant Program. Like to move this forward with defective date along with technical amendments for style, clarity and whatever. Like to. I note that it has a blank amount so we put in report language.

The suggested amount should House Finance decide to move this Forward is between 20 to 25 $1.0 million. Members, any questions, comments, concerns? Seeing none. Vice Chair for the vote.

Thank you Chair. On House Bill 716-Chair's recommendation is to pass with amendments noting all Members present. Any Members voting no. Any Members voting with reservations? Member Alcos and Garcia?

Thank you Chair. Your measure. Chair, your recommendation is adopted.

Thank you. House Bill 302 relating to medical cannabis. Like to move this forward with a House draft defecting the date and adding a new section amending hrs453.1.3C that was referred to in testimony and this would allow online consultation for purposes of issuing a medical Marijuana card. Members, any questions, comments, concerns? Sorry.

302 Members, any questions, comments, concerns on HB 302 seeing none Vice Chair.

Thank you Chair. On House Bill 302, Chair's recommendation is to pass with amendments noting all Members present. Any Members voting no with reservation. Chair, your measure is adopted.

Thank you. On HB600, also on medical cannabis, I'd like to thank the author of the bill for introducing this. However, concerns were raised by the Department of Health as well as Attorney General regarding the difficulties in tracking out of state users so with that. I'd like to defer that bill. Final bill HB 434 relating to doulas.

I'd also like to defer this. I think, and I think that more discussion is needed and consulted with the author and he agrees with that. Members we're adjourned.