House Standing Committee on Health

Good morning everyone. Members and testifiers, thank you for being here and surviving the storm. I'd like to welcome you to our 9am Joint Hearing hearing of the House Committees on Health and Committee as well as Committee on Human Services and Homelessness. Thank you Chair Martin for being here as well.

First up we have HB553 relating to biomarker testing. And first up we have let's see. DCCA Insurance Division. Okay. Offering comments. Thank you. Let's see. Cynthia Au, American Cancer Society.

Good morning Chairs and Vice chairs and Joint Committee Members. Cynthia Au with Government Relations Director for American Cancer Society Cancer Action Network or ACS CAN. We stand in strong support for House Bill 553. Thank you for the opportunity to hear this bill. Thank you so much for your consideration on it.

We ask that you and your Members in the Committee pass this critical legislation that will improve patient access to care. Timely access to comprehensive biomarker testing will enable more patients to access the most effective treatments for their disease and can potentially help achieve the triple aim of healthcare, better health outcomes, improve quality of life and reduce costs.

A recent peer reviewed study found that 64% of Hawaii policies reviewed were more restrictive than the National Comprehensive Cancer Network guidelines for biomarker testing for advanced breast, non small cell lung cancer, melanoma and prostate cancer.

Currently in the last five years, clinical trials have shown that therapies that come from clinical trials requires a biomarker test for the patient to even get that therapy. Ensuring equitable access to biomarker testing by improving coverage for and access to testing across insurance types is a key to reducing health disparities.

Indeed, without action like this to expand coverage for biomarker testing, including Medicaid, advances in precision oncology could increase existing health disparities. I'd like to draw your attention to the written testimony submitted by Natalie Hyman and Susan and Peter Hirano and I think some of them may be joining us here today.

Both these stories highlight the inadequate coverage of biomarker testing by insurers in Hawaii.

Natalie and Susan both received biomarker testing that was ordered by their oncologists to guide treatment for their cancers and both received big bills because their insurers did not want to cover the testing in order to make sure that Hawaii patients have the access they need. This is a game changing test of this game changing testing.

The Legislature should ensure that that necessity is determined by doctors and the latest evidence, not insurance companies. This legislation is designed to align the evidence that plans follow in determining which patients can access biomarker testing. This legislation has passed in 20 states.

HB553 would make it possible for more patients to get the right treatment at the right time. Thank you.

Thank you very much. Director Ryan Yamane on zoom.

Aloha. I'm Judy Mohr Peterson. And on behalf of Director Yamane, the DHS stands on its written testimony. We definitely appreciate the intent. We offer comments and request amendments. Thank you.

Thank you very much. Let's see on zoom. We have from Kaiser Permanente John Kim Ritzer.

I'm sorry. Good morning. Good morning. Chairs, Vice Chairs and Committee Members John Kim Ritzer, Council for Kaiser Permanente. Kaiser stands on its written testimony offering comments available for any questions. Thank you.

Thank you. Let's see. HMSA Don Kurisu. Thank you. Hawaii Association of Health Plans, Rachel Wilkinson. On zoom. Pedro Haro, American Lung Association. Not present. Offering support. Let's see on zoom. Natalie Hyman, please proceed.

Hi, Good morning. Committee Members and chairs and vice chairs. My name is Natalie Hyman. I live in Kailua and I'm a patient advocate living with stage 4 metastatic breast cancer. And I'm in strong support of HB553. I was diagnosed with stage 4 metastatic breast cancer in 2020 and I'm still here.

And thanks in large part due to biomarker testing at the time of my original diagnosis, my oncologist ordered biomarker testing of my tumor.

At the time, that biomarker test was the professional standard of care in breast cancer oncology, which is probably why my local oncologist ordered the test without expressing any concerns to me about insurance coverage or possible denial. Because the results of the test would reveal if any targeted therapies might work on my cancer.

My insurer denied coverage for the test based on their determination of medical necessity.

The company's reason for denying me coverage for the standard of care biomarker testing was, and I quote, "the use of comprehensive genomic profiling, expanded cancer mutation panels for selecting targeted cancer treatment does not meet payment determination criteria because there is a lack of evidence that this technique improves health outcomes." Okay. That's what they told me.

Many patients give up upon initial insurance denials because they don't have the energy or the knowledge to appeal it. In my case, the testing company agreed to appeal on behalf with help from my oncologist. However, despite their months long efforts, the insurer still refused to pay for it and the cost was $5,800.

And this biomarker test, I want to point out, arguably already meets the definition of medical necessity under Hawaii law. Medically necessary as decided by the insurer plan's medical director is often inconsistent with the recommendations of the treating physician, professional standards of care and clinical practice guidelines. I have one more example to share.

Another example of my insurer denying coverage for medically necessary biomarker testing happened to me in 2023. In July of 2023, my cancer progressed, which means I needed to change treatments. Earlier that year, on January 27th, the FDA approved a new drug called Elacestrant for ESR1 mutated metastatic breast cancer with disease progression. I fit that exactly.

FDA at that time also approved a companion diagnostic advice which was a specific biomarker test to identify patients with breast cancer for treatment with this new drug. Elacestrant my cancer subtype and treatment history aligned with the new approved drug. So my oncologist ordered the corresponding test.

It revealed that I did in fact have the ESR1 mutation and I was approved to receive the Elacestrant treatment. However, my insurer did not approve coverage for the test. It's been over 18 months now since July 2023, and my insurer still has not issued a coverage decision. I'll just be one more second.

Can I just ask you to summarize, please? We need to wrap up.

Yeah. The test cost $9,650. And again, this biomarker testing was fit within the Hawaii definition of medical necessity. So, in short, patients should be able to get biomarker testing when it's ordered by their Doctor and there's sufficient information to guide their treatment. But that's not what's happening today.

The insurers can use their own definition of medical necessity in order to deny coverage.

Thank you so much. Susan Hirano.

Good morning. My name is Susan Hirano. I was here on Wednesday as well. Hopefully both of our nerves are a little less today than they were then. And I promise I won't talk quite as long. I just wanted to give you a little personal context.

When you have a conversation with your oncologist for treatment, they make the recommendations of what kind of treatment you should receive. It's not the patient saying, I want a biomarker test. It's the Doctor coming to you saying, we need to determine the best course of care for you.

And in order to do that, you need a specific blood test to find out what mutations you have. So similar to when you all go to the Doctor for a regular checkup, they order blood work and we review that blood work in order to determine what the next steps are.

It's the same thing in oncology it's just more specialized. And you never have the conversation with your oncologist as to whether or not that's going to be covered by insurance. Your doctor never says, you might want to check if it's covered. It may or may not be.

You just assume, for lack of a better word, that it is. And then a few months later, you get a Bill for $9,600 and go, okay, what do I do with this? So similar to Natalie's situation, we are in the same boat. My husband and I have a bill that's two years old.

We're still trying to get it paid for by the insurance company and how to go through the appeal process. But I just thought maybe that analogy might help you see it in a different light. So thank you.

Thank you. And thank you so much for being here. And I am not quite as nervous. Thank you. Let's see, we have about a half dozen other individuals who've provided written testimony in support. Have I missed anyone? Anyone else wishing to testify on HB 553, please identify yourself.

Good morning, Chairs, Vice Chairs, and Committee Members. My name is Shane Morita. I'm a surgical oncologist. I've been back here for 16 and a half years. 20 years ago this month, my father died of terminal cancer in Hilo, where options were very sparse. I did training at the National Cancer Institute as well as the Johns Hopkins Hospital.

There's been a paradigm shift in cancer care where now we have options to treat patients personally with targeted therapy and precision medicine in ways that we can tailor what's best for the patients. I strongly advocate this bill as a clinician as well as someone who watched their father die of this disease.

So I really appreciate the time and opportunity. I'm here representing American Cancer Society as the medical officer for the Hawaii Chapter. Thank you.

Thank you so much. Did you provide written comments to the committee?

No, I did not. I felt that it was more effective if I was here in person, sir. Thank you.

That's fine. We're going to have our Committee Clerk give you an email in which you might be able to submit written comments. That way we can have it for the written record. Thank you. Have I missed anyone else wishing to testify on HB553, either in person or on zoom. On zoom.

Please proceed and identify yourself.

Aloha Chair, Vice Chair, Members of the Committee, I'm Pedro Haro, Executive Director of the American Lung Association. We send in a written testimony, would like to support and add that you know, one of the things that you're going to hear from the industry is to make this a narrower bill than it currently is.

We support the current format. As we often see at the American Lung Association, a high tide lifts all boats. Although cancer might be top of mind for some of these issues, we are incredibly supportive of the other issues. We don't live in our body parts. Right. We live as people, as whole people.

So limiting this kind of technology for a certain disease or for a certain body part makes no sense when we know that it can provide those same kind of benefits to other aspects of our health. So we're very supportive of this Bill.

Thank you so much for hearing it and thank you for creating such a broad scope that it includes most diseases that are able to benefit from this, from this type of technology. Thank you.

Thank you very much. Last call for anyone who wish to testify. Seeing none. Members, any questions for the test fires? Representative Chun.

HMSA. Hi. Morning. Thanks for being here. So I know we've kind of been working on this issue since last session and we had other study and really the focus was around the medical necessity standard. But as you've heard, there might be some issues with the standard of care, even though that's included in the definition of medical necessity.

Would you folks still be willing to open, still be open to looking at expanding it beyond medical necessity?

I think right now, currently, I think it's important that we keep the medical necessity statute. However, I do think that each individual going on this journey is very unique and their care journey is very unique as well.

And so we're certainly open to having a conversation and looking into any of those claims that were denied or any of those treatments that were questioned. I do think that it's important that we ensure that all of our Members get the highest quality of care.

Okay, thank you. Thank you, Chair. And thanks for being open to work with me on it.

Sure. And certainly open to furthering the conversation as well. Thank you. Members, any other questions?

Seeing none. Let's move on to HP 556 regarding colorectal cancer. First up we have Director Yamani, Department of Human Services.

Aloha, Chair, Good morning. Judy Mohr Peterson, Med Quest Administrator. On behalf of the Department of Human Services. We stand on a written testimony offering comments. Let me get my testimony here. And we appreciate the intent. We offer comments regarding sections 1, 4 and 5.

I also would like to note that we respectfully request that this program and appropriation not conflict with, reduce or replace priorities identified in the Executive budget. Thank you very much.

Thank you. Department of Health, offering comments. Thank you. Let's see. DCCA Insurance Division.

Offering comments. Thank you. Written testimony. Offering comments. Yes. Let's see. On Zoom, we have Community Clinic of Maui, Andrew Van Wieren, please proceed.

Good morning, everyone. Aloha. My name is Andrew Van Wieren. I'm a primary care physician, internal medicine physician, and the Chief Medical Officer at Community Clinic of Maui Malama Ke Ola, a federally qualified health center at Maui. I submitted written testimony as well, which I stand by.

And I just wanted to say a few comments this morning as well that I and our clinic are strongly in support of House Bill 556. And specifically we're charged by the Federal Government to take care of patients regardless of the ability to pay for their service, including patients without health insurance.

And for those patients, the main way that they're able to access screening for colorectal cancer screening is through stool based tests such as a fecal occult blood test or a cologuard test, which you may have heard of. And if those tests are negative, great. We repeat them in one to three years as recommended.

But if those tests are positive, then the recommendation from all the screening guidelines is to then complete a colonoscopy. And currently it's extremely difficult and virtually impossible for an uninsured patient to access a colonoscopy in the State of Hawaii. There just aren't good mechanisms set up currently.

And I think from my understanding of this Bill, it will help set up those mechanisms. We've had a handful of cases in the past couple years. It's not a huge number of patients, but it's an important equity issue. And we're seeing uninsured patients have positive stool screening tests without access to colonoscopies.

And that's a very difficult position to put those patients and our providers in. So again, we're strongly in support of this Bill and I'd be happy to answer any questions at any point.

Thank you very much. Let's see. We have Cynthia Au, American Cancer Society.

Thank you Chairs, Vice Chairs and Committee Members. Cynthia Au, American Cancer Society Cancer Action Network Government Relations Director. We stand in support with amendments. Colorectal cancer, or CRC, is the third leading cause of cancer in Hawaii and the third leading cause of cancer deaths nationwide. But these deaths are preventable from increased access to screenings.

Everyone should have equitable access to care. As a member of the Colorectal Cancer Task Force under the Hawaii Comprehensive of Cancer Coalition under the Department of Health, the task force has identified barriers in prevention, preventive screening for the uninsured and underinsured population in Hawaii.

We urge the Legislature to fund a program akin to the Hawaii Breast and Cervical Cancer Control Program. We offer amendments to the Bill found in our written testimony for the similar program language. Thank you for this. Time to testify.

Thank you very much. Let's see. Rachel Wilkinson, Hawaii Association of Health Plans. Thank you. Let's see. That's all the I have about a half dozen other organizations offering comments in support. Have I missed anyone else wishing to testify on HB556, in person or on Zoom? Yes, Doctor, please.

Good morning again Chair, Vice Chairs, Committee Members. Again, Shane Morita, surgical oncologist for 16 and a half years, Medical Officer for the American Cancer Society Hawaii Chapter, strongly endorsed this Bill as representing American Cancer Society. As a clinician, taking care of these colorectal cancer patients are extremely important. Early detection does save lives.

We all know that the rate of colorectal cancer has doubled in those under 50 years of age. So this is very important and I strongly support this. Thank you for this opportunity.

Thank you very much. Members, any questions of our testifiers? Seeing none. Let's move on to decision making on these two bills. First of all, we have HP553 relating to biomarker testing coverage. I suggest we move on.

Move this Bill on with a House draft providing for technical amendments for style, clarity and consistency, as well as adding a defective date of July 1st, 3000. For Members of the audience, adding a defective date doesn't literally mean we make it defective in 3000. It simply ensures that there is further discussion of this Bill as it progresses.

So that's my recommendation. I know there's further discussion to be had, but there are two more committees in which this discussion will be had. So Members, any questions, comments, concerns?

Chair this is a good Bill. I would like to see these pass. Recently I lost my wife in November 21st last year and battling cancer stage four.

And if we had to take on all these bills that, you know, through programs that not covered in our medical this is high money and we don't make enough to save this kind of money to pay these medical, so whatever offers that can help the families at home and making it easier, you know, highly recommend moving forward these bills. Thank you.

Thank you. Thank you so much. Any other questions, comments, concerns? If not Vice Chair, would you take the vote for Committee on Health?

[Roll Call]

For the Committee on Human Services, same recommendation. Any questions or comments? Seeing none. Vice Chair for the vote, please.

Voting on HB553 chair's recommendations is to pass with amendments. Are there any representatives voting no? With reservations? Chair, your recommendation is adopted.

Thank you very much. Next Bill is HB 556 relating to colorectal cancer. Recommendation is to move this Bill forward with technical amendments as well as a defective date. Note that it has a blank amount and is so noted. Will be so noted in the report language.

Also on page one, we'll adopt the recommendations to change references from Medicare to Medicaid where it's mentioned twice in error. Members, any questions? Comments, concerns if not Vice Chair for the vote.

Thank you. Chair, Voting on House Bill 556, Chair's. Recommendation is to pass with amendments. Seeing all Members here. Any Members voting no? Any with reservation? Chair, your motion is adopted.

Thank you. For the Committee on Human Services and Homelessness, same recommendation. Vice Chair for the vote, please.

Voting on HB556 Chair's recommendation is to pass with amendments. Any Members voting no? With reservations? Chair, your recommendation is adopted.

Thank you very much. Let's move on to our 915 agenda of the Committee on Health. First up, thank you again for being here. Forgot to mention some standing housekeeping rules. We appreciate all of your testimony. We'd like to Institute a. We do have a two minute suggested time limit.

Ask that you try and hold your testimony to that time. We have your written comments and testimony, so be assured that we've have access to it and have reviewed it so we have that on the record. For those on zoom, please keep yourselves muted until it's time to testify and unmute yourself when you're done.

Try and avoid the use of any copyrighted images or images while you testify because that's against our zoom rules. And appreciate everyone being civil and courteous to each other, exercising the aloha spirit, which pretty much is not need to be said.

So let's go on to first bill up, which is House Bill 712 relating to 340B drug pricing. And first up, we have the Department of Health.

Good morning, Chair, Vice Chair, Members of the Committee. My name is Lorrin Kim. I'm the Planning and Policy Officer for the Department of Health, and, of course, proud resident of House District 34. So happy to be here and happy to be in front of your Committee, Chair. The Department is offering comments. We have...

We recognize how important the contract pharmacy issue is for Hawaii's healthcare system and our residents. We do express concerns that regulating private commercial activity between oftentimes for profit entities, or at least involving for profit entities, is really not in the department's wheelhouse and we do not possess the expertise.

If the Department were tasked with regulating private contracts and deceptive and unfair practices, we would require additional resources and we would hesitate to recommend that or want to see that in a built because this will change the trajectory and the referral. There are other vehicles out there that maybe we can have that conversation as it progresses through the committees, but we just really need to bring this Committee's attention to the need for somebody to do something about this.

That's really got to be Congress at this point, although we do see some states enacting some measures just to try to chip away at it. That being said, again, this is not something the Department of Health has staffed to do and would require us to acquire this expertise and knowledge. So thank you very much. I'm available for questions.

Understood. Let's see, on Zoom, we have the Attorney General. Not on zoom, present. Yes, please proceed.

Good morning, Chair, Vice Chair, Members of the Committee. Melissa Chee, Deputy Attorney General. To add to what Mr. Kim was saying, they don't have the expertise to implement the bill as written. So we were suggesting, as our testimony stated, it be placed in 481B of the Hawaii Revised Statutes. And if you have any questions, I'm happy to try and address those. Thank you.

So noted. Thank you very much. Let's see. Pharmaceutical Research and Manufacturers of America, William Goo.

Morning, Chair, Vice Chair, Committee Members. My name is William Goo, here on behalf of PhRMA, which is a trade association for many of the largest pharmaceutical companies in the United States. PhRMA stands on its written testimony in opposition to the bill. I'd just like to add that, notwithstanding the contents of this measure, that PhRMA's members are in compliance with the intent of the federal 340B program mandates and are committed to its success. Thank you for the opportunity to testify.

Thank you. Let's see, on Zoom, we have Hawaii Pacific Health, Michael Robinson.

Good afternoon, Chair. Mike Robinson, Hawaii Pacific Health. We'll stand on our written testimony. I will add that the savings from the 340B program provides the type of support that we need to keep critical services at our hospital system. For example, at Straub Medical Center, due to the practices of pharma, we're losing about a million a month from these unilateral decisions that are being made. I would also add that this bill is identical or very close to statutes that have been passed in many other states.

So it is not a new type of intervention at the state level and it has survived legal challenge almost in every case. So I think even when you think about services like the Straub Burn Center that we know was stretched very thin during the most recent firework tragedy that occurred, I mean, these are the types of revenue streams that nonprofit hospital systems in our state rely upon. So very important that this bill gets passed and that we figure out some way to address this. Thank you.

Thank you. Also on Zoom, we have Hawaii Island Community Health Center, Melissa Bumgardner.

Good morning. Thank you, Committee Chair, Vice Chair, Committee Members, for the opportunity to speak on behalf of my organization and myself. My name is Melissa Bumgardner. I'm the Director of Pharmacy Services at Hawaii Island Community Health Center.

We did submit written testimony, which I stand on today, and I'm here today solely to speak speak on behalf of the patients who are not represented in this room. The testimony that I submitted speaks about the program and what it brings to our health center, but I would like to represent what it means for our patients.

There is not a single manufacturer right now that will ship insulin to our contract pharmacies. My daughter, last year, who was 15 years old, was diagnosed with type 1 diabetes. Her name is Amaris. Lukalani is three years old. She was diagnosed with type 1 diabetes when she was one year old.

Nadine has had type 1 diabetes for 30 years. They cannot access insulin at our contract pharmacies because the drug manufacturers will not ship it there. We have only one pharmacy in our health center to service our entire population of 40,000 patients right now on our island.

Without access to 340B priced medications at our contract pharmacies, our patients cannot access the low cost medications that this program was designed to provide to our patients. I strongly encourage you to consider the people that we are here to serve.

The mission of our Department is E ala, E alu, E kuilima, which means, loosely translated, up together, join hands. It is a call to come together to tackle a given task. And our task is to to ensure that our patients have access to the medications they need. Without this bill that will stop the restrictions that are currently in place, we simply cannot do our job. Thank you for considering.

Thank you. Let's see. Healthcare Association of Hawaii, Hilton Raethel.

Thank you, Chair, Vice Chair, Members of the Committee. Hilton Raethel, President and CEO of the Healthcare Association. Thank you for the opportunity to testify by in strong support of this bill. This legislation, what we're proposing would prohibit drug manufacturers from limiting access, as you've just heard, to necessary drugs under the 340B program in communities across this entire state.

Hawaii hospitals are currently losing at least $30 million a year due to these restrictions. And our federally qualified health centers, as you just heard, are also negatively impacted by by the policies of the drug manufacturers. We believe Hawaii should join nearly 20 other states and adopt this legislation that stops these practices.

Our written testimony provides much more detail about the 340B program, how it's designed to work, and how the actions of drug manufacturers stand in the way of this program. The restrictions are imposing are diverting critical funds from not for profit hospitals and community health centers.

We are asking for amendments to the measure today to reflect language that has withstood legal challenge in other states. We ask for your support for this legislation, which will protect the 340B program and help preserve healthcare access for Hawaii's most vulnerable residents. Thank you for your time, and I'm available for questions.

Thank you. Let's see. We have Queen's Health Systems.

Aloha. Good morning, Chair, Vice Chair, and Members of the Committee. Jacce Mikulanec on behalf of The Queen's Health Systems. I want to thank you for hearing this important measure. And we'll largely stand on our written testimony, but I would like to underscore that, similar to HPH, the 340B program serves the most critical hospitals in our state that are serving the most underserved populations in the state.

For Queen's alone, this has translated into upwards of $10 million a year that we're losing right now because of the restrictions that manufacturers are placing on this particular program. So we would simply like you to preserve this bill, make sure that the intent of Congress is executed to its full extent, and please pass this measure out. And we support the amendments that HAH has proposed as well. Mahalo.

Thank you. Let's see. We have written comments from 19 organizations and individuals expressing support. Also statement in opposition from Biotechnology Innovation Organization. Have I missed anyone else wishing to testify on HB 712 in person or on Zoom? If not, Members, questions? Let's see. Just quick question for Healthcare Association. Mr. Raethel, I know your written testimony reflects this, but for those who may not have access to your written testimony, can you describe how many hospitals are affected by this and whether they're all located on Oahu or elsewhere?

The how many hospitals? 15. So 15 hospitals across the state, not all located on Oahu. So this is a statewide issue. And the one of the Important things to note is that the hospitals and federally qualified health centers were able to participate in this program by these, through these contracts with contracts with. Sorry, using pharmacies in their communities.

It's a recent change by the pharmaceutical manufacturers that has limited their ability. So hospitals and the federally qualified health centers were able to take broad advantage of this program. but through recent action by the pharmaceutical companies in Hawaii and other states, that access has been restricted. And what we're asking for is legislation to go back to the original intent of the 340B program, a federal program. Yeah, we would love for it to be fixed federally, but in the absence of a federal fix, we're asking for the states.

It has, legislation has been passed that, in a number of other states, that legislation has been challenged in the courts. And in every single instance where it's been challenged in the courts, that legislation has been upheld that supports the 340B program. We're asking for that same legislation here in the State of Hawaii.

Thank you. And how much roughly do hospitals benefit from the existing program and how much would they benefit from the measure should it pass?

Well, right now, the best estimate for the hospital side is a loss of revenue of about 30 million a year. We don't have the number from the federally qualified health centers. We just haven't been able to get that information. So that would be on top of that $30 million a year.

So this is funding that the hospitals and federally qualified health centers used to get. Now, it's important to understand there's no state funds here. There's no state funds, there's no federal funds. This is simply an issue between hospitals, the contract pharmacies, and the drug manufacturers. So we're not asking for a handout. We're not anything like that.

It's simply, we're saying hospitals rely on this revenue. The federally qualified health centers rely on this revenue. They've not been able to use that. They've lost access to that revenue over the last few years because of these, of these contracts put in place by the pharmaceutical manufacturers.

And finally, should you be able to gain access to the 30 million or so dollars, what would you use the money for?

This money is used. All of our hospitals, every single hospital in the State of Hawaii is not for profit. They're all here to serve their community. Their ability to serve their community is dependent on funding streams like this to, you know, you heard stories since earlier testimony about uninsured patients.

This type of funding allows us to provide care to uninsured patients or underinsured patients. So we, not all the programs as we know, Medicare, Medicaid, others, cover costs, the entire cost of care. These types of revenue streams help fill that gap to provide care inpatient. And especially, as you heard, for our most vulnerable patients, those who have no insurance or who are underinsured.

Zero, thank you. No more questions. Any other? Okay. If not, let's move on to House Bill 72 regarding registration of pharmacy technicians. And first up, we have, let's see, UH system in support. I'm sorry. Yes. Written only. Okay. In support. Hawaii Pharmacists Association, Corrie Sanders.

Good morning. Chair, Vice Chair, Members of the Committee, Corrie Sanders. Director of the Hawaii Pharmacists Association. We'll stand on our written testimony and I'll remain available for questions.

Thank you. Walgreen Company. Tiffany Yajima. Not here. Okay.

Morning. Chair, Vice Chair, Members of the Committee, Tiffany Yajima. On behalf of Walgreens. Walgreens submitted comments on this measure and offers suggested amendments. With these amendments, we are in full support of it. In 2024, the Legislature passed Act 104 that allowed technicians to administer immunizations. This measure builds upon Act 104.

We do offer, as I mentioned, several amendments to our testimony to clarify the different roles of pharmacy personnel who are behind the counter. Happy to answer any questions. Thank you.

Thank you. Let's see. Molokai Drugs. Kimberly Mikami.

Good morning, Chair and Vice Chair and Members of the Health Committee. As a rural health care provider, access to comprehensive, high quality health care services is our mission at Moloka Drugs. On behalf of our employees and patients, I am testifying in favor of HB72, which will create necessary regulations for pharmacy technicians in our state.

At Molokai drugs, now celebrating 90 years of service, our pharmacy technicians are essential in workflow management, from data entry, to helping confirm inventory management, to contacting providers on island and off island, to product dispensing, to giving the prescription to the verifying pharmacist, to returning the final medicine to the patient at point of sale.

Hawaii is the only state in the United States without an active managed list of practicing pharmacy technicians. Beyond enhancing our Molokai patient safety, this measure will lay the foundation for pharmacy technicians in Hawaii to expand their scope of practice in the future.

Across the country, pharmacy technicians are taking on advanced roles, such as administering immunizations and assisting with medication management. Right now, at Molokai Drugs, our pharmacy technicians administer over 40% of our immunizations. Without regulation, Hawai'I risks falling behind in providing the best possible care to our communities, especially rural communities like Molokai with limited medical resources.

Many of our people, especially our kupuna, have challenges getting on island healthcare. With only one airline and no ferry providing transportation, our people have even more challenges getting to Oahu, Maui and the mainland for medical services and procedures. I would like to add to the written testimony I have an event today, so I'm here for this event.

I flew in Wednesday night to miss the storm. Two weeks ago my Mokulele Airlines flight was canceled. They were not flying for five days. I took a 23 foot boat from Kaneohe to Molokai that took three hours and 45 minutes so I could get home to my pharmacy.

You are going to hear more and more about the challenges we have with healthcare. When you add transportation issues where our one airline cannot provide service that is needed, you're gonna start seeing even more people getting sicker.

And like I tell people who wanna move home, I tell them if you have a healthcare issue, you do not wanna move to Molokai at this time. HB72 comes at a very reasonable price tag. Even small pharmacies such as Molokai Drugs are willing to pay for these regulations.

On behalf of our staff and island population of 7,000 full time residents, we ask that you support HB72 and help Hawaii become the 50th State of 50 to finally align our pharmacy technicians with national standards. Our Molokai based pharmacy technicians live full time on our island and know our people.

They work hand in hand with our licensed pharmacists. Our pharmacy technicians are essential healthcare employees and they help keep Molokaians healthy and thriving. Thank you.

Thank you so much for being here. You know you can zoom.

I normally zoom. I normally zoom, but I was here for an event today. Okay.

In the future. Thank you. Let's see. We have statements from eight other individuals in support as well as from KTA Pharmacy. Have I missed anyone else wishing to testify on HB72 either here or in person? If not Members, Any questions? Seeing none, let's move on. Next Bill is HB714, Healthcare Workforce Development.

And first up we have Department of Health.

The Department will stand on its testimony supporting the intent.

Thank you. Supporting intent. Hawaii Health Systems Corporation in support. University of Hawaii System. Please step forward.

Good morning Chair, Vice Chair, Members of the Committee. I'm Della Teraoka, the interim Vice President for the University of Hawaii Community Colleges. We do support this HB 714. And I've submitted written testimony and I'll be available if you have questions. Thank you.

Thank you. Department of Education. Thank you. Let's see. Hawaii State Council on Developmental Disabilities. Healthcare Association of Hawaii.

Morning Chair, Vice Chair. Members of the Committee, thank you for the opportunity to testify in strong support of this measure. This measure will provide state funding for two years to continue and expand proven healthcare workforce development programs for high school students and entry level healthcare workers.

Hawaii currently has nearly 4,700, 4,700 openings for non physician patient facing healthcare roles with a growing need for entry level positions like certified nurse aides. The two programs supported by this measure are having a material impact already on addressing our workforce challenge.

In 2024 we were able to train more than 100 public high school students across 14 schools achieving a 98% completion rate and a 75% employment rate. The second program in this funding would support is a CNA to LPN glidepath program. In 2024 we were able to support 34 CNAs in this program.

This year we have 50 students enrolled in this program. These individuals are able to earn their licensed practical nurse licensure while continuing to work which provide the opportunity to increase their salaries materially and which moved them up one step on the healthcare career ladder.

Healthcare employers have heavily invested in these programs providing instructors and hands on training to support students. And we have more applicants in all counties waiting to enter this program. With this funding we'll be able to continue both of these programs.

We have requested an amendment to direct funding to the Department of Business, Economic Development and Tourism which currently administers a program. Thank you again for your time.

Thank you. Let's see on Zoom. I believe we have Kaiser Permanente. Please proceed.

Good morning Chair, Vice Chair. Jonathan Chang for Kaiser Permanente. I'll stand on our written testimony. I'm in strong support of this measure. And also just note that we also concur with the requested amendment from the Health Care Association of Hawaii. Thank you very much. Available for any questions.

Thank you. We have written comments and support from Hawaii Pacific Health, Hawaii Primary Care Association as well as Queen's Health Systems. Anyone else wishing to testify on HB714 in person or on Zoom? If not Members any questions? For Mr. Raithel? Question? I understand that in the year 2024 this program was appropriated about $700,000 in state funding.

The request in the Bill is for double that amount in each of the next two years. Can you explain what the difference is? I mean, why is there a substantial increase in requests?

Yep. Good morning Committee. Paige Heckathorn Choy with the Healthcare Association. We had requested about 750,000 per program. So individually for the healthcare certificate programs in the public high schools and then also for the CNA to LPN Glide path. So this year we're just squishing them together. And that's why I think it looks like it's doubled the funding, but it was just funding for two different programs.

So it's actually. Thank you. It's actually this. I was trying to work out what was going on. It's. Yeah. It's actually the same level of funding.

Okay, got it. Thank you. You're just combining different programs. Thank you very much. Any other questions? If not, let's move on to HB1179 Rural emergency hospitals. Department of Health.

Good morning, Chair, Vice Chair, Members Lauren Kim, Department of Health. The Department supports this measure.

There is a specific hospital looking to make this change and we had been in communication with them and we recognize that this is going to make that facility much more viable and more improve healthcare access that aligns with their strengths for their community.

That being said, our initial research in the Department of Health is that we don't necessarily need state authority to do this, but we do think it's a good idea to codify it. Recognizing that triple referral deadline is just days away, we would like to request until Monday to get you specific amendments.

I was driving out to Kapolei yesterday specifically for a meeting to provide this Committee with amendments, and I made the mistake of getting on the freeway at 3 o'clock in the afternoon and when visibility got to 10ft, we turned the car around and went back home.

So I'm prepared to work with my colleagues to prepare amendments to Chapter 321, specifically authorizing rural emergency hospital designations by the Department of Health. But again, I apologize, I don't have it this morning.

Okay. Let me just offer this comment at this time because this is a triple referral Bill. Yeah. I'm going to suggest that should the Committee move this forward, that you provide that testimony to subsequent committees. Understood. For their consideration. Yes, Chair. Because of our deadline. Definitely recognize the referral deadline. Let's see. Department of Human Services.

Aloha, Chair, Members of the Committee, Judy. Moore Peterson, Med Quest Administrator on behalf of the Department of Human Services. We stand out of written testimony offering comments. We appreciate the intent, but we do note some concerns around the intent to preserve Medicaid protections, which are actually at the federal level and not at the state level.

We have some concerns and we will do some research on that. Thank you. Thank you very much.

Let's see. We have.

Lynn Fulton, Maui Health Systems on Zoom.

Yes, Aloha Chair, Vice Chair and Members of the Committee. I'm Lynn Fulton, the CEO at Maui Health. I stand on the testimony that I submitted, but I do want to stress that the value that this will bring to Maui Health and specifically our hospital on Lanai.

We will be able to better utilize the two beds that most of the time stay completely empty and move those over into long term care. And we will be able to obtain additional funding which will help us be able to continue to provide essential services on the island.

I'm here to answer questions, as is my colleague Deb Cartwright, our CFO.

Thank you. Thank you. Healthcare Association of Hawaii, Hilton Raethel.

We stand in standard outwritten testimony and support of this measure.

Thank you. Thank you. Let's see, that's all testifiers I have on HB 1179. Have I missed anyone or anyone on Zoom? If not Members, any questions? Seeing none. Let's move on.

HB139 regarding coverage for fertility services. First up, we have Insurance Division DCCA. Offering comments, thank you. Cynthia Au, American Cancer Society. In support, okay.

On Zoom. Alliance for Fertility Preservation. Joyce Reinecke. Not present. In support. Okay. Don Kurisu, HMSA. Support, okay. Rachel Wilkinson, Hawaii Association of Health Plans. In support. Allison McKechnie.

Hi, good morning, morning Chair, Vice Chair and Committee Members. My name is Allison McKechnie and I'm a current breast cancer patient. I was fortunate enough to undergo fertility preservation treatments earlier this month.

I was only able to receive this really expensive treatment due to the benefits of my insurance coverage, and without it, I wouldn't have the current peace of mind and optimism that I have while continuing treatment.

So I'm just here to advocate for all of my breast cancer peers and a lot of other cancer patients who suffer similar fertility challenges due to their cancer treatments. I believe that everyone deserves this coverage to be legally mandated.

A lot of insurance plans do cover sperm banking for men undergoing cancer treatment, but they don't currently cover egg or embryo freezing for women, despite this being much more complex and prohibitively expensive.

So I just urge you guys to pass this Bill and join the other states who have similar legal protection for to recognize fertility preservation for women. Thank you and I appreciate the opportunity to testify.

Thank you for being here. Let's see, we have written comments in support from, I believe, six organizations. Anyone else here wishing, in support by the way, anyone else wishing to testify on HB139 in person or on Zoom? Seeing none. Members, any questions? Okay. Seeing none. Let's move on. House Bill 612 prohibiting certain surgeries.

First up, we have Hawaii State LGBTQ Commission. On Zoom. Please proceed.

Aloha, Chair, Vice Chair and Members of the Committee, thank you for the opportunity to testify on behalf of Hawaii's LGBTQ Commission in strong support of HB 612, and we stand by our written testimony. To highlight a point, there is overwhelming patient advocacy and international support for banning surgeries to address non stereotypical genitalia.

The choice of removing sensitive genital tissue should only be made with the consent of the patient and there is no evidence that these surgeries do not affect sensation. Furthermore, it is unlikely parents are consistently able to provide accurately informed consent within the first year of the child's life.

I appreciate the written comments presenting concerns about potential unintended consequences of this Bill, such as preventing surgeries to correct hypospadias. The Bill does already, however, include provisions for procedures that are required to address an immediate risk of physical harm. That being said, there are also parents groups that question medical necessity and implementation of hypospadia surgeries in general.

Parents expressed they feel that the risks and expected outcomes were not accurately conveyed to them. This led to a lack of informed consent and many express they might have made different decisions given more information. These parents and others advocate, for example, for Centers of Excellence for these surgeries.

Due to the complexity of these surgeries, it is extremely difficult to acquire sufficient expertise to perform hypospadia surgeries with ideal outcomes outside of such a center. Therefore, it's difficult to advocate for such surgeries for intersex infants except when absolutely necessary to prevent immediate medical harm.

And finally, to quote from a 2024 systematic review, sex normalizing, quote, interventions are conducted based largely on rationales that were not adequately supported by evidence, a desire from parents and surgeons to match genital cosmesis typically ascribed to male and female bodies, and a parental desire for intervention conduct.

Legislating and medical regulatory bodies should advocate for ending the conduct of irreversible elective sex normalizing interventions conducted without the full free and informed consent of the person concerned to promote and protect the highest attainable standard of health for people with intersex variations. Again, the Commission and I strongly support HB612. Thank you for your time.

Thank you. Kapiolani Medical Center Dr. Lesli Nicolay.

Good morning. I am Dr. Lesli Nicolay, one of four practicing and board certified pediatric urologists privileged to care for children of Hawaii. I am speaking today as a medical professional representing Kapiolani Medical Center for Women and Children, a mother and most importantly an advocate for our children, the children of Hawaii. Thank you for the opportunity to testify.

We oppose HB612, which oversimplifies the complex nature in these conditions. Intersex makes up a very small subset of children with physical sex variations that are complex and diverse. They vary greatly in genetic, hormonal, gonadal and genetic aspects.

As a result, each child is unique and best served by the expertise of a multidisciplinary approach involving specialists across several fields. This is not a single physician working independently, rather a team working together and evaluating all aspects. Neither I nor Members of this group are in favor or against surgery.

The evaluations and recommendations are centered on scientific data and the best practice guidelines in a thoughtful and methodical way. Parents are educated and given the ability to make their own informed decisions to advocate for their child, which is encouraged and respected by the team. Imposing legislative regulations will undermine individual care.

Additionally, this Bill could have the unintended consequence to impact treatments for common conditions that are not associated with intersex. For example, hypospadias, a condition where the hole that passes urine is not at the tip of the penis and one of the most common congenital findings in males.

Hypospadias affects 1 in 250 boys born and the incidence is increasing. We know that delaying surgery increases the rates of complications. This Bill could delay treatments, harm children and potentially be more costly. Families may not be given any other option than to seek treatments that meet the standard of care outside of Hawaii.

We are concerned that the regulations by physician practices via statutory measures may set harmful precedent. A Bill that attempts to legislate limits on health care options, fails to individualize treatments, ignores scientific data and best practice guidelines, limit parental rights, creates a potentially dangerous situation that may harm children and negatively impact care that is delivered in Hawaii.

Thank you again for this opportunity.

Thank you, Doctor. Thank you, Doctor for being here. Let's see on zoom. I believe we have Stonewall Caucus of the Democratic Party of Hawaii.

Mahalo and Aloha Chair, Vice Chair, Members of the Committee. My name is Abby Simmons. I am the chair of the Stonewall Caucus of the Democratic Party of Hawaii. And I'm here to stand on our written testimony and strong support of HB612.

Mahalo. Thank you. Next, we have Pride at Work Hawaii. Michael Golojuch Jr.

Aloha. Good morning. Michael Golojuch Jr. He/him pronouns. Again, Happy New Year. What we're actually talking about here today is ending forced genital mutilation. There's nothing medically necessary about scooping out the reproductive organs of an infant. There are unintended consequences of this Bill are not there because of the protective wording that's already in this Bill.

This Bill was crafted in such a way to ensure that there are no unintended consequences. What we are trying, and yes, intersex do make up a small subsect of our entire population. What the previous testifier failed to mention is that we don't exactly know how many intersex children are out there or how many births because they're so.

Because of these invasive medical procedures that happen so quickly after birth. The estimates is one-in-a-thousand to two-in-a-thousand, one-in-a-thousand to one-in-two-thousand births as a child is born intersex. What we are calling for in this Bill is to protect those.

We have put guidelines, we have put restraints on the medical professions to protect the most vulnerable. And that is our intersex community. They go unseen. They are unheard. And we are here to advocate for them to ensure that this Bill is not perfect.

We would actually rather see this ban be held until their 16th birthday to give the keiki a chance to grow and mature and figure out who they are. And so we hope that you will pass this Bill forward so we can continue this conversation to help protect the most vulnerable.

Because in the list of specialists that the doctor provided, there is not one intersex person that's listed as a specialist here. And there is no such. And also to give the parents a chance to learn who their baby is and let them grow naturally and figure this out for themselves. So let's protect the most vulnerable.

And remember, the medical professional also just 50 years ago thought being gay or lesbian was a mental health problem. And we now know that is not true. So side of the, be bold today, do good trouble, and pass this Bill out. Mahalo.

Thank you. Thank you, Mr. Golojuch. Let's see. We have statements and support from 17 individuals as well as one in opposition. Anyone else I missed who is wishing to testify on HB612 in person or on zoom? If not, Members, any questions? Excuse me. Seeing none. Let's move on. Okay, let's move on to HB250.

zero, regarding prior authorization, first up, Dr. Jack Lewin, Hawaii State Health Planning and Development Agency.

Aloha. Good morning, Chair, Vice Chair, Members of the Committee. Thank you for the opportunity to testify. I'm Jack Lewin, the administrator of State Health Planning and Development Agency. Prior authorization is a controversial topic today across the entire country. We all realize that there are tensions around it, and I'm not here to Vilify anybody in the process.

I'm here to propose a solution and that's what I hope HB250 can be. There are 8 bills around prior authorization for you to review this year and we'll be supporting a number of those because there are some short term fixes that are needed that are, that are included in those bills.

This is a more of a longer term solution Bill. I understand the complexity of it. I try to maintain friendly relations with all the health Sector folks, including our insurance industry here. And we're all supporting Hawaii, the health state vision of the future. So that's, that's good. But HB250 does two things.

It requires reporting on prior authorization parameters and practices to Shipta. So we have a better understanding of what's really going on. And there's transparency. This shouldn't be that hard because the Federal Government requires reporting as well.

The second part is, you know, a bit of a innovation suggestion, which is to create a body that would look at the standards that already exist across this country in every specialty and every disease focus area that have been painstakingly created. They're peer reviewed by excellent scientists and professional bodies and they exist today.

And if we use those, and we agreed on what the standards are for the top hundred causes of the triggers of prior authorization in our state, understanding the complexity there, we could automate the process. I mean, the patient could understand whether they're care will be provided and paid for before they leave the office.

That could happen as you're admit before you're fully admitted to the hospital. It could happen that quickly. And that's, I think all of us think that goal would be great. And I think that's true of the insurers as well as doctors and everybody else. SHIFTA can manage this process.

We don't need all the scientists, we don't need a bunch of consultants to help us do this because we can bring that expertise from the insurance industry, from the physician community, from the hospital community to the table to help us deliberate on this. If we could come up with those agreements, we could automate prior authorization.

A lot of people believe it's just too complicated to do this. But the reality is we live in the information age today. We're here now. We do a lot of things that are very complicated. And I ran the American College of Cardiology for eight years.

We created guidelines with the American Heart Association for Cardiovascular Disease, which are recognized as the top standards in this country today. Government participates in the development of them as well. Those Standards are very complicated. If you have heart failure, that's not enough. You might have heart failure with kidney disease or with diabetes or with 10 other conditions.

That all has to be considered in a prior authorization circumstance. But we can go through that kind of complexity today. It exists. There are ways for us to do it. So I just want you to know that it's not too complicated. We can do this if we really work on it together.

And the good news is that these national standards are available today without us having to pay any money to create them. I suggest three amendments to this Bill. I put the word commission in there when I thought about creating it. It's actually better to have it be a working group or a task force. It's much simpler.

And it might also comply that we might get this done in two years if we try to really put our minds to it. So it might not need to be permanent. Thank you, Doctor. Secondly, it doesn't have lab and diagnostics in there and the list of things, things that need to be included.

Thank you.

And they, they have to be in there. And, and finally, just it, it could be. Let's revisit it in two years if we create it and it works to see if, if it did work before we proceed further. Thank you for the opportunity to test.

Appreciate your comments.

Department of Health Vice Chair Members Lorrin Kim, Department of Health the Department will stand on its testimony largely corroborating the suggestions from Shipta, but wanting to point out, as Dr. Lewin said at the end of his testimony, strongly recommend a working group and not a task force that requires advice and consent.

That's actually the position of the Executive branch, but we think this is a good idea for our community to come together and talk. Story over the number one piece of feedback from physicians across the state. So thank you for the opportunity to testify.

Thank you. HMSA Dawn Kurisu.

Good morning. Aloha Chair, Vice Chair, Members of the Committee, Dawn Kurisu on behalf of HMSA, we certainly appreciate the opportunity to provide our comments on HB250 and we want to thank the Committee for taking the time to understand such a complex and really nuanced issue.

We're committed to working together to improve the prior authorization process while also ensuring the highest quality of care for our Members and the community at large.

HMSA provided comments on the measure, highlighting that There are new CMS requirements beginning in 2026 that health plans will be required to adhere to, which address many of the concerns raised about prior authorization frustrations under the new CMS requirements, prior authorization timelines will be shortened, further reducing the burden associated with the process.

Transparency around medical necessity criteria and prior authorization reporting will be strengthened and the adoption of electronic prior authorization processes will be required. We believe it would be premature to add any new statutory requirements around prior authorization this year. However, we are open to continuing the conversation and working collaboratively with stakeholders internally.

Just so you know, we are committed to forward progress and continue our own efforts to listen to our providers and make adjustments where possible.

We have eliminated PA requirements for certain procedures, expanded our Fast Pass program, which is like gold carding for qualifying providers, and are moving towards a fully integrated and digitized prior authorization process to further improve accuracy, efficiency and turnaround time should the Committee choose to move this measure forward.

We ask the Committee to consider our suggested amendments which are noted in our testimony. Just highlighting amending Section 2 to include inserting the new statutory language into Chapter 4312 under the Insurance Commissioner, who is the appropriate authority regulating insurance and consumer protection in Hawaii, and amending the B section of the Health Care Appropriate Appropriateness and Necessity Commission.

Again, we are committed to working together with the various stakeholders to ensure that prior authorization is efficient, less burdensome, and continues to ensure the best care for those we love. Mahalo, and we're available for any questions.

Thank you. Let's see on zoom we have the Hawaii Association of Professional Nurses, Jeremy Creekmore not present in support. On Zoom Kaiser Permanente Jonathan Ching.

Aloha Chair Vice Chair, Jonathan Ching again for Kaiser Permanente. I first of all want to apologize for submitting late testimony. I don't know if the Committee's had a chance to review it, but I'm standing submitting written comments, but also suggesting an amendment.

I don't want to read my testimony explicitly, but I will highlight again, really, that prior authorization shouldn't inhibit the timely access of clinically appropriate care. As some of the Members may know, for Kaiser Permanente, as a fully integrated system with our own physicians, we really use prior authorization sparingly.

But that being said, we completely understand and acknowledge that this is a growing issue not just here in Hawaii, but also, as we all know, nationally.

To that extent, we understand that, you know, there is not reporting requirements to the state, the Medicaid plans, all of the participating Medicaid plans already do submit this to the state Medicaid Director. But in the interest of transparency, we are totally supportive of the understanding of health plans submitting their prior authorization data.

Our friendly amendment is very similar to HMSA in that we think that there are new federal requirements. And it would be, we think that it would be better to be not duplicative of two different reporting requirements to the state and also the Federal Government. So our amendments align with that.

And also note that we would request, if the Committee were to consider it, that this should be in Chapter 431 under the Insurance, under DCCA, the Insurance Division versus HRS332D.

Again, totally understanding, there are many bills on this and we appreciate that the Committee has heard this Bill to be considered, but we just would ask for timely consideration of our friendly amendment. We're available for any questions and we understand that this is a discussion that will continue to move forward this legislative session.

Thank you for the opportunity to testify.

Thank you. Also on Zoom, we have Dr. Kelly Withey.

Aloha Chair, Vice Chair, and Members of the Committee, thank you for your service to the people of Hawaii. My name is Kelly Withey. I'm a family physician who does not practice anymore. Instead I teach and I perform the physician workforce assessment that shows we have a shortage of over 700 physicians.

And Healthcare Association of Hawaii shows we have a shortage of many thousands of other healthcare workers. I submitted written testimony that is the results of a survey of Hawaii doctors last year. But I would like to share just two things. One is a doctor and one is a patient. I love patient care.

I love talking with people and helping people. I know it sounds corny, but that's what I love about medicine. But I don't do it anymore. One of the favorite things in my life, I don't do it because prior authorization causes a barrier and a time requirement that is unrealistic in the relationship between patient and doctor.

We need to recruit more healthcare providers right away and I think this is one of the steps to doing that. As a patient, I have chronic pain. I've had a prior authorization treatment denied twice and then I serendipitously changed insurances and now I have that treatment and I very rarely have chronic pain.

So I would say both from the doctor perspective, we must start this open, honest, transparent conversation that does not happen right now. And we must pass this Bill or something very similar to it, whether it's a task force, a Commission. We need to get the data.

We need everybody to look at the data and we need to come to some solutions that yes, do conform with Medicare, but we need to do this and we need to do it now. So thank you for hearing this and please pass this on.

Thank you Doctor. We have statements, written comments from 50 plus individuals and organizations in support. Is there anyone else I missed who wishes to testify on HB250 in person or on zoom, if not Members? Any questions? I do have a question for Dr. Lewin, if you don't mind. Dr. Lewin. We heard from HMSA saying in their testimony that we expect to have CMS guidelines in this matter issued in 2026 and if so, why do we need this Bill?

I strongly support. Thank you for the question. I strongly support the CMS guidelines which will become in 2027 available to everybody. They won't cover all commercial coverage, so it's really kind of focused on the federal coverage that they're. So it's not as broad as we'd like it to be.

And my fellow physicians and hospital folks would like to see this happen even faster than CMS is proposing. They have a. I think they have a three day turnaround time, seven days maximum or three days. It's good. It's better than what we have now and we fully support it.

What I propose in 250 is something quite different and that is really that we begin to agree on what the standards are, go down the list of the top hundred and identify those. If we do that, we can then automate prior authorization.

It can happen immediately because we've all agreed on the standards and they're complex, but we can apply those to any patient because we live in the information age. So I would like to see us do this. It's different than what CMS is attempting to do, but I certainly support their new rule. Thank you very much.

Thank you. If there are no other questions, let's move on to HB 1085 which raises our tobacco tax. And first up, we have, let's see, Department of Attorney General.

Good morning, Chair, Vice Chair, Members of the Committee. My name is Chelsea, Chelsea Okamoto. I'm a Deputy Attorney General assigned to the Tobacco Enforcement Unit. And thank you for hearing this Bill. Our Department is in support of this Bill and at risk of sounding like a broken record because we did have HB441 scheduled on Wednesday.

Our Tobacco Enforcement Special Fund has been plummeting and that's because as cigarette tax go down, so do the special fee that feeds into our Special Fund. And as stated in our testimony, it's important to keep our Special Fund maintained in order to ensure that our annual MSA payment to the state is protected.

But I do today I do want to take a moment to highlight the differences between HB441 and HB1085. Last session when we were discussing a cigarette tax increase, the idea was presented by the legislative body. Hey, you have people that are not smoking as many cigarettes, and they're smoking e-cigarettes.

We have this new tax on an e-cigarette. Why don't we give that e-cigarette tax money to those Special Funds that are now having plummeting revenues? And so off session, we had a conversation amongst the agencies. How do we make that idea work?

And we had meetings with, uh, UH, DOH, DOTAX, BNF, like, how do we make this system? How do we revise it for that idea? And so HB1085, as a result of all those meetings. We are looking at widening the pool.

So instead of relying now on cigarette taxes, it widens the pool to everything collected under Chapter 245, which includes now cigars, little cigars, smokeless tobacco products, and e-liquids and e-cigarettes. So now that gets to be distributed to the different special funds. And another cool feature about this Bill is looking forward.

We know that the tobacco industry constantly innovates. There's constantly new products out there. So if the Legislature in the future decides, hey, we want to tax this new product, like maybe nicotine pouches, then that product was already under Chapter 245.

It'll immediately be just automatically included in that revenue pool so the Legislature won't have to constantly go back and fix the statutes to include the new revenues. So looking forward, while cigarette sales are declining, and that's great, again, we're glad that people aren't using cigarettes. We know that new products will constantly emerge.

And this Bill will now redesign and reorient the state to Fund programs who are dealing with the consequences of old products and new products at the same time. And so we ask you to pass the Bill. We're available for any questions. And thank you again for this opportunity to testify.

Thank you, Department of Health.

Good morning, Chair Takayama and Members of the Committee. I'm Lola Irvin, representing Director Kenny Fink. I am aging, so these glasses will go off and on. Aging in place.

And this is a great place to age in place because we have worked together across agencies and the Department of Health has a vision that everyone have the opportunity to achieve their optimal health.

And so it's amazing to work with state agencies that also agree that we want to protect and preserve the health of people and give everyone the opportunity to be healthy. And the thing is, we know that raising cigarette taxes is a proven and effective way to help people not start and to help people quit.

We also have programs to help people quit and it's free. It's called the Hawaii Tobacco Quit Line. Because of the Members of the Legislature, we also then have the ability to Fund community health centers. There are amazing tobacco prevention specialists and treatment specialists. There are resources to help people who want to quit.

Now the thing is, we haven't raised the taxes since 2011. And so the taxes remained at $3.20 a pack. And we still have 1,400 people who die from smoking related deaths a year. I think I mentioned last time that that included my dad. He started smoking at age 12.

It includes my best friend's dad who started smoking at age 5. It includes, for me, cousins and really great friends who have passed away before age 50. It includes others who also suffered from secondhand smoke. It's not just about helping people quit, but it's also about keeping the loved ones in our lives. We do support HB1085.

It would increase the tax by 5 cents a stick. We know that it would actually bring down the overall tobacco consumption by 3 to 5%. And that's worth it. That's worth it. So that people will have the opportunity to live long, good, quality years of life. So thank you for the opportunity to provide testimony.

Thank you. University of Hawaii.

Want to make sure it's two minutes. So good morning. Aloha. And so I'm Director of the University of Hawaii Cancer Center, Naoto Ueno. So we stand on this Bill. It's a very important Bill because it does support the cancer center.

So do you happen to know what is a national goal of the cancer mortality that we have to reduce in 2040? Cancer, moonshot. The goal is 50%. Okay. Historically, Hawaii, do you know what the number we have achieved in the past four decade? 25%. We're behind from the national number.

So for us to be aligning, we have to reach about 35%. So as a cancer center, we have put a lot of effort and we have been successful. And it is critical as a Director, not asking for more money, but really trying to focus on the future of what we need.

And this Bill is extremely important because it's not about sustainability but how do you see the future? The future should be people will not struggle. And currently this is not just about clinical trial, but when you have cancer, what happens in Hawaii. I'm actually from MD Anderson. The first thing is what's out there in the continent.

And this absolutely needs to stop. We need to work with the health care system and we need to make sure that we provide the best quality of care regardless of the island you live. And that's what this money is about.

And this helps us, the cancer center, to work with the health care system to take us to the next level. So I'm going to close quickly that I myself is a two time cancer survivor. I had a fatal disease. I'm alive because of clinical trials and multiple support from different system. Is this available here? It's still limited.

So let's think about people who are struggling. How can we prevent from that happening that people don't have to leave the island. Let's prevent cancer so that you don't have cancer. And we need to be proud to be ourselves that we don't have to think about the continent. So thank you very much for the opportunity to.

Thank you.

Thank you Dr.

Mike Department of Taxation offering comments Tax foundation of Hawaii Tom Yamachika on zoom.

Yes. Good morning Chair, Members of the Committee, this is Kay Mcmillan on behalf of Tom Yamachika for the Tax Foundation of Hawaii, we have submitted some comments on the Bill. Our comments are considering. Our comments consider the fact that the tobacco tax is meant to have the goal of prohibiting making it cost prohibitive to smoke.

And as we can see with the decrease in the tobacco tax revenue that that's working. But in that same regard, if that is the effect, then why should we expect the tax to continue to raise revenue?

So we're just sort of commenting that the fiscal reliance on funds of syntax such as this is not advisable for the long term. Thank you.

Thank you American Cancer Society.

Thank you, Chair, Vice Chair and Committee Member Cynthia Au, on behalf of the American Cancer Society Cancer action network or ACS can we're in strong support of HB1085. Tobacco is the number one preventable cause of cancer and an estimated 1400 adults in Hawaii will die from smoking this year.

I want to thank the Committee for Considering the increase in the cigarette tax to help youth not to start smoking and for adults to quit.

We support funding the UH Cancer center, the only NCI designated cancer center in the Pacific and the top 4% of cancer centers in the US which provides important cancer research, access to life saving treatment, including clinical trials, education, which all play a critical role in reducing the cancer burden and for our unique population in the State of Hawaii.

So thank you for this time to testify.

Thank you. Healthcare Association of Hawaii Hilton Ral in support. Thank you Hawaii Public Health Institute Kevin Ramirez.

Aloha and good morning Chair, Vice Chair and Members of the Committee. I'm Kevin Ramirez, Program Manager for the Coalition for Tobacco Free Hawaii, which is a program of the Hawaii Public Health Institute. Raising taxes on tobacco products is a proven strategy to help reduce tobacco product use and dependence and can be a benefit for public health.

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

Currently, no revenue from tobacco taxes is appropriated for tobacco prevention and cessation. Populations that continue to experience higher rates of smoking would be the primary beneficiaries of these prevention and cessation activities, helping to provide resources needed to quit smoking and to help cut the high costs associated with tobacco use.

We humbly ask that a portion of the proposed tobacco tax revenue be dedicated to support tobacco prevention and cessation programs. Thank you for the opportunity to provide testimony in support of HB1085.

Thank you. Susan Hirano.

Good morning again, Susan Hirano. I'm a patient advocate with the University of Hawaii Cancer center, also stage 4 metastatic breast cancer patient. Before I get started, I would like to offer my condolences to Representative Alcos. While this Bill has a broader stroke, I just like to talk about how it affects the patient.

The funding of this Bill provides some of the monies necessary for the cancer center to bring clinical trials to the island. Some of the reasons that's so important is as a cancer patient, when you are going through treatment and have exhausted all of your possibilities, your next ray of hope is a clinical trial.

For me, I've been through eight different types of treatment in the last 15 months. I've done five different rounds of chemo, all of which have shown progression. So for me, the clinical trial is my next ray of hope. Access to those clinical trials currently is on the mainland.

To be able to access those clinical trials, I'm required to leave my family. So the support of Yorohana when you're going through this, and you've heard me say this on Wednesday as well, is critical during this time. There's also the financial aspect, as we talked about earlier, is cross prohibitive to many, many people in our community.

We have different islands that come to Oahu for treatment. It's, you know, we talked about Molokai earlier. It's very difficult and expensive for them to fly to the mainland for treatment. Airfare, lodging, clinical trials can last for months and sometimes years, preventing people from even considering a clinical trial.

So I'm just here today to show you a patient perspective and ask that you support the Bill so that we can bring that type of care here to the island and save lives in our own community and be with our Ohana while we're going through treatment. Thank you.

Thank you. Thank you, Susan. Let's see. We have testimony, written testimony from. I counted 18 supporters and seven opponents. Anyone else wishing to testify on HB 1085 in person? Dr. Lewin.

Thank you. Thank you. Chair, Vice Chair and Members of the Committee, I apologize. Somehow we uploaded our testimony inappropriately, so you don't have it. However, I will just simply say this, that SHIPTA passionately supports this measure and we prefer 21 cents as a tax over 18 cents. So we prefer this Bill over 441. Mahalo.

Thank you. Yes, please step forward and support. Thank you. Last call. Anyone else wishing to testify on HB1085 in person or on Zoom? Please proceed.

Aloha, Chair, Vice Chair, Members of the Committee, Pedro Haro, Executive Director of the American Lung Association in Hawaii. Apologies. Not only does my testimony for your various hearings have the scarlet letter of late across my testimony, but it's also missing from this particular Bill. The American Lung Association supports this Bill.

I want to extend our condolences also to Representative Alcos.

And I want to make sure that for you folks that are sitting on that table, your staff and the people that are that are viewing this, the American Lung Association stands by to support any family Members who have Members who are dealing with obviously a multitude of lung issues, but particularly lung cancer, to be able to provide any assistance.

What I always like to do is to give my personal cell phone number. If any of you or any of your staff or any of your constituents have any issues around lung cancer, please have them contact me directly and I'll be happy to be able to help however I can.

We also stand with HIFI in asking for an allocation to tobacco control programs as part of this tact. Thank you very much.

Thank you. Now, anyone else wishing to testify on HB 1085? Seeing none. Members, questions? Seeing none. Let's move on. Final bill on the agenda, HB 756, prohibiting flavored tobacco and nicotine products. First up, Attorney General.

Hello again. My name is Chelsea Okamoto, Deputy Attorney General with the Tobacco Enforcement Unit. Thank you again for hearing this bill. Our Department's in support of this bill. It's no secret that the tobacco industry targets our kids with flavors, and there's new product innovation there.

It's had a significant impact on an entire generation of our kids and young adults. The Department asked for several amendments, which we've outlined in our written testimony, and we referenced HB 1116 for wording. We know concept flavors have come up in markets like California when they're attempting to skirt around the flavor bans that are in California.

So they have chemicals in these products that mimic the cooling effect of menthol without the actual flavor of menthol. So we recommend definitions to be inserted from HB 1116 to address those new product, those new products that are on the market. We asked for a definition for inspector to be inserted, to create a separate definition of nicotine that's separate out from nicotine products.

And we suggest some wording in our testimony for that. And we also asked to include a repeal of the preemption statute found in 328J-115 HRS. We asked for other smaller technical changes, as outlined in our written testimony. And we ask that you include these amendments and pass this bill. We're available for questions, and thank you for the opportunity to testify.

Thank you. Hawaii State Council on Developmental Disabilities.

Thank you, Chair, Vice Chair, Committee Members. Daintry Bartoldus for the Hawaii State Council on Developmental Disabilities. We stand in strong support of this measure. We'd just like to really emphasize for our population, especially individuals with intellectual and developmental disabilities, it's very easy for them to be manipulated and encouraged to try such flavored tobaccos and E-cigarettes because they are the highest bullied group and they want to fit in.

And so more parents come to us and have expressed how their children are being enticed more and more to try E-cigarettes. It's easy to teach somebody a cigarette is bad, but the canisters that E-cigarettes come in look like an inhaler. And a parent told me her son, after a soccer game, was given an inhaler, and it had bubblegum flavored in it. And she saw the kids laughing at him because he was coughing, and he had this coughing fit for over three hours. And so we're finding it's increasing more and more.

And we've noticed as other states ban flavored E-liquid. Excuse me. That Hawaii's being targeted more and more with different flavors, such as Molokai hot bread, POG, Shaka. So they're targeting Hawaii's youth more and more because to make up for that revenue, and it's really alarming. So we're in strong support of this. Thank you.

Thank you, Department of Health.

Good morning. I'm Lola Ervin representing Dr. Kenneth Fink for the Department of Health. So I'm a parent of three, and I work in the Department of Health because I believe in our vision to optimize our health. And we want children to be curious and to explore their world and to be healthy.

And so we work to create communities that thrive, and we have community intervention programs so that children can move about safely. But what's happening and I kind of like to use this analogy of we send the kids out like, I had a free range childhood, right.

Climbed a mango tree, jumped from a mango tree to a lychee tree, and then went riding the bike down the hill and then went down the pier. But okay, but I got to explore. And we had aunties and everybody who watched out for us.

But now what's happening with this kind of marketing, of these flavored products, flavored tobacco products, it's almost like we have pukas in the ground and it's the adults. We're putting the pukas in the ground so we can catch the kids and make money off of them. These products are highly addictive, right.

So the amount of nicotine in these e-cigarettes is like three to four packs of cigarettes. They are addictive, and as my colleague mentioned that especially for students who are special needs, these products also then take over their brain function. So it will interfere with sleep. It will accelerate mood disorders and we know teenagers.

I was a moody teenager. Imagine that being worse because of the effect of nicotine and the addictive control of nicotine and also it'll interrupt their memory. So short term memory gets disrupted. So it will affect their academic success. This Bill is a little different.

Unlike others that have come before this body, it puts the Department of Health as the administrative agency, and so in terms of then the consequences, it's an administrative enforcement, it's not a criminal enforcement. And the Department of Health is willing to take this on. We want our children to have healthy community environments they can grow up in.

We are getting complaints from elementary schools wanting our prevention posters because they've caught second graders using e-cigarettes. So we want to be part of the solution, and we're willing to be part of that. Like the Attorney General's Office mentioned, we do prefer the definitions in HB1116, and we have hyperlinked that in our testimony.

The structure of this creates a new definition of nicotine products versus what's already in statute with the definition of tobacco products. So HB1116 relies on the existing language and law and simplifies it a little bit more than HB756, but we strongly support this and thank you so much for the opportunity to provide testimony.

Thank you. Hawaii Public Health Institute Kevin Ramirez.

Aloha again, Kevin Ramirez, Program Manager for the Coalition for Tobacco Free Hawaii Program of Hawaii Public Health Institute, here to testify in strong support with amendments for HB756. We respectfully request a few minor amendments be made so the law can be implemented in a way that aligns with the intent of the Bill.

Those amendments align with the recommended changes from the Department of Health and the Ag's Office. Hawaii Voters want regulations in a December 2024 poll of registered Hawaii voters conducted by Ward Research on behalf of the Coalition, 74% support a law prohibiting all flavors, including menthol of tobacco products and e-cigarettes.

Local ordinances prohibiting the sales of flavored tobacco products have already been passed in Honolulu, Hawaii and Maui Counties and Kauai is considering the same. Most of the flavored e-cigarette products used by youth contain extremely high levels of nicotine and are illegal.

One 5% strength nicotine e-cigarette marketed as containing 5,000 puffs contains as much nicotine as 30 packs of cigarettes. Most are illegal because the FDA has only authorized 34 e-cigarette products, none of which I have ever seen collected as as contraband at our local schools.

Additionally, the tobacco industry continues to develop, market and promote new flavored products like nicotine pouches that are growing in popularity among youth. Ending the sale of all flavored tobacco products will reduce their appeal and protect our children from a lifetime of addiction. Thank you for your consideration of HB756.

We respectfully ask you to pass this measure with amendments. Thank you.

Thank you. Let's see, we have Campaign for Tobacco Free Kids Liza Ryan Gill.

Aloha Chair, Vice Chair, Members of the Committee, thank you for hearing this Bill and also a special mahalo to Vice Chair for her work in championing the trigger ordinance on Hawaii island as a Council Member before coming to this body, so we're so thankful for your support on that.

I want to echo all of the testimony that's already been offered by the Department of Health and HiPHI and support their amendments. Just also wanted our role as an international and national organization and also representing here in Hawaii, want to highlight a couple of perspectives that we've been able to see in other states.

So similar bills have passed already in California, Massachusetts, New York and Rhode Island. In all of these states, we've seen substantive decreases in the sale of e-cigarettes. In California, nearly 50% decrease; in Massachusetts, nearly 90% decrease.

New York nearly 63 and Rhode Island, about 55% decrease in the sale of e-cigarettes in the time that they have implemented this policy. During that time, all of these states have also seen reduction in combustible cigarette sales as well. So just when you're thinking about how would this impact us, we do have good research.

This is from the CDC Foundation. We're willing to share this with all of you. But I always feel as the campaign for Tobacco Free Kids, it's important to bring our youth, since many of them are in school and unable to be here, back into the room as well.

And we pull together with the help of our comms team, a short video about 30 seconds long with real ads and influencer materials that our youth are seeing every day on their algorithm.

So I encourage you, if you haven't opened that email and look at and look at that video, it's to help you gain a perspective on what it's like to be 12 to 15 years old right now and how much our kids need our support for their mental health and to address this nexus of things, whether it's social media and their cell phones and nicotine addiction that are really harming both their ability to focus and also just their connection with their peers and with their parents and their loved ones.

And so I just ask you to remember and try to bring those 12 year olds, those 10 year olds in the room. I have a preschool and a toddler. I certainly don't want to be back here by the time that they're entering elementary school and still talking about this. Mahalo.

Thank you. On zoom, we have Reason Foundation, Guy Bentley, please proceed.

Thank you, Chair, Vice Chairman, Committee. My name is Guy Bentley. I'm a Director of the recent foundation. We're nonprofit public policy think tank headquartered in California.

You have our written testimony, but I just want to highlight one part of that for you today, which is as the legislation is written, this would, this Bill would ban not just mental cigarettes, combustible cigars and so on and some of the youth appealing products that we've heard from other witnesses.

It would also ban a whole suite of products that the People Food and Drug Administration has authorized as, quote, appropriate for the protection of public health, unquote. And these are products that the FDA has evaluated and authorized sale because they help adult smokers switch to a safer product. But crucially, they don't appeal to youth.

And that's one of the big issues we want to bring up with the Committee to ensure that the legislation as written does cover those products as well, which could be detrimental to public health. Also unfortunately from other jurisdictions.

According to Yale University's Abigail Friedman, when we have seen these kind of bans put in place, we have seen cigarette sales increase after flavored alternatives to combustible cigarettes are banned. So, for instance, one e-cigarette flavored pod for every one that is not sold because of a ban, an additional 13 cigarettes sold. But with that we'll leave.

Gregg, thank you so much for your time.

Thank you. Also on Zoom we have Chinatown Liquor Sakanashi not present in opposition. Number one store on Zoom Hee Nam Hwang please proceed.

Good morning. Hello, my name is Hee Nam Hwang. I oppose HB756. I am local business owner in Honolulu. I have owned my store for 20 years. I may not speak in good English, but I am very responsible owner. This Bill will be harmful for store owners like me and teacher put children in danger.

This is because your data and research show radical enforcement when being like this past what you can see clear in the illegal markets. The State which lost a lot of tax dollar and would you cost the State even more money to enforce this Bill, flavored vapes is not the answer.

Auditors have the right to use favorable products that are authorized by FDA. Strict enforcement and prosecution of open data is needed. Thank you for your time today.

Thank you. Thank you. Discount Smoke Shop Hawaii Michelle Jordan not present in opposition. Kaiser Permanente Jonathan Ching, not present. Wawa Village Market Young park in opposition. On Zoom American Lung Association, Pedro Haro.

Aloha Chair, Vice Chair Members of the Committee. Pedro Haro Executive Director of the American Lung Association. We send in full support of this proposed legislation. I just wanted to highlight something from my testimony. We sent on a written comments.

One of the things the tobacco industry will try to do is to carve out menthol from these type of bills.

And I know that I'm speaking to the choir, but all of you said in other committees where this might come into play with other chairs the importance and what you always have to think about the biggest flavor that they have to their disposal for tobacco companies to get new smokers which at least 90% of their of the base new consumers are people under the age of 18 is menthol.

And the reason that they have that is because it masks the negative intake side effects when you start smoking, when you start vaping. So it's incredibly important for tobacco companies in order to addict children to have menthol in their flavoring.

So you'll go to any vape shop, you go to any tobacco product stores and you'll see menthol included in almost every single product that they have. And the reason for that is because it helps with the addiction. Now, while many store owners will inherently talk about that we don't sell to children.

They will talk about how this is important. We have to remember the tax dollars and the profits that are brought to the businesses in Hawaii are on the backs and the lives of our current keiki. So this is blood money that is in our hands. We are trading in profit for the lives of people.

It's really, really important to keep menthol in this Bill. It's incredibly important to hold tobacco companies accountable. And this is one of those ways that we know is a proven method to be able to stop having our children be addicted in future generations and our current generation. Thank you very much. Available for questions.

Thank you. Let's see. We have written testimony. My rough count is 32 in support, 11 in opposition from individuals and organizations and businesses. Anyone else wishing to testify on House Bill 756 in person or on zoom? Seeing none. Let's have questions. Members. Seeing none. Attorney General, I have a question, if I may.

See, this Bill contains a blank amount for an appropriation. The Bill you referenced, the governor's Bill, HB1116, suggests $1.0 million per year, is that similar recommendation for this Bill?

Again, Deputy Attorney General Chelsea Okamoto on behalf of the tobacco unit. So HB1116, that is the Administration package Bill. And so that is the recommended amount that was requested by the Department of Health to effectuate this Bill. And maybe Department of Health would be better able to answer that question.

I'm trying to find out what blank amount should be filled in for this Bill.

Right. So we understand that that would be the appropriate amount because that aligns with the Administration package.

Okay, thank you. Okay, thank you. Also, while you're up there in your testimony, you suggest repealing the preemption statute. Can you explain why?

Sure. So in order to have a more comprehensive approach, we'd like to pair what the local counties are currently trying to with their flavor bans and then also include this administrative enforcement.

So you have the criminal stuff that the flavor ban that would be triggered by the repeal of the preemption that would be in effect alongside the administration enforcement by the Department of Health. So they kind of are complementary in nature.

And we just want to be as comprehensive as possible when we are trying to tackle this problem, to do both things at the same time.

Okay, thank you. Thank you. Any other questions? If not Members, let's proceed to decision making. Just give me a minute to. Okay.

So, Members, on the first Bill, HB 712, regarding the 340b statute. My suggestion is that we move this ahead with several House amendments, and that would, number one, incorporate the suggestion from the Attorney General that we place this measure under HRS, Chapter 481b, which affects unfair practices, which is more appropriate than what is in the Bill.

Secondly, I'd like to adopt the recommendations from the Hawaii that. From the Healthcare Association of Hawaii, which would delete references to wholesale distributors, as well as making it clear that violations of this section shall be covered under unfair or deceptive acts or practices. And finally, provides clarification on several definitions of 340B covered entities. 340B drug and manufacturers.

Finally, I'd like to defect the date and move this forward. Members, any questions, comments or concerns? If not Vice Chair for the vote.

Thank you, Chair. Members voting on House Bill 712. Chair's recommendation is to pass with amendments. Chair votes aye. Vice Chair votes aye. [Roll Call] Chair your motion- I keep doing this wrong. Chair, your recommendation is adopted.

Thank you. And just a matter of housekeeping for the bills that we move forward as House drafts. Just want to add that we're going to defect the date on all of them, and this simply ensures that there is further discussion in the subsequent committees that consider this.

Also, if there is an appropriation, we're going to blank it out and put that amount in the recommended report language. Next, Bill. HB 72 regarding registration of pharmacy techs. I'd like to move this forward with amendments suggested by Walgreens, which excludes auxiliary pharmacy personnel, such as cashiers, from this registration.

Also clarifying the duties of pharmacy technicians and clarifying that supervision by a pharmacist of technicians. We should remove the word, quote, observation, so that the pharmacist doesn't directly have to observe a technician administering a vaccination, for example. Finally, defect the date and there's no appropriation. So with that, Members, any questions or comments?

I might add that I think there's good reason to register pharmacy techs. You know, under the measures we passed last year, they, for example, have the authority to administer vaccinations and their shots to the children as well. So I'd like to move that forward. Vice Chair for the vote.

Thank you, Chair voting on House Bill 72. Chair's recommendation is-

712.

I'm sorry.

I'm sorry. 72. You're right.

Voting on House Bill 72, Chair's recommendation is to pass with amendments, noting all Members present. Any Members voting no? Any Members voting with reservations? Chair, your recommendation is adopted.

Thank you. Next Bill. HB714 relating to healthcare workforce development. First of all, I'd like to adopt the change which was suggested by several testifiers which changes the receiving agency or the administering agency to DBEDT, I think, UH and DOE is now in there. Replace that with DBEDT.

Um, blank out the appropriation and put in the report language suggestion that the amount of $1.4 million per year for each of the next two years be considered. Finally, technical and changes as well as the defective date. Members, any questions or comments or concerns? If not Vice Chair.

Thank you, Chair. Members voting on House Bill 714 recommendation of the Chair is to pass with amendments. Chair votes aye. Vice Chair votes aye. Noting all Members present. Any Members voting no? Any with reservations? Chair, your recommendation is adopted.

Thank you. Next Bill. HB 1179, rural emergency hospitals like to move this forward with technical changes as well as a defective date in report language.

I'd like to note testimony from Department of Human Services to the effect that they will seek a clarification from Medicaid as to ramifications of this change to, quote, "Critical access hospitals from what is currently rural emergency hospitals." So any questions, comments? If not Vice Chair for the vote.

Thank you, Chair. Voting Members voting on House Bill 1179. Chair's recommendation is to pass with amendments. Chair votes aye. Vice Chair votes aye. Noting all Members present. Any Members voting no? Any with reservation? Chair, your recommendation is adopted.

Thank you. The next Bill is HB139, providing coverage for fertility preservation services for people undergoing treatment. I'd like to move this forward with a defective date as well as report language for future committees to consider whether spouses of those who are currently covered should be specifically included. There are cost implications.

From a health perspective, we think it's warranted, but since there are cost implications, we'd like that to be considered by future committees. So, Members, any questions or comments? If not Vice Chair.

Thank you. Members voting in House Bill 139. It is the Chair's recommendation to pass with amendments. Noting all Members present. Anyone voting no? Any with reservations? Chair, your recommendation is adopted.

Thank you. This next Bill, HB 612, prohibiting certain surgeries. You know, I was prepared to move this forward, but I thought the testimony from Dr. Nicolay was very compelling and provided doubts in my own mind.

I note that there is a Senate companion, so it may well move over and provide further discussion, but at this point I'd like to defer the Bill. Next Bill is HB250 regarding to prior authorization. Bear with me, Members. I know this is a somewhat complex Bill, but I'd like to move this forward with several recommended amendments.

First of all, I'd like to thank the author of the Bill for putting a lot of work into this. Chair Martin, thank you. I'd like to add to the purpose clause a third purpose clause to the quote release.

A third purpose would be to reduce delays in considering prior authorization requests for urgent and non urgent health care services period.

I'd like to therefore add a new section using language from HB954, page 13 through page 15, to the effect and please bear with me because this is new language, I'll read it literally. Prior Authorization for Non Urgent Healthcare Services Submission of Requests Determination Time Frame. Automatic approval to the effect that a healthcare professional shall submit prior authorization request for a non urgent health care to the utilization review entity no later than five calendar days before the provision of the healthcare service.

Subsection B, a prior authorization request submitted pursuant to subsection A, shall be deemed approved 48 hours after submission of the request if the utilization review entity fails to 1. Approve or deny the request and notify the enrollee or the enrollee's healthcare provider. Subsection 2.

Requests the healthcare provider for additional information needed to render a decision or subsection 3. Notify healthcare provider that prior authorization is being questioned for medical necessity within the 48 hour period.

The utilization review entity shall have an additional 24 hours to process the request from the time the healthcare provider submits the additional information requested pursuant to paragraph 2 subsection 3. I'm sorry Paragraph 2. Furthermore, any healthcare provider who fails to submit the information requested pursuant to subsection B within 24 hours shall submit a new prior authorization request.

Finally, for purposes of this subsection, information needed to make a decision includes the results of any face to face clinical evaluation or second opinion that may be required.

Further Subsection regarding prior authorization requests for urgent healthcare services determination, time frame and automatic approval. Subsection A, a prior authorization request submitted for an urgent healthcare service shall be deemed approved 24 hours after the submission of the request if the utilization review entity fails to subsection 1.

Approve or deny the request and notify the enrollee or the enrollee's healthcare provider. Subsection 2, request the healthcare provider for all additional information needed to render a decision or subsection 3.

Notify healthcare provider that prior authorization is being questioned for medical necessity within the 24 hour period. The utilization review entity shall have an additional 12 hours to process the request from the time the healthcare provider submits the additional information pursuant to paragraph 2.

Finally, subsection B, any healthcare provider who fails to submit the information requested pursuant to subsection A2 within 12 hours shall submit a new prior authorization request. Also, I'd like to make amendments suggested by Dr. Lewin Shipdale on page five, line two, adding laboratory and diagnostic tests to the list of services that trigger prior authorizations.

Also, change all references in the measure from Commission to working group. Finally, on page four, line three, change the word Commissioner to agency. Finally, add a defective date. And also in the Committee report, I'd like to note that several testifiers suggested different compositions for the working group that is to be created.

You know, because this is more regulatory than a health related decision. I'd like to add report language that suggests future committees consider the most effective composition for this working group that could carry out the intent of the Bill. Finally, I'd like to thank HMSA for moving forward on their efforts on prior authorization.

However, I'd like to move the Bill forward because I think it keeps the conversation alive. We're the first of three Health Committees to consider this. It's not a finished product, but I'd, as I said, like to keep this issue alive. So with that, Members, thank you for bearing with me any questions, comments or concerns.

I just want to comment. Thank you for taking so much time to make a better product. I really appreciate it.

Thank you Vice Chair for the vote.

Thank you Chair. Members voting on House Bill 250, Chair's recommendation is to pass with a very thought out amendment. We have Chair voting aye. All Members present. Anyone voting no? Members, any with reservation? Chair, your measure passes.

Thank you. Next Bill HB 1085, raising the cigarette tax. Members, I know that a few days ago we considered a similar Bill, HB441. The reason is we couldn't consider both is as I explained earlier is because the referrals didn't quite enable us to do so at the time. But having said that, I'd like to move this forward.

I think it has merit and in expanding the cigarette tax to include E-cigarettes and having the proceeds be moved instead of a General Fund to the entities mentioned in the Bill, including Cancer Center. I'd like to make technical amendments as well as defecting the date and and move this forward.

Any questions, Comments, Concerns? If not Vice Chair. On HB 1085.

Thank you Chair. Members voting on House Bill 1085. It is the recommendation of the Chair to pass with amendments. Noting all Members present. Any Members voting no? Any with reservation? Chair, your measure is adopted.

Thank you very much. Now on the final Bill, HB756 relating to prohibition on flavored nicotine products and such, like to move this forward, adopting the recommended amendments we heard articulated from the Deputy Attorney General in which she suggested seven amendments. I'd like to adopt all but one of them, the final one, which would repeal the preemption statute.

I'd like to keep the preemption statute but adopt the other recommendations from the AG. Also adopt several amendments suggested by Tobacco Free Kids, which are more or less technical in nature. They clarify the definitions for tobacco product flavor enhancer, include pouches and lozenges in the types of tobacco and nicotine delivery mechanisms.

Removes employee from the definition of retailer and includes importers, distributors and retailers who add things to packages to claim that the product is flavored as prima facie evidence that the product is a flavored nicotine product in the prohibition on mislabeling of products.

Finally, I'd like to blank out the Bill language regarding the two FTE program specialists and one FTE hearings officer put this in report language along with the suggested appropriation of $1 million per year to carry out this measure and defect the date.

Now, I understand concerns expressed by retailers and others that, you know, even though we ban it, this product might still be available on the Internet and in the black market. But, you know, that hasn't prevented the state from banning, prohibiting other harmful substances, drugs, fireworks, a number of other products.

But I think the important substance of this Bill is that it would reduce the advertising and marketing of these products to young children because we all know how influenced they are by such advertising and marketing. So that is really, I hope, the ultimate effect of this Bill. So, Members, any questions or comments? Representative Amato.

Thank you, Chair. I just want to say thank you for your work on this measure. I'm really hopeful we can actually pass the ban and see it cross the finish line this session. It's been a lot of work over many sessions to try and do it. So thank you, Chair.

Thank you. So do I. Any question?

Chair? Representative I apologize, everybody, for holding you guys up. I'm in strong support. I appreciate you hearing this Bill. Chair I just want to share my own personal experience. When I was 19 years old, I was in the service. I was deployed to Iraq. And what's very common, especially amongst infantrymen, is the pickup of nicotine products.

Both dip, chew and cigarettes on that deployment. My experience was I started flavor dipping first and then menthol cigarettes in that deployment. It was very hard to kick the habit. It's very common and I'm sad to say that one of my buddies on that deployment currently has stage two lung cancer. He has children.

They just found out during Christmas time and they are afraid it's going to be rediagnosed to stage three. In my previous experience working as a social service provider, predominantly working with homeless and street identified youths, vaping, flavor vaping was very, very common. That tends to be the entrance way for them getting into it.

As we see with a lot of the cancer treatments we have here, you know, we're setting up our use for failure. So I appreciate it. Chair thank you.

Thank you very much. Any other questions or comments? If not Vice Chair.

Thank you, Chair. Members voting on House Bill 756 is the Chair's recommendation to pass with amendments. Noting all Members. Any Members voting no? Any Members with reservation? Chair your measure is adopted.

Members, thank you very much. We're adjourned.